Every finding on record at Avantara Norton

Based on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI) report, interview, record review, and policy review, the provider failed to follow professional nursing standards regarding following physicians orders timely for one of one sampled resident (112) who was not administered antibiotic medications as ordered and notifying the physician about one of one sampled resident (88), who complained of feeling dizzy after receiving dialysis (a treatment that removes waste products and excess fluid from blood when the kidneys are unable to) that the resident was not consistently administered his blood pressure medication as ordered or of his low blood pressures. Findings include:1. Review of the SD DOH FRI report revealed that the provider received orders for resident 112 for cefuroxime (antibiotic) for a urinary tract infection (UTI) on Friday, 7/11/25. The order was left on a fax machine in the front reception area over the weekend, so it was not implemented. The provider found those orders on Tuesday, 7/15/25, and that same day received physicians' orders for a different antibiotic, nitrofurantoin, after the urine culture results were completed. On 7/15/25, resident 112 and her family requested to go to the emergency room. To prevent further instances from occurring, the provider educated all on-call managers and weekend managers to check the fax machine behind the reception desk for faxed orders and to give those orders to the respective nurses. The nurses were educated to check the main fax machine for orders throughout their shift. The physicians' offices were given updated fax machine numbers to which they should send orders to. 2. Phone interview on 3/30/26 with resident 112's son revealed that a few days after admission to the facility, resident 112 became more confused, had back pain, and he was concerned the resident had another UTI. He requested that she have urine collected for urinary analysis (urine testing for health issues such as infections, also known as UA) collected on a Monday. He called the facility that Tuesday to see if her urine sample was collected, and was told it would be collected that afternoon. He was told by staff that on Wednesday, they had collected the sample, but it had sat in the refrigerator for too long, and it had to be recollected. The person he talked to at the nursing home said he was going to deliver it to the laboratory himself. He said the facility did not start the antibiotic that was ordered while the urine culture (UC) was pending. He was told that the resident was given a dose of a newly prescribed antibiotic on 7/15/25, before she went to the emergency room. In the emergency room, the papers that were sent by the facility indicated that the antibiotic was not given to the resident. Resident 112 was admitted to the hospital on [DATE] and did not go back to the nursing home, per his request. He reported he was upset about the situation, and talked to the nursing home administration about his frustrations regarding his mother's delayed care. 3. Review of resident 112's electronic medical record revealed she admitted on [DATE]. Her 7/3/25 Brief Interview for Mental Status (BIMS) assessment score was 11, which indicated she had moderate cognitive impairment. Her diagnoses included respiratory failure (a condition making it hard to breathe) and pneumonia (lung infection). Her 7/2/25 care plan indicated she had the potential for infection. Staff were to monitor for signs and symptoms of infection. She was at risk for altered thought process, and staff were to notify the physician if she displayed any changes in her cognitive function or behavior. She had a urinary catheter that was to be changed per the physician's orders. A 7/8/25 at 4:24 a.m. progress note by registered nurse (RN) S stated that resident 112's son called with concerns that his mother was more confused, and he requested a urine sample to be collected. RN S notified the resident's physician. A 7/8/25 physician visit report indicated that resident 112 had increased confusion, and the physician ordered a UA. On 7/8/25, physician orders were received to change her urinary catheter and collect a urine sample for UA/UC. That order was noted as reviewed on 7/8/25 by licensed practical nurse (LPN) KK. On 7/8/25 at 11:19 a.m., a progress note by LPN KK included the resident 112's physician ordered a UA/UC. On 7/8/25 at 3:37 p.m., a progress note by LPN KK stated that resident 112 had been confused all day. She was supposed to wear her oxygen at a flow rate of four liters (L) per minute, but the resident refused to wear the oxygen tubing because she thought there was urine in the tubing. LPN KK educated her, and reapplied her oxygen. On 7/8/25 at 4:37 p.m., a progress note by LPN KK indicated that resident 112 continued to be confused. The resident was on her phone talking to a friend, and she told her friend she was going to be kicked out of the facility. Resident 112's treatment administration record (TAR) indicated that her catheter was to be changed prior to the UA being collected, and the catheter was scheduled to be done on 7/8/25 at 6:00 p.m. It was documented as completed on 7/9/25 at 5:23 a.m. by RN S. A 7/10/25 at 3:13 p.m. lab report indicated the urine sample was collected on 7/10/25 at 1:30 p.m. and received on 7/10/25 at 2:53 p.m. The report was sent to the physician, and orders were received on 7/11/25 for Cefuroxime antibiotic 500 mg to be given to the resident twice a day for five days. This order was not noted as reviewed by staff. On 7/10/25 at 4:20 p.m., a progress note by RN F indicated that lab results were received and faxed to the physician. A 7/11/25 lab report indicated that resident 112's urine sample was collected on 7/9/25 at 1:07 a.m. and was received on 7/10/25 at 7:39 a.m. That lab result indicated there was Enterobacter cloacae complex (type of bacteria) in more than 100,000 (Colony Forming Units per milliliter) CFU/mL (indicates the number of bacterial cells found in the test), and susceptibility (a lab report that indicates what antibiotic could be used to treat the specific infection) was to follow. This urine lab result report was noted as reviewed by LPN KK on 7/11/25. On 7/11/25 at 11:20 p.m. progress note by LPN KK indicated that she had notified the physician of the above lab results. A 7/12/25 preliminary (an early report from the lab while the sample is still being tested) UC lab report indicated that the resident's urine sample was collected on 7/10/25 at 1:30 p.m. and received on 7/10/25 at 2:53 p.m. The result indicated the urine sample had Enterobacter cloacae and contained greater than 100,000 CFU/mL. The susceptibility was to follow. This report was not noted as reviewed. A 7/13/25 at 12:13 pm final UC result lab report indicated the urine sample was collected on 7/9/25 at 1:07 a.m. and received on 7/10/25 at 7:39 a.m. The result indicated growth of more than 100,000 Enterobacter cloacae complex, and to see the previous culture for susceptibility report. The physician responded to this result on Monday, 7/14/25, and ordered to stop cefuroxime and to start Nitrofurantoin 100 mg (antibiotic) twice a day for five days. This order was noted as reviewed on Tuesday, 7/15/25, by an unidentified staff member. A 7/13/25 at 12:13 p.m., a final UC result with susceptibility lab report indicated the sample was collected on 7/10/25 at 1:30 p.m. and received on 7/10/25 at 2:53 p.m. It indicated the Enterobacter cloacae complex bacteria was not susceptible to cefuroxime, but it was susceptible to Nitrofurantoin. This report was noted as reviewed by two unidentified staff members on an unknown date. On 7/15/25 at 10:45 a.m., a progress note by LPN H indicated that the physician originally ordered cefuroxime 500 milligrams (mg) twice a day for five days, but after the UC results, he discontinued that antibiotic order and ordered Nitrofurantoin 100 mg twice a day for five days. On 7/15/25 at 11:36 a.m., a progress note by LPN H indicated that the resident had severe flank pain and Nitrofurantoin antibiotic was to be started that day at 5:00 p.m. Resident 112's son was in the resident's room and was updated on the lab results and treatment plan. Since resident 112's pain was not controlled he wanted her sent to the emergency room. On 7/15/25 at 11:40 a.m., a progress note by director of nursing (DON) B indicated that she completed an investigation on why the 7/11/25 physician's order for cefuroxime was not started. It was found at the same time as the 7/15/25 order was found to stop the cefuroxime and to start nitrofurantoin. She updated the resident's family and physician regarding the incident. On 7/15/25 at 3:45 p.m., a progress note by social service designee (SSD) E indicated that resident 112's son discussed his concerns about the situation about his mother with her, and told SSD E that the resident had an infection in her spine. SSD E offered to him to hold the resident's bed at the facility for when she discharged from the hospital, but he declined. On 7/15/25 at 5:34 p.m., a progress note by LPN LL indicated that resident 112 was admitted to the hospital related to a UTI. 4. Interview on 3/26/26 at 1:04 p.m. with LPN O revealed that physician orders were to be processed within the first few hours after being received and completed by the end of their shift. Physician orders were faxed by the physician's office to the facility's fax machine, which was specific to the unit where the resident resided. Sometimes the faxes were received at the front reception area fax machine, and the managers would check that fax machine. Sometimes they did not receive those orders until the next morning, and they processed them as soon as they could. 5. Interview on 3/26/26 at 1:20 p.m. with LPN W revealed the facility received physician orders by fax or by paper if the physician was at the facility. Faxed orders were supposed to go to the unit where the resident resided, and sometimes the orders went to the front reception area fax machine, which was to be checked by the managers, including on weekends. During non-business hours, on-call physicians were available if a resident needed physician services. The nursing staff could contact them if a resident had a change in their medical condition. If abnormal lab results were received during non-business hours, and a resident's current ordered antibiotic was not susceptible to treat the resident's infection, the nursing staff were to notify the on-call provider. If UA was ordered, they had 24 hours to collect it, put it in the refrigerator after it was collected, and it would be taken to the lab in the morning. To process physician orders, two nurses needed to note them as reviewed to ensure they were completed correctly. She was unsure how quickly the orders needed to be processed after being received, but they needed to be completed by the end of their shift. 6. Interview on 3/30/26 at 2:05 p.m., 4:00 p.m., and 4:35 p.m. with DON B revealed she was unsure why resident 112's 7/9/25 UA was recollected. If physician orders were received for a UA, it needed to be collected that same day. If the sample was not collected that same day, the physician needed to be notified. She expected that physician orders would be processed the same day they were received. She expected physician orders to be noted as reviewed and to include the date, not the time, and by whom. She expected the resident's physician to be notified of lab results. If the physician was out of the office or if it was after hours, she expected the nurse to notify the on-call physician. After the incident regarding 112, she stated that only nurse managers and unit managers received education regarding checking the fax machine at the front reception area for physician orders. Her investigation did not include information regarding resident 112's UA not being collected promptly, or that the on-call physician was not notified of the preliminary lab results. The incident investigation did not include steps to determine if other residents were affected. She did not educate nurses to check the main fax machine for orders throughout their shift, as indicated on the provider's report sent to the SD DOH. 7. Interview on 3/30/26 at 3:52 p.m. with SSD E revealed she did not remember what the frustrations resident 112's son talked to her about on 7/15/25 at 3:45 p.m. She documented in the EMR if residents or their families reported concerns to her. 8. Interview on 3/31/26 at 1:20 p.m. with administrator A revealed she did not recall if she spoke with resident 112's son. If she had, she would have documented it in the EMR. 9. Interview on 3/24/26 at 3:24 p.m. with resident 88 revealed that after he received dialysis treatments, he was dizzy and felt better the next day. When asked if staff were aware of his dizziness, he stated he was not sure. 10. Review of resident 88's EMR revealed he admitted to the facility on [DATE]. His 2/17/26 BIMS assessment score was 15, which indicated his cognition was intact. He had diagnoses of end-stage renal disease (the kidneys no longer work well enough to sustain life), dependence on renal dialysis, hypotension (low blood pressure), hypertension (high blood pressure), and heart failure (where the heart becomes too weak or stiff to pump blood efficiently). He had 2/2/26 physician's orders for dialysis treatments on Monday, Wednesday, and Friday, and the order commented that his ride came at 5:00 a.m. A 2/25/26 progress note indicated he had his dialysis fistula (a surgical connection between an artery and a vein on the arm created to make an access point for cleaning the blood) placed. He had 2/2/26 physician's orders to receive Midodrine 10 mg three times a day for hypotension, and it was to be held if his systolic blood pressure (SBP) (top number of the blood pressure) was 120 or greater. He had 2/3/26 physician's orders to receive Metoprolol Succinate ER (extended release) 25 mg daily for hypertension. This medication order did not have parameters when it needed to be held. Resident 88's March 2026 medication administration record (MAR) indicated he did not receive Midodrine on Monday, Wednesday, and Friday mornings, the days of his dialysis treatments. From 3/9/26 through 3/30/26, he received Metoprolol Succinate ER on e time, on 3/20/26, on the day of his dialysis treatments. There was no documentation that his physician was notified that he did not receive those medications consistently as ordered on those days. Resident 88's dialysis records from 3/9/26 through 3/25/26 indicated that his blood pressure before dialysis was 112/62 on 3/9/26, his 3/11/26 records were not provided, his blood pressure on 3/13/26 was 122/24, on 3/16/26 it was 118/62, on 3/18/26 it was 115/62, on 3/20/26 it was 98/56, on 3/23/26 it was 117/62, and on 3/25/26 it was 118/62. Resident 88 March 2026 MAR indicated that his blood pressure was 79/44 on 3/20/26 before his 5:30 p.m. scheduled dose of Midodrine was given. His blood pressure was not checked again until the next morning, 3/21/26 at 7:30 a.m., was 81/43. There was no documentation that his provider was notified of those low blood pressures. He received his metoprolol (a medication that can lower blood pressure) on these days. Resident 88's treatment record (TAR) indicated that staff were to monitor him for post-dialysis complications, including low blood pressure symptoms, twice daily on Mondays, Wednesdays, and Fridays. His treatment record indicated the only day he had symptoms was on 3/6/26, and the other days he did not. 11. Interview on 3/26/26 at 1:04 p.m. with LPN O revealed that the physician was to be notified when a resident vital sign (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were not within the specific parameters, included in the resident's physician's orders. 12. Interview on 3/31/26 with DON B at 1:05 p.m. and 2:15 p.m. revealed she expected resident 88 to be given Midodrine before he went to dialysis if his blood pressure was within his ordered parameters. She verified that his physician was not notified that it was not given consistently before dialysis when his blood pressure was outside those parameters. If his blood pressure was low and he was not symptomatic, she did not expect his blood pressure to be rechecked or his physician to be notified. The physician would be notified based on the nurse's assessment. She stated there was no hard and fast rule when the physician needed to be notified. The facility did not have a policy regarding vital sign parameters. The parameters to notify the physician were not in the resident 88's orders. 13. Review of the provider's 11/18/25 Following Physician Orders policy revealed that all physician orders should be followed as ordered. If orders are not followed, the physician is to be made aware, including omission, medication not in stock, repeated resident refusals for medications/treatments, etc. 14. Review of the provider's 11/18/25 Notification of Change of Condition policy revealed that the facility will notify the physician of a resident's change in status. The facility must promptly notify the physician when there is a significant change in the resident's physical status. The physician was to be notified if a resident refused treatments or procedures at least three consecutive times.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, SD DOH complaint intake report, record review, observation, interview, and policy review, the provider failed to implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) prevention interventions for one of one sampled resident (16) identified with risk for developing pressure ulcers who developed a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer on her left buttock and one of one sampled resident (9) with a history of pressure ulcer and identified with risk for developing pressure ulcer who developed a stage III (3; open wound with full thickness skin loss, fatty tissue may be visible) pressure ulcer to his right gluteal fold (the horizontal skin crease separating the buttock from the posterior upper thigh) and his coccyx (tailbone), a left lateral heel deep tissue injury (DTI), left lateral lower leg stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to his left lateral (outer) lower leg. Findings include: 1. Review of the provider's 3/17/26 FRI submitted to the SD DOH regarding resident 16 revealed: *Resident 16's daughter reported concerns related to the quality of care being provided for resident 16 related to her not being provided with routine bathing, not being changed regularly and not consistently being assisted out of bed for meals. *After receiving resident 16's daughter's concerns the provider completed a skin assessment and found resident 16 had a two centimeter (cm) in length by 0.6 cm in width stage II pressure ulcer to her left buttock and Scabs that appear to be from being in bed. -The location of the scabs was not identified on the 3/17/26 FRI. *The provider's standing orders for skin concerns were initiated on 3/17/26. *The provider initiated a nursing order for resident 16 to be assisted into her chair for lunch and supper meals per the daughter's request and the management staff was to be notified if resident 16 refused to get up into her chair. 2. Review of resident 16's electronic medical record (EMR) revealed: *She admitted to the facility on [DATE]. *Her 3/6/26 Brief Interview of Mental Status (BIMS) assessment score was 4, which indicated her cognition was severely impaired. *Her diagnoses included diabetes (a condition involving disruptions in how the body regulates blood sugar), depression, and senile degeneration of the brain (progressive loss of cognitive function and brain tissue associated with aging). *Her 3/2/26 Braden Scale (a tool used to assess the risk of developing pressure ulcers) assessment indicated she had a high risk for the development of a pressure ulcer. *Her 3/3/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated resident 16 had difficulty with communication, required the assistance of one staff member for repositioning in bed, required a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position)with the assistance of one staff member for transfers, and was dependent upon staff for her personal hygiene needs. *She had a 3/3/26 focus area on her care plan for the potential for impairment to skin integrity [related to] weakness [and] decreased mobility with intervention of Apply wound treatment as ordered by the physician, Assess for pain and administer pain medication as ordered, observe feedback and notify MD [medical doctor] as necessary, Encourage good nutrition and hydration in order to promote healthier skin. *A 3/11/26 skin assessment indicated resident 16 had blanchable redness (reddened skin turned white when pressure was applied to that area) to her buttocks and barrier cream (a cream to provide a moisture barrier) to the skin on her buttocks. *On 3/16/26 licensed practical nurse (LPN) X documented a facility acquired 2 centimeter (cm) in length by 0.6 cm in width abrasion to resident 16's left buttocks and coccyx (tailbone) with redness surrounding the area, a facility acquired 4 cm in length by 0.3 cm in width undescribed area to the back of resident 16's right thigh, and a facility acquired 1.5 cm in length by 0.2 cm in width undescribed area to the back of resident 16's left thigh. *On 3/17/26 LPN Y documented resident 16's pressure ulcer on her left buttock as a stage II that measured 3.5 cm in length by 0.8 cm in width by 0.1 cm in depth with redness surrounding the pressure ulcer. *On 3/17/26 the focus area related to skin integrity was revised to indicate that, resident 16 has actual impairment to skin integrity. Left Buttock Pressure, Stage 2. Bilateral [both sides] Posterior [towards the backside] Upper thighs, Scabs with added interventions of Consult RD [registered dietician] as needed for nutritional recommendations for optimal wound healing, Monitor/document location, size, and treatment of skin ulcer. Report abnormalities, failure to heal, signs and symptoms of infection, maceration [moisture related skin damage] etc. to MD and Weekly monitoring of wounds by wound nurse or designee: Assessments, recommendations, measurements. *On 3/23/26 LPN Y documented resident 16's pressure ulcer on her left buttocks as a stage II that measured 3 cm in length by 2 cm in width by 0.1cm in depth. -That pressure ulcer was larger in area than the assessment on 3/17/26. *On 3/23/26 the skin integrity focus area had added interventions of, Encourage/Assist to turn and reposition at least every 2 hours and as needed, Keep skin clean and dry. Use lotion on dry skin, Pressure redistributing cushion to wheelchair, and Pressure redistributing mattress to bed. 3. Observation and interview on 3/25/26 at 2:15 p.m. of wound care certified/regional nurse consultant (RNC) L and licensed practical nurse (LPN) X changing the wound dressing on resident 16's left buttock pressure ulcer revealed: *Resident 16 was lying on her back in bed. The head of resident 16's bed was elevated, and resident 16 had slid down in bed and was bending at her chest. *LPN X and wound nurse certified/RNC L lowered the head of the bed, rolled resident 16 from side to side to cleanse her pressure ulcer, applied a new dressing on the wound, and replaced her incontinence brief. *LPN X and wound nurse certified/RNC L then rolled resident 16 onto her back again and raised the head of resident 16's bed. 4. Interview on 3/25/26 at 2:50 p.m. with certified nursing assistant (CNA)/ certified medication aid (CMA) R revealed: *Director of nursing (DON) B and administrator A told her resident 16's daughter was concerned when she came to visit her mother, that she was still in her bed with her night gown on, CNA/CMA R had transferred resident 16 by pivot-transfer (when assisted to a standing position, the resident then turns their body to move to another surface) instead of the care planned sit-to-stand, and she had developed sores on her bottom. *CNA/CMA R stated she was assigned to care for resident 16 that day and that was the first time she had cared for resident 16. *She looked in resident 16's room and asked if she needed anything several times that day, but the resident did not reply to her, so she left her in bed. 5. Interview on 3/26/26 at 10:15 a.m. with CNA/CMA V revealed: *She was responsible for providing resident 16's cares on 3/26/26. *She used the Kardex (a report of the resident's care needs and interventions) or the pocket care plan (a document that identifies residents' care needs and interventions) to determine each resident's care needs. *She did not know what pressure prevention interventions were used before resident 16 developed her pressure ulcer or what was currently being provided for pressure reduction. 6. Observation on 3/30/26 at 1:52 p.m. of resident 16 in her room revealed: *She was lying in bed on her back. *The head of her bed was elevated and she was in a position that she bent at her chest. 7. Phone interview on 3/30/36 at 2:08 p.m. with resident 16's daughter revealed: *She spoke with the facility's administration about concerns she had related to the quality of care her mother had received. *She had come in to visit her mother one day around 2:30 p.m. (near the date she reported her concerns) and she found her mother lying in bed with her pajamas on and food on her face and clothing. *Her mother had been bathed one time between her admission date (3/2/26) and 3/16/26. *She was told by the wound nurse that her mother had developed a pressure ulcer on her buttocks. *The wound nurse said the pressure ulcer was because the staff were pulling her mother up in bed by her arms instead of using a lift sheet. *Resident 16's daughter stated she had turned on her mother's call light one day, because she needed to be boosted up in bed. No one answered the call light for 30 minutes, so she went out into the hallway and could not locate a staff member. She went into another hallway and found a staff member to assist her mother. *She stated resident 16 was not able to use her call light to get assistance with her needs and could not get out of bed or reposition herself in bed without the staff's assistance. 8. Observation on 3/30/26 at 3:30 p.m. of resident 16 in her room revealed: *She was lying on her back. *The head of her bed was elevated, and she was bending at her chest. 9. Interview on 3/31/26 at 8:56 a.m. with restorative aide (RA) PP revealed she: *Used the Kardex to determine each resident's care needs. *Did not know what pressure prevention measures had been in place for resident 16 before she developed the pressure ulcer on her left buttocks or what was currently being used for pressure reduction interventions. *Acknowledged that residents who were not repositioned were at increased risk for the development of a pressure ulcer. *Acknowledged that residents who did not receive routine bathing were at risk for the development of skin impairments. 10. Interview on 3/31/26 at 10:02 a.m. with LPN Y, wound care certified, RNC L, and DON B revealed: *LPN Y started her role as the provider's wound nurse in the beginning of March 2026. *She was supervised by DON B and wound care certified, RNC L. *She had received wound education from online resources, wound care certified RNC L, and a consultant from their wound dressing supply company. *LPN Y stated the nurse who was caring for resident 16 identified the pressure ulcer on resident 16's buttock and reported that ulcer to LPN Y. *LPN Y assessed the newly identified pressure ulcer on resident 16's left buttock the day after it was found. *LPN Y stated the scabs on resident 16's upper back of her thighs were identified on the same day she assessed resident 16's left buttock pressure ulcer. *She stated the scabbed areas on the upper back of resident 16's thighs were determined as being caused by shearing (a mechanical force occurring when skin sticks to a surface such as sheets while the underlying tissue and bone slide causing tissue layers to tear, stretch and damage blood vessels). *LPN Y stated she notified resident 16's daughter and physician of the newly identified pressure ulcer and added resident 16 to her wound rounds for the assessment and documentation of the wound weekly. *Certified wound nurse/RNC L acknowledged that resident 16's head of her bed being elevated increased the risk of shearing and the development of a pressure ulcer when she slid down in her bed. *DON B verified resident 16 could not turn herself in bed without staff assistance was able to adjust her hips by herself. She was unable to raise her hips up off the bed to reposition herself to prevent shearing of her skin. *DON B expected the staff to assist resident 16 with turning while she was in bed *Upon admission to the facility each resident's skin was to be assessed for alterations in their skin, and a Braden scale assessment was completed to assess for that resident's risk for developing a pressure ulcer. *Resident 16 did not have alterations in her skin upon her admission to the facility on 3/2/26, but she was identified as being at risk for the development of a pressure ulcer. 11. Interview on 3/31/26 at 10:45 a.m. with DON B revealed: *All residents were placed on a pressure reduction mattress upon admission and received a dietary consultation. Barrier cream was to be applied with each incontinence product change or if the resident was assisted to the toilet, if that resident had episodes of incontinence. *DON B was unable to find documentation in resident 16's EMR to support barrier cream was applied to the resident's skin or that she had refused the application of barrier cream. *DON B expected residents who could not reposition themselves to be assisted with repositioning by the staff every two hours, according to standard practice. *That repositioning was not documented by the staff when it was completed. If a resident refused repositioning DON B expected the nurse to be notified of the refusal so it could be documented in that resident's EMR. *DON B could not find documentation that supported that resident 16 refused repositioning in her EMR. *She expected the nurse managers to round (monitor) in their hallways to be sure each resident's care needs were attended to, which included repositioning. *Air mattresses were generally not used for pressure ulcer prevention, but were typically used if a resident had a stage III pressure ulcer and on a case-by-case basis when a resident was receiving hospice services. *DON B verified resident 16 did not have an air mattress prior to or after the development of her pressure ulcer. *The pressure ulcer preventions put into place before resident 16 developed a pressure ulcer were standard for all admissions and not individualized related to her identified risk for being at risk for the development of a pressure ulcer. *She expected the staff to document in the resident's EMR if they refused any cares that were offered to them such as assisting a resident out of bed, bathing, repositioning, or skin cares. 12. Interview on 3/31/26 at 1:41 p.m. with administrator A revealed: *She had received concerns from resident 16's daughter on 3/17/26 related to care that resident 16 was receiving. *After she received those concerns LPN Y assessed resident 16's skin and identified the pressure ulcer on resident 16's buttock. *She thought resident 16's scabbed areas were caused by CNA/CMA R having used a split leg sling (a piece of the sling goes behind each leg and crosses over through the legs of the resident to attach to the lift) for the full body lift, so they changed resident 16 to be transferred with a full body sling (a one pieced complete rectangular sling). -Resident 16 was care planned to be a sit-to-stand lift at the time she developed the pressure ulcer on her left buttocks and the scabbed areas on the upper back of her thighs were found. *Administrator A stated resident 16 was receiving hospice services and refused care at times so she expected the resident to develop some skin breakdown. *She expected the staff to follow the residents' care plan while attending to each resident's care needs. 13. Review of the SD DOH complaint intake report for resident 9 revealed: *He was seen in an emergency department on 3/23/26 and was dehydrated despite being provided nutrition products and water through a feeding tube (a tube surgically placed through the abdomen into the stomach to administer liquid nutrition, fluids and medications). *He returned to facility on 3/23/26. *He discharged to an inpatient hospice facility on 3/25/26. *Upon admission to the hospice care facility he presented with the following wounds gluteal cleft wound, left buttocks wound, right upper thigh posterior wound, left heel wound left lateral calf, right lateral calf, right upper thigh anterior, penile wound, mouth and tongue red and irritated with skin peeling off, which made speech difficult for him. 14. Review of resident 9's electronic medical record (EMR) revealed: *He admitted to the facility on [DATE]. *He admitted to hospice services on 3/21/26. *He was discharged to an inpatient hospice facility on 3/25/26. *He had diagnoses of Spinal stenosis (narrowing of spaces within the spine which puts pressure on nerves and spine), Chronic kidney disease (a long-term condition where kidneys are damaged and cannot filter blood properly), Atherosclerotic heart disease (a chronic condition where fats, cholesterol and plaque build-up in artery walls restricting blood flow to the heart), Urine retention (inability to fully empty the bladder), Dysphasia (difficulty swallowing), Protein-calorie malnutrition (a severe deficiency of protein and calories, causing muscle wasting, weight loss and fatigue). *His 3/25/26 Brief Interview for Mental Status (BIMS) assessment score was 13 which indicated his cognition was intact. *His 3/19/26 Braden scale (assessment for predicting injury risk) score indicated he had a high risk for developing pressure ulcers. *He had skin evaluations completed on 1/16/26 which indicated he had redness on his bilateral heels and a PEG tube (a medical device inserted through the abdominal wall into the stomach to deliver nutrition, fluids, and medications directly, bypassing the mouth and esophagus) site. *He had a skin evaluation completed on 1/23/26 which indicated he had an abdomen-PEG tube site, and treatments in place to his right heel blister, upper thigh blister, mid back surgical site, coccyx pressure ulcer. *He had a 1/30/26 skin evaluation that identified a right heel blister, pressure ulcer to sacrum, left gluteal fold pressure ulcer, left lower back pressure ulcer, and right upper thigh gluteal fold pressure ulcer. *His 2/7/26 skin evaluation indicated that resident 9 was not available for a skin assessment due to his hospitalization. *He had a 2/14/26 skin evaluation that indicated no skin concerns and his feeding tube was intact with no concerns. *He had a 2/22/26 skin evaluation indicated that he was not available for a skin assessment due to his hospitalization. *His 3/2/26 skin evaluation identified redness to the coccyx, that treatment was in place for wound prevention and he had a feeding tube to his left abdomen with no signs or symptoms of infection. *His 3/9/26 skin evaluation identified that treatment was in place for wound prevention to his coccyx and he had a feeding tube to his left abdomen with no signs or symptoms of infection. *His 3/10/26 Skin alteration evaluation identified a right gluteal fold pressure ulcer measuring 2.5 centimeters (cm) x 2 cm x 0.1 cm stage II. *His 3/16/26 skin evaluation identified a coccyx wound treatment was in place for wound prevention, and he had a feeding tube to his left abdomen with no signs or symptoms of infection noted. *A 2/12/26 skin/wound progress note regarding wound rounds were completed for pressure ulcerations to resident 9's coccyx, left gluteal fold, left lower back, and right outer heel, right upper thigh at gluteal fold, a mid-back surgical wound. Those areas were healed, and the provider and resident were updated. *On 3/10/26 a skin/wound progress note indicated an open area under resident 9's right buttock that measured 2 cm x 2.5 cm x 0.1cm that was freely bleeding. The resident complained of pain with cleaning of the area, and collagen and border gauze were applied. The provider and family were notified. *On 3/13/26 a skin/wound progress note indicated that his right gluteal fold was reclassified from moisture associated skin damage (MASD) to a pressure ulcer after reassessment. His physician was notified. *On 3/14/26 a physician's order for Wound right gluteal fold cleanse apply collagen cover with border gauze, every day shift for pressure was received and entered into his treatment administration record (TAR). *On 3/19/26, a skin /wound progress note indicated a pressure area to his coccyx, measuring 9 cm x 6.5 cm x 0.20 cm and that an air mattress would be placed in the resident's room to assist with pressure offloading. *On 3/19/26 a skin/wound progress note stated pressure area to left lateral heel with non-blanchable (area does not turn white when pressed with a finger) discoloration consistent with a deep tissue injury (DTI), measurements 6.6 cm x 5.4 cm depth not measurable due to intact skin. PCP notified, added to weekly rounds, heel boots were applied, and air mattress will be placed in the resident room to assist with pressure offloading. *On 3/19/26 a skin/wound progress note stated pressure noted to left lateral lower leg with blister present consistent with stage 2 pressure injury measurements 13 cm x 3.5 cm depth unable to be measured due to intact skin provider notified, placed on weekly rounds and air mattress added to resident room to assist with pressure offloading. *On 3/19/26 a skin/wound progress note stated right gluteal fold pressure injury measured 6 cm x 5.5 cm x .10 cm and Urethral meatus surgical incision [measure] 1.2 cm x 0.9 cm, Right heel redness noted but blanchable (indicates blood flow is present to the area). Care plan had been reviewed and updated. *He had physician's orders on 3/19/26 for: -Wound care urethral meatus cleanse with wound cleanser, pat dry and apply bacitracin (antibiotic ointment) every day and night shift. -Wound care left lateral lower leg pressure/blister cleanse with normal saline, pat dry, cover with no sting skin prep to intact skin, apply border foam dressing every day shift every other day. -Wound care coccyx pressure cleanse with normal saline, pat dry, cover with no sting skin prep to intact skin (peri wound) and cover with bordered foam dressing every day shift every other day. *He had a physician's order on 3/24/26 for staff to encourage resident 9 to wear heel boots (specialized footwear designed to eliminate pressure on the heel and foot to prevent pressure injury) when in bed or float heels (elevating heels off mattress to prevent pressure ulcers) every shift. *His March 2026 treatment administration record (TAR) revealed the above ordered wound care treatments were documented completed on 3/20/26 and 3/22/26. They were not documented as completed on 3/24/26. *His current care plan indicated: -He had actual impairment to skin integrity of right gluteal fold stage III pressure injury, Urethral meatus surgical incision, left lateral heel pressure DTI, left lateral lower leg pressure blister stage II, coccyx pressure ulceration stage III, blanchable redness to groin, coccyx and sacrum initiated on 1/9/26 and revised on 3/19/26. -He had a history of scattered scabs and bruising to bilateral upper arms, right inner thigh, red raised rash, right inner heel blanchable redness, closed left gluteal fold, pressure stage II, closed left lower back pressure stage II, closed right outer heel pressure stage II, right upper thigh at gluteal fold pressure stage III and a history of mid back surgical incision initiated on 1/9/26 and revised on 3/19/26. -He had interventions: --An air mattress to his bed, that was initiated on 3/19/26. --Apply a pressure redistributing cushion to the wheelchair, initiated on 1/20/26 and revised on 1/30/26. --Apply wound treatment as ordered by physician initiated on 1/9/26. --Assess for pain and administer pain medication as ordered, observe for feedback and notify MD as necessary initiated on 1/9/26. --Consult RD [registered dietitian] as needed for nutritional recommendations for optimal wound healing initiated on 1/9/26. --Encourage good nutrition and hydration to promote healthier skin initiated on 1/9/26. --Keep skin clean and dry. Use lotion on dry skin initiated on 1/9/26. --Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, macerations, etc. to MD initiated on 1/9/26 and revised on 3/19/26. --Weekly monitoring of wounds by wound nurse or designee assessments, recommendations, and measurements initiated on 1/20/26 and revised on 3/19/26. --He required assistance with ADL's (bed mobility, transfers, dressing, locomotion, personal hygiene, eating and toileting) initiated on 1/9/26 and revised on 2/1/26. --He had interventions of two-person staff assistance with mechanical full body lift for transfers, he was dependent for bed mobility, dressing, personal hygiene, toileting, and bathing initiated on 1/9/26 and revised on 1/9/26. --He would use two mobility bars as an assistive device to help him to turn, reposition and/or transfer, initiated on 3/4/26 and revised on 3/4/26. 15. Interview on 3/31/26 with Physician Assistant Certified (PA-C) QQ revealed: *Resident 9 had developed sores in his mouth the evening of 3/24/26. She was notified by the hospice staff who requested an order for Lidocaine (a prescription anesthetic used to temporarily relieve pain) solution which she ordered on 3/25/26 when she saw him. *Resident 9 often refused cares. She was notified by the facility that he had refused to get up in his wheelchair twice daily, to be weighted and was refusing to participate in physical therapy. *She felt he was bedfast (confined to bed) and he refused to wear the heel lift boots on his heels. *She would expect the facility to have preventative measures in place to prevent re-occurrence of developing pressure ulcers such as an air mattress. 16. Interview on 3/31/26 at 8:49 a.m. with registered nurse (RN) unit manager J revealed: *Resident 9's air mattress was ordered on 3/19/26. *He refused to get up twice a day and they notified the MD of those refusals around 2/13/26. *The facility-initiated bed mobility bars to aid with repositioning on his bed. *She was unsure if he was on a turning or positioning schedule. *He had heel lift boots that he refused to wear. *She felt the facility did the best they could with residents to prevent them from redeveloping pressure ulcers. 17. Interview on 3/31/26 at 10:25 a.m. with licensed practical nurse (LPN) Y and director of nursing (DON) B revealed: *Staff encouraged resident 9 daily to get up in his wheelchair twice daily. On admission he had a pressure reducing mattress on his bed, InterDry (a cloth that [NAME] moisture away from skin) in his abdominal folds, and Triad wound dressing paste to his coccyx. *On 3/19/26 his pressure injuries were documented, an air mattress was ordered, new treatment orders were received, his provider was notified of the pressure ulcers and weekly skin evaluations were started. *The floor nurses complete the weekly skin evaluations. *He received orders for heel lift boots for his heels. He would allow them to be placed and then would ask the certified nursing assistants (CNA's) to remove them shortly after applying them. *The facility's standard practice was to reposition all residents every two hours. *His doctor or provider was notified of his refusals to wear his heel lift boots and to get up into his wheelchair. *He had a pressure redistributing mattress; and air mattresses were usually implemented after a resident had a stage III pressure ulcer. *He had orders to be up in his wheelchair twice daily (BID), which he refused to do. *He had wound care orders for his pressure ulcers. *He could move in his bed but required assistance from staff for that. *He was not on a repositioning schedule. *His heels were offloaded and repositioned as needed. *The pressure ulcer that resident 9 had on admission had healed on 2/11/26 and then redeveloped. 18. Interview on 3/31/26 at 10:45 a.m. with DON B revealed: *She expected wound orders to be completed by the nursing staff as ordered. *She agreed that if wound orders had not been signed as completed in the TAR on 3/24/26 they were not completed. *She stated that his wound areas would become worse if his treatments were not completed. *She felt that pressure redistribution mattresses were effective pressure ulcer prevention interventions. *Resident 9 admitted to hospice services on 3/21/26. *She was unsure if an air mattress would have prevented his re-occurrence of his 3/19/26 developed pressure ulcers. *She expected all refusals to be documented or the CNAs to tell the nurse what approaches were successful, so they could be documented. 19. Review of the provider's revised March 23, 2023 Skin and Pressure Injury Prevention Program policy revealed: *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 and to promote the healing of pressure injuries/wounds that are present. *3. Risk Factor- Bed-fast Resident: -a. Offer repositioning at least every two hours and more frequently as needed if resident unable to move self. -b. Consider off-loading pressure hourly if the head of the bed is greater than 30 degrees (i.e., for residents with tube feeding or respiratory issues). -c. Use a special mattress that contains foam, air, gel, or water, as indicated. -d. Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments, medical necessity, and resident comfort. e. Unless resident has both sacral and ischial pressure ulcers, avoid placing directly on the greater trochanter for more than momentary placement.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure resident safety and accident prevention when:*A staff member safely transferred one of one sampled resident (53), who needed to be transferred with the use of a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) according to that resident's care plan by one of one certified nursing assistant (CNA) VV, who attempted to transfer the resident without using the stand lift. That failure resulted in the resident sustaining a skin tear on his left forearm and a bump on his head, requiring him to be sent to the emergency department (ED), where a CT scan (a series of x-ray images taken from different angles used to produce three dimensional images of bones, organs, or soft tissues) revealed a subdural hematoma (a life-threatening collection of blood between the brain's surface and outer covering).*One of one sampled resident (16) was not safely transferred with the use of a sit-to-stand lift according to that resident's care plan, which placed her at risk for harm or injury.*Chemicals were not securely stored away from resident access in one of three bathtub rooms, and one of one housekeeping carts was left unattended in the main dining area with residents present by housekeeper CC.Findings include: 1. Review of the 3/4/26 SD DOH FRI revealed that on 3/4/26 at around 3:15 p.m., CNA VV was transferring resident 53 from the toilet to his wheelchair. Resident 53's legs gave out and resident 53 was lowered to the floor, hitting the back of his head against the fall. Resident 53's care plan stated that resident 53 should have been transferred using a sit-to-stand lift [a mobility device that assist patients to transition from sitting to standing]. CNA VV's employment was suspended during the investigation of the fall. Resident 53 was assessed by nursing staff, and a skin tear was found on resident 53's left forearm. There was a bump on the back of resident 53's head. Resident 53's blood pressure and pulse were elevated. Due to resident 53's history of using blood thinning medications and elevated blood pressure, he was sent to the ED for further evaluation. Resident 54 had a CT scan of his head and cervical spine [neck] in the ED. Results of the head CT revealed a subdural hematoma. CNA VV's employment was terminated for not following resident care plans after being educated multiple time. 2. Review of resident 53's electronic medical record (EMR) revealed that he was admitted to the facility on [DATE]. He had medical diagnoses that included hemiplegia [paralysis of one side caused by brain damage] following cerebral infarction [stroke] of the left side. On 3/10/26, his Brief Interview for Mental Status (BIMS) score was 9 (indicating severe cognitive impairment). His care plan stated that he was to transfer with 1 person using a stand-lift. 3. Interview on 3/31/26 at 12:30 with director of nursing (DON) B and regional nurse consultant (RNC) M revealed that both were in the facility on the day of the incident. DON B revealed that CNA VV had received education on the morning of 3/4/26 regarding the importance of following resident care plans. DON B reported that when she interviewed CNA VV after the incident, CNA VV acknowledged being educated that morning on the importance of following resident care plans. DON B stated that when she asked CNA VV why the care plan was not followed, CNA V told DON B that she could complete the transfer faster without using the stand-lift. DON B expected CNAs to follow each resident's care plans to help prevent falls and injuries. 4. Review of the provider's 3/17/26 FRI regarding resident 16 revealed resident 16's family member reported concerns related to the quality-of-care including reports that resident 16 may have been injured during a transfer involving a mechanical lift operated by CNA/CMA R. Resident 16 used a sit-to-stand lift since she was admitted to the facility on [DATE] and was changed to a full body lift (a mechanical lift and sling used to lift a person's full body) due to a decline in her health on 3/18/26. 5. Review of resident 16's EMR revealed she admitted to the facility on [DATE]. Her diagnoses included senile degeneration of the brain (progressive loss of cognitive function and brain tissue associated with aging) and her 3/6/26 BIMS assessment score was 4, which indicated her cognition was severely impaired. Resident 16's 3/3/26 care plan indicated she was to be transferred with the use of a sit-to-stand lift, which was revised on 3/18/26 to indicate she transferred with the use of a full body mechanical lift. Her 3/4/26 lift assessment completed by RN CCC indicated she could not bear at least 50 percent of her weight on one leg, was unable to sit upright without physical assistance, and was not able to follow simple instructions. That assessment stated that if a resident could not do one of the criteria listed, they were not a candidate to transfer with the use of a sit-to-stand lift. Resident 16 was documented as not being able to do three of the criteria but RN CCC indicated within the summary and plan portion of the lift assessment that resident 16 was to use a sit-to-stand lift for bed to chair transfers. Review of resident 16's skin assessments revealed there was no documentation of bruising or purple discolorations on resident 16's arms or legs on those assessments. 6. Interview on 3/25/26 at 2:50 p.m. with CNA/CMA R revealed administrator A and DON B told her that resident 16's family member had expressed some concerns related to resident 16 being left in her night gown in bed until 2:30 p.m., transfers, and sores on her buttock. CNA/CMA R stated she was not assigned to assist resident 16 with her cares prior to 3/17/26 when resident 16's family member expressed her concerns related to the care her mother had received by the staff. On 3/17/26 resident 16's family member asked her to get resident 16 out of bed. The pocket care plan indicated resident 16 was a pivot transfer (when assisted to a standing position, the resident then turns their body to move to another surface) with the assistance of one staff member. Resident 16's family member told her resident 16 was a pivot transfer with the assistance of two staff members. CNA/CMA R transferred resident 16 with resident 16's family member by putting their arms under resident 16's arms and pivot transferring her from her bed to the bath chair. While they were transferring resident 16 from the bed to the bath chair resident 16 would not follow directions or move her feet. CNA/CMA R stated she held resident 16 up while she quickly pulled the bath chair under resident 16 and sat her down. Resident 16's family member had not expressed any concerns to her but had spoken with LPN Y that day. 7. Interview on 3/26/26 at 10:15 a.m. with CNA/CMA V revealed she used the resident's Kardex (a report of the resident's care needs and interventions) or the pocket care plan (a document that identifies residents' care needs and interventions) to determine how a resident transfers. She asked the unit managers to update the pocket care plans at times because it was not kept up to date with each resident's care needs. 8. Review of the blue hallway's undated pocket care plan indicated resident 16 was to be transferred with a full body mechanical lift with a full body sling. 9. Interview on 3/30/26 at 2:08 p.m. with resident 16's family member on the phone revealed she spoke with administrator A about her concerns related to the quality-of-care resident 16 received from the staff. She came to visit resident 16 one day around 2:30 p.m. and found her lying in her bed, in her pajamas with food on her face and clothing. She stated the staff did not know how to lift her mother. They had not used a gait belt (a waist strap gripped as support for safe mobility and transfers) when they transferred her. Resident 16's daughter stated she had assisted staff members with pivot transferring resident 16 at times. At times the staff were using the sit-to-stand lift to assist her mother with transfers, but she recently had been changed to a full body lift. One time she had witnessed a CNA place the sit-to-stand sling behind resident 16 while she was seated at the side of the bed and then the CNA left her mother to go out into the hallway to get the sit-to-stand mechanical lift and her mother fell backwards into the bed. Resident 16's daughter felt the bruises on her mother's arms and legs were related to the sit-to-stand lift. Resident 16's daughter stated she was not aware of resident 16 having any falls since her admission to the facility. When resident 16 admitted to the facility on [DATE] a staff member had told her that resident 16 was a pivot transfer with the assistance of one staff member. Resident 16's daughter told that staff member that resident 16 would require at least two staff members to assist her with a pivot transfer because she used a mechanical lift in the facility she previously lived in. Resident 16 was designated to be transferred with a sit-to-stand lift after that conversation, but some staff continued to transfer resident 16 by pivot transfer with the assistance of two staff members and did not use a gait belt. 10. Observation on 3/30/26 at 3:30 p.m. of resident 16 in her room revealed she was lying in bed covered with blankets with her right arm outside the blankets. On her right arm were round purple discolorations of various sizes. 11. Interview on 3/31/26 at 8:56 a.m. with RA PP revealed she referred to the resident's Kardex or the pocket care plan to determine how to care for each resident. The pocket care plan and the residents' Kardex would include how that resident transfers. She stated the pocket care plans are not always kept up to date. 12. Interview on 3/31/26 at 10:02 a.m. with LPN Y revealed she had notified resident 16's daughter of resident 16's pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) on her left buttock but did not speak with her about any of her other concerns. 13. Review of resident 16's EMR and interview on 3/31/26 at 10:45 a.m. with DON B revealed resident 16 used a sit-to-stand lift to transfer since she admitted to the facility on [DATE]. She was changed to a full body mechanical lift after her daughter brought forward the concern she had possibly been injured during a transfer with a mechanical lift and a 3/17/26 lift evaluation was completed and indicated she was not a candidate for a sit-to-stand lift. Resident 16's daughter had told DON B that family members had been pivot transferring resident 16 but she was not aware the staff had been transferring resident 16 that way. DON B stated she was not aware of any bruises on resident 16 and stated there was no documentation of bruises on resident 16's skin assessments. She was not aware there were bruises on resident 16's arms and stated that if they were there they would be of an unknown origin. DON B verified resident 16's initial lift assessment completed by RN CCC indicated she was not a candidate for a sit-to-stand lift for transfers by the established criteria in the assessment, but RN CCC documented in the summary at the end of the assessment that resident 16 was to use a sit-to-stand lift for transfers. 14. Interview and review of resident 16's EMR and the facility's investigations related to resident 16's family member's concerns on 3/31/26 at 1:41 p.m. with administrator A revealed resident 16's family member reported her concerns related to the care resident 16 was receiving on 3/17/26. One of the concerns that was expressed by resident 16's family member was bruising related to an injury sustained by a mechanical lift, but she was unable to expand on that information. A skin assessment was completed by LPN Y after resident 16's family member brought forward her concerns. Administrator A did not recall resident 16's family member talking to her about the staff members using a stand pivot method for transferring her mother. She was not aware resident 16's 3/4/26 lift assessment completed by RN CCC indicated resident 16 was not a candidate for a sit-to-stand lift but was care planned to use a sit-to-stand lift despite the assessment results. Administrator A expected the staff to follow residents' care plans when they assisted each resident with their care needs. 15. Review of the provider's 5/20/2022 CNA job description revealed In keeping with our organization's goal of improving the lives of the Guests we serve, the Certified Nursing Assistant (C.N.A.) plays a critical role in providing superior customer service and nursing care to all Guests. The C.N.A. safeguards the health, safety, and welfare of all Guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential functions of the CNA included 4. Attends to individual needs of all Guests in regards to incontinent care, transferring, ambulation, range of motion, communication and other needs. 5. Provides care that maintains Guest's skin integrity to prevent pressure ulcers, skin tears and other damage by changing incontinent Guests, turning, repositioning immobile Guests and by applying moisturizers to fragile skin and other areas. 7. Must be knowledgeable of individual care plans and support the care planning process by providing supervisors with specific information and observations of the Guest's needs, preferences and report any behavioral changes. 16. Review of the provider's 5/14/2025 care plans policy revealed Policy: Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. 3. Care planning is consistently in process; it begins the moment the resident is admitted to the facility and doesn't end until discharge or death. 5. The physician's orders (including medications, treatments, labs, and diagnostics) in conjunction with the resident's care plan constitute the total 'plan of care'. 17. Observation on 3/25/26 of the blue hallway bathtub room revealed the tub room door was open and there were no staff members in the bathtub room. On top of the bathtub was a pink crate that contained two spray bottles. One spray bottle was labeled Multi-Surface Peroxide (a multi-surface cleaner). The label on that bottle indicated it, Causes skin irritation and Causes serious eye damage. The second spray bottle was not labeled with what was in the bottle and it was two-thirds full of an unidentified liquid 18. Observation on 3/30/26 at 1:00 p.m. of the blue hallway bathtub room revealed the bathtub room door was open and there were no staff members in the bathtub room or near the entrance of the bathtub room. The two spray bottles were in the pink crate on top of the bathtub. 19. Observation and interview on 3/30/26 at 1:54 p.m. of the main dining room revealed there was an unsupervised housekeeping cart in the dining room. There were two residents sitting at a table in the dining room and no staff members were present. A bottle of toilet bowl cleaner was on the housekeeping cart with the spout open. The door on the housekeeping cart where the cleaning chemicals were stored was unlocked. In the lockable compartment was a bottle of Multi-Surface Peroxide cleanser and Micro Kill foaming disinfectant cleaner. The keys to unlock the cart were on the top of the cart. At 2:04 p.m. administrator A entered the main dining room and verified the chemicals were not secured away from residents' access. She called on her walkie-talkie and housekeeper CC entered the main dining area. Housekeeper CC acknowledged the housekeeping cart was hers and she had left it unlocked and unattended, and the toilet bowl cleaner was stored on her cart in a location that could not be locked. 20. Observation on 3/30/26 at 3:34 p.m. of the blue hallway bathtub room revealed the door was open; there were no staff members in the bathtub room or near the entrance to the bathtub room. The two spray bottles were in the pink crate on top of the bathtub. 21. Observation on 3/31/26 at 8:09 a.m. of the blue hallway bathtub room revealed the door to the bathtub room was open with no staff members in the room. The two spray bottles in the pink crate were on top of the bathtub. 22. Observation and interview on 3/31/26 at 8:18 a.m. with CNA WW revealed she had given residents' baths in the blue hallway bathtub room. She verified there were two spray bottles on top of the bathtub but stated she did not know what they were used for and she acknowledged the door on the blue hallway bathtub room was to remain closed to prevent residents from accessing the room unsupervised. 23. Interview on 3/31/26 at 8:32 a.m. with RN T revealed the door to the bathtub rooms were to be closed and locked to prevent residents from entering the room and tripping as well as to prevent them from being exposed to unsecured chemicals. 24. Interview on 3/31/26 at 10:45 a.m. with DON B revealed she did not know what the chemical spray bottles in the blue hallway bathtub room were used for. She expected the door to the bathtub room to be closed to prevent residents from entering when eh room was unattended and chemicals were present. She acknowledged the chemicals in the blue hallway bathtub room were unsecured with the door open and posed a potential risk for a resident to be exposed or have access to those chemicals. She expected all chemicals to be labeled with what was in the bottle. 25. Observation and interview on 3/31/26 at 11:25 a.m. with regional nurse consultant (RNC) M revealed in the blue hallway bathtub room revealed she verified there were two spray bottles in the pink basket on top of the bathtub. One of the bottles was Multi-Surface Peroxide cleanser and the other bottle was unlabeled. RNC M smelled the liquid in the unlabeled spray bottle and verified the bottle did not contain water, but she was unsure what the liquid was. 26. Interview on 3/31/26 at 1:41 p.m. with administrator A revealed she did not know the bathtub door in the blue hallway was left open. She stated the bathtub room was to be closed, locked, and accessible only by staff through a code pad on the door. She expected all chemicals to be stored in their original labeled container in a secure location to prevent a resident's access to the chemical.

Based on observation, record review, interview, and policy review, the provider failed to assess and manage pain for one of one sampled resident (78) who showed signs of having pain.Findings include:1. Observation on 3/25/26 at 9:15 a.m. in the hallway by resident 78's room revealed he was being wheeled to his room by (name of hospice agency) certified nursing assistant (CNA) YY after receiving a shower. Resident 78 could be heard moaning and his face was grimacing suggesting he was in pain. CNA WW wheeled resident 78 into his room and then closed the door to provide cares to resident 78. Over the following several minutes, resident 78 could be heard screaming outside his closed bedroom door.2. Review of resident 78's electronic medical record (EMR) revealed that he was admitted to the facility on [DATE]. Resident 78's medical diagnoses included Alzheimer's Dementia, Displaced fracture of right femur, and Polyneuropathy (neurological condition resulting from widespread damage of peripheral nerves, often causing numbness, tingling, pain, and muscle weakness). Resident 78's 1/5/26 Brief Interview for Mental Status (BIMS) assessment score was not completed. Question one of the assessment was Should Brief Interview for Mental Status be assessed? Answer was 0. No (resident is rarely/never understood). (meaning the resident does not have the cognitive ability to complete the assessment).Resident 78 was admitted to Hospice (a specialized comfort-focused form of care for individuals with a terminal illness. This care prioritizes quality of life, pain management, and emotional/spiritual support the patient and family) on 12/23/25.Resident 78's medication orders revealed that he received scheduled acetaminophen (mild pain reliever) and Tramadol (opioid for moderate to moderate/severe pain). There was an order for PRN (as needed) Morphine (a narcotic pain medication) 5 mg (milligrams) every two hours as needed for pain or dyspnea (shortness of breath).Resident 78's electronic medical record revealed that on 3/25/26, a medical diagnosis of Pseudobulbar Affect (a neurological condition characterized by sudden, uncontrollable, and inappropriate episode of laughing or crying that do not match a person's actual inner emotions) was added to his list of diagnoses.3. Interview on 3/25/26 at 9:24 a.m. with CNA YY revealed It's tough to determine if he [resident 78] is actually in pain because he has a lot of anxiety. He has a lot of lower body rigidity [involuntary, sustained stiffness or tension of muscles, causing discomfort and reduced range of motion].4. Observation on 3/25/26 at 11:10 a.m. outside of resident 78's room revealed that resident 78 could be heard outside of his room with the door closed moaning and yelling. CNA XX was observed walking with licensed practical nurse (LPN) H to resident 78's room and gave him PRN Morphine.5. Interview on 3/25/26 at 3:50 p.m. with LPN H revealed that she felt resident 78 was often feeling pain when he was moved and transferred. She did not feel that [name of hospice agency] was managing resident 78's pain appropriately. She reported that she had made her unit manager aware of her concerns about resident 78's pain.6. Interview on 3/26/26 at 10:09 a.m. with CNA/CMA BB revealed that she had provided cares for resident 78 for over a year. She felt that resident 78's behaviors were tough to interpret at times. He does have different noises. Some are happy, neutral, and crying. She reported that resident 78 will sometimes answer yes or no if he was in pain, but does not answer on a 10 point pain scale (used to determine someone's pain on a scale of 1 through 10). She stated, he is very rigid, and there probably is some pain when he is moved. She also felt it would be a good idea to medicate resident 78 before frequent movement.7. Observation on 3/26/26 at 10:21 a.m. outside of resident 78's room with the door closed revealed that he could be heard making moaning and yelling sounds while the staff were in the room providing cares for him.8. Interview on 3/26/26 at 10:29 a.m. with CNA ZZ after exiting resident 78's room revealed that when asked if she felt resident 78 was experiencing pain when cares were being provided, she responded I just started last week. I'm not sure if he is in pain. She did not feel she was able to judge his emotions yet.9. Interview on 3/26/26 at 11:07 a.m. with registered nurse (RN) unit manager J regarding resident 78's diagnosis of Pseudobulbar Affect revealed that there was conversation between the staff about resident 78's behaviors that led to the review of his EMR that revealed he had a previous diagnosis of Pseudobulbar Affect and it must have dropped off of his list of diagnoses. The resident's primary care provider was faxed to ask if it was appropriate to add the diagnosis of Pseudobulbar Affect to his list of diagnoses. She reported that she was not made aware by staff that resident 87 was experiencing increased pain.10. Interview on 3/26/26 at 11:33 a.m. with CNA AAA revealed that she had provided cares for resident 78 for about a year and a half. She felt that resident 78 cries out when he expresses pain. She reported that resident 78 does not always cry when he is being transferred. She stated that earlier in the morning, resident 78 was crying when she took him to the dining room for breakfast and she felt he was experiencing pain, and she reported that to the nurse, LPN O.11. Interview on 3/26/26 at 12:41 with LPN O revealed that she felt resident 78 was tough to read. Sometimes his laugh sounds like a cry. Usually if he is in pain, I try the morphine. If that doesn't help, I try the Ativan [anxiety medication]. He seems really anxious when being transferred. I don't know that he is in pain.12. Review of resident 78's medication administration record (MAR) revealed that LPN O did not administer morphine that day or during March 2026.13. Observation on 3/30/26 at 3:26 p.m. with CNA/Staff coordinator AA and CNA/CMA BB changing resident 78's incontinence (involuntary urine or bowel leakage) brief revealed resident 78 appeared calm before the staff moved him. When resident 78 was turned onto his right side, he was constantly grimacing. He began to moan ga ga ga ga ga ga ga ga. His face was red with a grimace and he appeared to be in pain. The resident responded similarly when he was rolled onto his left side. CNA/Staff coordinator AA and CNA/CMA BB attempted to hold resident 78's hand and talk to him while changing his incontinence brief, but that did not seem to help.14. Interview on 3/30/26 at 4:28 p.m. with LPN H and RN P revealed that it was their opinion that resident 78's pain was not being managed appropriately. LPN H was told by DON B that LPN H should only be administering resident 78's PRN morphine when he had extreme pain. LPN H reported that she felt resident 78 was sometimes in extreme pain, so she treated it with the ordered morphine.LPH H reported that resident 78 was not cognitively intact and his pain could not be appropriately assessed using the 10 point pain scale. She used the PAINAD [Pain Assessment in Advanced Dementia. An observational tool that assesses 5 behaviors; breathing, negative vocalizations, facial expressions, body language, and consoloability] assessment to assess resident 78's pain and treated his pain according to that assessment.15. Observation and Interview on 3/31/26 at 9:25 a.m. with resident 78 near the nurse's station revealed he was well dressed and groomed. When asked if he was experiencing pain, he did not reply. When asked if he could describe his pain on a scale of 0-10, with 0 being no pain at all, and 10 being the worst pain he had ever experienced, he did not respond.16. A review of resident 78's documented pain rating assessments revealed that between 3/20/26 and 3/31/26, there were 51 pain assessments documented. 27 assessments were documented using the 10 point pain scale, and 24 assessments were documented using the PAINAD scale.17. Interview on 3/31/26 at 10:06 a.m. with DON B revealed that she was aware of resident 78's recent diagnosis of Pseudobulbar Affect. She stated that after surveyors had started to question if resident 78 was experiencing pain, it caused the staff to look to see if there may be other reasons for resident 78's behaviors. She reported that after a review of resident 78 VA (Veterans Administration) records, the staff found that the resident was diagnosed with Pseudobulbar Affect before being admitted to the facility.18. Review of resident 78's VA discharge documentation from 1/25/22, before admission to the facility, revealed there was no diagnosis of Pseudobulbar Affect listed in his medical diagnoses.19. Interview on 3/31/26 at 2:25 p.m. with RNC M revealed that after requesting documentation of resident 78's original documentation of Pseudobulbar Affect, RNC M stated The Pseudobulbar Affect diagnosis came from me. She reported that resident 78 was admitted initially under an inappropriate dementia diagnosis. She admitted that resident 78 was never diagnosed with Pseudobulbar Affect before 3/25/26. She did not feel that the 10 point pain scale was appropriate for a resident whose cognition was not intact and typically did not provide more than one word responses.20. Review of the providers 4/28/25 pain management policy revealed 1. The pain management program is based on a facility wide commitment to resident comfort. 2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical conditions and established treatment goals. Recognizing Pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs Of pain: A. Verbal expression such as groaning, crying, screaming. B. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; C. Changes in gait, skin color and vital signs; D. Behavior such as resisting care, irritability, depression, decreased participation in usual activities

Based on interview, record review, observation, and policy review, the provider failed to ensure one of one registered nurse (RN) (F) administered a medication according to the physician's order for one of one sampled resident (44) with a history of heart disease who required the use of the medication to prevent chest pain. Findings include: 1. Interview on 3/24/26 at 9:22 a.m. with resident 44 revealed that he was admitted to the facility about three weeks ago. He was very upset about not receiving his nitroglycerin patch heart medication (a medication patch used to prevent chest pain caused by heart disease) as ordered the previous morning. He stated that he spent the entire day and night worrying that something terrible would happen to him.He asked the day nurse yesterday three or four times for that medication and was told he was not the only resident to whom the nurse had to provide medication, that he would receive his medication when the nurse brought it to him, and not to worry about it.Resident 44 stated that he had a heart attack in the past, had numerous stents (small mesh tubes used to hold open blood vessels) placed, and not receiving his nitroglycerin patch was causing him a lot of anxiety.He told the evening nurse, when she came to remove the patch on the evening of 3/23/26, that he did not receive that medication at all that day. He stated, I hope she documented that.He stated that he was at the facility once before last year and felt that the facility was aware of his healthcare needs and should have known that his nitroglycerine patch medication was important not to skip. 2. Review of resident 44's EMR revealed he was admitted to the facility on [DATE].He previously resided at the facility from 7/9/25 through 7/15/25, was discharged to the hospital due to chest pain, and then went home for several months before being admitted to the facility again this month.His 3/11/26 Brief Interview for Mental Status (BIM) assessment score was 15, indicating that his cognition was intact.A 3/5/26 focus area indicated that resident 44 has a diagnosis of anxiety. A goal that resident 44 will not be affected with signs/symptoms of psychosocial stressors, and that his episodes of anxiety will be relieved in a short period of time with staff intervention.His 7/9/25 care plan indicated a focus area that resident 44 was at risk for altered cardiovascular function related to atherosclerosis (a disease of the arteries where fatty material deposits on their inner walls), HTN [hypertension (high bloop pressure)], PVD [peripheral vascular disease (a progressive narrowing or blockage of blood vessels)], iron deficiency, anemia (not having enough red blood cells to carry oxygen to the body's tissues), unstable angina (a condition in which the heart does not get enough blood flow and oxygen), obesity (overweight), CKD [chronic kidney disease (kidney damage)], and TIA [transient ischemic attack (a brief blockage of blood flow to the brain)]. The 3/5/26 goal indicated that resident 44 will be free from signs and symptoms of complications of cardiac problems. Interventions included Administer medications as ordered.There was a 3/6/26 physician's order for Nitroglycerin Transdermal Patch 0.4 milligrams/hour (mg/hr), apply two patches transdermally (to the skin) one time a day and remove per schedule. This was scheduled to be applied each day at 8:00 a.m. and removed each day at 7:59 p.m.Resident 44's March 2026 medication administration record (MAR) indicated that on 3/23/26 at 8:00 a.m., registered nurse (RN) F, administered the Nitroglycerine Transdermal Patches. On 3/23/26 at 7:59 p.m., licensed practical nurse (LPN) G documented, Per resident patches were not applied this AM [morning]. 3. Interview on 3/25/26 at 3:15 p.m. with LPN/unit manager C regarding resident 44's report that he did not receive his physician-ordered nitroglycerin patches on the morning of 3/23/26 revealed that resident 44 told her about that incident today (3/25/26) after he mentioned it to the surveyor. She reported that information to director of nursing (DON) B and administrator A to conduct an investigation. 4. Interview on 3/25/26 at 3:18 p.m. with DON B and administrator A revealed LPN/unit manager C reported to them today that resident 44 stated that he did not receive his nitroglycerin patches on the morning of 3/23/26. They identified the nurses who worked that day, and were in the process of interviewing resident 44, RN F, and LPN G. 5. Observation and interview on 3/25/26 at 3:21 p.m. with DON B and LPN/unit manager C revealed that LPN C and DON B completed a count of resident 44's Nitroglycerin Transdermal Patches 0.4 mg/hr. There were 22 patches remaining in the box.DON B planned to contact the pharmacy to confirm how many patches had been dispensed. The investigation was ongoing at that point, and she was unsure if resident 44 received all of the ordered doses of his patches at that time. 6. Review of resident 44's March 2026 MAR indicated that it was documented that resident 44 received 20 doses (40 patches) of his Nitroglycerin Transdermal Patches 0.4 mg/hr. 7. Review of RN F's 3/25/26 written statement revealed, I tried to give him [resident 44] his nitro patch in the dining room but he said later in my room and I gave them to him later when he came back to his room. 8. Interview on 3/26/26 at 9:07 a.m. with DON B revealed that she contacted the pharmacy regarding resident 44's Nitroglycerin Transdermal Patches. The pharmacy dispensed 60 patches; 20 doses of that medication (40 patches) were documented as administered, and 22 patches remained in the box. She expected there to be 20 patches remaining in the box.There was one dose (two patches) more than she expected. She felt that resident 44 had not received his 3/23/26 morning dose of that medication.RN F was suspended. DON B submitted a report to the South Dakota Department of Health and contacted resident 44's physician. On 3/25/26 at 4:48 p.m., she implemented monitoring of resident 44's pulse, blood pressure, and reports of chest pain or dizziness to occur for three days. Resident 44 was his own responsible person.DON B conducted interviews with resident 44, RN F, and LPN G.DON B reported that resident 44 told her that he felt anxious about not receiving his medication, but that resident 44 had not reported any dizziness or chest pain. 9. Interview on 3/30/26 at 4:00 p.m. with pharmacist II revealed she was notified of a possible medication error involving resident 44 not receiving a dose of his Nitroglycerin Transdermal Patches.She felt that DON B put in place appropriate monitoring of resident 44 once she became aware of the possible medication error, and pharmacist II was told that resident 44 did not experience any adverse effects, and because of that, she would not have considered this medication being missed a significant medication error.She declined to list the potential adverse effects of resident 44 missing a dose of his physician-ordered Nitroglycerin Transdermal Patches. She stated that the facility identified what monitoring was needed and that monitoring had been put in place. 10. Interview on 3/31/26 at 8:04 a.m. with LPN G revealed that on the evening of 3/23/26, when she went to remove resident 44's Nitroglycerin Transdermal Patches, there were no patches on his chest to remove, and she documented that.She did not inquire why those patches had not been put on or report that there were no patches to remove from resident 44's chest to her supervisor because she thought there must have been a valid reason resident 44 had not had them put on. Resident 44 stated that the morning nurse did not put his patches on, but she was unsure if resident 44 said why the patches were not put on.She stated that she was very busy that night, and after she documented that there were no patches to remove, she did not think about it again. Her only interactions that night with resident 44 were when she provided him with his medications. She did not recall if resident 44 was upset about not receiving his medication as ordered. 11. Review of the provider's undated Medication Administration - General Guidelines policy revealed Medications are administered as prescribed in accordance with good nursing principles and practices. Review of the provider's reviewed 5/14/25 Medication Errors policy revealed Errors will be documented, investigated, reported, and reviewed for need of intervention and to prevent recurrence.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to support the residents' right to choose and receive the frequency of bathing consistent with their preferences for four of thirty-four sampled residents (16, 36, 61, and 77) who preferred to receive bathing at least twice a week. Findings include:1. Review of the provider's 3/17/26 SD DOH FRI regarding resident 16 revealed resident 16's family member reported concerns related to the staff not providing resident 16 routine bathing.Administrator A indicated in the 3/17/26 FRI that resident 16 received a bath on 3/9/26 and 3/16/26 and was provided an additional bath on 3/17/26 at the request of resident 16's family member. 2. Review of resident 16's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her Brief Interview of Mental Status (BIMS) assessment score was 4, which indicated her cognition was severely impaired.Her 3/25/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated she preferred to have a shower or bath two times a week.The 1/28/26 through 3/25/26 bathing documentation for resident 16 indicated she received a bath on 3/9/26, refused her bath on 3/13/26, received a bath on 3/16/26 and was not available for a bath on 3/20/26. There was no documentation that she received or was offered bathing on 3/23/26.Resident 16's 3/20/26 progress note indicated there was no documentation that resident 16 was out of the facility or any other reason she was unavailable for her bath that day. 3. Interview on 3/30/26 at 2:08 p.m. with resident 16's family member revealed that staff provided her mother one shower since she admitted to the facility on [DATE] and when she expressed her concerns about the care her mother received on 3/17/26. 4. Interview on 3/24/26 at 1:51 p.m. with resident 36 revealed there were times when he did not receive a bath for a week. He stated he had to repeatedly remind the staff that he needed a bath before he would get his bath. The days of the week which he was given his bath were not consistent. At times he would wait a week between his baths and other times his baths were every other day. 5. Review of resident 36's EMR revealed he admitted to the facility on [DATE]. His 2/25/26 BIMS assessment score was 12, which indicated his cognition was moderately impaired. His 3/25/26 care plan indicated he preferred to receive a shower or a bath two times per week.The bathing documentation from 1/28/26 through 3/25/26 for resident 36 indicated he was to be provided baths or showers two times a week on Wednesdays and Saturdays. He was scheduled to receive a bath or shower on January 28 and January 31; February 4, 7, 11, 14, 18, 21, 25, and 28; and March 4, 7, 11, 14, 18, and 21. There was no documentation that he refused to bathe or shower.Before his shower on 2/21/26, it was seven days since he had received a bath or shower and before his shower on 3/13/26, it was six days since he had received a bath or shower. 6. Interview on 3/24/26 at 2:00 p.m. with resident 61 revealed he did not receive the showers that he was supposed to. He was scheduled for a shower on 3/24/26 but he stated he did not know if he was going to receive a shower that day. 7. Review of resident 61's EMR revealed he admitted to the facility on [DATE] and his 2/25/26 BIMS assessment score was 15, which indicated his cognition was intact. His 3/25/26 care plan indicated he preferred to receive a shower or a bath two times per week.The bathing documentation from 1/28/26 through 3/25/26 for resident 61 indicated he was to be provided baths or showers two times a week on Tuesdays and Fridays. He did not receive a bath or shower on 2/13/26, 3/3/26, 3/6/26, and 3/17/26. There was no documentation that he refused to bathe or shower. Between 2/10/26 and 2/17/26 resident 61 was not bathed or showered for seven days, between 2/27/26 and 3/10/26 he was not bathed or showered for ten days, and between 3/13/26 and 3/20/26 he was not bathed or showered for seven days. 8. Observation and interview on 3/24/26 at 2:48 p.m. with resident 77 revealed he had long jagged fingernails and smelled like urine. He wanted his showers on Sundays and Thursdays but there were times he did not receive his shower on his scheduled day, or the day was changed. He stated there were times when the staff told him he was not going to get a shower because the shower was being repaired. 9. Review of resident 77's EMR revealed he was admitted to the facility on [DATE]. His 2/20/26 BIMS assessment score was 10, which indicated his cognition was moderately impaired, and his 3/24/26 care plan indicated he preferred to shower two to three times a week.Resident 77's shower documentation from 1/28/26 through 3/25/26 indicated he was to be provided a shower twice weekly on Sundays and Thursdays. He did not receive a shower on 1/29/26, 2/26/26, 3/5/26, and 3/19/26. There was no documentation that he refused to bathe or shower.Between 1/25/26 and 2/1/26 resident 77 did not bathe for six days, between 2/22/26 and 3/1/26 he did not bathe for six days, between 3/1/26 and 3/8/26, he did not bathe for six days, and between 3/15/26 and 3/22/25 he did not bathe for six days. 10. Review of the provider's undated Center Hall Bath Schedule revealed that resident 77 was scheduled to receive bathing on Sundays and Thursdays, resident 16 was scheduled to receive bathing on Mondays and Fridays, resident 61 was scheduled to receive bathing on Tuesdays and Fridays, and resident 36 was scheduled to receive bathing on Wednesdays and Saturdays. 11. Review of the provider's grievance log from November 2025 through March 2026 revealed on 11/19/25 four residents brought forward a concern of not having received their baths or showers. On 1/21/26 during a resident council meeting the residents expressed their concern about not having received their baths.On 3/6/26 residents 28 and 92 filed grievances because they were not receiving their baths. On 3/18/26 during a resident council meeting the residents indicated they wanted a designated bath aide to give them their baths and showers. The resolution indicated, Educated [the] residents in [the] resident council [meeting] on why [a] bath aide hasn't worked in the past, reviewed [the] resident's baths and they are receiving [their] baths, refusals [were] documented. 12. Interview on 3/25/26 at 10:00 a.m. with the resident council revealed there were eleven residents present during the interview and seven residents expressed concerns related to bathing.They said that the baths were not completed as scheduled. They were told by the CNA that was supposed to given them their bath that they were being skipped because there were other residents who had waited longer for their bath. They were told in resident council a bath aide was hired to give them their baths, but that did not last. They were told that they were short-staffed and the staff could not give the residents their baths.One resident said she had waited eight days to get a bath, another resident thought she previously waited two weeks between her baths, a third resident stated it was two weeks since his last bath because the chair he needed broke and was not fixed or replaced, and another resident stated he had one bath in three weeks and his preference was two baths per week.The residents stated they felt the provider worked on the issues they brought to the resident council meetings but then the issues returned after they were provided a resolution during resident council. 13. Interview on 3/31/26 at 8:32 a.m. with registered nurse (RN) T revealed she had received residents' complaints related to not receiving their baths as they were scheduled. There were times when leadership asked staff to come in to work an extra shift to attempt to get the residents bathed.If a resident refused a bath, she expected the CNA to reapproach that resident for their bath later. If that resident continued to refuse their bath, the CNA should document that resident's refusal in their EMR.She acknowledged that the residents not receiving their baths as scheduled could potentially contribute to odors, dignity concerns, and skin breakdown.RN T did not know how to determine what the residents' scheduled baths were or what each resident's bathing frequency preference was. She stated the residents' bathing schedule used to be on the pocket care plan (a document that identifies residents' care needs and interventions) but it was no longer there. 14. Interview on 3/31/26 at 8:56 a.m. with restorative aide (RA) PP revealed she gave residents' their baths when she worked as a CNA. She stated residents had complained to her about not receiving their baths as often as they preferred. The residents' baths were not completed as they were scheduled. There were times a resident may not be provided with a bath for more than one week. She acknowledged that the residents not receiving their scheduled baths had the potential to contribute to odors, skin conditions, and could impact that resident's dignity.The identified bathing preferences were in each resident's care plan, and the baths were scheduled on a bath schedule form.The CNAs working with the residents who were scheduled for a bath on that day were responsible for assisting those residents with their bathing. There were two bathing rooms on the long-term care side of the facility and one bathing room for the short-term rehabilitation residents. 15. Interview on 3/31/26 at 10:45 a.m. with director of nursing (DON) B revealed she expected the residents to be bathed according to the residents' identified preferences in their care plans. The provider did not have a designated bath aid, the CNA responsible for the resident who was scheduled to have a bath that day would give that resident their bath.If a resident refused their bath, she expected that refusal to be documented in the resident's EMR.She was aware there were grievances brought forward during the resident council meeting several months ago related to residents not receiving their preferred bathing frequency. She felt the issue related to residents receiving their baths according to their identified preferences had improved.Each morning the facility's leadership staff reviewed any EMR triggered alerts related to bathing, which included if a bath was not given as scheduled. 16. Interview on 3/31/26 at 1:41 p.m. with administrator A revealed she had spoken with resident 16's family member about her concerns related to resident 16's bathing and felt she was not receptive to the explanation of the cares that were provided to resident 16.She expected the staff to follow the residents' care plans while they attended to each resident's care needs.Administrator A did not know why resident 16 was documented to be unavailable for her bath on 3/20/26. There was no additional information documented in the EMR about that. 17. Review of the provider's 5/14/25 Bathing policy revealed The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The resident has the right to choose timing and frequency of bathing activity. Document bathing activity or refusal of the bathing activity. If [the] resident refuses bathing, reapproach [the] resident at a later time or offer another day to bathe the resident.

Based on record review, interview, and Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure five of six sampled residents' (2, 8, 36, 41, and 49) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas of Pre-admission Screening and Resident Review (a mandatory federal process that ensures people with mental illness or intellectual disabilities are not inappropriately placed in nursing homes)(PASRR), insulin administration, and prescribed psychotropic medications (drugs that affect brain activities associated with mental processes and behavior). Findings include:1. Review of resident 8's electronic medical record (EMR) revealed he admitted to the facility on [DATE] and had an approved PASRR Level II on 12/6/24. His 9/3/25 comprehensive MDS assessment indicated he did not have a PASRR Level II, and his PASRR Level II was added to his care plan on 2/2/26. His 3/6/26 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. He had diagnoses of depression (persistent sadness, low energy, and loss of interest in activities), bipolar disorder with psychotic features (extreme mood swings, mania or depression, accompanied by a temporary break from reality), and anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). He did not have a physician's order to take any medications for those diagnoses. 2. Review of resident 49's EMR revealed she admitted to the facility on [DATE] and had an approved PASRR Level II on 8/28/25. Her 9/26/25 comprehensive MDS assessment indicated she did not have a PASRR Level II, and her PASRR Level II was added to her care plan on 2/1/26. Her 3/5/26 BIMS assessment score was 15, which indicated her cognition was intact. She had diagnoses of major depressive disorder and generalized anxiety disorder, a 1/9/26 physician's order for Sertraline (a depression medication). 3. Interview on 3/26/26 at 12:45 p.m. with social services designee (SSD) E revealed that she entered resident information regarding PASRRs on the MDS assessments, and she should have entered that resident 8 and resident 49 had a PASRR Level II (an in-depth evaluation required by federal law for anyone applying to a Medicaid-certified nursing home who is suspected of having a serious mental illness or an intellectual/developmental disability). 4. Interview on 3/30/26 at 2:05 p.m. with director of nursing (DON) B revealed she expected the MDS to indicate a resident had a PASRR Level II if they had one. 5. Interview on 3/24/26 at 1:51 p.m. with resident 36 revealed he was being administered a long-acting insulin one time per day and a short-acting insulin with each meal. 6. Review of resident 36's EMR revealed he admitted on [DATE]. His 2/25/26 BIMS assessment score was 12, which indicated his cognition was moderately impaired. He had a 2/5/26 physician's order for Aspart insulin (a short acting insulin) three times a day with meals and Glargine insulin (a long-acting insulin) one time a day for diabetes (a condition involving disruptions in how the body regulates blood sugar). Item N0350 of his 3/6/26 quarterly MDS assessment was coded as he had not received insulin injections during the seven-day look-back period (the time period over which the resident's condition or status is captured by the MDS assessment) of that MDS assessment. 7. Review of resident 2's EMR revealed she admitted to the facility on [DATE]. She had a physician's order for trazadone (an antidepressant medication) to be given at bedtime for depression and escitalopram (an antidepressant medication) to be given one time a day for anxiety. She did not have a physician's order for an anti-anxiety medication. Item N0415 of her 1/16/26 and 3/6/26 quarterly MDS assessments were coded as she had received an anti-anxiety medication during the seven-day look back period of those MDS assessments. 8. Review of resident 41's EMR revealed she admitted to the facility on [DATE]. She had a 9/25/24 physician's order for Rexulti (an antipsychotic medication) once daily for behaviors related to Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions). Item N0415 of her 8/26/25 and 12/1/25 quarterly MDS assessments were coded as she did not receive an antipsychotic medication during the seven-day look back period of those MDS assessments. 9. Interview and EMR review on 3/31/26 at 9:42 a.m. with minimum data set (MDS)/registered nurse (RN) D revealed she was responsible for the accurate submission of the residents' MDS assessments. She verified resident 2 was not prescribed an antianxiety medication but her 1/16/26 and 3/6/26 MDS assessment was coded as she had received antianxiety medications. She verified resident 36 was administered insulin four times a day since 2/5/26, but his 3/6/26 MDS assessment indicated he did not receive insulin which was inaccurate. She verified resident 41 took an antipsychotic medication since 9/25/24, but her 8/26/25 and 12/1/25 MDS assessment did not indicate she had taken an antipsychotic medication, which was inaccurate. 10. Interview on 3/31/26 at 10:45 a.m. with director of nursing (DON) B revealed she supervised the MDS nurses and she expected the residents' MDS assessments to be coded accurately. 11. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 revealed that when answering the N0350 question related to a resident's use of insulin the number of days during the seven day look back period that the resident received an insulin injection was to be entered for N0350A. When coding medications within N0415 they are to be coded according to the medication's therapeutic category and/or pharmacological classification, not how it is used. Any medication that has a pharmacological classification or therapeutic category of antipsychotic medication must be recorded in this section, regardless of why the medication is being used. Residents suspected of having MI may require certain care and services provided by the nursing home or the state. When answering the PASRR question on the MDS assessment, question A1500 should be coded as a yes if the resident had a PASRR Level II, which would then require question A1510 to be answered to indicate the reason for PASRR Level II, Serious mental illness, Intellectual Disability, or Other related conditions. 12. Review of the provider's 5/14/25 PASRR policy revealed the Preadmission Screening and Resident Review (PASRR) is a federal requirement to ensure the Nursing Facility (NF) residents with Serious Mental Illness (SMI) or Intellectual and Developmental Disability (ID/DD) are identified and evaluated, placed in the most appropriate and least restrictive setting available, transitioned to an appropriate community setting when they no longer meet criteria for NF placement, and to provide with the MI/ID/DD services they need, including specialized services.

Based on interview, record review, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was completed within 48 hours of the resident's admission to the facility for three of nine sampled residents (2, 6, and 98), and was reviewed with, and a copy was offered to the resident or the resident's representative within 48 hours of the resident's admission to the facility for seven of nine newly admitted sampled residents (2, 6, 30, 36, 44, 61, and 98). Findings include:1. Interview on 3/24/26 at 9:22 a.m. with resident 44 revealed that he admitted to the facility about three weeks ago. He was upset about not receiving his nitroglycerin patch heart medication, which was ordered the previous morning. He stated that he spent the entire day and night worrying that something terrible would happen to him because he was not given that medication. There was a meeting the second week he was at the facility, where the staff members had discussed his care, and he was provided with a copy of his care plan. He pointed to the whiteboard in his room that indicated Care Conference 3/9/26. 2. Review of resident 44's electronic medical record (EMR) revealed he was admitted to the facility on [DATE], and his 3/11/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. There was an uploaded signed paper copy of his baseline care plan. It was signed by resident 44 on 3/9/26 to indicate that he had received a copy and that it was reviewed with him. 3. Interview on 3/24/26 at 2:00 p.m. with resident 30 revealed once she reviewed her baseline care plan she was not aware it included behavior issues. She disputed the statement in her care plan that she had a history of substance abuse and was a member of Al-Anon (a program of recovery for families and friends of alcoholics). She denied being a drug abuser, but it was in her care plan. She was not offered a copy of her care plan or her baseline care plan to review after her admission to the facility. 4. Review of resident 30's EMR revealed she admitted to the facility on [DATE]. Her baseline care plan was completed on 7/30/25. There was no documentation that a copy of the baseline care plan was offered to or reviewed with resident 30. 5. Interview on 3/25/26 at 3:54 p.m. with licensed practical nurse (LPN)/unit manager C revealed that she expected all residents' baseline care plans to be initiated during their nursing admission assessment on the day of their admission to the facility. She expected each resident to receive a copy of that baseline care plan when it was reviewed with them at their 48-hour care conference. Social services designee (SSD) E was responsible for printing the care plan, providing it to the resident, and scheduling the care conference. She stated that resident 44 admitted to the facility on a Thursday (3/5/26), and his care conference was held on the following Monday (3/9/26). The team reviewed his care plan with him during his care conference, and she thought that resident 44 had received a copy of his care plan that day. She confirmed resident 44 did not receive his baseline care plan, and it was not reviewed with him within 48 hours of his admission to the facility. 6. Interview on 3/26/26 at 9:52 a.m. with resident 36 revealed he did not recall anyone reviewing his baseline care plan with him or having been offered a copy of his baseline care plan after he admitted to the facility. He stated the physical therapy department was the only staff members who spoke with him about their plans and talked to him about his goals. 7. Review of resident 36's EMR revealed he admitted to the facility on [DATE], and his 2/25/26 BIMS assessment score was 12, which indicated his cognition was moderately impaired. His baseline care plan was documented by SSD E as having been reviewed with the resident or the resident's representative on 11/21/25. There was no documentation that resident 36 or his representative was offered a copy of his baseline care plan. 8. Review of resident 6's EMR revealed she admitted to the facility on [DATE], and her baseline care plan was documented by SSD K as having been reviewed with the resident or the resident's representative on 10/13/25, five days after she was admitted to the facility. There was no documentation that resident 6 or her representative was offered a copy of her baseline care plan. 9. Review of resident 61's EMR revealed he admitted to the facility on [DATE], and his baseline care plan was documented by SSD E as having been reviewed with the resident or the resident's representative on 11/21/25. There was no documentation that resident 61 or his representative was offered a copy of his baseline care plan. 10. Review of resident 2's EMR revealed she admitted to the facility on [DATE], and her baseline care plan was not locked to indicate it was completed until 1/6/26, seven days after she was admitted to the facility. There was no documentation that resident 2 or her representative was offered a copy of her baseline care plan. 11. Review of resident 98's EMR revealed she admitted to the facility on [DATE], and her baseline care plan was documented by SSD E as having been reviewed with the resident or the resident's representative on 3/16/26, five days after she admitted to the facility. There was no documentation that resident 98 or her representative was offered a copy of her baseline care plan. 12. Interview on 3/26/26 at 12:48 p.m. and again with SSD K regarding resident 30's baseline care plan revealed resident 30 did not agree with some items in her care plan and refused to sign it until SSD K clarified it. SSD K attempted to revise the resident's care plan wording without omitting needed information for the resident's approval and signature, but the resident did not agree to the care plan's content and did not sign it. SSD K confirmed there was no documentation resident 30 was offered a copy of the baseline care plan. 13. Interview and record review on 3/31/26 at 8:46 a.m. with SSD E regarding resident 44's baseline care plan revealed that the nurse who admitted him to the facility initiated his baseline care plan on 3/5/26. SSD E added information to that care plan and scheduled his care conference to be held on 3/9/26. She printed resident 44's baseline care plan and provided him a copy at the 3/9/26 care conference when they reviewed it with him. She stated that when a resident would admit to the facility on a Thursday or a Friday, she would schedule the resident's conference for Monday or Tuesday of the following week. That meeting was considered the 48-hour care conference, where the care team would review the resident's care plan with the resident. She did not consider whether the weekend days should have been included when she calculated the 48 hours. She confirmed that resident 44 received his baseline care plan four days after he was admitted to the facility, and not within the 48 hours as required. 14. Interview on 3/31/26 at 12:13 p.m. with director of nursing (DON) B revealed she expected that all the residents would be provided a copy of their baseline care plans and that those baseline care plans would be reviewed with the resident or their representative within 48 hours of their admission to the facility. Resident 44 did not receive his baseline care plan, nor had it been reviewed with him or his representative within 48 hours of his admission to the facility. 15. Interview on 3/31/26 at 1:35 p.m. with administrator A revealed she knew residents were to be offered a copy of their initial care plan within 48 hours of their admission to the facility. She expected the interdisciplinary team to offer residents or their representative a copy of their initial care plan during the initial care conference. 16. Review of the provider's 5/14/25 revised Care Plans policy revealed 2. A Baseline Care Plan is started by nursing staff on the first day of admission to provide guidance to direct care givers as soon as possible after admission and completed no later than 48 hours after admission. 5. During the care conference the care plan is reviewed with the resident and/or resident's representative. A care conference sign in sheet may be utilized or the facility may list those in attendance on the LGHC Multidisciplinary Care Conference UDA. The care plan may be printed (select print with signature page) and signed by the resident or resident representative.

Based on observation, interview, record review, and policy review, the provider failed to ensure an ongoing restorative nursing program was completed according to the residents' care planned needs for two of two sampled residents (40 and 43) at risk for a decline in range of motion. Findings include:1. Observation and interview on 3/25/26 at 9:10 a.m. with resident 40 in her room revealed that she was frustrated that the fingers on her right hand were stiff and she could not make a fist. She felt she was not receiving the exercises she needed to maintain her strength and was getting weaker. She stated that there used to be exercises, but no one came to get her for her exercises anymore. She stated that she complained to the therapy department about not getting her exercises and was told those exercises were to be completed by the restorative nursing aides now. 2. Review of resident 40's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her diagnoses included Type 2 Diabetes Mellitus (a condition involving disruptions in how the body regulates blood sugar)with diabetic neuropathy (nerve damage that leads to weakness, numbness or tingling in one or more parts of the body), acquired absence of left leg above the knee (amputation), adjustment disorder with depressed mood, and stage 4 (severe) chronic kidney disease (a progressive kidney disease that reduces the kidneys ability to remove waste and keep the blood pressure normal), for which she required dialysis treatments three times per week.A 2/3/26 health status note indicated that the physician had ordered the staff to encourage participation in restorative activities.A 3/25/26 physician's order indicated staff were to Encourage patient to participate in restorative activity 3x [three times] weekly- Complete progress note when completed every day shift.Her 4/31/25 revised care plan included a focus area that resident 40 will participate in restorative therapy, with a goal that she would maintain her current functional ability. Interventions were per therapy and nursing recommendation of AROM [active range of motion].Her 2/25/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact.Her most recent quarterly 2/25/26 Minimum Data Set (MDS) assessment indicated she had a functional limitation in range of motion in one lower extremity (hip, knee, ankle, foot) and one upper extremity (shoulder, elbow, wrist, hand), and had received two days of active range of motion Restorative Nursing Programs during the seven day look back period (the time period over which the resident's condition or status is captured by the MDS assessment). 3. Review of resident 40's 12/15/25 through 3/28/26 restorative nursing program, lower extremity exercise task documentation revealed it was documented on nine days that resident 40 was not available, and on four days, resident 40 had refused. Eight days were documented as Not Applicable. Resident 40 received restorative lower extremity exercises on 2 days between 12/15/25 and 3/28/26.Review of resident 40's 1/1/26 through 3/31/26 restorative nursing program, kinetic bike exercise documentation revealed it was documented on nine days that resident 40 was not available, and on five days, resident 40 had refused. Six days were documented as Not Applicable. Resident 40 received restorative kinetic bike exercises on four days between 1/1/26 and 3/31/26. 4. Observation and interview on 3/30/26 at 2:15 p.m. with resident 43 in her room revealed that she used an iPad that translated conversations from her native language to English. She used a power wheelchair and had limited use of her upper and lower extremities. She participated in physical therapy when she admitted to the facility and was discharged from physical therapy services to a restorative program. She was upset that she had not been receiving her exercise program and had complained about that to director of rehab (DOR) MM. She was well informed about the exercise program that had been set up for her. She stated that no one came to get her for the exercises and felt that she was losing her strength and her ability to stand and transfer. 5. Review of resident 43's EMR revealed she was admitted to the facility on [DATE]. Her diagnoses included Rheumatoid Arthritis (a chronic disease that causes pain, swelling, and stiffness in joints in both the upper and lower extremities), polyneuropathy (nerve damage to many nerves throughout the body), and she had sustained fractures to her right lower leg and foot.Her 1/8/26 BIMS assessment score was 15, which indicated she was cognitively intactHer most recent modification of the quarterly 1/8/26 MDS assessment indicated she had a functional limitation in range of motion in one lower extremity (hip, knee, ankle, foot and she had received no restorative nursing exercise programs.Her 1/30/26 care plan included a focus area that resident 43 will participate in a restorative therapy program, with a goal that she would maintain her current functional abilities. Interventions were per therapy and nursing recommendation, Active ROM [range of motion], sitting exercises 3# [pound] green t-band [TheraBand], trunk exercises x 15 reps [repetitions], and Transfers: standing with walker up to 10 min [minutes]. 6. Review of resident 43's 1/26/26 through 3/30/26 restorative nursing program lower extremity exercise task documentation revealed that on ten days, resident 43 had refused. Four days were documented as Not Applicable. There was no documentation that resident 43 had received lower extremity exercises or had stood with her walker for ten minutes between 1/26/26 and 3/30/26. 7. Interview and review of residents 40 and 43's Restorative Nursing Program Transfer Forms with on 3/30/26 at 3:03 p.m. with DOR MM and physical therapy assistant (PTA) NN revealed that the therapy department made written recommendations to the restorative nursing program on those forms and that director of nursing (DON) B would set up those programs. They expected that restorative aide (RA) OO and RA PP would complete those restorative exercise programs with the residents.Resident 40 was to receive upper and lower extremity exercise programs three to six times per week using an arm bike, a lower extremity kinetic recumbent bike, five-pound weights, and green exercise bands.Resident 43 was discharged from physical therapy around 1/26/26. She was to begin a restorative nursing lower extremity exercise program three to six times per week that included standing for ten minutes with her walker, exercises with a three-pound weight, and green exercise bands. It was noted that she did not like to use the exercise bikes. 8. Interview and review of residents 40 and 43's restorative documentation on 3/31/26 at 9:01 a.m. with restorative aide (RA) OO revealed that she and RA PP provided restorative exercise programs to approximately 44 residents who resided at the facility. Each resident was scheduled to receive restorative exercises for 15 minutes seven days a week. Some days, she and RA PP worked together, but they were scheduled to work alternating weekends and had different days off, so there were several days when one RA was scheduled. It was impossible to see all 44 residents when one RA was working, but they did the best they could.Some residents could get to and from the restorative therapy room independently, and others required assistance to get to the restorative exercise room. They could not leave the residents alone in that room, and getting residents to and from the exercise room was challenging. She felt that there were residents who participated in restorative exercise programs more than others because they were ready for their exercises at their scheduled times, could get to the room independently, and enjoyed exercising. Some residents were known to refuse, and when they were busy, they had to prioritize the residents who were known to participate.She felt that resident 40 preferred to complete her restorative exercises with RA PP, was known to refuse, and was often unavailable because she attended her dialysis treatments three times a week. She was unsure of the last time she had completed resident 40's restorative exercises with her.RA OO stated that resident 43 was scheduled to receive restorative exercises daily, but that she had not completed restorative exercises with resident 43 in over a month. She thought that RA PP may have been assisting resident 43 with her restorative exercise program. 9. Interview by phone on 3/31/26 at 10:44 a.m. with RA PP revealed that she and RA OO provided restorative exercises seven days a week to residents who were listed as participating in restorative nursing exercise programs. There were more residents than could be seen each day, but they tried to accommodate all of the residents' schedules and preferences. Some residents participated regularly, others would refuse, would be unavailable due to medical appointments, or were more difficult to get to the exercise room.She was not allowed to be alone with resident 40, and resident 40 had to complete her exercise program in the main therapy room. It was difficult to get resident 40 to the main exercise room when the exercise bike was available, another staff member was present, and resident 40 was not at her dialysis appointments. She did not recall when she had last seen resident 40 for her restorative exercises program.Resident 43 had refused to complete her restorative exercise program with RA PP once or twice. RA PP thought that RA OO was assisting resident 43 with her restorative program. She was unsure of the last time resident 43 had been offered restorative exercises. 10. Interview on 3/31/26 at 12:17 p.m. with DON B and regional nurse consultant M regarding the provider's restorative nursing program revealed that RA PP was recently hired, and the nurse who was previously in charge of that program was on a medical leave from the facility. DON B had been overseeing the restorative nursing program and expected that restorative exercises be offered and provided to all residents who currently had a written program for at least 15 minutes per day. She was aware that RA OO and RA PP had been having some difficulty providing the program to all of the residents as scheduled. They confirmed that resident 40 had received a total of seven days of restorative exercises since 12/15/25, and that it did not appear that resident 43 had received any restorative exercises since 1/26/26. They were unaware that residents 40 and 43 had concerns about not receiving their restorative exercise programs. 11. Review of the provider's revised 11/18/25 Restorative Nursing policy revealed Restorative Nursing Program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning. A decision to implement a Restorative nursing program can be made.at any time the services are indicated. For a specialty program, restorative staff will be trained in the techniques that promote resident participation in the activity.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, record review, interview, and policy review, the provider failed to protect the residents' right to dignity and privacy for two of two observed sampled residents (16 and 74) with soiled clothing and unclean hands and faces, and one of one observed sampled resident (3) not provided privacy while receiving personal care in his shared room by two of two observed certified nursing assistants (CNA) (N and Q). Findings include: 1.Review of the provider's 3/17/26 SD DOH FRI regarding resident 16 revealed resident 16's family member reported concerns related to the quality of care being provided for resident 16. Resident 16's family member reported that she did not feel resident 16 was being changed regularly or was assisted out of her bed and taken to the dining room for meals. 2. Observation on 3/24/26 at 2:23 p.m. of resident 16 in her room revealed she was sitting in her wheelchair with a dried green substance on her nose and, had a urinary catheter (flexible tubing placed in the bladder to drain urine). 3. Observation on 3/24/26 at 3:47 p.m. of resident 16 in her room revealed she was lying in her bed and the dried green substance remained on her nose. 4. Review of resident 16's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 3/6/26 Brief Interview of Mental Status (BIMS) assessment score was 4, which indicated her cognition was severely impaired. Her diagnoses included depression and senile degeneration of the brain (a progressive age-related cognitive decline caused by brain cell death). Her 3/25/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated she had difficulty with communication and was to be asked yes or no questions. The staff were to provide resident 16 with clear, careful explanations to facilitate her understanding. Resident 16 required the assistance of one staff member with getting dressed, was dependent upon the staff for her personal hygiene needs, and was to be transferred between surfaces with the assistance of two staff members with the use of a full body lift (a mechanical lift and sling used to lift a person's full body). 5. Interview on 3/25/26 at 2:50 p.m. with CNA/CMA R revealed director of nursing (DON) B and administrator A spoke with her about resident 16's family member's concern about resident 16 being left in her bed with her nightgown on until 2:30 p.m. CNA/CMA R stated she was not assigned to assist resident 16 with her cares prior to 3/17/26 when resident 16's family member expressed her concerns related to the care her mother had received by the staff. CNA/CMA R stated she had checked on resident 16 on 3/16/26 and asked her if she needed anything but resident 16 did not answer her so CNA/CMA R left her in her bed with her night gown on. 6. Interview on 3/30/26 at 2:08 p.m. with resident 16's family member on the phone revealed she had spoken with administrator A about her concerns related to the quality-of-care resident 16 received from the staff. Resident 16's family member stated that the resident was unable to use her call light to ask for assistance by the staff and was dependent on the staff for assistance with all of her personal care needs. About one week after resident 16 admitted to the facility, resident 16 was lying in her bed and spilled her juice on her stomach and her bed sheets. Resident 16's family member visited later that day and saw she had spilled juice on herself. The next day resident 16's family member arrived at the facility to visit the resident and noticed the resident's bed sheets were not changed because the dried juice stain was still on them. She came to visit resident 16 one day around 2:30 p.m. and found her lying in her bed, in her pajamas with food on her face and clothing. She was unable to remember the date of that observation but stated it was close to the day that she expressed her concerns to the administrator (3/17/26). On 3/17/26 resident 16's family member told administrator A that she wanted the resident to be out of bed to eat lunch and supper in the dining room and not be left uncared for in her room. 7. Interview on 3/31/26 at 1:41 p.m. with administrator A revealed she had completed the 3/17/26 DOH FRI. Resident 16's family member expressed her concerns about the quality-of-care resident 16 received from the staff to administrator A. Resident 16 refused some cares the staff offered her and at times refused to get out of bed for meals. Administrator A reviewed resident 16's EMR during her investigation of resident 16's family member's concerns and determined that the CNAs documented resident 16's clothing and incontinence (involuntary urine or bowel leakage) products were changed. 8. Observation on 3/24/26 at 9:06 a.m. of resident 74 revealed he was lying in his bed. He had a white shirt on that had multiple brown discolorations on the chest and arms of that shirt. 9. Observation and interview on 3/24/26 at 11:33 a.m. with resident 74 in the dining room revealed he was wearing a white shirt with the brown discolorations on the chest and sleeves. He was drinking out of a handled mug. When he brought the mug towards his mouth, the brown liquid from the mug spilled out onto his clothing protector and shirt before he could bring the mug to his mouth. Resident 74 stated he was drinking coffee. During the lunch dining observation resident 74 continued to spill the coffee onto his clothing protector and shirt as he attempted to drink. The staff in the dining room did not offer assistance or interventions to avoid resident 74's drink spilling onto his clothing protector and shirt. 10. Observation and interview on 3/24/26 at 2:44 p.m. with resident 74 in his room revealed he was lying in his bed, wearing the same white shirt with the brown discolorations on the chest and arms, and pieces of food were in his beard around his mouth. He stated he would have liked the staff to change his shirt because it was dirty, he had trouble with spilling food and drinks on his shirt at times and would like more assistance with eating and drinking. 11. Observation on 3/30/26 at 1:03 p.m. of resident 74 sitting in his wheelchair in the hallway beside the nurses' stations revealed he had food in his beard and a thick orange substance on his fingers surrounding his fingernails. 12. Observation on 3/30/26 at 3:27 p.m. of resident 74 sitting in his wheelchair in the hallway beside the nurses' station revealed he had thick orange substance on his fingers surrounding his fingernails, orange and white substances in his beard, and red and orange pieces of food on his shirt. 13. Review of resident 74's EMR revealed he admitted to the facility on [DATE]. His 2/9/26 BIMS assessment score was 00, which indicated his cognition was severely impaired. His 3/25/26 care plan indicated that his speech was unclear at times but usually understood others and was usually able to be understood. He was dependent upon the staff for his personal hygiene, oral hygiene, and dressing. Resident 74's CNA task documentation and nurse progress notes did not indicate on 3/24/26 or 3/30/26 that he refused having his clothing changed or his face and hands washed. 14. Interview on 3/31/26 at 8:32 a.m. with registered nurse (RN) T revealed she expected the staff to offer to change a resident's clothing if it became soiled, but that the resident could refuse. If a resident refused to have their clothing changed, she expected the refusal to be documented in that residents EMR. She expected a resident's hands and face to be washed when they became soiled. Resident 74 required assistance from the staff to wash his face and hands and change his clothing. Resident 74 had refused his clothing being changed at times but had allowed them to be changed other times. 15. Interview on 3/31/26 at 8:56 a.m. with restorative aid (RA) PP revealed residents' clothing was to be changed when it was dirty. A resident's face and hands should be washed after meals and any time they were soiled. Resident 74 allowed staff to change his clothes and wash his hands and face if they asked him. She felt it was undignified treatment when residents did not get their clothing changed or their hands and face washed when they were soiled. She thought that resident 74 often was not assisted by the staff to change his clothing or wash his face and hands when they were soiled and stated that happened to other residents as well. 16. Interview on 3/31/26 at 10:45 a.m. with director of nursing (DON) B revealed she expected the staff to change a resident's clothing and wash their hands and face when they were soiled. If the resident refused to have their clothing changed or their face and hands washed, she expected the CNA to document the resident's refusal and notify the resident's nurse so she could document the resident's refusal. 17. Observation on 3/24/26 at 2:55 p.m. of CNAs N and Q in resident 3's room revealed they each put on a pair of gloves and then placed a gait belt (a waist strap gripped as support for safe mobility and transfers) around resident 3's waist. They assisted him to stand at the sink, lowered his pants, removed his incontinence brief, cleaned his private areas with a wet wipe, and put a new incontinence brief on the resident. Resident 3's roommate was lying in his bed at that time. The privacy curtain was not pulled far enough to prevent the roommate from seeing resident 3 during the observed personal care above, and the window blinds were open. 18. Interview on 3/25/26 at 10:59 a.m. with CNA/staffing coordinator AA revealed that resident 3 should have been changed while lying in his bed or standing by his bed, with the privacy curtain pulled, and out of view of the window. 19. Interview on 3/31/26 at 1:05 p.m. with DON B revealed that she expected resident 3 to be changed in bed or in an area where he could not be seen by others. She acknowledged that the above observation did not provide him with dignity or privacy. 20. Review of resident 3's EMR revealed his 3/12/26 BIMS assessment score was 2, which indicated his cognition was severely impaired. He had diagnoses of depression (persistent sadness, low energy, and loss of interest in activities) and anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). His 2/18/26 care plan indicated he had a severe mental illness with a risk for abuse and neglect. 21. Review of the provider's 11/18/25 Resident Dignity and Privacy policy revealed that the facility was 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. Groom and dress residents according to resident preference. Clothing should be changed when soiled. Document any resident refusals. Privacy was to be provided to residents when assisting them with their personal care. And the doors, window blinds, and divider curtains were to be closed to provide privacy.

Based on record review, interview, and policy review, the provider failed to ensure the code status (emergent treatment a person wishes to receive if their heart or breathing would stop) for two of two sampled residents (2 and 25) was currently and accurately documented in the residents' electronic medical records (EMR). Findings include:1. Review of resident 25's EMR revealed she admitted to the facility on [DATE]. A banner located at the top of her EMR indicated her code status was Full code [to start life-sustaining measures if one's heart or breathing stopped]-cardiac resuscitation [chest compressions and/or rescue breathing, also known as CPR] but no intubation [the insertion of a tube into the windpipe to maintain an open airway].There was a [DATE] physician's order for Full code-cardiac resuscitation but no intubation.Resident 25's [DATE] signed code status form was signed by resident 25 on [DATE] and the physician on [DATE]. That form indicated her wishes were Do Not Resuscitate [no life-sustaining measures if one's heart or breathing stops, also known as DNR]. There were no other signed code status forms in resident 25's EMR.The provider's undated pocket care plan (a paper reference used by staff to identify a resident's basic care needs) for resident 25 indicated she was a Full Code. 2. Review of resident 2's EMR revealed she admitted to the facility on [DATE] and admitted again on [DATE] after a hospitalization from [DATE] through [DATE]. A banner located at the top of her EMR indicated her code status was DNR: OK to intubate. There was a [DATE] physician's order that stated DNR: OK to intubate.On [DATE] resident 2 and a medical provider signed a Resuscitation Designation Order that indicated resident 2 wanted to be a DNR. There was no documentation on that form that indicated she wished to be intubated.The provider's undated pocket care plan for resident 2 indicated she was a Full Code. 3. Interview on [DATE] at 10:15 a.m. with certified nursing assistant (CNA)/certified medication aide (CMA) V revealed she referenced the Kardex (a report of the resident's care needs and interventions) within the resident's EMR or their pocket care plan.The nurse managers were responsible for updating the pocket care plan for their code status. The pocket care plans were not always up to date. If she noticed a pocket care plan was not up to date, she would notify the nurse manager that it needed to be updated.CNA/CMA V referenced resident 2 and 25's pocket care plans and stated they indicated both residents' code status was listed as full code. 4. Interview and EMR review on [DATE] at 3:46 p.m. with licensed practical nurse (LPN) O revealed a resident's code status was found on their EMR banner. If the identified code status displayed on the EMR screen was clicked on it would access that resident's written code status form.LPN O stated she would reference the resident's code status on the EMR banner or the resident's pocket care plan. She reviewed resident 2's and 25's EMR banners, signed code status forms, and their pocket care plans and verified that both residents' code statuses were not the same within those three areas.LPN O acknowledged that the differences between the residents' EMR banners, signed code status form, and their pocket care plans posed a risk that those residents' wishes may not be followed if they had a medical emergency and were unresponsive. 5. Interview on [DATE] at 10:45 a.m. with director of nursing (DON) B revealed the nurse managers and the social services staff were responsible for documenting the residents' code statuses on the written code status form and in that resident's EMR. 6. Interview on [DATE] at 1:41 p.m. with administrator A revealed the nurse manager reviewed the residents' wishes related to their code status when they admitted to the facility.The nurse manager would document the resident's desired code status on the written code status form, the resident or the resident's representative would sign the code status form, and then the form would be sent to the physician to be signed. The nurse manager entered the resident's desired code status into that resident's EMR banner.The resident's code status was to be reviewed with the resident or the resident's representative quarterly and updated as needed.Administrator A acknowledged that resident 2's and resident 25's code statuses were not consistent between their signed code status forms, the EMR banners, and the pocket care plans, which had the potential for the residents' wishes to not be followed if their heart or breathing stopped. 7. Review of the provider's [DATE] Advanced Directive policy revealed it was the policy of the facility for each resident to choose their Advanced Directives upon admission and such may be changed by the resident at any time during their stay. An Advanced Directive for (as provided by the healthcare facility) shall be completed with [the] resident and/or legal representative to verify treatment options as well as code status. The resident's Advanced Directive choices/options shall be reviewed with [the] resident/resident representative during quarterly and significant change assessment and care planning.

Based on South Dakota Department of Health (SD DOH) Facility Reported Event (FRI) report, interview, record review, observation, and policy review, the provider failed to protect the resident's right to be free from neglect for one of one sampled resident (15) who was left in the dining room for approximately 10 hours by one of one certified nursing assistant (CNA) (RR) and one of one licensed practical nurse (LPN) (SS) without receiving identified interventions to meet his care needs. Findings include:1. Review of the 11/8/25 SD DOH FRI report revealed that on 11/8/25 at around 10:00 p.m., CNA AA notified director of nursing (DON) B that resident 15 was left in the dining room without being changed. Upon camera review, resident 15 was brought out to the dining room around 8:30 a.m. and was not taken back to his room until 6:31 p.m. The report indicated that resident 15 had a urinary catheter (flexible tubing placed in the bladder to drain urine), was able to move around in his wheelchair, readjust himself in his wheelchair, was forgetful and needed the staff to assist him with using the bathroom. His skin was assessed, and he did not have skin breakdown related to the incident. He was not incontinent of his bowels. When interviewed, resident 15 indicated he felt safe at the facility. CNA RR and LPN SS were responsible for providing his care needs that day (11/8/25). CNA RR's employment with the facility was terminated, and LPN SS was educated and returned to work after the investigation was completed. To prevent similar incidents from occurring, the facility reminded all staff to ensure that residents were taken out of the dining room between meals to have their cares completed, audits to ensure residents were not left in the dining room between cleans to receive cares were to be completed every four weeks and then monthly for two months, and all staff were educated about the provider's abuse and neglect policy. 2. Interview on 3/25/25 at 8:45 a.m. with resident 15 revealed that he did not answer questions appropriately and smiled. 3. Review of resident 15's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 12/31/25 Brief Interview for Mental Status (BIMS) assessment score was 1, which indicated his cognition was severely impaired. He had diagnoses of metabolic encephalopathy (a decline in brain function related to a chemical imbalance in the body) and dementia (a group of symptoms affecting memory, thinking, and social abilities). He had a 4/3/25 physician's order to receive Donepezil 10 milligrams (mg) daily (a medication for dementia). Resident 15's 1/5/26 care plan indicated he was at risk for skin impairment related to his Braden score (a tool used to assess the risk of developing pressure ulcers) and a history of having a stage II (open wound or blister with partial-thickness skin loss) pressure ulcer to his right buttock and left foot. He was to be repositioned by staff every two hours and as needed, to prevent skin damage. He had a urinary catheter and was at risk for urinary infections. His urine output was to be documented every shift, typically after each emptying. He required substantial assistance from staff with completing his toileting hygiene care every two to three hours, transferring, and with his wheelchair mobility. He had a risk for falling, he required extensive care, and his care needs would be provided during his stay at the facility. Resident 15 would be treated with respect, dignity, and reside in the facility free of mistreatment. 4. Observations of resident 15 and other residents during the survey process from 3/24/26 through 3/26/26 and 3/30/26 through 3/31/26 revealed that residents were not left in the same area for prolonged periods of time. 5. Interviews completed with direct care staff during the survey process indicated that they received education to not leave the residents in an area for a prolonged period of time without care being provided. 6. Interview on 3/31/26 at 12:24 p.m. with registered nurse (RN) T revealed she monitored the resident's care provided by the staff, and she would document in the resident's EMR that scheduled repositioning was completed for the residents who needed to be repositioned. 7. Interview on 3/31/26 at 12:27 p.m. with CNA TT revealed that if he saw a resident sitting in the same area for a prolonged period without care he would notify the nurse. 8. Interview on 3/31/26 at 12:29 p.m. with dietary aide GG revealed that she would notify the nurse to assist residents who needed help if they were left in the dining room for a prolonged period. 9. Interview on 3/30/26 at 4:00 p.m. with DON B revealed the provided list of staff who were educated about the abuse and neglect policy did not include all of the facility staff. 10. Interview on 3/31/26 at 9:25 a.m. and 1:05 p.m. with DON B revealed that the facility's investigation of the above incident determined that resident 15 was neglected by the staff because CNA RR did not follow his care plan and did not provide him care for approximately ten hours. CNA RR's employment with the facility was terminated. She could not find documentation that all staff were educated on the abuse and neglect policy after the 11/8/25 incident, as was indicated in the provider's final investigation report to the SD DOH. 11. Review of the provider's 5/14/25 Abuse and Neglect policy revealed It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse,.neglect, or mistreatment. It defined neglect as 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. Employees were to be trained on abuse and neglect during orientation and to have annual continuing education.

Based South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the staff followed the care planned interventions for one of one sampled resident (72) identified as requiring all of her care to be provided by two caregivers who expressed distress and reported that one of one certified nursing assistant (CNA) (JJ) was rough with the resident when that CNA did not provide the resident's care with another staff member present. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.Findings include:1. Review of the provider's 11/16/25 SD DOH FRI revealed that on 11/16/25 at 11:30 a.m., resident 72 reported to licensed practical nurse (LPN) UU that CNA JJ was rough with her. CNA JJ was suspended pending the results of an investigation.LPN UU completed a skin assessment of that resident, and no new areas of concern or evidence of significant harm or injury were noted.Interviews conducted with staff on duty identified that resident 72 was screaming after [CNA JJ] went into the room and started helping her [resident 72], then left to get a second person to assist. CNA JJ confirmed that she went into the resident's room alone and assisted [resident 72] with care.Resident 72 had a history of allegations of staff being rough and is care planned to be cared for in pairs [two people] by staff.CNA JJ was not following the resident's care plan. and [her employment] was terminated effective 11/18/25. Staff education was initiated on cares in pairs [care provided by two staff members]. Audits [were] implemented to ensure care in pairs are being followed weekly x4 [for four] weeks. The resident's physician, the police department, and the family were notified. 2. Review of resident 72's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 10/28/22 care plan indicated a focus area of MANIPULATIVE BEHAVIOR (ALLEGED MISTREATMENT) [Resident 72] may voice allegations of mistreatment or exploitation by caregivers. This behavior appears to be related to feeling [a] loss of independence. Will also exhibit [the] behavior of abusive language.Interventions for that behavior included Assure [resident 72] that she is safe and secure. prefers caregivers without accents in her room. [resident 72] continues to make accusations against staff of African decent [descent]. Implement special care strategies as she will have two (2) caregivers address [her] needs and to observe the entire session. Have supervisory personnel observe care delivery, as [much as] possible and in accordance with privacy and dignity considerations. Offer staff of Caucasian descent when able.Her 11/16/25 skin evaluation indicated there were no new skin issues observed. 3. Observation and interview on 3/24/26 at 3:22 p.m. with resident 72 in her room revealed she did not recall the specific incident on 11/16/25, but indicated that she felt like the staff Do everything wrong. She stated that every time the staff touched her, they hurt her. She felt like they were trying to break her bones. She stated that they always bonked her on the head when they transferred her. And they never positioned her correctly in the bed or in the wheelchair. She did not like her custom wheelchair, her bed, or her door open. She stated she waited hours to be put to bed and that she wanted to be put back to bed. At 3:24 p.m., resident 72's call light was turned on, and at 3:26 p.m., an unidentified staff member entered the room and stated that she would get another staff member to assist her with putting resident 72 back to bed. At 3:28 p.m., CNA U and regional nurse consultant (RNC) L assisted resident 72 back to bed and with her care.This surveyor exited the room while those staff members provided the resident's personal care to maintain the resident's right to privacy. There were no episodes of the resident calling out observed.After that care was provided, the surveyor entered the resident's room and continued the interview. Resident 72 reported that she liked that one girl, but the other staff member tried to hurt her, went too fast, she felt like her fingers were broken, and she had not been positioned comfortably in bed. She declined the offer to inform the staff that she was uncomfortable and to request staff assistance to be repositioned. 4. Interview on 3/24/26 at 3:44 p.m. with CNA U regarding resident 72's report of the care she received when assisted to bed during the above observation and interview revealed that resident 72 was to always receive care with two staff present because of the accusations she at times made after receiving care. Resident 72 told inconsistent stories, was manipulative, did not like new staff members, and was known to scream even before some staff members touched her. Resident 72 was very particular about who she allowed to help her. RNC L was not a familiar care provider to resident 72CNA U stated she felt she had a good relationship with resident 72 because the resident liked her, but it was very hard to make the resident happy. She felt that resident 72's reports of events were often not believable, and that resident 72 had not reported a concern with the care provided when she and RNC L assisted her to bed and had stated that she was comfortably positioned when they left her room. 5. Interview on 3/30/26 at 2:42 p.m. with administrator A and DON B regarding resident 72's 11/16/25 report that CNA JJ was rough with her during her care revealed that LPN UU had notified them of the incident on 11/16/25 and administrator A confirmed they immediately suspended CNA JJ, reported the incident to the SD DOH, resident 72's physician, and the resident's power of attorney, and conducted an investigation. They identified that the incident occurred because CNA JJ did not provide resident 72's care with two staff members present, as indicated in her care plan. They provided immediate education to all nursing staff working at that time and initiated ongoing education with all caregiver staff members. They interviewed residents identified as requiring their care to be provided in pairs to ensure that two staff members were present when care was provided and implemented weekly audits beginning on 11/21/25. They reviewed those audits in their QAPI program and continue to monitor that nursing staff members are following the residents' care plans related to providing cares in pairs for the residents with that intervention identified on their care plan. 6. Review of the provider's Abuse and Neglect, Cares in Pairs, and Care Plan, policy staff education initiated on 11/17/25 revealed that all nursing staff were educated about the information in those policies. 7. Review of the provider's QAPI notes from 12/10/25 revealed that resident 72's 11/16/25 allegations of abuse were reviewed, and a care plan performance improvement project (PIP) meeting had been scheduled. 8. Review of the provider's audits after resident 72's 11/16/25 report revealed the provider completed five audits a week for four weeks to observe if the resident's care plans were followed by the staff members providing the resident's care to ensure care was provided to the residents in accordance with the provider's cares in pairs expectations and no further issues were observed. No additional staff education was needed as a result of the audits. 9. The provider's implemented actions to ensure the deficient practice does not recur were confirmed on 3/31/26 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding expectations for following resident care plans and the resident's identified as requiring cares in pairs, the provider's care plan policy was reviewed, and audits were completed. Interviews with nursing staff revealed they understood the education provided regarding the resident care plans, and were able to identify residents who required cares in pairs both in the resident care plan and with signage posted on the residents' doors. Observations of resident care were conducted on residents requiring cares in pairs and confirmed that staff followed the resident care plan, and two staff members were present when indicated in the resident care plan. A QAPI meeting was held on 12/10/25, and the incident regarding resident 72 and the completed audits were reviewed to implement a corrective plan. The audit results will continue to be a part of their QAPI process for review and recommendations as needed. 10. Based on the above information, non-compliance at F684 occurred on 11/16/25, and based on the provider's 1210/25 implemented corrective actions for the deficient practice confirmed on 3/31/26, the non-compliance is considered past non-compliance.

Based on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure one of one observed dietary aide (DA) (EE) washed her hands after touching her face, hair, and pants, washed her hands for the required amount of time, wore gloves before handling resident's food, and replaced a milk jug lid after it fell on the floor in one of three dining rooms (Central). Findings include:1. Observation on 3/24/26 in the Central dining room revealed that at 11:34 a.m., DA EE touched her face, did not wash her hands, and placed covers on plates for the room trays. She touched her face again, did not wash her hands, and put the trays on the room tray cart. At 11:48 a.m., DA EE touched a resident's shoulder, took that resident's coffee cup into the kitchen, came out of the kitchen, and gave it back to her. She touched her face, did not wash her hands, obtained a plate of food for another resident, and served that to a resident. She touched her hair, obtained a plate of food, and served it to another resident. At 11:53 a.m., DA EE went into the kitchen and obtained butter. She did not wash her hands and used her bare hands to touch a resident's bread to apply the butter. At 11:59 a.m., DA EE dropped a chocolate milk lid on the floor in the dining room, picked it up off the floor, and put it back on the chocolate milk container. At 12:06 p.m., DA EE washed her hands in the sink for approximately four seconds, wiped her hands on paper towels, then wiped her left hand on the back of her pants, obtained a plate of food, and served it to a resident. 2. Interview on 3/24/26 at 1:42 p.m. with DA EE revealed she was to sanitize her hands after every three resident plates were served and before putting the room trays on the cart. She was supposed to sanitize her hands after touching a resident, her face, her hair, and her pants before serving resident plates. She was supposed to wash her hands and put on gloves before she touched the resident's food. When washing her hands in the sink, she was supposed to wash them for approximately 20 seconds. She did not recall dropping the chocolate milk lid on the floor and putting it back on the chocolate milk container. The milk lid should have been thrown away if it had been dropped on the floor. 3. Interview on 3/30/26 at 4:07 p.m. with dietary manager (DM) FF revealed that DAs are to sanitize their hands after every three resident plates are served, before putting room trays on the room tray cart, after touching their face or pants, and after touching residents. If the milk lid fell on the floor, it was to be thrown away.4. Review of the provider's 5/15/25 Hand Hygiene policy revealed that the facility considers hand hygiene the primary means to prevent the spread of infections.When washing their hands with soap and water, staff are to wash their hands for at least twenty (20) seconds. They are to wash their hands before and after handling food, and before and after direct contact with residents.

Based on observation, interview, and policy review, the provider failed to ensure the staff followed standard infection control practices regarding:*Hand hygiene (handwashing or hand sanitizer use) and glove use by two of two housekeepers (DD and HH) while cleaning residents' rooms.*Manufacturer's recommended chemical contact time (the duration a disinfectant must remain visibly wet on a surface to effectively kill pathogens) was followed by two of two housekeepers (DD and HH) while cleaning residents' rooms. Findings include:1. Observation on 3/24/26 at 2:29 p.m. of housekeeper HH cleaning room [ROOM NUMBER]revealed she put on a pair of gloves without performing hand hygiene. She entered room [ROOM NUMBER] and removed the garbage bags from the garbage cans on both sides of the room. The garbage bags were brought into the hallway and put in the garbage container on her housekeeping cart. Without removing her gloves or performing hand hygiene housekeeper HH took two clean garbage bags off a roll on her housekeeping cart, returned into room [ROOM NUMBER] and replaced the garbage bags on both sides of the room.Housekeeper HH exited room [ROOM NUMBER] with the same gloves on, did not remove the gloves or perform hand hygiene, and removed a bottle of Multi-Surface Peroxide cleaner and a cloth from her cart and brought them into room [ROOM NUMBER]. She sprayed the countertop beside the sink and immediately wiped it off with the cloth. She then exited the room, entered the hallway, and placed the cloth and Multi-Surface Peroxide cleaner in her housekeeping cart. She did not remove her gloves or perform hand hygiene.Housekeeper HH then entered room [ROOM NUMBER] with another cleanser and cloth and washed dried mud off the floor beside the resident's bed that was closest to the door. She exited the room and returned to her housekeeping cart in the hallway with the same gloves on, did not remove her gloves, or perform hand hygiene.She took the broom into room [ROOM NUMBER], swept the floor of the entire room and used the dustpan to pick up the dirt. She exited the room with her gloves on, with the broom and dustpan, and dumped the dirt in the garbage on her housekeeping cart. She did not remove her gloves or perform hand hygiene.Housekeeper HH then removed the mop pad from cleaning solution on her cart with the same gloves on, took it into room [ROOM NUMBER] and mopped the room. Once she had completed mopping, she exited the room with her gloves on. At her housekeeping cart she removed her gloves and used alcohol-based hand sanitizer to perform hand hygiene and applied a new pair of gloves. 2. Observation and interview on 3/30/26 at 1:08 p.m. of housekeeper DD while she cleaned resident room [ROOM NUMBER] revealed she put on a pair of gloves without performing hand hygiene, sprayed the Multi-Surface Peroxide cleaner on the recliner and wiped it off with a cloth. She then sprayed the cabinet with the Multi-Surface Peroxide cleaner and wiped it off with a cloth.Housekeeper DD sprayed the bed with the Multi-Surface Peroxide cleaner and wiped it off with a cloth. Housekeeper DD then exited the resident room, removed her gloves and performed hand hygiene.Housekeeper DD stated she used the Multi-Surface Peroxide cleaner when she cleaned hard surfaces in residents' rooms. She stated she would let the Multi-Surface Peroxide cleaner remain on a surface if it was visibly soiled before she wiped it off. If the area was not visibly soiled, she sprayed the cleaner on and wiped it off immediatelyThe label on the Mult-Surface Peroxide cleaner stated, 1. Spray on hard surfaces to be cleaned. 2. Wait: 1-2 [one to two] minutes. 3. Agitate (if necessary). 4. Wipe Dry. 3. Interview on 3/31/26 at 12:22 p.m. with housekeeper EEE revealed she used the Multi-Surface Peroxide cleaner on surfaces in the residents' room such as their over-the-bed table and countertop beside the sink.She did not know if the Multi-Surface Peroxide cleaner had a contact time for disinfection. She stated she would have to read up on that. 4. Director of housekeeping DDD was not in the facility or available for interview during the second week of the survey. 5. Interview on 3/31/26 at 12:40 p.m. with licensed practical nurse (LPN)/unit manager/infection preventionist C and wound care certified, regional nurse consultant (RNC) L revealed LPN/unit manager/infection preventionist C expected staff to perform hand hygiene before they applied gloves and after they removed their gloves, before entering a resident's room, and after leaving a resident's room.Gloves were to be changed between residents, when a dirty task was completed and before a clean task was started.LPN/unit manager/infection preventionist C stated she would expect staff to follow the identified contact time needed for each chemical to disinfect the surface it was applied to.Wound care certified, regional nurse consultant L advised LPN/unit manager/infection preventionist to answer no further questions related to housekeeping glove use and hand hygiene or chemical contact times because she could not speak for housekeeping's infection control practices. 6. Interview on 3/31/26 at 1:41 p.m. with administrator A revealed hand hygiene and glove use was standard between all departments within the facility unless there was something specific identified in the policy.She expected all staff to follow the recommended contact time for each chemical they used to clean resident care items and surfaces. 7. Review of the provider's 5/15/26 Hand Hygiene policy revealed All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. If hands are not visibly soiled, use an ABHR [alcohol based hand rub] .for all the following situations:Before and after direct contract with residentsWhen entering and leaving a Resident care area/roomBefore donning [putting on] and after removing gloves. The use of gloves does not replace hand hygiene. Hand hygiene must be completed prior to and after [the] removal of gloves.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure residents received quality care when one of one certified nurse aide (CNA) N applied Nair (chemical hair removal cream) cream to one of one sampled resident's (2) peri area (perineum, the skin between the genitals and anus) who did not have a physician's order for use of that cream and subsequently sustained a chemical skin burn. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include:1. Review of the provider's 1/19/26 SD DOH FRI revealed:*On 1/16/26 CNA N had applied Nair cream to resident 2's peri area when she gave the resident her shower.*CNA N reported the Nair cream was in resident 2's room, and the resident wanted the cream applied.*On 1/17/26, during a regular wound treatment on resident 2, licensed practical nurse (LPN) G noticed resident 2's peri area was red, and the resident indicated the area was sore.*LPN G verified with CNA N, who had given resident 2 her shower on 1/16/26, that resident 2's peri area was not shaved with a razor, but did have Nair cream applied to it.*LPN G notified resident 2's family of the incident and informed them that the Nair cream needed to have a physician's order for it to be used in the facility.*The Nair cream was discarded in the garbage per the family's request.*Resident 2's physician and the local police department were notified of the incident.*Resident 2 had a weekly scheduled skin assessment on 1/18/26. The peri area was documented as pink and appears healed. The area was treated with Aquaphor (skin protectant ointment).*On 1/20/26 at 1:45 p.m., resident 2 had a scheduled Urology appointment and was taken to that appointment by her sister in a private car.*At the Urology appointment, resident 2 did not verbalize responses appropriately and was more confused than at her baseline cognitive level.*Resident 2's mother, who was her legal guardian, requested that resident 2 be sent to the emergency department (ED) for further evaluation.*Resident 2 was admitted to the local hospital on 1/20/26 for acute encephalopathy (diffuse disease of the brain that alters its structure or function) with an unknown cause of the disease.*The wound care team at the hospital assessed resident 2's peri area to be moist, pink, and red and 100 percent epithelial tissue [skin].*On 1/21/26, the hospital reported to SD DOH that resident 2 came to the hospital with chemical burns on her bilateral thighs/labia due to the Nair cream being left on the resident for too long. Resident 2 had progressive multiple sclerosis and was dependent on staff at the facility for all of her care, and was unable to wipe the Nair cream off of herself.*The hospital indicated that the mother of resident 2 was aware of the incident that occurred at the nursing home facility, and the facility investigated and addressed the incident.*Resident 2 returned to the facility on 1/23/26.*CNA N was initially suspended pending the investigation and then CNA N's employment at the facility was terminated because of the incident. 2. Review of resident 2's electronic medical record (EMR) revealed:*She was admitted to the facility on [DATE].*Her diagnoses were multiple sclerosis (MS) (a chronic autoimmune disease of the central nervous system), cerebral vascular disease (CVA) (a stroke), hemiplegia (total paralysis of one side of the body), hemiparesis (weakness or partial loss of strength), deep vein thrombosis (DVT) (a blood clot), and Epilepsy (a seizure disorder).*Her 1/12/26 Brief Interview of Mental Status (BIMS) assessment score was 5, which indicated her cognition was severely impaired.*She had a 1/20/26 physician order for Triamcinolone cream 0.1% (a cream to decrease redness and irritation to the skin) to be applied to the pubic area topically twice daily.*Her 1/20/26 hospital admission papers indicated she was assessed as having acute encephalopathy; etiology [cause] is unclear; however, a possible reason could be cellulitis (bacterial infection affecting the skin's deep layers and underlying tissue) from the chemical burn from the waxing cream [Nair].*She had prescriptions from her physician for her chronic pain that she had received before the chemical burn, and no additional pain medications were needed.*Resident 2's 6/15/22 revised care plan indicated her stay at the facility was identified as long-term, and she required extensive care (assistance from the staff in the long-term care setting). 3. Interview on 2/3/26 at 2:03 p.m. with LPN J revealed a request from a resident to use a hygiene product, such as Nair cream, would require a physician's order. 4. Interview on 2/3/26 at 2:12 p.m. with LPN K revealed:* She was not aware of any resident who used Nair cream and resided at the facility.*A physician's order would be required for a resident to be allowed to use Nair cream.*The Nair cream would need to be locked in a medication cart or in the medication room for safe storage. 5. Interview on 2/3/26 at 2:20 p.m. with LPN/Unit manager C revealed:*All over-the-counter (OTC) medications, such as Nair cream, would require a physician's order and would need to be stored in the locked medication cart.*A medication self-administration assessment needed to be completed to determine if a resident was able to safely administer the Nair cream by themselves. 6. Interview and observation on 2/3/26 at 2:30 p.m. with CNA L in the shower room revealed:*There were no hygiene products in the shower room that required a physician's order.*She indicated that a cognitively impaired resident would not be a reliable source if they requested a chemical hygiene product, such as Nair cream, to be applied to their skin without a physician's order to do so.*A chemical hygiene product would be required to be applied by a nurse, as that is not part of her work delegated tasks and responsibilities as a CNA. 7. Interview on 2/3/26 at 2:40 p.m. with resident 2 revealed:*She was not aware of what the Nair cream was.*She did not know who applied the Nair cream to her peri area, but indicated that the staff member did not provide additional care for her that day.*She was not concerned about her safety at the facility. 8. Interview on 2/3/26 at 3:03 p.m. with CNA D revealed:*On 1/16/26, she gave resident 2 her shower.*She did not apply the Nair cream to resident 2's peri area.*She indicated that the Nair cream was applied by CNA N in resident 2's room and then taken off the resident's skin before she was brought to the shower room.*She indicated resident 2 was happy that the Nair cream was applied to her peri area and thought it would alleviate the discomfort she experienced when staff used the sling to assist with her transfers.*She did not see any redness to resident 2's skin on her peri area when she showered her. 9. Interview on 2/3/26 at 3:34 p.m. with resident 2's mother revealed:*She purchased the Nair cream for resident 2 when she was admitted to the facility.*She indicated that resident 2's family applied the Nair cream to resident 2's legs.*LPN G called resident 2's mother on 1/17/26 and informed her of the chemical burn resident 2 acquired from the use of the Nair cream and indicated it was applied to the resident's peri area.*She requested that LPN G discard the Nair cream in the garbage.*She stated LPN G instructed her that all over-the-counter medications brought into the facility by the family for a resident must be discussed with the nurse, an order must be received from the physician to use that medication, and it must be kept locked up.*She had no safety concerns for resident 2 and stated that she received good care from the staff at the facility. 10. Interview on 2/4/26 at 10:15 a.m. with the director of nursing (DON), B revealed:*She was not aware that resident 2 had the Nair cream in her room.*She interviewed CNA N, and she indicated that she used it as a personal hygiene product for resident 2 and followed the directions on the bottle.*CNA N should not have applied the Nair cream to resident 2's peri area on 1/16/26.*The hospital indicated that the Nair cream had caused a chemical burn to resident 2's skin, and as a result, she developed cellulitis from the burn.*She started weekly audits of 5 resident rooms to ensure there were no ointments, creams, or treatments at their bedside without a physician's order.*She started weekly audits with 5 staff to ensure they understood that an order is needed for all treatments applied to residents and that it is not appropriate for a CNA to apply medicated treatments.*Provider's next QAPI (Quality Assurance and Performance Improvement) meeting was scheduled for 2/21/26, and they planned to review the audits and the additional education that was provided for all staff to ensure they are effective in preventing the reoccurrence of this type of injury. 11. Interview on 2/4/26 at 11:20 a.m. with LPN G revealed:*On 1/17/26, during a regular wound treatment for resident 2, she noticed the resident's peri area was red, and resident 2 indicated the area was sore.*She stated the skin looked like it had razor burn from being shaved with a razor.*She verified with CNA N, who worked on 1/16/26, that resident 2's peri area was not shaved with a razor, but indicated she applied the Nair cream when resident 2 requested it.*She notified resident 2's family of the incident and informed them that the Nair cream must have a physician's order for it to be used in the facility, and it must be locked up for resident safety.*The Nair cream was discarded in the garbage per the family's request. 12. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 2/4/26 after a record review revealed:*The provider followed their quality assurance process, and education was provided to all staff.-All staff were educated on items brought in by family members and that a physician's order is needed for those items. Competencies were conducted, and weekly audits were conducted of 5 resident rooms by the administrator or designee.*These will be reviewed during the QAPI meeting on 2/21/26 and thereafter for compliance.*A letter was sent out to families to ensure that any treatment they would like for the residents to have while in the facility must have a physician's order. The items needed to be brought to the nursing staff, and a physician's order must be obtained.*The letter was added as part of the admission paperwork for all residents and their families. *The social worker will do monthly check-ins with resident 2 for the next 3 months to ensure she feels safe at the facility.*Observations and staff interviews revealed that the staff understood the education provided and the revised processes 13. Review of the provider's 5/20/22 Certified Nursing Assistant job description revealed: In keeping with our organization's goal of improving the lives of the Guests we serve, the Certified Nursing Assistant (C.N.A.) plays a critical role in providing superior customer service and nursing care to all Guests. The C.N.A. safeguards the health, safety, and welfare of all Guests under their care by following applicable laws, regulations, and established nursing policies and procedures.The Essential Functions are included: 1. Provides quality nursing care to Guests in an environment that promotes their rights, dignity, and freedom of choice. 2. Provides individualized attention, which encourages each Guest's ability to maintain or attain the highest practical physical, mental, and psychosocial well-being. 3. Carry out assignments required for the Guest's activities of daily living (ADL's) which include but not limited to bathing, dressing, grooming, toileting, and feeding. 4. Attends to individual needs of all Guests in regards to incontinent care, transferring, ambulation, range of motion, communication and other needs. 5. Provides care that maintains each Guest's skin integrity to prevent pressure ulcers, skin tears and other damage by changing incontinent Guests, turning, repositioning immobile Guests, and by applying moisturizers to fragile skin and other areas. 6. Performs various tasks assigned by the floor nurse, including checking vital signs, weighing Guests and by applying creams/ointments and collecting specimens. 14. Review of the provider's January 2018 Medication Storage in the Facility policy revealed: Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Based on the above information, non-compliance at F684 occurred on 1/16/26, and based on the provider's implemented corrective action for the deficient practice confirmed on 2/4/26, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) complaint report review, record review, observation, interview, and policy review, the provider failed to monitor and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (1) who admitted to the facility with a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone) that worsened and who developed a pressure ulcer to her right ankle. Findings include:1. Review of the 1/23/26 SD DOH complaint report revealed:*Resident 1 had an infected open wound on her buttocks when she was admitted to the hospital 12/16/25.*Resident 1 was admitted to the facility from the hospital on [DATE].*When a family member asked a nurse about what treatments were being done to resident 1's bed sores the nurse stated she was not aware resident 1 had bed sores.*The family member was told at that time that the wound nurse was on vacation.*The nurse placed some dressings on resident 1's buttocks.*The family member dated those dressings and reported they remained on her buttock for nearly two weeks without being changed.*The family member stated, at the time of the report, there were no dressings on resident 1's buttocks.*Resident 1 was reported to be having increased confusion and continued weight loss since she admitted to the facility on [DATE].*She was reported to be weak, wanted to sleep all of the time, and was unable to adjust herself in bed or transfer from her bed to her chair.2. Review of resident 1's electronic medical record (EMR) revealed:*She was admitted to the facility from the hospital on [DATE].*Her 1/28/26 BIMS assessment score was 7, which indicated her cognition was severely impaired.*Resident 1's 12/31/25 hospital transfer orders indicated:- Miscellaneous Discharge OrderComments: Skin Breakdown Risk:1) Assess Bony prominences2. Turn/reposition every 2 hours3) Heels up/off bed.4) Protect skin- keep clean and dry.5) Moisture barrier for incontinence [involuntary urine or bowel leakage].6) Use lift pad [a pad used to lift or transfer a resident designed to prevent the dragging of a resident on the surface that they were being transferred to or from].7) Specialty bed if indicated (or air mattress overlay per facility protocol).* Coccyx pressure point Open with red wound bed.* Bedside RN [registered nurse] made aware of assessment and recommendations. Make sure patient is being repositioned at least every 2 hours to more frequently, heel lift boots are in place when in bed, and patient is sitting in the chair and/or ambulating [walking] as able.*A 12/31/25 progress note written by licensed practical nurse (LPN) J in resident 1's admission summary stated, open wound on coccyx (triad [a zinc-based paste to manage draining wounds such as a pressure ulcer] & [and] Mepilex daily).*Resident 1's 12/31/25 skin assessment upon her admission stated, the pressure ulcer was on her coccyx and measured 1 centimeter (cm) in length, 0.6 cm in width, and 0.1cm in depth. Resident 1's pressure ulcer was staged as a II.-There was no documentation of redness to her ankles, elbows, or hips.*Her 12/31/25 Braden Scale assessment (a tool used to assess the risk of developing pressure ulcers) indicated she had high risk for the development of a pressure ulcer due to her pressure ulcer that was present on admission.*On 12/31/25 there was a physician's order for Heel boots while in bed every shift for promotion of skin integrity but the order was not scheduled to start until 1/8/26.*On 1/4/26 there was a physician's order for Please offer recliner to resident BID [two times daily] for 1-2 hours two times a day for promotion of skin integrity.*A 1/6/26 progress note written by LPN K stated, The [redacted identification] approached writer and requested the resident's skin/wounds be checked. Writer assessed residents [resident 1's] skin per request. No current treatments noted on the treatment list at this time of assessment. Skin assessment revealed redness to the right outer ankle; existing mepilex dressing was removed and replaced. Sacral [done directly above the tailbone] area noted to have bony prominence with a partially healed area consistent with a previous pressure injury; Mepilex dressing was removed and triad paste was applied to the area. Bilateral hips noted to have bony prominence; mepilex dressings present for cushion only, no open areas or skin breakdown underneath. Redness noted to bilateral elbows; Mepilex dressings were replaced. The resident tolerated assessment and care without distress. Findings were reported to PCP [primary care provider] and requested to have dressing changes completed every other day. Awaiting response at this time.*Resident 1's skin assessments indicated:-On 1/7/26 a skin evaluation was completed and stated there was a pressure ulcer on her coccyx, but it did not include the measurements, description of the wound bed or the surrounding tissue, or if there was any drainage from the wound.--The Mepliex dressings that were in place on that evaluation were on resident 1's bilateral hips, not on her elbows or ankles.-LPN/wound nurse O's first documentation of the pressure ulcer on resident 1's coccyx was on 1/8/26. It stated resident 1 had a stage III (3; open wound with full-thickness skin loss. Fatty tissue may be visible) pressure ulcer to her coccyx that measured, 0.4 cm in length, 0.5cm in width, and 0.1 cm in depth. The wound base was 50 percent covered in slough (yellowish, soft, stringy, and moist layer of dead tissue that acts as a barrier to healing) with redness and maceration (the softening and whitening of skin caused by prolonged exposure to moisture) to the surrounding tissues.*A 1/8/26 physician's order stated. Check areas covered by mepilex daily & [and] notify [resident 1's doctor] if wound develops; right outer ankle, bilateral hips and bilateral elbows,*A 1/9/26 physician's order for Arginaid [a supplement used to help with wound healing} two times per day.-The 1/9/26 physician's order for Arginaid was not charted as being attempted to be administered until 1/12/26.*On 1/14/26 LPN K documented the measurements of resident 1's stage III pressure ulcer to her coccyx as 0.4 cm by 0.5cm by 0.1cm. She also documented that resident 1's right outer ankle wound was a pressure ulcer but did not document measurements or a description of the wound.-The 1/14/25 wound evaluation completed by LPN/wound nurse O did not include an assessment of resident 1's right outer ankle.*Resident 1's medication administration record (MAR) and treatment administration record (TAR) indicated the physician's order for santyl [a cream to remove dead tissue] dressing was to be applied to resident 1's coccyx wound bed daily and as needed from 1/14/26 through 1/19/26.-It was not documented that the santyl dressing change was completed on 1/19/26.*A 1/19/26 physician's order stated, wound: coccyx- pressure: cleanse, collagen to wound bed, cover [with] silicone foam, change every other day and as needed.*On 1/21/26 LPN/wound nurse O documented resident 1's pressure ulcer to be no longer present.*On 1/23/26 an air mattress was ordered to promote skin integrity.3. Observation and interview on 2/3/26 at 11:15 a.m. with resident 1 in her room revealed:*Resident 1 was lying in her bed and was positioned on her right side with a pillow underneath her back.*The head of the bed and the foot of the bed were in a raised position.*She appeared thin and frail.*There was an air mattress on her bed.*There were two Prevalon boots (a cushioned boot that lifts the heel off the surface of the mattress, to help reduce pressure) on top of a cushion in her wheelchair.*Resident 1's heels were resting on the air mattress.*She had Mepilex dressings (a foam dressing used to treat wounds such as a pressure ulcer) on both of her elbows.*Certified nursing assistant (CNA) H entered resident 1's room. She woke up resident 1 and asked her if she could get her up for lunch, resident 1 stated no after multiple attempts and encouragement to get her out of her bed for lunch.*CNA H stated she had taken the Prevlon boots off resident 1 earlier that morning because she had had them on all night.*CAN H left the room and resident 1 stated the staff helped her when she needed help, but she did not want to get up or eat, she wanted to sleep.4. Observation on 2/3/26 at 12:00 p.m. of resident 1 in her room revealed:*She is lying in bed with the head of the bed and the foot of the bed elevated.*Her Prevalon boots were on both of her feet.*The pillow remained behind her back, positioning her onto her right side.5. Interview on 2/3/26 at 1:56 p.m. with LPN K revealed:*On 1/6/26 resident 1's family member had asked her what the treatments were for her resident 1's wounds.*LPN K stated she did not know resident 1 had wounds, but she would look at resident 1's EMR.*LPN K stated there were no wound treatment orders in resident 1's EMR.*Resident 1 did not have a skin evaluation scheduled for that day, and she was unable to talk to the wound nurse.*LPN K looked at resident 1's skin and stated there were Mepilex dressings on both sides of her hips, right ankle, and coccyx.*Resident 1's hips and ankle did not have any wounds on them.*Her coccyx area had an open area on it.*LPN K stated she had measured the size of the open area on resident 1's coccyx but she was unable to find the measurements when she reviewed resident 1's EMR.*LPN K stated she had notified LPN/wound nurse O of resident 1's wounds at that time.*LPN K stated the Mepilex dressings she had removed were dated 12/31/25.*LPN K stated that on 1/6/26 resident 1 did not have an air mattress on her bed, a cushion in her wheelchair, or Prevalon boots for pressure ulcer treatment and prevention.6. Interview on 2/3/26 at 2:05 p.m. with LPN J revealed:*She had admitted resident 1 on 12/31/25 with director of nursing (DON) B.*She stated resident 1 was malnourished (an imbalance or deficiency of nutrients leading to poor physical health).*She had reddened areas on her both sides of her hips, both elbows, both ankles, and an open wound to her coccyx.*The wound on resident 1's coccyx was open, and there was a large area of redness.*LPN J and DON B measured resident 1's wound on her coccyx and documented the skin evaluation information in resident 1's admission assessment within her.*LPN J replaced the Mepilex dressings that covered those areas and notified LPN/ wound nurse O of the coccyx wound and the reddened areas.*LPN J stated that the interventions and treatments that the staff followed when a resident was admitted to the facility were the physician's orders from the hospital.*She did not know what those interventions were but stated they would be documented in resident 1's MAR or TAR.7. Observation on 2/3/26 at 2:45 p.m. of resident 1 in her room.*She was seated in her recliner which did not have a seat cushion.*She was not wearing her Prevalon boots and her heels were resting on the foot rest of the recliner.8. Interview on 2/4/26 at 8:30 a.m. with LPN M revealed:*On 1/7/26 resident 1's family member told LPN M that no one had looked at resident 1's skin.*LPN M completed a skin assessment on resident 1 and documented it in resident 1's EMR.*She stated resident 1 had an open area on her coccyx with slough in the wound.*She verified that she had not measured the open area on resident 1's coccyx because the wound nurse would do weekly rounds on the residents with wounds and document the appearance and measurements of those wounds.*LPN M notified LPN/wound nurse O of the open wound on resident 1's coccyx and the red areas on her hips, ankles, and elbows.* After review of resident 1's EMR LPN M verified the order for the Mepilex dressing changes every three days did not begin until 1/8/26, eight days after she was admitted .9. Interview on 2/4/26 at 9:28 a.m. with LPN/unit manager C and DON B revealed:*LPN/unit manager C stated the provider's process for wound identification and treatment upon admission to the facility was the nurse who completed the admission assessment would document any skin issues or wounds on the resident's admission assessment.-That nurse would then notify the wound nurse of any wounds or areas of concern and then the wound nurse was expected to follow up by the next business day.-The wound nurse would complete a detailed assessment of the wound, write a progress note in the resident's EMR, and update the resident's care plan (personalized plan that addresses a resident's care needs, goal, and interventions) with any preventative interventions or treatments that the resident was to have.*DON B expected that the wound nurse would assess a resident's wounds or skin concerns within 48 hours of admission to the facility and update that resident's care plan.*DON B stated that LPN/wound nurse O was the wound nurse at the time of resident 1's admission but had resigned from that position at the facility recently.*LPN/unit manager C stated she had removed resident 1's Mepilex dressing to her left heel on 1/5/26, replaced it with a new Mepilex dressing, and applied Prevalon boots on resident 1's feet.*After reviewing resident 1's EMR she verified that the Prevalon boots were not documented as having been applied routinely by the nursing staff until 1/8/25 and resident 1 did not have an air mattress until 1/23/26.*LPN/unit manager C did not know why the 12/31/25 physician's order for Prevalon boots did not start until 1/8/26.10. Interview on 2/4/26 at 10:00 a.m. with DON B revealed:*She reviewed resident 1's EMR and verified the initial wound nurse visit was completed on 1/8/26, which was eight days after resident 1 was admitted to the facility.*DON B verified resident 1's care plan was not updated by the LPN/wound nurse O with interventions or treatments when she was admitted to the facility on [DATE].*DON B staged resident 1's pressure ulcer when she was admitted to the facility on [DATE].*DON B did not know why resident 1's 1/9/26 Arginade supplement order was not started until 1/12/26.Continued interview on 2/4/26 at 12:00 p.m. with DON B revealed:*The provider did not have a skin assessment or evaluation policy.*She was unable to locate any documentation that LPN/wound nurse O had evaluated resident 1 between her admission on [DATE] and 1/8/26.*DON B verified LPN/wound nurse O did not evaluate or provide preventative interventions or treatments for resident 1's wounds to prevent the worsening of the pressure ulcer on resident 1's coccyx and to prevent the reddened areas on both her ankles, both sides of her hips, and both elbows from developing into a pressure ulcer until 1/8/26.*DON B acknowledged the delay in providing pressure reduction interventions and treatment for resident 1's pressure ulcer on her coccyx could have delayed the time it took for the pressure ulcer to heal.11. Review of the provider's 5/14/25 Skin and Pressure Injury Prevention Program policy revealed:* To provide care and services to prevent pressure injury development and to promote the healing of pressure injuries/wounds that are present.* A baseline assessment of the resident's skin status will be completed upon admission/readmission by completing the Nursing Admission/readmission UDA [User Defined Assessment].* A plan of care (POC) will be put into place for residents that are identified with actual skin breakdown or at-risk for skin breakdown.* Nursing personnel will utilize the results of the physical exam and the Pressure Injury Assessment tools to determine an individualized pressure injury prevention program for each at-risk resident. This will include interventions to:a. Protect skin against the effects of pressure, friction, and shear.b. Protect skin from moisture.c. Encourage optimal nutrition and fluid intake.d. Educate staff, residents and families.e. Train front-line caregivers.f. Immediate prevention plan instituted when potential areas are identified.* A wound assessment will be completed:A) When a pressure injury is identified: This assessment will include,a) Site, stage, size, appearance of wound bed, (use %) undermining, depth, drainage, (amount, color, type, consistency and odor) and status of peri-wound tissue;b) Treatment of the pressure injury (cleansing, debridement, dressings);c) A review of the resident's current POC and medical status- any other possible risk factors, impaired healing due to diagnosis.* Reassess the wound at least weekly (if the wound has not improved within 2-3 weeks, contact MD [medical doctor]/Provider for a change in treatment.* Nursing personnel will develop a plan of care (POC) with interventions consistent with resident and family preferences, goals and abilities, to create and environment to the resident's adherence to the pressure injury prevention/treatment plan. POC to include: Impaired mobility, including turning and repositioning at least every two hours or more if indicated by assessment. 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 into place to prevent.* If the assessment is completed by a LPN, there should be collaboration with a RN (may be the DON or other designated RN) to ensure wound status, treatments and interventions are reviewed. This may be accomplished through the facility's at risk meeting or other documented means to show LPN to RN collaboration is occurring at least weekly.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure the staff safely transferred a resident according to the resident's care plan for one of one sampled resident (4) who needed to be transferred with the assistance of two staff members by one of one certified nursing assistant (CNA)(P) who attempted to transfer the resident without the assistance of another staff member. That failure resulted in the resident having pain in her left knee and sustaining two skin tears to her left leg.Findings include:1. Review of the 1/20/26 SD DOH FRI revealed that on 1/15/26 at around 4:00 p.m., resident 4 sustained two skin tears when her left leg hit her wheelchair during a transfer. According to resident 4's care plan, she was to be transferred with the assistance of two staff members. CNA P attempted to transfer resident 4 by herself. During the transfer, resident 4's left leg hit her wheelchair causing the skin tears. After the incident, resident 4 did have increased pain in her left knee and received an x-ray of that knee on 1/19/26.2. Review of resident 4's electronic medical record (EMR) revealed that her 11/21/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated that her cognition was intact. She had diagnoses of muscular dystrophy [a genetic disease that causes irreversible weakness and degeneration of skeletal muscles], unsteadiness on her feet, and decreased mobility. Her 11/24/25 care plan had a Focus area of requires assistance with ADLs [activities of daily living] r/t [related to] muscular dystrophy and an intervention of Transfers: Extensive assist of 2 [2 staff members].3. Interview on 2/3/26 at 3:55 p.m. with CNA P revealed that she was aware that resident 4 was supposed to be transferred with two staff members. She recalled that she had transferred resident 4 by herself before without any problems. She said that she had grabbed resident 4 under her armpits and lifted her up from the wheelchair, then turned to place her on the bed. CNA P then realized that she did not put resident 4's bed in a low position and was unable to lift her high enough to get her onto the bed. She turned back to place resident 4 back in her wheelchair. When she set resident 4 down, resident 4 started to slide down out of her wheelchair and was lowered to the ground. CNA P admitted that she should have had a second staff member to assist with the transfer.4. Interviews were conducted on 2/4/26 in the afternoon with CNAs E, F, and H. They were aware of where to find resident information regarding resident cares and transfers.5. Interview on 2/4/26 at 12:40 p.m. with director of nursing (DON) B revealed she was notified of the incident by the staff after it happened. She reported that CNA P was immediately interviewed about the event and was educated on the use of resident care plans. She expected CNAs to follow the resident's care plans to help prevent falls and injuries.6. Review of the provider's 5/20/2022 CNA job description revealed In keeping with our organization's goal of improving the lives of the Guests we serve, the Certified Nursing Assistant (C.N.A.) plays a critical role in providing superior customer service and nursing care to all Guests. The C.N.A. safeguards the health, safety, and welfare of all Guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential functions of the CNA included 4. Attends to individual needs of all Guests in regards to incontinent care, transferring, ambulation, range of motion, communication and other needs. 5. Provides care that maintains each Guest's skin integrity to prevent pressure ulcers, skin tears and other damage by changing incontinent Guests, turning, repositioning immobile Guests and by applying moisturizers to fragile skin and other areas. 7. Must be knowledgeable of individual care plans and support the care planning process by providing supervisor's with specific information and observations of the Guest's needs, preferences and report any behavioral changes.7. Review of the provider's 5/14/25 care plans policy revealed Policy: Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. 3. Care planning is constantly in process; it begins the moment the resident is admitted to the facility and doesn't end until discharge or death. 5. The physician's orders (including medications, treatments, labs, and diagnostics) in conjunction with the resident's care plan constitute the total 'plan of care.'

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure the safety of two of two sampled residents (2 and 3) who eloped (left the facility without staff knowledge) from the front door of the facility on 7/26/25 and 9/12/25. Both residents had been mistaken for visitors at the time of their elopements. The facility's front door alarm system had been bypassed during the elopements by using an employee's badge. Findings include:1. Review of the provider's 7/26/25 SD DOH FRI involving resident 2 revealed:*On 7/26/25 at approximately 1:47 p.m., certified nursing assistant E returned to the facility after being on break and noticed resident 2 sitting outside in his wheelchair on the sidewalk near the entrance by himself.*According to the provider's investigation, the resident left the facility at approximately 1:27 p.m. when a visitor had opened the front door.*Resident 2's goal was to go outside and enjoy the sun and the warm weather. He maneuvered his wheelchair independently.*Resident 2 willingly returned with licensed practical nurse (LPN) K to the facility at approximately 1:47 p.m. with the assistance of a staff member.*After his return inside, his vitals were taken and were stable. His skin assessment was completed and found to be normal.*The resident's family, his primary care physician, the administrator, and the director of nursing (DON) were notified of the resident's elopement.*Elopement audits were updated to include staff identifying residents named in the elopement binder as at risk for elopement. 2. Review of resident 2's electronic medical record (EMR) revealed:*He was admitted to the facility on [DATE].*He had an elopement risk evaluation on admission [DATE], and it was determined he was not at risk for eloping.*His brief Interview for Mental status (BIMS) score was ten, which indicated he was moderately cognitively impaired. *His diagnoses included Hypertension (high blood pressure), venous thrombosis (blood clot that blocks a vein), transient ischemic attack (TIA) (brief blockage of blood flow to the brain), and tachycardia (fast heart rate). Interview on 12/30/25 at 12:32 p.m. with resident 2 revealed he was not aware of the date, time, his location, or past events when asked questions. 3. Interview on 12/29/25 at 5:18 p.m. with certified nurse assistant (CNA) E revealed:*He remembered on 7/26/25, after returning from his break, he saw resident 2 sitting outside of the facility alone and stated, I just knew he could not be alone.*He knew that resident 2 was to be with a staff member when being outside.*He alerted nursing staff, and the resident was brought back into the facility, assessed, and found to be stable.*He indicated there is an elopement binder at both nurses' desks and at the front desk that has information on which residents are at an elopement risk, with a picture of each resident. 4. Review of the provider's 9/12/25 SD DOH FRI involving resident 3 revealed:*On 9/12/25 at approximately 6:42 p.m., LPN K had seen resident 3 sitting outside of the facility with another resident who had been safely assessed to go outside alone.*According to the provider's investigation, the resident left the facility at approximately 6:31 p.m. when certified nurse aide (CNA) F and H were exiting the facility through the front door after their scheduled shift.*Resident 3's goal was to sit outside with her friend and enjoy the weather.*She willingly returned to the facility at approximately 6:42 p.m. with the nursing manager and was assessed by LPN K and found to be stable.*The resident's family, her primary care physician, the administrator, and the director of nursing (DON) were notified of the resident's elopement. 5. Review of resident 3's electronic medical record (EMR) revealed:*She was admitted to the facility on [DATE].*She last had an elopement risk evaluation on 6/9/25, and it was determined she was a high risk.*She had a history of wandering in the hallways, and this was documented on her care plan.*Her BIMS score was 3, which indicated her cognition was severely impaired.*Her diagnoses were anxiety, depression, and dementia. Interview on 12/30/25 at 12:38 p.m. with resident 3 revealed:*She did not recall the incident that had occurred on 9/12/24, but did know that if she wanted to go outside, she must go with a staff member. 6. Interview on 12/29/25 at 3:50 p.m. with CNA F revealed:*He remembered on 9/12/25, after completion of his working shift, he exited the front door of the facility with CNA H and held the door open so resident 3 could exit the building.*He indicated that he was not aware that resident 3 was a resident at the facility and stated he thought she was a visitor.*He stated that he had only worked at the facility for a couple of months, so he was not sure who all the residents were who resided at the facility.*He indicated that after the incident had occurred, he found out that there was an elopement binder at both nurses' desks and at the front desk that had information on which residents were an elopement risk, with a picture of each resident for staff to reference.*He stated he remembered he received education on elopements and the elopement binders when he was first hired, but had forgotten about the elopement binder. 7. Interview on 12/29/25 at 4:33 p.m. with CNA H revealed:* She remembered on 9/12/25, after completion of her working shift, she exited the front door of the facility with CNA F, who held the door open so resident 3 could exit the building.*She indicated that she was not aware that resident 3 was not allowed to go outside without a staff member.*She stated resident 3 was with another resident who had always gone outside alone, so she thought it was okay for resident 3 to go outside with that resident.*She indicated that after the incident had occurred, she had learned there was an elopement binder at both nurses' desks and at the front desk that had information on which residents were an elopement risk, with a picture of each resident.*She stated she remembered she received education on elopements and the elopement binders when she was first hired. 8. LPN K, who had assessed residents 2 and 3 after their elopements in July and September 2025, was not available for interview during the survey. 9. Interview on 12/30/25 at 2:36 p.m. with administrator A and director of nursing (DON) B regarding residents 2 and 3 revealed:*Camera footage was reviewed for 7/26/25 when the resident eloped. They indicated resident 2, who used a wheelchair independently, had left the facility and gone through the front door around 1:27 p.m. that day.*The front door that the resident had exited out of had been locked, but the alarm sensor was bypassed with the use of a staff member's badge. The badge allowed the sensor on the front door to release the lock, allowing the visitor and the resident to open the door and exit the facility.*Camera footage for resident 3 was reviewed for 9/12/25 when the resident eloped. They indicated resident 3, who used a wheelchair independently, had left the facility and gone through the front door around 6:31 p.m. that day.*The front door that resident 3 had exited out of had been locked, but the alarm sensor was bypassed with the use of one of the CNAs ' badges. The badge allowed the sensor on the front door to release the lock, allowing both CNAs and resident 3 to exit the facility.*They had indicated that at the time of the residents' elopements, the elopement binder was at both nurses' desks and at the front desk. The binder has information on which residents are at an elopement risk, with a picture of each resident for staff to reference. 10. Review of the provider's elopement drills that were first initiated on 7/31/25 through 11/27/25 and the 9/16/25 -9/17/25 Staff In-Service Sheets revealed that all staff were educated on the provider's elopement policy, the binders, and the residents who were currently at risk for elopement. 11. Review of the provider's elopement policy that was last revised on 5/14/25 revealed:*Policy-The facility must take steps to keep the resident safe and assess residents to identify those who are at risk for elopement. Facility personnel must investigate all reports of missing residents. Elopement drills should be conducted monthly. *Procedures-1. Each resident will be evaluated upon admission to ascertain elopement risk. Care plan interventions will be initiated based on results. Elopement evaluations will be completed upon admission, readmission, significant change, and quarterly. Additionally, the evaluation will be completed should a resident have an elopement.-2. It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of going missing to the charge nurse immediately. A resident who has been evaluated as safe for leave of absence (LOA) should have a physician's order and sign out before leaving the facility.- .4. Upon return of the resident to the facility, the Director of Nursing or charge nurse should:--a. Examine the resident for injuries.--b. Contact the attending physician and report what happened.--c. Contact the resident's representative and inform him/her of the incident.--d. Complete an incident report in the Risk Management section of PointClickCare (PCC).--e. Make appropriate notations in the resident's medical record and update the care plan.--f. Complete the Elopement Risk Evaluation UDA. 12. The provider's 7/31/25 implemented actions to ensure the deficient practice does not reoccur was confirmed on 12/30/25 after record review revealed the facility had followed their quality assurance process, education was provided to all staff regarding resident elopements, all staff were educated on elopements, interviews revealed staff understood the education provided regarding those topics, observations revealed that staff are present at the front entrance when residents are present to ensure safety, and review of the provider's weekly and monthly elopement drills, and follow up elopement risk assessments revealed substantial compliance. Based on the above information, noncompliance at F689 occurred on 7/26/25 and 9/12/25, and the provider's 7/31/25 and 9/12/25 and implemented corrective actions for the deficient practice confirmed on 12/30/25. The noncompliance is considered past noncompliance.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, policy review, observation, interview, and record review, the provider failed to ensure that one of one employee (cook J) served food at a safe temperature, according to the provider's policy, which potentially led to one of one resident (4) having skin redness after spilling soup on himself. This citation is considered past noncompliance based on review of the corrective actions the provider implemented immediately following the incident.Findings include:1. Review of the provider's 12/19/25 FRI revealed that at about 7:30 p.m. on 12/19/25, resident 4 was eating tomato soup in his room. The soup was 180 degrees Fahrenheit on the steam table line in the kitchen as it was plated. When resident 4 was about finished with his soup, he accidentally spilled the soup on the left upper quadrant of his chest and his left upper arm. He alerted nursing staff and reported no pain at that time.His skin was assessed and noted light redness to the areas where the soup had been.No blisters were seen and the skin remained intact. His skin returned to his normal color about 15 minutes later. Resident 4 continued to report no pain. The provider planned to continue skin assessments daily for three days to monitor the area.The last hot beverage assessment performed on 12/16/25 indicated that resident 4 was deemed appropriate for eating and drinking hot beverages. Resident 4 agreed to having hot beverages and soup served in a cup with a lid after the spilling incident.2. Review of the provider's 3/19/20 Food Temperatures policy revealed that acceptable serving temperatures for hot entree items, like soups, casseroles, and meats, were acceptable to be served between 140 to 165 degrees Fahrenheit. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving.3. Observation and interview on 12/29/25 from 5:02 p.m. to 5:50 p.m. in the kitchen with cook I revealed the supper menu was chicken tenders, baked potato casserole, season green peas, bread and margarine, pear crumble, and beverage of choice.Cook I measured the temperature of the food items. The baked potato casserole was at 170 degrees, the brown gravy was at 171 degrees, the plain mashed potatoes were at 180 degrees, the ground chicken was at 169 degrees, the pureed peas were at 145 degrees, and the regular peas were at 181 degrees. [NAME] I indicated that the chicken tenders were in the fryer at that moment, and they cooked them in batches to maintain crispiness.Cook I said that some of the food items were too hot to serve. She first turned down the temperature of the steam wells and removed the covers from the food pans. She said that 165 degrees was the top ideal temp according to the policy. She added room temperature liquid butter alternative to the regular peas to bring the temperature down. She temped the peas again, which were 165 degrees. The fried chicken strips were measured at 169 degrees. She confirmed she was aware of the provider's policy for serving temperatures for the safety of residents.4. Interview on 12/29/25 at 5:50 p.m. with dietary manager (DM) C revealed that there were soups on the current menu cycle. She was aware of the soup spill that occurred on 12/19/25. At that time, the entire facility was on isolation due to a flu outbreak, so all residents were served room trays. Because of the room trays, and the increased amount of time from when the food was plated to when it was delivered, they wanted to keep higher temperatures on the steam table. The food loses temperature during transportation, even when using the insulated covers and carts. Resident 4's room was far away from the kitchen, so it would have taken more time to deliver his food, so the food temperatures would have decreased significantly after it was plated until it was served.Immediately after the resident's spill incident, she spoke with cook J on the phone and provided education about the food temperature policy, and to cool down the food if it was too hot prior to serving to the residents. She educated cook J on ways to cool the food to bring it down to an acceptable and safe temperature.5. Interview on 12/30/25 at 1:29 p.m. with administrator A revealed that the provider's December 2025 monthly staff meeting included the topic of hot liquid safety. She and the director of nursing provided education to all staff starting on 12/17/25.6. Interview on 12/30/25 at 1:50 p.m. with resident 4 revealed that he described the soup as scalding on the day he spilled it on himself. He was sitting in bed while eating his supper that day. He confirmed the head of his bed was raised so he was seated in an upright position for eating his meal. All meals were served in their rooms at that time because of the flu.He said that as he was lifting the bowl to take a drink of the soup, he accidentally spilled it on his chest and left arm. He was covered with a blanket, so most of the soup was spilled on the blanket. He yelled for help to get cleaned up. He said the burn was not painful, but it stung. His skin was reddened a bit after the spill but returned to its normal color within two hours. He confirmed that hot liquids were now served to him in a cup with a handle and lid. He mentioned that he was fine with the hot liquids being served in those cups, but he did not enjoy his hot cereal served in those cups.7. Phone interview on 12/30/25 at 1:54 p.m. with cook J revealed that he did not modify the soup prior to serving to the residents on 12/19/25. The final cooking temperature of the tomato soup was 181 degrees, and the temperature when he started plating the food that day was 171 degrees. He confirmed that he received education regarding safe food temperatures and steps to take if the food was too hot before serving it to the residents.8. Interview on 12/30/25 at 2:24 p.m. with DM C revealed that the provider's monitoring system after the spill accident for resident 4 on 12/19/25 included observational audits of meal service to ensure the cooks were properly temping the foods and modifying the foods if the temperatures were outside the acceptable and safe serving temperatures. She provided immediate education to staff if their process deviated from the policy expectations. She also reviewed the food temperature logs each day to ensure the cooks were recording the food temperatures for each food item served.9. Review of the provider's menu for supper on 12/19/25 revealed that the meal included tomato soup, grilled cheese sandwich, creamy cucumber salad, spiced peaches with ice cream, and beverage of choice.10. Review of the provider's meal temperature log from 12/19/25 revealed that the soup had a final cooking temperature of 181 degrees and a serving temperature of 171 degrees.11. Review of the provider's 12/19/25 Staff In-Service Sheet revealed that all dietary staff were educated on the food temperature policy and what to do if the food was too hot or too cold prior to serving to the residents.12. Review of the provider's 12/17/25 through 12/19/25 December All Staff Meeting In-Service Sheets revealed that all staff across all departments received education on the provider's hot liquid safety policy.13. Review of resident 4's electronic medical record revealed that on 12/19/25 at around 7:20 p.m., a staff member heard resident 4 screaming in his room.upon entering [resident 4's] room, it could be seen [that] resident had tomato soup on his throat, upper left quadrant of his chest and left arm. When questioning resident on how [the] situation occurred he stated he was eating his soup, put it on his table and was turning [the] side table away, he then 'smacked the bowl with the back of his hand', when attempting to move [his] arm back.Resident 4 was cleaned up and the nurse assessed his skin. His skin was intact and there were no blisters. His skin was mildly red and blanchness noted to skin, meaning that it remained pale when pressed which could indicate reduced blood flow to the area. He had mild pain to the area. His power of attorney (POA), primary care provider, and the director of nursing were notified about the incident.A new intervention was added to his care plan on 12/20/25 that read hot liquids will now be put in a cup for resident to better access/use cup, [resident 4] agreed and is very pleased with the intervention.His skin was evaluated for three days following the accident with no alterations noted.Resident 4 admitted to the facility on [DATE]. His admission hot liquids safety assessment completed that day indicated that he required hot liquid safety measures such as a lidded cup and staff assistance with hot liquids.A hot liquid safety assessment was completed upon his admission to the facility and every three months afterwards. On 3/15/25, he was reassessed as safe and resident is not considered to be at risk related to hot liquids at this time. The lidded cup was removed from the intervention list. On 6/16/25, he was reassessed as needing hot liquid safety interventions of staff assistance and hot beverage at table. On 9/16/25, he was assessed as not a risk at this time, with the interventions remaining the same as 6/16/25. On 12/18/25, he was assessed as not a risk at this time.Resident 4 was reassessed for hot liquid safety on 12/19/25 after his spill of the hot soup, which indicated he was a low risk. A comment was added that read, Resident has a history of hot liquid spill/injury, new intervention is required. The intervention included using a lid on the cup or mug.14. Review of the provider's 11/18/25 Hot Liquid Safety policy revealed that staff should serve the hot beverages between 140 and 155 degrees. Hot liquid temperatures should be taken and recorded at every meal and/or when prepared to ensure the temperature is within the above parameters before being served.15. The provider's 12/19/25 implemented actions to ensure the deficient practice does not reoccur was confirmed on 12/30/25 after record review revealed the facility had followed their quality assurance process, education was provided to dietary staff regarding acceptable serving temperatures, all staff were educated on hot liquid safety, interviews revealed staff understood the education provided regarding those topics, observations revealed that the dietary staff appropriately adjusted the temperature of the food to ensure safety, and a review of the provider's follow-up monitoring process revealed substantial compliance.Based on the above information, noncompliance at F804 occurred on 12/19/25, and the provider's 12/19/25 implemented corrective actions for the deficient practice confirmed on 12/30/25, the noncompliance is considered past noncompliance.

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (3) with a pressure ulcer received the necessary dressing changes as ordered and interventions according to the resident's care plan to prevent his ulcer and infection from worsening. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include:1. Review of resident 3's electronic medical record (EMR) revealed:*He was admitted on [DATE] for intensive (extreme in degree of care) wound cares with intravenous (administration of medications directly into a vein) (IV) antibiotics. *He had a Brief Interview for Mental Status (BIMS) assessment score of 11, which indicated he had moderate cognitive impairment.*His diagnoses included: an unstageable pressure ulcer (a full-thickness wound where the depth cannot be determined because the base of the ulcer is obscured by slough, which is (yellowish, tan, gray, green, or brown dead tissue,) or eschar, which is (black, brown, or tan dead tissue) to his left lower leg/heel, non-pressure chronic ulcer (a persistent skin wound caused by conditions other than pressure), type two diabetes mellitus (the body does not use insulin properly), diabetic polyneuropathy (nerve damage complication of diabetes that causes pain), peripheral vascular disease (narrowing of blood vessels that reduces blood flow to limbs and organs), and cellulitis (bacterial skin infection that causes redness, swelling, and pain) of his left lower leg. *His current care plan interventions included:*A physician order initiated on 4/15/25 for staff to offload (remove or reduce pressure to body areas) his heels.*A physician order initiated on 4/15/25 for staff to ensure he utilized a crow boot (a specialized boot that redistributes pressure and stabilizes the foot) to his left foot and a custom shoe to his right foot when he was out of bed.*A physician order initiated on 4/15/25 for staff to monitor and document the location, size, and treatment and to report abnormalities, failure to heal, and signs and symptoms of infection to the medical doctor. *A physician order initiated on 4/15/25 to change the dressing to left lower leg/heel twice daily and as needed with betadine (topical antiseptic used to prevent and treat infections), adaptic (non-adhering dressing), 4x4's gauze pads, ABD (gauze pads to absorb wound drainage), wrap with kerlix (woven gauze bandage roll) and an Ace wrap (elastic bandage wrap). *A physician order initiated on 4/15/25 for IV Zosyn (an antibiotic) 4-0.5 GM/100ML therapy was to be administered three times daily through his PICC line (long, thin, flexible tube inserted into a vein in the arm, and threaded into a large vein near the heart to administer fluids or to draw blood samples). *A physician order initiated on 4/17/25 his left lower leg/heel ulcer was to be monitored weekly by licensed practical nurse (LPN)/wound nurse C.*He had been seen by the physician on 4/29/25 with much improvement to the pressure ulcer and less swelling and signs of infection to lower left leg/heel.*On 5/1/25 at 9:19 PM revealed resident 3's left lower leg/heel ulcer measurements were 12.10 Length (L) x 11.00 width (W) x 0.10 diameter (D).*Treatment administration record (TAR) documentation for 5/1/25 through 5/5/25 had been signed off by registered nurse (RN) J, RN K, RN M, and RN N, indicating resident 3's dressing changes to left lower leg/foot/heel had been completed twice daily, as ordered by the physician.*On 5/6/25, a progress note revealed resident 3's Left medial ankle wound communicating to left lower leg, rear. Left lower leg, pressure unstageable: 16.00 L x 32.50 W x 0.10 D.-On 5/6/25, LPN/wound nurse C had completed the dressing change after identifying that it had not been changed on 5/1/25 at 9:00 PM, and 5/2/25, 5/3/25, and 5/4/25, at 8:00 AM, and 9:00 PM as ordered. There was heavy drainage, wound bed wetness, and an odor noted during the dressing change. -Resident 3 had increased fatigue and was afebrile. *Resident 3's primary care provider was notified that resident 3 had not received wound care to his left lower leg/heel on 5/1/25 at 9:00 PM, and 5/2/25, 5/3/25, and 5/4/25, at 8:00 AM, and 9:00 PM as ordered. -Orders were received for blood work and to notify the infectious disease (ID) doctor for further management. *An order was received on 5/5/25 by the ID doctor for resident 3 to be sent to the emergency room for further evaluation. -Resident 3's laboratory results showed an up-trending white blood count (WBC) which was 16.0 on 4/28/25 and on 5/5/25 it was 20.2 which indicated he had an infection and a mild increase in C-reactive protein (CRP) (measures the inflammation in the body) which was 137.1 and reference range is less than 5.0 milligrams per liter (mg/L). -Radiography (X-rays) of his left tibia and fibula (two bones of the lower leg) did not show osteomyelitis (infection in the bone). *Resident 3's primary care provider and his family had been notified regarding his care on his dressing changes to his left lower leg/heal had not been changed as ordered by the provider. *Resident 3 returned to the facility on 5/6/25 after his evaluation in the ED. *Orders received from the ED included:-A doctor's order to continue IV Zosyn 4-0.5 GM/100ML every eight hours until seen by ID.-A doctor's order for doxycycline (an antibiotic) oral tablet, 100 milligrams (MG) by mouth twice daily for seven days.-To continue with the same wound care to his pressure ulcer on his left lower leg/heel as was previously ordered and follow up with the ID clinic on 5/20/25.*Resident 3 had blood drawn on 5/12/25 to be tested at the lab to recheck WBC and CRP (C-reactive protein).-Those lab results verified that there had been a decrease in his WBC and CRP levels. *Documentation in EMR indicated that resident 3 complained of more open wounds than he had previously on his left lower leg/heel.*A 5/13/25 doctor's order for wound care on resident 3's lower left leg/heel had increased from twice daily to four times per day and as needed. *Resident 3 had discharged on 5/21/25 to his private home. 2. Interview on 7/9/25 at 2:45 p.m. with director of nursing (DON) B and LPN/wound nurse C revealed:*Resident 3 had not received his scheduled physician-ordered dressing changes to his lower left leg/heel ulcers seven out of nine times.*Resident 3's lower left leg/heel pressure ulcers had gotten worse with heavy serosanguineous (a mixture of plasma and red blood cells) drainage and erythema (redness of the skin) and required additional oral antibiotics and continuation of IV antibiotics. They expected for the doctor's order for the dressing changes to resident 3's left lower leg/heel to be followed. *They expected each resident's care plan to be followed for any interventions listed. 3. Interview on 7/10/25 at 8:30 a.m. with RN J revealed he:*Verified those were his initials that were documented on the TAR for 5/2/25 at 9:00 p.m., which revealed this was a treatment that had not been completed.*Completed a dressing change on resident 3 but was not real sure which one it was.*Indicated the resident had multiple dressing changes that were to be completed. 4. Interview on 7/10/25 at 9:45 a.m. with RN K revealed he:*Verified those were his initials documented on the TAR for 5/3/25 and 5/4/25 at 8:00 a.m., which revealed this was a treatment that had not been completed.*Could not recall if he had completed the dressing change on resident 3's left lower leg/heel ulcer. 5. Interview on 7/10/25 at 12:30 p.m. with RN M revealed:*He verified those were his initials documented on the TAR for 5/3/25 at 9:00 p.m., which revealed this was a treatment that had not been completed.*He did not remember resident 3 or if he had completed the resident's dressing change on the left lower leg/heel ulcer.*He usually worked one day per month at the facility. 6. Interview on 7/10/25 at 1:18 p.m. with RN N revealed she:*Verified those were her initials documented on the TAR for 5/1/25 and 5/4/25 at 9:00 p.m., which revealed this was a treatment that had not been completed.*Could not justify doing the dressing change on resident 3's left lower leg/heel ulcer, as the previous one completed was done late. 7. Interviews on 7/10/25 at 3:45 p.m. with LPN O and RN K revealed education was provided to all staff on following physician orders, abuse and neglect, and skin and pressure injury prevention. 8. Review of the provider's updated 9/11/24 skin and pressure injury prevention program policy revealed:*A wound assessment will be completed:*When a pressure injury is identified: This assessment will include: a) Site, stage, size, appearance of wound bed, (use %) undermining, depth, drainage, (amount, color, type, consistency and odor) and status of peri-wound tissue;b) Treatment of the pressure injury, (cleansing, debridement, dressings);c) A review of the resident's current POC and medical status- and other possible risk factors, impaired healing due to diagnoses;d) Type of skin injury (MD/Provider is asked to identify type of injury, if needed-e.g., pressure, stasis (venous), ischemic (arterial), or neuropathic (Diabetic), and provide skin treatment orders. Reassess the wound at least weekly (If the wound has not improved within 2-3 weeks, contact MD/Provider for a change in treatment). * Pressure injuries are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition.The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 7/10/25 after record review review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding the Provider Orders Policy, Abuse and Neglect Policy, and Skin and Pressure Injury Prevention Policy. Interview with staff revealed they understood the education provided regarding the topics, and the importance of following physician orders to prevent ulcers and infection from worsening. Audits were completed on following physician orders for dressing changes to ensure they are being completed as written. These were started on 5/9/25 and completed weekly x 4 weeks and then monthly x 2. These will be reviewed during QAPI (Quality Assurance and Performance Improvement) meetings. Observations and staff interviews revealed the staff understood the education provided and the revised processes.Based on the above information, non-compliance at F686 occurred on 5/1/25, and based on the provider's implemented corrective action for the deficient practice confirmed on 7/10/25, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, resident council interview, and policy review, the provider failed to ensure prompt response to call lights and necessary care and services were provided for eight sampled residents (4, 6, 12, 47, 51, 64, 65, and 349) and four additional council meeting residents (3, 10, 61, and 62) to maintain their physical, mental, and emotional well-being. Residents reported frustration, sadness, incontinence, and pain related to the delay in staff's response to their call lights and requests for assistance. Findings include: 1. Interview on 2/25/25 at 6:57 a.m. with registered nurse (RN) E regarding day shift staffing revealed: *RN E stated the halls/wings were staffed with two nurses. -One nurse was staffed on the T-wing/East-wing hall. -One nurse was staffed on the Red unit. *She stated the halls/wings were staffed with four certified nursing assistants (CNAs). -Two CNAs were staffed on the T-wing/East-wing hall. -Two CNAs were staffed on the Red unit. *She provided copies of the nursing staff report sheets for T-wing and the East-wing. -The report sheets identified residents that were to receive care and assistance with two people. -She stated the residents were identified as Pairs with Cares with pear signs posted outside of the resident rooms. 2. Observation and interview on 2/25/25 at 8:41 a.m. with resident 12 revealed: *He was sitting up in bed and watching television with his call light within his reach. *He stated there was not enough staff to help him and he started to cry. *He stated, I hate it here and the upper managers don't care about us, they just care about the money. *He had stated living here made him very depressed and he was tired of being here when no one cared. *He stated it had taken staff five minutes to three hours to answer his call light and sometimes staff had not come at all. *The staff's response to answer the call light had been terrible and made him feel upset and mad. *He stated at different times he had to call the receptionist's desk on the phone and tell her to send staff for help. *He could not get out of bed by himself and required assistance from staff. *He would have liked to have been out of bed every day. *He thought he had not been out of bed since Wednesday 2/19/25. *He said he had not received his scheduled shower on Sunday 2/23/25 and had not yet been offered a shower since then. *He had stated, They don't have enough help, and I get infections because they don't take care of me right. *He felt the incontinent products he used did not fit him properly, leaked, and had caused him to have rashes in his groin area and made his skin sore. *The resident continued to cry and paused when he was unable to speak about his care. *He asked staff for different incontinence products, but no alternative had been offered. -He was unable to release the adhesive strips on the incontinence products by himself timely and would become incontinent and unable to use the urinal. *He became frustrated and mad and would refuse staff assistance by the time staff responded to his call light. -He had become tired of waiting and figured what was the point. -He said the staff would respond, shut the call light off, tell him they would return, leave, and not come back to assist him. Review of resident 12's EMR revealed: *He was admitted to the facility on [DATE]. *He had a 11/26/24 Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated he was cognitively intact. *His diagnoses included immobility syndrome (paraplegic), chronic pain, rheumatoid arthritis, and spinal stenosis (narrowing of the spaces within the spinal canal). -He was non-ambulatory. *He required two staff for assistance with his activities of daily living. -He was identified as Pairs with Cares with pear sign posted outside of his room. -He required an EZ-stand lift (a mechanical lift used to assist from a seated to a standing position) for all transfers. Review of call light logs from 2/1/25 through 2/26/25 for resident 12 revealed: *He had utilized his call light 248 times. Of those: -45 times the response time was over 10 minutes. -40 times the response time was over 20 minutes. -21 times the response time was over 40 minutes. -16 times the response time was over 60 minutes. *The longest response time identified was one hour fifty-nine minutes and twenty-four seconds. 3. Observation and interview on 2/25/25 at 9:16 a.m. with resident 6 in his room revealed: *He was lying in bed with his call light within his reach. *He stated it could take staff one to two hours to respond to his call light. -Some staff would respond to the call light, shut it off, and leave his room without saying anything, and did not return to assist him. -Some staff were unable to assist him and would respond to the call light, tell him they would send someone to assist him, but no one would return. *He stated at different times he and his roommate had to call the receptionist's desk on the phone and tell her to send staff for help. Interview and observation on 3/4/25 at 10:09 a.m. with resident 6 in his room revealed: *He stated that he had pushed his call light at approximately 9:30 a.m. for assistance to get up out of bed. *The assistant director of nursing (ADON) C responded to the call light, shut it off, and told him she would send a CNA to assist him, and then left his room. *No CNA had come to assist him as of 10:09 a.m. *He stated some staff did a good job but most of them did not. *When surveyors were present staff would do better, but it would never last. *He stated it was all about the money and that was the facility's primary concern. -He stated that made him feel sad and mad and his concerns should be important. *He stated staffing issues had always been a problem and would stay a problem and he felt the staff's pay was not enough for the hard work that was done. Observation and interview on 3/4/25 at 10:20 a.m. with resident 6 in his room revealed: *The resident pushed his call light for staff assistance. -He stated he needed his urinary catheter drain bag emptied. -Licensed Practical Nurse (LPN) L responded to his call light at 10:29 a.m. and assisted him. Review of resident 6's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *He had a 1/16/2025 Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated he was cognitively intact. *His diagnoses included a history of an embolism with stroke, legal blindness, Type 1 Diabetes, neuromuscular dysfunction, tremor, and segmental and somatic dysfunction of the cervical region (impaired function of the spine). *He required two staff for assistance with his activities of daily living. -He was identified as Pairs with Cares with pear sign posted outside of his room. Review of call light logs from 2/1/25 through 2/26/25 for resident 6 revealed: *He had utilized his call light 116 times. Of those: -20 times the response time was over 10 minutes. -18 times the response time was over 20 minutes. -10 times the response time was over 40 minutes. -12 times the response time was over 60 minutes. *The longest response time identified was two hours forty-four minutes and twenty-nine seconds. 4. Observation on 2/26/25 at 11:39 a.m. of rooms on the East-wing and T-wing revealed: *Seven resident rooms had a Pairs with Cares symbol/sign posted on the outside of their doors. -Two of 18 residents in the East-wing were to be assisted by two staff with their cares. -Six of 21 residents in the T-wing were to be assisted by two staff with their cares. 5. Interview on 2/26/25 at 2:01 p.m. with director of nursing (DON) B regarding nursing department staffing revealed he stated: *They utilized their own staff and were contracting with two to three travel nurses to staff appropriately. *They were currently orienting three new nursing staff employees. *The staffing ratio for the day shift for the facility units/halls were four nurses, two medication aides, and nine CNAs. *The staffing ratio for the evening/night shift for the facility units/halls was three nurses, and seven CNAs. *They currently had two to three CNA positions available for hire. *The units/halls would have had a shortage of CNAs on occasion related to staff callouts and illness. -Other staff on the units/halls and other licensed staff from management would have assisted during those staffing shortages. 6. Observation of call lights on 3/5/25 from 8:34 a.m. through 8:49 a.m. of the T-wing hall revealed: *Call lights for residents 313 and 325's rooms were alarming when the surveyor began observing at 8:34 a.m. *At 8:48 a.m. the assistant director of nursing (ADON) C responded to room [ROOM NUMBER]'s call light. -That was a minimum time of 14-minutes for staff to respond. *At 8:49 a.m. CNA R responded to room [ROOM NUMBER]'s call light. -That was a minimum time of 15-minutes for staff to respond. 7. Interview on 3/5/25 at 8:50 a.m. with restorative aide O revealed she stated she thought 10 minutes would be an appropriate amount of time to answer a resident's call light. 8. Interview on 3/5/25 at 9:17 a.m. with CNA R revealed an appropriate amount of time to answer a call light would be within seven to eight minutes, or as soon as possible. 43021 9. Interview on 2/25/25 at 1:08 p.m. with resident 4 in her room revealed she: *Felt there was not enough staff to assist her with the care she needed. *Had waited 30 minutes to one hour, at times for her call light to be answered by the staff. *Felt the staff nurses and certified nursing assistants (CNAs) were really good but there was not enough of them to help the residents. Interview on 2/27/25 at 9:16 a.m. with resident 4 in her room revealed: *She stated having to wait a long period of time for staff to respond to her call light had become almost a daily event and staff response times were hardly ever within 15 minutes. *She said on 2/26/25 she had returned from physical therapy around 1:00 p.m. and had eaten her lunch in her room. *She then put on her call light for assistance to get into her bed. -After waiting quite a while, a staff member came into her room and turned the call light off and said she would be back as she left the room. -She stated they never come back and she sat in pain for a while. --She stated her pain level was at seven, nearing eight on the pain scale (a tool used to measure and describe the intensity of pain on a scale range from 0 to 10). --She stated her pain caused her physical distress. -She then put her call light on again and a staff member came in again and stated she was waiting for sheets to put on her bed, turned off the call light, and then left the room. --She waited in pain for another 15 to 20 minutes for the staff to return with the sheets to make her bed and then she was transferred into her bed by two staff using the full body mechanical lift around 2:30 p.m. *She stated the pain in her right leg caused her distress as she needed to lay down in her bed for the pain to ease. -She stated her pain was so intense she was frustrated and close to tears. 10. Interview on 3/5/25 at 10:45 a.m. with certified nursing assistant (CNA) S revealed: *She worked full-time at the facility on the day shift. *When fully staffed, she was responsible for assisting between eight to ten residents with their care needs. *When not fully staffed, she was assigned to assist 18 to 20 residents. -She stated that not being fully staffed occurred randomly, she estimated about 25% of the time she worked. *She had worked on 2/26/25 and recalled the interaction with resident 4 that day after lunch. -She stated they were fully staffed that day. -She stated resident 4 had complained to her about not being transferred to bed timely. -The resident stated she waited too long for her call light to be answered and was in pain. --She added the resident is always in pain and recalled that the resident had requested her pain medication. --CNA S recalled she had informed the nurse of resident 4's request for pain medication. Review of the 2/26/25 call light log for resident 4 revealed: *At 1:27 p.m. the call light was activated with a response time of 15 minutes and 47 seconds. *At 1:57 p.m. the call light was activated with a response time of 1 minute and 46 seconds. Record review of resident 4's call light log from 2/1/25 to 2/26/25 revealed there were 20 of 58 call light response times were over 15 minutes which indicated 35% of the staff's response times to resident 4's call light were over 15 minutes. Interview and review of resident 4's call light log on 3/5/25 at 10:27 a.m. with director of nursing (DON) B revealed: *He stated his expectation was that staff would respond to residents' call lights within five to ten minutes. *He acknowledged resident 4's call light response times were long and stated There is much going on during the day and he was unable to provide a reason for those long response times. Interview and record review on 3/5/25 at 11:00 a.m. with DON B regarding resident 4's report of pain on 2/26/25 revealed: *He confirmed CNA S had worked that day. *In reviewing resident 4's medication administration record (MAR) no pain medication had been administered on 2/26/25. *The resident's February 2025 MAR included twice daily pain evaluations. -He noted that her pain rating on 2/26/25 was 0 during Day Shift and 0 on Evening Shift. Further interview and record review on 3/5/25 at 12:23 p.m. with DON B regarding resident 4's February 2025 MAR, pain levels, and staff's comments revealed: *The February 2025 pain evaluations revealed 21 of 28 day shift ratings were 0 which indicated no pain. -One day shift pain level had been rated at six which indicated a moderate pain level. -There were no levels recorded of the resident having severe (rating of seven to nine) or excruciating pain (rating of 10). *Nineteen of 28 evening shift ratings were 0 which indicated no pain. -Seven times on evening shift her pain level had been rated at a four or five which indicated moderate pain. -There were no levels recorded of the resident having severe or excruciating pain during the evening shift. *MDS coordinator H's 2/25/25 progress note, provided by DON B revealed Resident states PRN Tramadol [pain medication] works to relieve their pain . States they sometimes get high pain but the Tramadol always helps to lower it to an acceptable level. *DON B was not sure of the reason why the resident's statements, CNA S's comment, and MDS coordinator H's progress note noted above were not accurately reflected in the resident's February 2025 pain evaluations. *DON B confirmed the resident's right leg caused her pain and that the staff should have responded timely to assist with her request to get into bed to relieve that pain. Review of resident 4's EMR revealed; *She had admitted to the facility on [DATE]. *Her 1/27/25 BIMS was 14 which indicated she was cognitively intact. *Her 1/27/25 Admission MDS indicated she experienced frequent pain at an intensity rating of seven on the pain scale that interfered with her day-to-day activities. *Her current care plan revealed: -She used a full body mechanical lift for transfers with an XL full body sling. -She was dependent on staff to assist her with toileting, personal hygiene, showers, dressing, footwear, bed mobility, and transfers. -She was at risk for pain . -Interventions included that staff were to: --Evaluate efficacy of pain management. --Observe for non-verbal signs of pain. --Offer to medicate prior to therapy/treatment. --Utilize non-pharmacological intervention like talking to loved ones, watching television, resting, reposition, [and] elevate legs. 51472 11. Observation and interview on 2/25/25 at 9:04 a.m. with resident 64 in is room revealed: *He was sitting in his wheelchair with a full body lift sling under him. *He stated there were times he did not feel there was enough staff. *He stated there were times that it took a long time for his call light to be answered and when it was answered staff would tell him there were not enough people to help him. *He stated he has given up on turning on his call light. *He stated one time he was lying in bed and could not reach his urinal. He turned on his call light, but it was not answered before he had to urinate. He stated he urinated in the trash can beside his bed because he did not want to urinate on the floor. *He stated that he felt like a bother sometimes. *When he requested pain medication some staff would give him his pain medication, others would turn off his call light, walk out the door and not return. Interview on 3/4/25 at 9:38 a.m. with resident 64 regarding his call light revealed: *At times when he had to wait a long time for his call light to be answered he felt like the staff were just sitting around and did not want to help him. *He stated he did not like to have to wait for staff assistance and sometimes it made him upset. *He stated a times staff answered his call light promptly, turned off the call light, and told him they would return. -By the time they returned it was too late (he could not hold his urine anymore). *He felt if he was promised something by the staff it should be done. *He felt like he could not do anything about the time it took the staff to answer call lights, or return to assist him, and that made him mad. Review of resident 64's EMR revealed: *He was admitted to the facility on [DATE]. *His 2/19/25 BIMS assessment score was 12, which indicated he had moderate cognitive impairment. *He transferred with a full body mechanical lift with the assistance of two staff. *He required staff to set up or assist with his activities of daily living. *He was occasionally incontinent of urine. *Staff were to Remind, offer and assist with toileting as needed. I use the urinal for voiding. Review of resident 64's call light logs from 2/2/25 through 2/25/25 revealed: *He had utilized his call light 36 times: -12 times the response time was greater than 10 minutes. -Six times the response time was greater than 30 minutes. -Three times the response time was greater than 45 minutes. -The longest wait time identified was one hour four minutes and fifty-one seconds. 12. Interview on 2/25/25 at 8:57 a.m. with resident 51 in her room revealed: *She stated when she asked for staff to do something, at times it takes a while. *She stated she had been incontinent of urine while she waited for her call light to be answered by the staff and that happened more than one time. Observation and interview on 2/27/25 at 9:47 a.m. with resident 51 in her room revealed: *She was lying in bed. *Her call light was draped over the bedside table away from her bed and out of her reach. *She requested her call light be given to her so she could call someone. *She stated she felt very restless when she had to wait for her call light to be answered. Review of resident 51's EMR revealed: *She was admitted on [DATE]. *Her 2/18/25 BIMS assessment score was 9, which indicated she had moderate cognitive impairment. *She required staff assistance with all her activities of daily living. *She had a history of falling. Interview on 2/27/25 at 8:30 a.m. with licensed practical nurse (LPN) K revealed it was her expectation that residents' call lights be answered within ten minutes. 51816 13. Observation and interview on 2/25/25 at 2:11 p.m. with resident 349 and his wife about call light response time revealed: *The resident was sitting in his recliner and his call light was on his bed out of his reach. *His wife stated, They have some definite issues with that here. *He stated he felt frustrated. *He would put his call light on to get help from staff to go to the bathroom, and it would sometimes take forever for his light to be answered. *He said sometimes, by the time he got help, it was too late, and he would become incontinent. *He said this made him feel like an old person. *He said he knew it was because they were short-staffed and [CNA V] is great, and she is doing all she can, but there was just too much work for the staff that's here. Review of resident 349's EMR revealed: *He was admitted on [DATE]. *He had a 2/17/25 BIMS assessment score of 13, which indicated he was cognitively intact. *He required substantial/maximal staff assistance with toileting hygiene. *He was at risk for falls related to his Parkinson's disease. *Staff were to: -Keep his call light within his reach. -Remind, offer and assist him with toileting as needed. No call light logs were available for review for resident 349's room. It was located in a part of an addition to the facility where call light audits had not been available. 45383 14. Interview on 2/27/25 at 7:30 a.m. with resident 65 regarding call light response time revealed: *One time she had to wait so long that it pissed her off so she wheeled herself over to the call buttons on the wall and pushed the emergency button. *She stated that the call light response times had been discussed as a concern in resident council meetings with no change or improvement. Review of resident 65's EMR revealed: *She had a BIMS score of 14 that had been completed on 12/17/24 which indicated she was cognitively intact. *She required the assistance of two staff and a total lift to transfer from her bed to her wheelchair. Review of call light times from 2/1/25 through 2/26/25 for resident 65 revealed: *Forty times the resident waited longer than 10 minutes for a staff response. *Three times she had waited for 50 minutes to one hour for her call light to have been answered. 15. Interview on 3/5/25 at 9:04 a.m. with administrator A regarding a staffing policy revealed: *Staffing was based on resident census and acuity. *She would have used her facility assessment to assist with staffing as well. 16. Review of the 8/2023 through 7/2024 facility assessment regarding staffing for the nursing department revealed: *Licensed nurses providing direct care needed was seven. *Nurse aides needed was 17. *Other nursing personnel (e.g., those with administrative duties) was eight. *Instructions were to consider if and how the degree of fluctuation in the census and acuity levels impact staffing. *This plan referred to CMS Minimum staffing rule. 45683 17. Interview on 2/25/25 at 9:45 a.m. with resident 47 in her room regarding call light response wait times revealed: *She had waited long periods of time for her call light to get answered by the staff and she had experienced pain. *She required more assistance when she returned from dialysis because she felt weaker on those days. *She would be embarrassed if she had an accident related to waiting for staff to assist her. *She wore a Rooke Boot (a boot that provided redistribution of pressure along the calf to help treat and prevent lower-extremity skin breakdown) on her left foot. -The Rooke boot limited her mobility. -Staff were needed to help her transfer in and out of bed. Review of resident 47's EMR revealed: *She was admitted on [DATE]. *She had an 11/7/24 BIMS score of 15 which indicated she was cognitively intact. * Her dialysis schedule was Monday, Wednesday, and Friday. Review of call light times from 2/1/25 through 2/26/25 revealed resident 47 waited longer than 10 minutes for a staff response 51 times. 18. Resident council meeting held on 2/26/25 at 1:30 p.m. with residents 3, 10, 12, 61, and 62 regarding staff response to resident call lights revealed: *Call lights were not answered timely in the afternoon, evening, during meals, and at staff shift change. *Call lights had been brought up at resident council meetings in the past. *The staff response times would get better for a while, but then it would go back to long wait times. *They felt there was no consistency to address the call light issue. *They expressed that they were frustrated with the lack of oversight and response to the call lights. 19. Interview and resident council meeting minutes review on 3/4/25 at 9:50 a.m. with social services DD regarding resident council meetings revealed: *If an issue was brought up during resident council meetings a grievance form was filled out and it was given to the appropriate department to be addressed. *Call light issues were normally investigated by the administrator. *She confirmed resident call lights were an issue that had been brought up at multiple meetings. *Resident council meeting minutes dated 2/12/25 revealed under old business: -Staff stating they return and not returning in a timely manner. -Nine residents agreed it was resolved. -Six residents disagreed it was resolved, indicating it was still an issue. 20. Interview on 3/5/25 at 11:56 a.m. with administrator A and DON B regarding call lights revealed: *Call light time expectations for staff answering them was 10 minutes or less. *There may be times when an incident happened that the response could take longer. *Staff had been educated about answering call lights. *Staff were to inform the resident if extra help was needed. *It was their expectation that all staff would answer call lights. *They confirmed that residents requiring staff assistance should have had their needs met in a timely manner. *They were unaware of any psychosocial or emotional distress being caused to residents. 21. Review of the provider's 9/30/24 revised Call Lights policy revealed: *It is the policy of the facility to ensure that there is prompt response to the resident's call for assistance. *1. Facility shall answer call lights in a timely manner. If immediate assistance cannot be provided and there is not an emergent need, call light may be turned off and resident informed that staff member will be back to assist them shortly. *2. Orient all new residents to the call light at bedside as well as the call light in the bathroom and in the shower or tub rooms, as applicable. *3. If a call light is not functional, notify the Administrator or Maintenance Director immediately. Evaluate and provide another means in order for the resident to call for assistance (i.e. bell) until the call light is fixed. *4. Ensure call lights are placed within reach of residents. *5. Ensure that when the call light is triggered, it will either alert the staff visually or audibly or both. *6. For residents who are physically unable to depress the traditional call light but cognitively able to call for help, evaluate the need for alternate call system i.e., soft touch, mouth call light activator, etc.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interviews with facility staff failed to ensure the safety of one of one sampled resident (1) whose tunneled chest catheter (a thin tube inserted into a vein in the chest, neck, or groin and tunneled under the skin to a large vein near the heart referred to as a central venous catheter (CVC) to allow access to the vein for medication administration) was removed by registered nurse (RN) (C), not trained to safely perform that task. Findings include: 1. Review of providers 10/25/24 DOH FRI report revealed: *Resident 1 is receiving intravenous (IV) antibiotics for osteomyelitis [a bone infection that causes bone tissue inflammation and swelling]. *She had a tunneled chest catheter placed in her right chest area and on 10/17/24, that tunneled chest catheter was removed by RN C. -Although resident 1 had questioned RN C about removing it, she was told it was no longer needed. -The nurse practitioner was not notified of the mistake (the removal of her tunneled chest catheter). -She had approximately 1 month of IV antibiotic treatment remaining at the time of the reported incident. 2. Review of resident 1's electronic medical record revealed: *Multiple references to a peripherally inserted central catheter (PICC) usually inserted into a vein in the upper arm rather than to the tunneled chest catheter or CVC that resident 1 had in her right chest. -Flush PICC line before and after medication administration every shift. -PICC dressing change to be completed every Wednesday. *She is currently hospitalized . *Resident 1's diagnoses included: -End stage renal disease -dependence on renal dialysis -chronic pain. -Osteomylelitis *She had a (brief interview of mental status) BIMS score of 10, which indicated moderate cognitive impairment. -Resident 1 was on an antibiotic therapy related to an Osteomyelitis infection. *On 10/10/24, she had a tunneled chest catheter placed at the hospital on the right side of her chest and returned from the hospital on 10/11/24. *On 10/17/24, an order from resident 1's nurse practitioner directed ok to remove PICC (a thin tube inserted into a vein in the arm, leg or neck and threaded into a large vein near the heart to allow long-term access to the vein) line. *On 10/18/24, an order was received from resident 1's nurse practitioner for placement of a new tunneled chest catheter to be placed on 10/22/24. 3. On 10/28/24 at 4:10 pm PICC line removal policy, and IV medication administration policy and PICC line training/education was requested from administrator B. -Administrator B did not provide a PICC line removal policy by the end of the survey on 10/29/24. *Staff training and education requested for RN C revealed the education packet did not include: -Tunneled chest catheter placement or removal. -IV medication administration. -Administrator B did not provide an IV medication administration policy. 4. Interview on 10/28/24 at 4:35 p.m. with RN C revealed: *He has been employed at the facility for one year and two months. *He had no training during his employment at the facility regarding: -IV medication administration. -The placement or removal of PICC lines or tunneled chest catheters. -He states the only training he received was what was included in the training packet he completed when he was hired. *He reported resident 1 had one PICC line present on the date that he removed the line. -He thought resident 1 had a PICC line present because that's the way it is noted in the chart. -He reported that the line he removed was located in resident 1's right upper chest. -He stated Sometimes PICC lines can be present in that location of the body. -He stated he was aware resident 1 had an order for antibiotics through 11/16/24. *He stated that he removed the PICC line because he got an order from the nurse practitioner to do so. -He stated, In my defense, I had the resident lie flat and hold her breath while I removed it. 5. Interview on 10/29/24 at 8:27 a.m. with assistant director of nursing (ADON) F revealed: -She participated in antibiotic stewardship and infection control. -Every morning, she receives a list of residents who were receiving an antibiotic. *Resident 1's antibiotic therapy was discussed at the intradisciplinary team (IDT) meeting on 10/17/24. -Note in resident 1's chart regarding the (IDT) meeting on 10/17/24 that indicated resident was not on an antibiotic, was written in error. -There was no order received by the facility to discontinue resident 1's IV antibiotic therapy. -Resident 1 was receiving IV antibiotic therapy on 10/17/24. 6. Interview on 10/29/24 at 9:36 a.m. with director of nursing (DON) A revealed: *He was aware that the nursing staff had received an order from the nurse practitioner to remove resident 1's tunneled chest catheter. *An order was not received to discontinue resident 1's IV antibiotic therapy. -He was aware that the day before resident 1's catheter was removed, her nurse practitioner came to the facility for a visit with her and documented to continue her IV antibiotics through 11/16/24. -He stated, Its possible that the nurse read the date of 11/16/24 and thought it said 10/16/24 as the date that the antibiotic therapy was to be completed. *He did not visualize the IV line that resident 1 had. *He stated that the facility received approximately one resident weekly with a PICC line present. -He stated the facility rarely receive residents with a tunneled chest catheter present. *He was not aware of any nursing education for the placement or removal of PICC lines or tunneled chest catheters. *He stated the pharmacy came on 9/12/24 to complete staff education for all nursing staff. *He states that the facility did not have a policy that includes PICC line removal or tunneled chest catheter removal. 7.Interview on 10/29/24 at 10:10 a.m. with Administrator B revealed: *She did not visualize the tunneled chest catheter that resident 1 had. -She was not aware of any policies regarding PICC line or tunneled chest catheter placement or removal. -She denied any education was provided by the facility to staff regarding PICC line or tunneled chest catheter placement or removal. *She denied any competencies regarding PICC line removals had been completed. 8.Interview on 10/29/24 at 11:10 a.m. with licensed practical nurse (LPN) E revealed she: *Had no education regarding IV antibiotic therapy while employed at this facility. *Did not administer any IV antibiotics to resident 1. *Denied being present at a pharmacy training in September 2024. 9.Interview on 10/29/24 at 11:15 a.m. with RN D revealed she: *Had administered IV antibiotics to resident 1 one time. *Had not had any training regarding IV antibiotic medication administration during her employment at this facility. *Was present at a pharmacy presentation in September 2024 but stated that no training was completed that day.

Based on South Dakota Department of Health (SD DOH) complaint online report, observation, interview, and policy review, the provider failed to implement pressure ulcer prevention interventions to prevent the development of pressure ulcers for one of one sampled resident (3). Findings include: 1. Record review of the SD DOH complaint revealed: *Resident 3 was coded that she did not have skin issues. -She had a pressure ulcer that had worsened. -She had no wound interventions in place to ensure her wound healed. -She did not have documentation in her electronic medical record of her refusing repositioning. -She did no have documentation of her being educated to why repositioning would be beneficial to her wound healing. 2. Observation on 8/19/24 at 4:45 p.m. revealed resident 3 was sleeping in bed on her back, with her call light within reach. 3. Observation on 8/20/24 at 4:45 p.m. revealed resident 3 was again sleeping in bed on her back with her call light within reach. 4. Observation and interview on 8/20/24 at 8:53 a.m. with resident 3 with certified medication aide (CMA) P and certified nursing assistant (CNA) Q revealed: *They were repositioning her in bed because she had shifted down her mattress. *CMA P stated resident 3 does have pain because her legs are stiff. *Resident 3 asked CMA P why they were moving her and told her it was because she said she was uncomfortable when she got her medications. *She had bilateral heel boots on, and refused to have a pillow placed between her legs and said Maybe later. *Resident said when she was at home her husband had taken care of her wounds but could no longer care for her. *She had a carton of Boost supplement, drank a few sips and said that was enough. 5. Interview on 8/20/24 at 11:53 a.m. with resident 3's family revealed: *Resident 3 accepted repositioning if she was comfortable and without pain. *He stated resident 3 had three pressure ulcers and the one on her sacrum (tailbone) was down to the bone and was the size of a half dollar. She had been cared for at home for 7 years and the wounds had healed, but would open easily with any movement. -The family used foam surgical tape and rolled towels for repositioning. -Pillows were kept under her feet to prevent heel wounds. -She would refuse to move from her recliner, which was brought from home, to bed because it was uncomfortable. - They could have stood her up and adjusted the cushion for repositioning. *Family stated she laid in a crappy diaper for half an hour, and they were short on help. *She had been placed on hospice care last week and they were readjusting her oxycodone (pain medication) so she doesn't sleep as much. *Call light staff response had taken an hour at times, and she would call her family and they would call the facility and ask someone to go help her. *They had talked to social service director N and she would file grievances. *She didn't get the heel boots until after the right heel wound had already started. Before that, she had been wearing regular nursing home slippers. 6. Interview on 8/20/24 at 9:14 am. with Registered Nurse (RN) D regarding resident 3 revealed: *She had a history of wounds at home and had come back but were getting better. *The heel wound was newer, and she had an order for heel protector boots. *Resident 3 had refused to wear the boots, and her refusals were documented. - She would wear them now because of the heel wound. *RN D said the wounds could have been prevented if she would have worn the Prevlon heel boots. *She would refuse repositioning because she couldn't see the TV while lying on her side. *She had refused physical therapy. 7. Interview 8/21/24 at 9:08 with CNA R regarding resident 3 revealed: *She would get repositioned every 2 hours but would refuse at times. *When she complained of pain it would have been reported and the nurse would get pain medication for her. 8. Record review of call lights response from 6/1/24 to 8/20/24 for resident 3 revealed on multiple occasions it had been on for 20-38 minutes. 9. Review of resident 3's care plan dated 3/13/24 revealed: *The skin ulcer prevention interventions did not include repositioning *She had heel protectors ordered but didn't care to wear them as she preferred socks. *Prevalon boots were not included in her care plan but were ordered on 8/2/24. 10. Review of resident 3's skin/wound note on 6/27/24 at 4:44 p.m. revealed Reviewed resident's sacrum/bilateral buttocks. When resident first admitted to facility resident resident had a stage 3 pressure, it healed and resident developed a rash. Rash has healed and resident's sacrum/bilateral buttocks has re-opened. Due to previously having a stage 3, it is classified as a stage 3 with re-opening. Current measurement: 13x13.0.01 cm. writer applied triad and border foam to area. Faxed provider update and for new orders. Updated family. 11. Review of resident 3's skin/wound care orders revealed: *On 5/28/24 Following facility standing wound orders. Cleanse with normal saline, pat dry, cover with collagen gel, apply bordered foam. *On 5/31/24 Reviewed resident's sacrum/buttocks. Current measurement: 10 x 8.5 cm. Applied current orders: Cleanse with normal saline, pat dry cover with collagen gel, apply bordered foam. Applied barrier cram to erythema. *On 6/20/24 Clean wound, apply medihoney and cover with bordered foam dressing daily until resolved. *On 6/28/24 PCP-ok to apply collagen particles mixed with triad daily and as needed with incontinence episodes to sacrum/bilateral buttocks ok to discontinue medihoney/borderfoam. *On 7/19/24 Updated orders: 1. Sacrum: cleans with wound cleanser, apply skin prep, apply collagen particles, and cover with hydrocolloid. 2. Bilateral buttocks: apply triad mixed with collagen particles. *On 8/19/24 Ok for [NAME] hopice to eval and treat. *On 8/19/24 Received fax from hospice . New orders: right heel-cover with optifoam dressing every other day. Coccyx-apply therahoney, then calcium alginate and cover with optifoam dressing every day. 12. Review of resident 3's wound assessments details report for her sacrum/buttocks and right heel revealed: *The reports were signed and completed by a licensed practical nurse (LPN). -There was no collaboration between a registered nurse (RN) and he LPN for skin assessments. *The wound was on the bilateral buttocks/sacrum. *The wound was facility-acquired 7/4/24 *The status, type, classification, clinical stage and measurement size in centimeters in Length (L) x width (W) x depth (D) of that wound was documented as follows: -On 6/6/24 active, rash, erythema (redness) and measured 10.00 x 8.50 x 0.01. -On 6/13/24 active, rash, erythema and measured, 9.00 x 6.50 x 0.01. -On 6/20/24 active, rash, erythema and measured, 9.00 x 7.00 x 0.01. -On 6/27/24 healed, rash, erythema and measured, 0.00 x 0.00 x 0.00. -On 7/4/24 active, pressure ulceration, stage 3, and measured 13.00 x 11.00 x 0.01. -On 7/11/24 active, pressure ulceration stage 3 and measured 13.50 x 12.0 x 0.01. -On 7/18/24 active, pressure ulceration, stage 3 and measured 15.00 x 12.50 x 0.01. -On 7/25/24 active, pressure ulceration, stage 3 and measured 12.50 x 12 x 0.01. -On 8/8/24 active, pressure ulceration, stage 3 and measured 13.00 x 12.50 x 0.10. -On 8/1/24 active, pressure ulceration, stage 3 and measured 12.50 x 12.0 x 0.01. -On 8/12/24 active, pressure ulceration, stage 3 and measured 3.20 x 4.50 x unknown. -On 8/19/24 active, pressure ulceration, stage 3 and measured 3.40 x 4.00 x 1.10. *On 8/1/24 active, pressure blister, deep tissue pressure injury and measured 2.0 x 3.50 x unknown. -On 8/8/24 active, pressure blister, deep tissue pressure injury and measured 2.0 x 3.50 x unknown. -On 8/12/24 active, pressure blister, deep tissue pressure injury and measured 2.70 x 2.20 x unknown. -On 8/19/24 active, pressure blister, deep tissue pressure injury and measured 4.10 x 2.90 x unknown. Summary Resident 3's Sacrum and buttocks wounds were healed 6/27/24 and a facility acquired pressure injury that measured 13.00 x 11.00 x 0.01 on 7/4/24 as a stage 3 and had worsened and measured 3.40 x 4.00 x 1.10. Her right heel wound was a facility acquired deep tissue pressure injury that measured 2.0 x 3.50 on 8/1/24 and had worsened to 4.10 x 2.90. 13. Record review of the providers skin and pressure injury prevention program policy dated March 23, 23 revealed: *To provide care and services to prevent pressure injury development to promote the healing pressure injuries/wounds that are present. 14. Grievances were reviewed, but none were found from resident 3.

Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to honor a resident's refusal to shower and to follow that resident's bathing preferences as directed on their care plan for one of one sampled resident (1). Failure to do so resulted in the resident expressing feelings of anger and mistrust towards a staff member. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's SD DOH FRI submitted on 5/28/24 at 11:22 a.m. revealed: *Resident 1 reported certified nurse aide (CNA) E was rough with her on the morning of 5/27/24. *She reported that CNA E forced her to wake up at 7:10AM and demanded she take a shower because she urinated on herself, and grabbed her by the arms and pushed her down into the chair. 2. Interview on 6/19/24 at 1:36 p.m. with resident 1 regarding the above incident revealed: *A staff member came in her room around 7:00 a.m. and woke her up. *She had not seen that staff person before. *The staff person startled her and was tried to tell her to get up to take a shower. -She asked the staff person who she was. -She said the staff person said, I don't work here, I'm just a temporary. *The staff person grabbed her by both arms and slammed her down in the shower chair. -Resident 1 said that she told the staff person to get your hands off me or I'm going to deck you. *She said that she was manhandled. *She said her shoulders were hurt because that staff person grabbed her. *She did not like to wake up that early and would rather have gotten up around 8:00 a.m. or 9:00 a.m. *She went to physical therapy after that incident and told the therapist about the situation. She thought that the therapist informed the head therapy gal. *Her son visited that morning, and she also told him about the incident. -Her son immediately informed the manager about the situation and demanded that that CNA was not to go into his mother's room anymore. 3. Interview on 6/19/24 at 2:58 p.m. with physical therapy assistant (PTA) H and physical therapist (PT) I regarding resident 1 revealed: *PTA H confirmed he was present on the day of that incident. *He remembered resident 1 having had mentioned being upset about not wanting to get up that early to shower. *He did not recall her saying anything about being manhandled. *PT I indicated if a resident concern was serious enough like this incident described, they would have reported it to administrator A or director of nursing (DON) B. *Neither of them reported resident 1's concern to anyone. 4. Interview on 6/19/24 at 4:25 p.m. with resident 1 regarding the above incident revealed: *She did not recall having been incontinent that morning. *She said, I may have piddled because she was startled. *She did not believe she was soaked with urine that morning. *She said in regards to having been awakened for bathing, It made me mad, first fucking thing in the morning. 5. Interview on 6/20/24 at 9:05 a.m. with CNA G regarding the above incident revealed: *She confirmed she was working that day. *She remembered hearing about the situation but had not witnessed it. *Resident 1 did not always like to shower, especially in the morning. *She confirmed she worked with CNA E that day and did not have any concerns with how CNA E had interacted with other residents. *She confirmed CNA E worked the entire shift from 6:00 a.m. to 6:30 p.m. 6. Interview on 6/20/24 at 9:18 a.m. with licensed practical nurse (LPN) D regarding the above incident revealed she: *Confirmed she was working that day. *First learned of the incident when the resident's son came to her that morning and told her that he did not want CNA E involved in his mother's care going forward. *Spoke to resident 1 and she told her CNA E had came in and hoisted her. *Said that resident told her she had reported the incident to PTA H earlier. *Recalled feeling frustrated about the situation because neither PTA H nor CNA E had told her about the incident. *Helped resident 1 with filling out a grievance form on 5/27/24 and gave that form to the manager on duty, LPN C, and texted administrator A that same day to let her know about the incident. *Told CNA E not to go into resident 1's room or answer her call lights anymore that day. *Indicated that day was her first time working with CNA E, but she was great at getting her job done and reported no other concerns with CNA E's demeanor. *Spoke with PTA H and reminded him to let them know if a resident tells [him] anything like that. *Confirmed that LPN C was on site that day from about 8:00 a.m. to around 4:00 p.m. 7. Interview on 6/20/24 at 10:49 a.m. with CNA E regarding the incident between her and resident 1 revealed: *She signed up for a full shift on 5/27/24. *They were overscheduled that day, so she was reassigned to help with showers in the rehabilitation (rehab) unit. *She had never worked on that unit before, and she did not know those residents. *She was not briefed on who the residents were, if they needed help with transferring, or anything directed on their care plans. -She was given a piece of paper with resident names and room numbers on it and was told those residents needed a shower that day. *No one told her that resident 1 did not like to wake up that early in the morning, or that the resident would rather shower in the evening. *Before breakfast that day, she knocked and walked into resident 1's room and introduced herself. -The resident needed to use the toilet. -She placed the resident's wheelchair next to her bed. -The resident was not steady. *She tried to explain to the resident that she needed to shower because her brief and clothes were wet. -She said the resident said to her, I don't give a fuck about being wet. -She was trying to convince her that you [resident 1] really need to shower. -Resident 1 said to her again, I don't want to shower. *She helped the resident undress and transfer to the toilet. *Resident 1 stood up from the toilet suddenly and looked unsteady, so she placed her right hand on the resident's left arm to guide her to the shower chair to prevent her from falling. *CNA G came in to help. *CNA E informed the nurse about the situation immediately. *She said after that incident, she had helped the resident two more times before the nurse instructed her to not go into resident 1's room anymore. -Resident 1 put her call light on twice after breakfast and was perfectly sweet. -The resident's son was the one who requested other staff to care for resident 1, not the resident herself. *She confirmed she worked the rest of her shift. *She confirmed that before she started working for the facility, she reviewed an orientation packet that included training on abuse and neglect. *Either administrator A or DON B contacted her on 5/28/24 to inform her of the investigation process and they would be in touch with her regarding her employment. *She received a notification from her staffing company that she was put on the do not return list for this facility. 8. Interview on 6/20/24 at 12:02 p.m. with LPN C regarding the above incident revealed: *She confirmed she was filling in as the manager on duty that day. -She was the only manager in the building that day, and it was a very busy day. *LPN D had informed her of the situation, but she said her understanding of the situation was resident 1 was frustrated with being here and had trouble with a CNA transferring her. *She had instructed LPN D to help resident 1 fill out a grievance form. *She did not review the grievance form before LPN D had slipped the form under the door of either the social worker or the administrator. *Her impression of the situation was not manhandling. -If I had been told that there was alleged abuse, I would have called [DON B] or [administrator A] right away. *Administrator A reeducated her, and the management team, regarding the provider's abuse and neglect policy and when to report incidents. *She spoke with resident 1 the next day and the resident had not reported any concerns at that time. *During shift change, staff were to have reviewed the daily assignments sheets, reviewed diets, special equipment, how residents transfer, and their code status. *Staff were to have a Kardex pocket care plan as well. 9. Interview on 6/20/24 at 12:29 a.m. with administrator A and DON B regarding the incident between resident 1 and CNA E revealed: *It was their expectation to have been notified immediately regarding any potential abuse or neglect situations. *Administrator A was notified of the situation through a grievance form on 5/28/24. *She immediately suspended the CNA pending the investigation and spoke with resident 1 regarding the incident. *She spoke with CNA E to obtain her side of the story. *As part of the investigation, she: -Interviewed other residents on the rehab unit to learn if there were any other resident concerns. -Interviewed staff to learn about their involvement. -Informed the director of therapy of the situation so she could educate therapy staff about what to report, when to report, and who to report to. -Reeducated staff from all departments about the provider's abuse and neglect policy and expectations for reporting. *Her expectation would have been to allow resident 1 to refuse the shower and to come back later or have a different staff member come back later to assist the resident. *Administrator A denied she had received a text from LPN D on 5/27/24 regarding the incident. *She informed the staffing agency to not allow CNA E return to the facility. 10. Review of the grievance form written by LPN D on 5/27/24 revealed: *The form was filled out at 12:30 p.m. *LPN D received information from both resident 1 and resident 1's son. *Under the Describe Grievance or Satisfaction section: -0700 [7:00 a.m.] - Resident reports that this morning CNA had come in to get her up. -Resident reports that CNA had put shower chair in front of her and resident had stated 'I don't want a shower this early.' -CNA then had said 'Well you peed all over yourself.' -Resident reports that then CNA [picked her] up by both her arms and placed her in shower chair. -Resident reports that CNA had told her she didn't [work] here and resident had replied 'Well why are you here.' -Resident also reports that CNA was very rough with her this morning. *The Resolution section read, Reported to DOH [Department of Health], see investigation Finding in file. 11. Review of the provider's investigation into the incident revealed the following: *When the administrator received the grievance form on the morning of 5/28/24, she immediately suspended CNA E pending the investigation. *A skin assessment was completed on resident 1 with no new skin concerns identified. *The resident expressed her experience through additional interviews. *Other staff and residents were interviewed regarding CNA E. -All other residents interviewed verbalized having been free from abuse and neglect. -No new concerns from other staff members were identified. *CNA E's staffing agency was notified that she was not allowed to return to the facility. *Resident 1 and her son were informed of the outcome of the investigation and indicated satisfaction with the grievance outcome. *A complaint was submitted to the South Dakota Board of Nursing regarding CNA E. 12. Review of resident 1's electronic medical record revealed: *She was admitted on [DATE]. *Her most recent Minimum Data Set assessment was completed on 5/22/24. -The Brief Interview for Mental Status score was 13, indicating she was cognitively intact. *CNA E documented resident 1 had received a shower on 5/27/24. -It was documented the resident required total dependence [of staff] of one person physical assist with the shower. *The resident's last documented shower before the incident was on 5/23/24 at 1:15 p.m. *Resident 1 was incontinent of bladder and continent of bowel on the morning of 5/27/24. *She had physician's orders for the following pain medications: -Acetaminophen Oral Tablet 500 MG [milligrams] (Acetaminophen) Give 500 mg by mouth three times a day for Pain don't exceed Tylenol 3gm [grams]/24 hours. That had a start date of 5/22/24. --On 5/27/24, she reported her pain level at a 0 out of 10 for the three doses administered. --On 5/28/24, she reported her pain level at a 4 out of 10 at the 9:00 a.m. dose, 7 out of 10 at the 1:00 p.m. dose, and 4 out of 10 at the 5:00 p.m. dose. -Acetaminophen Oral Tablet (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for pain or fever. That had a start date of 5/16/24. --She did not take any of the as needed (PRN) acetaminophen between 5/27/24 and 5/31/24. -oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 2.5 mg by mouth every 4 hours as needed for pain management until 6/13/24. She did not use the PRN oxycodone during May 2024. Review of resident 1's care plan at the time of the incident (5/27/24) revealed: *A focus area that read, [Resident 1] requires assistance with [activities of daily living] (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). Initiated on 5/16/24. Revised on 5/28/24. -An intervention under that section read, Assist resident with shower/bathing 2 showers per week in evening. Initiated on 5/16/24. Revised on 5/16/24. *There was nothing in her care plan at the time of the incident indicating how the resident was to have been transferred. -An intervention was added on 5/28/24 that read, [Resident 1] is independent with toileting hygiene and transfers will self-propel in wheelchair without pedals, she will at times remove her foot pedals and will at times remove the bag off the back of the wheelchair for foot pedals. Initiated on 5/28/24. Revised on 6/19/24. Review of the therapy provider's progress notes revealed: *Resident 1 received occupational therapy and physical therapy services on 5/27/24. *The occupational therapist assistant's note read: -Pt [patient] presents supine [laying on her back] in bed and requires supervision to push up into sitting at EOB [edge of bed]. -Pt ambulates to bathroom with use of FWW [front wheeled walker] and transfers onto toilet with use of grab bars with CGA-SBA [contact guard assist-stand by assist] for safety. -Pt ambulates throughout facility with FWW and CNA and demonstrates ability to ambulate from room to therapy gym. -There was no mention of the resident's demeanor or any complaints during the occupational therapy session. *The physical therapist assistant's note read: -Patient pleasant and cooperative with no new complaints. Denies any new pains/soreness. 13. Review of the provider's February 2024 Grievances policy revealed: *Procedure: - .2. The facility Administrator has been designated to receive all grievances. - .6. During the investigation, the facility will put in place immediate action to prevent potential violation of resident's rights. -7. If the grievance includes suspected abuse, neglect, injury of unknown source, or misappropriation of property, abuse protocol will be followed. (See Abuse and Neglect Policy) -Process: Party initiating the comment of Grievances or Satisfaction: -- .If there is a grievance that needs immediate attention, please bring it to your charge nurse's attention right away so it can be addressed by the facility Administrator. --Some situations that require a more immediate response include but are not limited to: .situations that could be abuse such as yelling, rough treatment, hitting, etc. -Process: Staff Member: -- .Submit the forms to the Charge Nurse. Alert the Administrator if immediate action needs to occur. -Process: Charge Nurse and Management Team Members: -- .If it is a Grievance, determine if immediate intervention is needed. Alert the administrator if immediate action needs to occur. 14. Review of the provider's February 2024 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, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. -The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. -These guidelines include compliance with the seven (7) federal components of prevention and investigation. *Types of Abuse and Examples: Physical -Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, [NAME], twisting, and roughly handling. -Any person in a position of power or authority may potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, .other visitors. *If abuse/neglect is suspected the facility will: -1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care. -2. Notify the appropriate/designated organization/authority that an investigation is being initiated immediately following intervention for the resident's safety. -3. Conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses. -4. Notify law enforcement authorities if indicated (i.e., a crime such as physical or sexual abuse, theft, etc.) -5. Report the investigation findings to all necessary state and/or local agencies and any other identified persons as required by law. *VII. Reporting/Response . -All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. -All allegations of abuse will be reported to your state agency immediately (within 2 hours) after the initial allegation is received. *In section 1150 B of the policy: -Reporting: All allegations and/or suspicions of abuse/neglect must be immediately reported to the facility Administrator or designee in the absence of the administrator. -Failure of an employee to report an allegation and/or suspicion of abuse will result in disciplinary action. -The Administrator is the Abuse Coordinator. -The abuse coordinator must submit a preliminary investigation report to their required state agency immediately once assurances for the resident's or other resident's safety have been established. The provider implemented actions to ensure the deficient practice does not recur was confirmed after: record review revealed the facility had followed their quality assurance process, provided education to all staff working within the facility regarding abuse, neglect, and reporting, and resident's rights, review of those educational materials and staff signature sheets of acknowledgement of that education, and interviews with several staff from various departments including housekeeping, social services, nursing, and therapy revealed staff understood the education provided regarding abuse, neglect, and the reporting process. Based on the above information, non-compliance at F550 occurred on 5/27/24 when resident 1's right to refuse a shower was not honored when staff gave her a shower after she verbalized she did not want to take a shower, and her previously care planned preferences for showering and bathing were not followed. Based on the provider's implemented corrective actions the deficient practice confirmed during the survey from 6/19/24 to 6/20/24, the non-compliance is considered past non-compliance.

Based on the South Dakota Department of Health (SD DOH) complaint online report, observation, interview, record review, and policy review, the provider failed to ensure: *One of one sampled resident (2) had staff supervision in place to prevent a hot liquid burn. *Two of two sampled residents (2, and 3) had hot liquid safety evaluations completed, were documented accurately, and interventions in place to prevent potential burns from hot liquids. Findings include: 1. Review of the 3/5/24 SD DOH facility reported incident regarding resident 2 revealed: *On 3/4/24 at approximately 10:30 a.m. resident 2 was in her wheelchair in the central dining room. *She placed hot water from a coffee/water dispenser into a personal plastic cup to make tea. *When the cup was filled with water, she pressed the lid onto the cup and placed the cup between her thighs on top of the wheelchair seat. *Resident 2 then used her arms to wheel herself out of the dining room and into the hallway toward her room. *When she entered the hallway, resident 2 yelled which caught the attention of a nearby nurse. *The plastic cup that held the hot liquid melted and spilled the hot water onto her inner thighs. *Resident 2 was quickly taken to her room by the responding nurse and cold compresses were applied to the areas. *The nurse completed a skin assessment that revealed a reddened skin area of 1.2 centimeters (cm) in width x 6.2 cm in length. *Physician's orders were obtained for treatment of the burn. Observation on 3/12/24 at 10:40 a.m. during the initial walk-through tour revealed: *Automatic coffee/ hot water dispensers in the following areas: -The central dining room. -The rehabilitative dining area. -Across the hallway from the nurse's station, but that coffee/hot water dispenser had been out of service. Interview on 3/12/24 at 11:45 a.m. with activities director D who was assisting with the central dining room meal service revealed: *The central dining room doors remained open all day. *Activities were conducted in that dining area such as bingo, or other scheduled activities for the residents to participate in. *Staff, visitors, and residents were free to come in and out of the central dining room for beverages if they chose. *The residents were able to get beverages independently. Interview on 3/12/24 at 11:50 a.m. with dietary manager F revealed: *Coffee and hot water were available for residents, visitors, and staff. *The doors of the central dining room stayed open because the room was used throughout the day. *Residents were in and out of the dining room for activities or leisure. *She confirmed residents could get hot water or coffee independently. *Insulated coffee cups were stored on a table nearby and were available if someone wanted a beverage. Review of resident 2's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) score of 12 indicated she had mild cognitive impairment. *Hospice services had began on 1/18/24. *Her diagnoses included the following: -Anemia. -History of amnesia. -Cirrhosis of the liver. -Osteoarthritis. -Congestive heart failure. -Atherosclerotic heart disease. -Chronic kidney disease. -Atrial fibrillation. -Anxiety disorder. *The physician was contacted on 3/4/24 and an order was received to continue monitoring the burn area. Apply cold/ice pack as needed. *An additional physician's order was received on 3/5/24 for Sulfadiazine cream to burn twice daily with an applied thickness of 1/16 inch. *Wound assessments and physician-ordered wound treatment was reviewed and completed by nursing staff. *The wound was healing. Review of resident 2's 1/15/24 admission Hot Liquids Safety Evaluation revealed: *The total score of the evaluation was four, that indicated she was at risk for injury related to handling hot liquids, and individualized interventions were to have been put in place. *Section B: Made decisions regarding tasks of daily life was documented with a score of one, and marked modified independence. *Section G: Demonstrates ability to handle eating equipment (cup, glass, utensils) was documented with a score of three, and marked no. *Section III: Determination -I. --A was blank: A Score of 3 or > (greater) list interventions put in place, in comments section below. --B was documented: Resident is not considered to be at risk related to hot liquids at this time. -II. The additional comments section was blank. Review of resident 2's 3/5/24 Hot Liquids Safety Evaluation revealed: *The form was documented with a score of four. *However, the evaluation was still documented: Resident is not considered to be at risk related to hot liquids at this time. *A note was added in the comments section, Resident used a cup for hot water that was not appropriate for hot water and it melted. Review of resident 2's 1/15/24 care plan revealed: *Interventions: [Resident name] has a burn to her inner right thigh from hot liquid. [Resident name] was educated on the importance of proper container use, use of a lid, and to ask for help pouring and transporting hot liquids. Initiated: 3/8/24. *Those interventions were not added to her care plan until after the resident was burned with hot water on 3/4/24. *If nursing staff had completed the admission Hot Liquids Safety Evaluation correctly, resident 2 should have had staff assistance when she had hot liquids from the time of her admission and the need for staff assistance would have been added to her care plan at her admission. Interview on 3/13/24 at 9:45 a.m. with resident 2 in her room revealed: *She was seated in her wheelchair next to her bed. *When asked about the incident that had resulted in her burn, she said she used a plastic cup that she thought would work for hot drinks. *She was in the central dining area after breakfast. *She went to the coffee/hot water dispenser while in her wheelchair to make a cup of hot tea. *She put hot water into her plastic cup, placed the cup between her legs, and wheeled out of the central dining room into the hall and toward her room. *Shortly after she got to the hall, she felt a hot sensation against the skin of her legs, yelled, and threw the cup from between her legs and onto the floor. *A nurse came over and helped her to her room and placed a cold cloth on the area. *The plastic cup had melted from the hot water. *The nurses would check the area twice a day, put a cream on it, and cover it with a bandage. *The wound was healing. *She had gotten hot beverages independently since her admission and that was the first time she had been burned. *After the burn incident, a nurse asked her to request staff assistance when she wanted hot beverages and she agreed to that. *The cup that she used when she had gotten burned was thrown away after the incident. 2. Observation on 3/12/24 at 12:23 p.m. in the central dining room with resident 3 revealed: *She left her spot at the dining room table, and wheeled her wheelchair next to the coffee/hot water dispenser. *She placed an insulated cup under the coffee spout, filled the cup with coffee, placed a lid on top of the cup, set the cup to her right between the side of the wheelchair and her right thigh and then wheeled back to her room. *Staff were present in the central dining room assisting other residents with their meals, but none of the staff approached and offered assistance to resident 3 with the hot coffee. Review of resident 3's EMR record revealed: *She was admitted on [DATE]. *Her BIMS score of 14 indicated her cognition was intact. *Her diagnoses included the following: -Cerebral Palsy -Adrenal gland disorder -Cancer of the left lower lung and bronchus -Anemia -Charcot's joint, left ankle and foot -Unsteadiness Review of resident 3's Hot Liquids Safety Evaluation revealed: *She had not had an evaluation completed in the last quarter *Her last evaluation was completed on 2/25/23 with a score of 4. *That score indicated she would require interventions regarding hot liquids and staff assistance. Review of resident 3's revised 3/5/24 care plan revealed: *There were no interventions related to the resident's handling hot liquids or the need for staff assistance. Interview on 3/12/24 at 4:45 p.m. with administrator A regarding residents 2 and 3 revealed: *Hot Liquids Safety Evaluations were to have been completed on admission, quarterly, and with a significant change of condition. *The Minimum Data Set (MDS) coordinator was primarily responsible for completing the Hot Liquids Safety Evaluations when the MDS assessments were done. *The floor nurses would complete the Hot Liquids Safety Evaluations when needed. *She confirmed that resident 2 and 3's evaluation forms had been documented incorrectly. *If a resident had scored higher than a three on the evaluation, the resident should have had staff supervision which would include the staff getting the hot beverage and delivering it to the resident in their room or the dining area. *Education on how to complete the evaluations would be prioritized to ensure the forms were completed accurately. *She agreed resident 2 should have had staff assistance according to their Hot Liquids Safety Evaluation scoring. *Resident 3 should have had a hot liquid evaluation completed the past quarter. *On prior evaluations resident 3 had scored a three or higher and should have had staff supervision with hot liquids. *The nurses had difficulty with completing the evaluations due to other duties on the floor. *They had issues filling the MDS coordinator position and had not had someone in that position consistently. -The current MDS coordinator was new to the position and had started at the beginning of 2024. Review of the provider's revised 3/23/23 Hot Liquid Safety policy revealed: *Hot Liquid Safety Evaluation will be completed on admission, re-admission, quarterly, with significant change, and as needed. *The Hot Liquid Safety Evaluation includes the following: -Vision -Decision Making Ability -Altered Level of Consciousness -Psychomotor Retardation -Upper Extremity Impairment -Upper Extremity Tremors -Ability to handle eating utensils -Diagnoses *Procedure: 1. Complete the [facility corporate name] Hot Liquids Safety Evaluation (West) to determine if the resident scores 3 or greater. 2. If resident scores 3 or greater proceed to care plan and implement individualized interventions for safe handling of hot liquids.

Based on the South Dakota Department of Health (SD DOH) complaint online report, record review, interview, and policy review, the provider failed to follow physician orders to provide pain medication before scheduled wound care was completed for one of one sampled resident (1). Findings include: 1. Review of the South Dakota Department of Health facility complaint online report revealed: *A family member of resident 1 had concerns regarding the resident receiving his pain medication, specifically his oxycodone that was prescribed for pain. *That family member reported that resident 1 was frequently in pain, would cry out in pain, and noticed a substantial decline in his health. *On 2/10/24 the resident requested to go to the emergency room (ER) due to complaints of his pain and rated his pain a 10 out of 10 scale rating (A pain scale with 10 being the worst pain you could experience) according to the records provided. The resident was admitted to the hospital for acute encephalopathy and cellulitis of the right lower extremity. He was later discharged into hospice care on 2/13/24 and passed away on 2/16/24. 2. Review of resident 1's electronic medical record (EMR)revealed: *The resident's diagnoses included Type 2 diabetes, chronic kidney disease, atherosclerotic heart disease, depression, and a history of [NAME]-[NAME] disease (a genetic disorder that caused blisters and erosions on the skin). *There were multiple days in January 2024 where there was no pain rating obtained by staff or only one pain rating documented for resident 1. * A Wound Care progress note dated 1/10/24 indicated that the resident had an unstageable pressure ulcer (An ulcer that has full-thickness skin and muscle tissue loss and covered in dead tissue making it difficult to stage) measuring 4 centimeters (cm) in length x 3 cm in width with no measurable depth with an area of 12 square (sq) cm. The resident reported pain 10/10 on the pain scale. *Resident 1's Medication Administration Record (MAR) indicated that he only had acetaminophen for pain as needed for pain twice daily. That was not administered on 1/10/24 when resident complained of the above 10/10 pain. *Wound nurse/licensed practical nurse (LPN) C had sent a fax on 1/10/24 to the resident's medical provider that stated, CNP [certified nurse practitioner] wound provider recommends lidocaine 4% gel or stronger oral pain medication for dressing changes based on 10/10 [pain scale] rating with recent dressing changes. Would you approve lidocaine and recommend an oral pain medication? *The medical provider's order was received and noted on 1/12/24 for lidocaine gel, would schedule Tylenol at that time. Administer tramadol 25 milligram (mg) thirty minutes before the dressing change, no more than once daily. *Review of the resident 1's January MAR revealed: -A physician order dated of 1/12/2024 for tramadol 25 mg tablet by mouth for thirty minutes before the scheduled dressing change. -A physician order for acetaminophen 500 mg tablet by mouth as needed for mild pain was only administered four times in the month of January (Dressing changes to resident 1's right heel was scheduled daily). *Review of resident 1's January Treatment Administration Record (TAR) revealed that the resident received wound care to the right heal on 1/12/24 through 1/21/24. *According to the January MAR the resident only received the tramadol 25 mg in four out of the ten dressing changes scheduled from 1/12/24 through 1/21/24. *According to the January MAR lidocaine gel was not documented as being administered from 1/12/24 through its discontinued date on 1/23/24. *Wound nurse/LPN C had sent a fax on 1/22/24 to the resident's medical provider stating Resident c/o [complains of] 10/10 pain with dressing changes with new order of tramadol 25 mg. Would it be possible to increase? Wound care CNP would like to debride site but still too painful with this medication and lidocaine. *An order was received and noted on 1/23/24 to increase tramadol to 50 mg PO (by mouth) daily PRN [as needed] with dressing changes. *Resident 1's January TAR revealed that resident 1 received wound care daily from 1/24/24 through 1/31/24. *Resident's January MAR revealed that resident had only received tramadol 50 mg before the scheduled wound care twice out of eight dressing changes. *On 2/1/2024 the resident was prescribed oxycodone 5 mg tablet by mouth every 6 hours as needed for pain. That medication was to have been given thirty minutes before the residents scheduled dressing changes. *The February TAR indicated that the resident received wound care from 2/2/24 through 2/8/24. *Resident 1's February MAR indicated that the resident had not received the oxycodone 5 mg tablet before his scheduled dressing change on 2/3/24, 2/7/24, and 2/8/24. *A nursing progress note dated 2/4/24 at 9:55 a.m. stated, Yelling out of room wanting for staff [requesting staff assistance], not using call light. Non-pharmacological interventions: reorientation to situation. Pharmacological intervention: NA *There was no documentation found that the resident's pain had been assessed or that the physician-ordered pain medication was offered or administered at that date and time. *A nursing progress note dated 2/7/24 at 4:26 p.m. stated that resident refused wound care (That was confirmed to have been due to his pain through an interview with wound nurse LPN C on 2/13/24 at 4:30 p.m.) *A nursing progress note dated 2/8/24 at 1:48 p.m. stated Resident attention seeking, moaning, and yelling from room all day long and stopped when wife and daughter came to visit resident. As soon as [the] family [had left,] resident started to moan and yell from [his] room despite all needs being met. Despite medication being given on time . No non-pharmacological or pharmacological interventions were noted. *Review of the February 2024 MAR indicated that on 2/8/24 the resident received his scheduled morning dose of acetaminophen 1000 mg, but the physician ordered oxycodone 5 mg had not been administered. *A progress note dated 2/8/24 from the resident's primary care provider CNP stated Resident continues to complain of right heel pain. Review of the [February 2024] MAR shows Oxy IR [oxycodone immediate release] has not been utilized to fullest extent. Resident had only received four doses [of the Oxy IR] since the initiation of that medication ordered on 2/1/24. He had been receiving scheduled acetaminophen twice daily. He had one additional PRN [as needed] dose of acetaminophen that could have been utilized. He had received no PRN doses of acetaminophen since [the physician's order] change on 2/1/24. His pain does not appear to be well managed with PRN dosing. *The resident's pain was only assessed once on multiple days in January 2024 other days there was no assessment of his pain documented. *Resident 1's care plan dated 12/26/23 revealed that the pain interventions included the following: -Evaluate the efficacy of pain management. -Medicate before therapy and treatment. -Notify the physician if there was inadequate pain relief. -Observe for non-verbal signs of pain. -Provide analgesics as ordered. -Utilize non-pharmacological interventions. 3. Interview on 3/12/24 at 1:45 p.m. with LPN/wound nurse C revealed: *When asked about the resident's pain medication before the resident's scheduled dressing change. She stated that he would often refuse medications and his scheduled dressing changes due to his complaints of pain. *She was only able to provide documentation for one day where resident 1 had refused his dressing change. When asked specifically about the lidocaine gel she stated that the wound care CNP normally would apply it for the resident's wound debridement and that was why it was never documented on the MAR. 4. Interview on 3/12/24 at 3:10 p.m. with long term care (LTC) unit manager E revealed the resident's pain was supposed to have been assessed every shift. 5. Interview on 3/13/24 at 10:30 a.m. with LPN/wound nurse C and director of nursing (DON) B revealed: *They were not able to locate any documentation for the dates requested that the physician ordered pain medication was administered before the scheduled dressing changes and documented in the MAR for resident 1. *They both agreed that if it was not documented they would not be able to prove that the resident received his pain medication before his dressing change. *When asked how it was determined that medication was ineffective when the dosage increases were requested, they were not able to answer that question. *DON B expected that the resident would have been assessed for pain and administered his pain medication before his scheduled wound care. 6. Review of provider's March 2023 Pain Management Policy revealed: *The process for managing pain included assessing for potential pain, recognizing the presence of pain, identifying characteristics of pain, addressing the causes of the pain, developing and implementing interventions for pain (including pharmacological and non-pharmacological interventions), monitoring effectiveness of the interventions, and modifying interventions as necessary. *Comprehensive pain assessments were to have been completed upon admission, with the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain. *Pain was to have been assessed at least twice daily during the day and the night shifts.

Based on observation, interview, record review, and review of grievances, the provider failed to ensure staff interactions and services were provided in a manner that maintained a sense of dignity and respect for two of two sampled residents (144 and 252). Findings include: 1. Observation and interview on 12/14/23 at 3:40 p.m. with resident 252 revealed she: *Was in her room on the [NAME] wing eating a late lunch while seated in a wheelchair. *Had moved in on Thursday, 12/7/23, into a room on the East wing and then was moved to the [NAME] [Medicare A therapy] wing on 12/11/23. *Had been left completely on my own in her room after moving in, and felt like a non-entity. *Waited for a nurse to go over her medications with her and take her insulin to the refrigerator but she never saw a nurse until 4 a.m. *Had asked for the nurse to come in to take my blood sugar. I kept calling for the nurse to do it. The nurse was upset with me. I overheard her tell someone, 'Tell her I'll get there when I get there.' *Waited over an hour for someone to come clean the toilet after it was soiled by a resident who shared the bathroom. No one returned after a staff person had initially answered her call light, and she ended up having to use paper towels to clean the toilet. *Heard one staff person say they had inadequate staff, and the staff appeared to be were running around. -Being left completely on my own after moving in, and she said I felt like a non-entity. -Could hear a resident repetitively saying, Please help me followed eventually by someone saying, What do you want? *Talked a bit with social services designee (SSD) E on Thursday, and then SSD E came back on Friday and asked, 'How was your first night?' She made excuses to address what had happened. *Reported to her physician on Friday when he came to check on her that she wasn't getting my anti-rejection drugs. The nurse gave excuses in front of him. *Believed the nurse did not put her insulin in the refrigerator and it had gotten ruined because, when she changed the insulin in the reservoir for her insulin pump on Saturday night, her blood sugar on Sunday was high at breakfast, and even higher at noon. *Did not get the daily chronicle or snacks for the first two days, not until Sunday. *Felt completely different on 12/11/23 after she moved to a room on the [NAME] wing. *Had tears in her eyes and struggled to talk several times when describing her experience. Administrator/temporary manager (ADM/TM) C was present and observed during the interview with resident 252. Review of grievance and satisfaction forms revealed resident 252 had voiced a grievance by email on 12/10/23 at 4:53 p.m. to a healthcare provider, which had then been forwarded to the nursing home on 12/11/23 at 1:20 p.m. (Refer to F 585, finding 1). Review of the Staff Huddle Daily Stand-up Meeting notes revealed resident 252's name was listed: *On 12/7/23, under Pending Admits with (Med A) room [ROOM NUMBER] (2 pm). *On 12/8/23, under Admission with (Med A) room [ROOM NUMBER]. *On 12/11/23, under Changes noting room [ROOM NUMBER]. Review of resident 252's electronic medical record (EMR) revealed: *She moved into the nursing home on 12/7/23. *The 12/7/23 nursing admission UDA, which was locked on 12/8/23 at 11:23 a.m., noted: *Her vitals were recorded on 12/7/23 at 2:45 p.m. in the nursing admission UDA, but the remaining sections were not completed at that time. No time was listed for education regarding orientation to facility, unit & [and] room, orientation to call light, and resident's medication review, upon admission. The UDA was locked on 12/8/23 at 11:23 a.m. *A 12/7/23 admission summary progress note at 2:45 p.m. stated, Arrived to the facility via wheelchair with assist of son .Insulin pump is controlled by resident. Had kidney transplant in 2017. Alert and oriented communicates with clear speech has a left foot heel ulcer and a pea size mark on her left skin. *A 12/7/23 Skin/Wound Note was documented at 10:18 p.m. that included measurements of the left heel ulcer and a discussion with resident 252 about therapy. *The 12/8/23 social services UDA noted the Resident's Attitude Toward Placement included Resident displays/is unsure/insecure/anxious about placement. *A 12/10/23 progress note at 4:24 p.m. noted resident 252 voiced grievances about not receiving therapy on that day. -Resident visibly upset (crying) stated that she came to the facility for therapy and wanted to be home for christmas [sic], she said she wasn't here because she needed to be taken care [of]. -Resident said she was writing a letter to her pcp [primary care provider] and asked the therapist's name to which writer did not ask. -Writer notified DON of situation and asked to have him touch basis [sic] with resident on Monday. *A 12/12/23 progress note at 3:48 p.m. noted resident 252 was concerned that her medications were not given at the times she normally takes them, printed off the order list and allowed the resident time to edit list and give times of meds [medications], reviewed list with resident and adjusted times on mar [medication administration record] to reflect resident preferences. *Review of the care plan revealed: -Initiated on 12/7/23 and revised on 12/12/23, requires assistance with ADL's, with an intervention initiated on 12/11/23 for Transfers: pivot assist 1-2 [staff persons]. -Initiated on 12/7/23 and revised on 12/12/23, at risk for fluctuating blood sugars, with an intervention initiated on 12/12/23, Resident self-administers blood glucose checks, supplies are kept at bedside table, she has been assessed and is safe to self-admin [administer], ok per MD order. *The 12/12/23 Medication Self-Administration Evaluation noted resident 252's cognition was alert and oriented x [times] 3, Able to recall instructions of how to administer medication. Able to recall what time medication should be taken. On 12/13/23 at 3:15 p.m., ADM A was requested to provide a copy of the provider's admission policy. She replied they had no policy related to the admission process. On 12/14/23, ADM A provided a typed document titled Admission Process that listed eight bullets that stated what each department would do for admission documentation when someone moved into the nursing home. Interview on 12/14/23 at 5:39 p.m. with DON B regarding resident 252's experiences after moving in, he *Agreed the approach should have been better. *Confirmed there was no process that described how a resident would have been welcomed and oriented to the nursing home. *Said those staff actions should happen from common courtesy. *Wished someone would have reported her concerns to him. *Had been in the nursing home on Saturday and Sunday but had not checked in with her. 2. Observation and interview on 12/14/23 at 4:04 p.m. with resident 144 revealed she: *Was in her room and seated in a wheelchair with a portable table in front of her while she worked on a beading craft. *Voiced concerns about the way staff had treated her recently when she called for help to the bathroom. *Turned on call light, waited 30 minutes before CNA F came and told her, You'll have to wait because we are serving meals. *Said that was about 4:30 [p.m.] It was about 7-7:30 [p.m.] before someone came. *Also voiced concerns about how CNA G was very belligerent with how the sling straps were positioned. *Described the interaction with CNA G as follows: -That presses the straps into my skin. -CNA G, We know how to put it on. -I'm telling you what is comfortable with me. -CNA G, We know what we are doing. She kept pulling the sling. -It's not going to work. Put me back on the bed and start over. -CNA G, You realize you are a lot bigger than we are. -Honey, I realize that. -CNA G pulled the sling out and threw it on the chair and walked out. *It really, really upset me. *Had only been in this condition since April. I've been here since October. *Never had experience with being in a nursing home until then. *Had tears in her eyes and struggled to talk twice when describing her concern. Administrator/temporary manager (ADM/TM) C was present and observed the interview with resident 144. Review of grievance and satisfaction forms revealed resident 144 had voiced two grievances related to the concerns reported above. (Refer to F 585, finding 2) Review of resident 144's EMR revealed: *She moved into the nursing home on 10/5/23. *The 10/6/23 social services UDA noted the Resident's Attitude Toward Placement included: -Resident views admission as necessary. -Resident appears to accept. -Resident appears positive. -Resident's coping skills were checked as: can verbalize feelings, strong supportive relationships, and planning/logical thinking. *On the 10/12/23 admission Minimum Data Set (MDS) assessment, the Brief Interview for Mental Status (BIMS) score of 15 noted she had intact cognitive function. *Care plan focuses on 10/5/23 related to: -Activities of daily living (ADLs) with assistance of 2 persons to transfer her using a full-body mechanical lift with a divided leg sling. -At risk for bowel and bladder functioning related to incontinence and high risk for skin breakdown. -At risk for chronic pain related to fibromyalgia and low back pain. *Care plan focuses were added on 10/7/23 for potential psychosocial well-being problem related to: recent admission and on 11/17/23 for manipulative behavior (alleged mistreatment). Review of progress notes for resident 144 revealed: *A behavior note on 11/26/23 at 11:30 a.m. noted similar information as the grievance on 11/27/23 noted above: -Resident 144 told cnas [sic] to straighten out her hoyer sling because it wasn't [was not] on right .her diaper is in the vagina and its [sic] hurting .the cna told her that it was because she was a much larger person than they were and that's [that is] why .she told them that her depend was on incorrectly and that all the cna did was take out the hoyer sling and left. -The Summary/Outcome noted: --Two cnas went in to assist resident .was asked about the sling never mentioned about the diaper until cnas were walking out. CNA stated that 'Went adjusted as best as we could' Resident said she was sitting on a knot and cnad [sic] took out the sling from underneath her. --Resident then changed demeanor with staff and to staff said 'If you would've [would have] done it right like I told you too [sic], it would've been on right!' --Cna said to resident 'you're not going to be respectful, we did the best we could.' --Resident then said 'I'll [I will] see about that!' --Cna states that she never once brought up the resident's size or anything they just told her they couldn't move hoyer sling. --Resident then called center nurses station asking to speak to DON. *A general progress note on 11/26/23 at 4:07 p.m. noted resident 144 reported concerns regarding staffing: -She told center med aid [medication aide] that her call light had been on for two hours and no one had answered call light. -Writer .let resident know that her call light had not been on for two hours since writer had been at nurses station for the last two hours and her call light had not been on until after [sic] and it was on for maybe 5-10 mins [minutes] max [maximum] when another nurse and CNA went in to assist resident. -Resident stated that she never said that her call light had been on for two hours but that she had put her call light on two different times around noon. *A behavior note on 12/2/23 that described the same situation as on the handwritten note by CNAs I and J, noted above. *A social service note on 12/5/23 noted resident 144's family member called and stated, Under no conditions do I want [CNA F] to be in [resident 144's] room again. Interview on 12/13/23 at 4:00 p.m. with licensed practical nurse/unit manager L about CNA F, she replied she was a good CNA. The interview was interrupted at that time and never resumed During the exit conference on 12/14/23 at 7:15 p.m., administrator A commented that resident 144 tears up very easily.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure staff were competent to safely use the mechanical lift equipment and provided with accurate information about each resident's transfer equipment needs, including sling size, for eight of twelve sampled residents (1, 9, 24, 32, 33, 77, 79, 244). Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on 10/31/23 at 7:03 p.m. to administrator A for F689 Accidents related to accurate assessment and care planning for the use of mechanical lifts and body slings: *Multiple staff interviews revealed staff were unable to state where they would find the transfer recommendations for residents, which included the appropriate mechanical lift and the appropriate type and size of sling. * A Facility Reported Incident identified on 10/23/23, two agency certified nursing assistants (CNA) used a full-body total mechanical lift for a resident transfer with a fall from three feet to the floor resulting in a hip fracture. The last lift evaluation for resident was 7/12/22. Resident's care plan intervention, last revised 10/22/22, requires assist of two with total lift . but does not specify type of sling to be used. *Observation on 10/31/23 of a full-body mechanical lift transfer of a resident with an agency CNA and staff member using the wrong type and size of sling resulting in the resident sliding out of the bottom of the sling onto her bed when the mechanical lift was being raised. *Provider did not have a system in place, including competencies demonstrated, to ensure agency staff receive orientation and training for using the full-body mechanical lift and multiple sizes and types of slings available. IMMEDIATE JEOPARDY REMOVAL PLAN On 11/1/23 at 3:03 p.m., administrator A provided the survey team with a written a plan for removal of the immediate jeopardy. The removal plan, after revisions, with guidance from the long-term care advisor for the South Dakota Department of Health, was approved by the survey team on 11/1/23 at 3:50 p.m.: *Director of Nursing (DON) or designee will provide education to all nursing staff on mechanical lift policy, Sling Selection Guideline, and Lift Assessments, and the process for finding appropriate type and size of sling and where to locate the information for each resident on Kardex or Care plan by end of day 11/1/2023 if unable to complete by end of day 11/01/2023 will be completed prior to next scheduled shift. *Identified 35 residents that utilize mechanical lift are at risk. All residents that utilize mechanical lift had new lift assessment completed 10/31/2023. All residents that utilize a mechanical lift care plan was reviewed and updated to reflect appropriate mechanical lift and appropriate type and size of sling 11/01/2023. DON or designee will complete a lift competency with all nursing staff, to include return demonstration, on mechanical lifts, how to identify type of mechanical lift, as well as type and size of sling by end of day 11/01/23 if staff unable to complete by end of day 11/01/23 will be completed prior to next scheduled shift. DON or designee will ensure new staff, including agency staff, receive verbal and written education on the mechanical lift policy and competency with return demonstration will be completed prior to first scheduled shift. *Guideline created for staff utilization and reference for appropriate sling type and size based on in house inventory of slings, manufacturer guidelines and resident assessment on 11/01/2023. All residents that utilize mechanical lift had new lift assessment completed 10/31/2023. All care plans for residents that utilize a mechanical lift were reviewed and updated to reflect appropriate mechanical lift and appropriate type and size of sling 11/01/2023. DON or designee will complete a lift competency with all nursing staff, to include return demonstration, on mechanical lifts, how to identify type of mechanical lift, as well as type and size of sling by end of day 11/01/2023 if unable to complete by end of day 11/01/2023 will complete prior to next scheduled shift. DON or designee will ensure new staff, including agency staff, receive education on the mechanical lift policy, Sling Selection Guideline and competency with return demonstration will be completed by end of day 11/01/2023 if unable to complete by end of day 11/01/2023 will complete prior to next scheduled shift. Upon admission/readmission/quarterly/significant change or as needed a mechanical lift assessment will be completed on residents, and care plan and Kardex will be updated. Audits will be completed by DON or Designee on 5 residents requiring mechanical lifts to ensure lift assessment is completed accurately and thoroughly, type and size of lift sling is on the care plan and Kardex. In addition, DON or Designee will audit 5 nursing staff, to include agency staff, will be observed transferring a resident with mechanical lift to ensure the appropriate type and size of lift sling was utilized. Audits will be weekly for four weeks and then monthly for three months. Results of audits will be reviewed by the DON or designee with IDT and Medical Director at monthly QAPI for analysis and recommendation for continuation/discontinuation/revision of audits based on findings. On 11/2/23 at 12:30 p.m., the survey team determined the immediacy was removed. After removal of the immediacy, the severity and scope was a level G. 2. Observation and interview on 11/6/23 at 3:16 p.m. with resident 24 revealed she: *Was lying in her bariatric bed with the head of the bed raised about 45 degrees. *Had just returned from being in the hospital for a few days. *Was being treated for a fractured hip because she fell out of bed. *Had no concerns about how staff used the mechanical lift. *Stayed in bed now and pain was managed. *The only concern she reported was the call light response is slow at night. Review of the 10/21/23 quarterly Minimum Data Set (MD)S assessment for resident 24 revealed: *The Brief Interview for Mental Status (BIMS) was scored at 11, which indicated she had moderately impaired cognition. *Four indicators of her mood were coded as present for half or more of a 14-day window, which gave her a severity score of 10, moderate depression. *No behavior indicators were coded. *She had lower extremity impairments on both sides of her body. Review of the electronic medical record (EMR) for resident 24 revealed a Late Entry Incident Note dated 10/23/23 at 4:45 p.m., created on 10/24/23 at 7:40 p.m. that documented: *The nurse was called to the room by two CNAs and observed the resident laying on the ground with the Hoyer [full-body mechanical lift] sling beneath her. *The nurse asked the CNAs about the transfer, and they stated the Hoyer machine was tilting because the resident was leaning more to one side than the other on the Hoyer sling. -No injuries were observed, and no pain was reported at that time. Review of the facility investigation of the incident, completed on 10/27/23, revealed: *Resident 24 complained of pain in her left leg and head when she was laid down after dinner. *The medical provider was made aware of the symptoms as a result of the incident and sent orders to transfer her to the emergency room department. *Resident 24 was transferred on 10/23/23 at approximately 10:00 p.m. and was admitted to the hospital with a fractured hip. *Hoyer lift was removed from service and is being inspected by maintenance. *Ceiling lift was inspected last night by unit manager and DON and was intact with not issues. *Hoyer lift was inspected by maintenance and did not show any malfunctions or mechanical issues. *Sling was inspected that was used for the transfer and was intact with no fraying or tearing noted .an appropriate size for [resident]. *After learning of resident's hip fracture, these [two CNAs] were interviewed again when they admitted that the resident fell three feet to the floor. Both work for [agency name]. *Staffing agencies state their CNAs are competent on tasks such as transfers; however, going forward, we will ensure the agency staff are trained on operation of the facilitys [sic] transfer equipment prior to their shift worked. Review of the 7/12/22 admission Lift Evaluation V.1 [version one] UDAs [user defined assessment) for resident 24 revealed: *A. 3. Can Resident stand, pivot, & walk with no assistance or with limited assistance from the staff with no risk of falling or injury to staff? was marked No. *A. 4. Level of Assistance was marked Dependent. *B. 1. Is the resident able to bear at least 50% [percent] weight on at least 1 [one] leg? was marked No. *B. 2. Can the resident sit upright without Physical Assistance? was marked No. *B. 3. Is the resident able to follow simple directions? was marked Yes. *B. 4. Resident has upper extremity strength to grip with at least one hand? was marked No. *B. 5. Is Resident able to tolerate moderate pressure to mid to lower back? was marked Yes. *C. 1. Can resident tolerate being in a semi-reclined position? was marked as Yes. *D. 1. Type of lift required: Total Dependent (Bariatric). *D. 2. Sling Size: xl [extra large] Review of the 10/22/22 quarterly OBRA [omnibus budget reconciliation act] MDS UDA - V3 [version three] Lift Evaluation section for resident 24 revealed: *B.2. Can the resident sit upright without Physical Assistance: was marked Yes. (Sit to Stand). *The remaining sections were answered the same as on the 7/12/22 admission Lift Evaluation V.1 UDA. Review of the 4/19/23 quarterly and 7/21/23 annual OBRA MDS UDA - V3 Lift Evaluation sections for resident 24 revealed: *All of the sections were answered the same as on the 7/12/22 admission Lift Evaluation V.1 UDA, except item D.2. was blank. Review of care plan for resident 24 revealed: *Focus: Assistance with ADL's [activities of daily living] (bed mobility, transfers .personal hygiene, .and toileting), initiated 8/13/21, revised 7/21/22. -Intervention: Ceiling lift for all transfers, initiated 10/29/21, revised and resolved 10/31/22. -Intervention: Requires assist of 2 [staff] with the total lift to get in/out of bed, in/out of wheelchair, initiated 7/21/22, revised 10/22/22 -Intervention: TRANSFERS - 2 person assist, HOYER - Ensure that sling is appropriate size and that sling is placed appropriately prior to transferring, sling size large, initiated 10/26/23. *Focus: At risk for falls related to current medication use, poor safety awareness, disease process agitated behavior such as verbal and motor activity, anxiety disorder, arthritis, cognitive impairment, decline in functional status, initiated 10/26/23. -Intervention: Ensure sling is positioned prior to lifting and transferring surfaces, initiated 10/26/23. *Focus: Actual impairment to skin integrity Surgical incision to left hip and outer left knee, initiated 11/3/23. Review of the Transferring section of the visual bedside Kardex report, as of 11/6/23, revealed resident 24: *Is dependent on staff for locomotions on and off unit in manual wheelchair. *Requires assist of 2 with the total lift to get in/out of bed, in/out of wheelchair. *TRANSFERS - 2 person assist, HOYER - Ensure that sling is appropriate size and that sling is placed appropriately prior to transferring, sling size large divided leg. Review of the undated T-Wing unit rounding sheet [used by staff as a quick reference sheet] revealed for resident 24 revealed, Hoyer - divided large sling. Interview on 10/31/23 at 5:26 p.m. with DON B revealed: *There was no ceiling lift in the building. *The Kardex is in the Point Click Care (PCC) electronic medical record (EMR) software for staff to reference and it provided interventions from the care plan. *The unit rounding sheets are a tool for care staff to use when they complete their care giving rounds during their shift. Interview on 11/6/23 at 4:12 p.m. with licensed practical nurse (LPN)/unit manager Y revealed: *The two CNAs felt the Hoyer cradle was tipping. *She was in the building at the time so she had the CNAs show how they transferred the resident. *They demonstrated use of the lift appropriately. *The correction made after the incident was to make sure they are using the divided leg sling, that wasn't specific before. *Resident 24 is not wanting to get out of bed at this time. She doesn't tolerate pain very well. Interview on 11/8/23 at 4:18 p.m. with DON B and regional nurse consultant (RNC) HH revealed DON B: *Was not aware of the reference to the ceiling lift in the 10/27/23 investigation report. *Stated it must have been a typing error. 3. Observation and interview on 10/31/23 at 4:23 p.m. with resident 32 revealed: *There was a strong urine odor in the hallway outside her room and became stronger upon entering her room. Her call light was turned on. *She was sitting in a semi-reclined position in a geriatric bed that was raised higher than the standard level with a half siderail in the up position on both sides of the bed. *LPN UU answered her call light and resident 32 requested her eye drops and insulin shot. LPN UU replied she would come back to check resident 32's blood sugar. *After that, resident 32 replied she was not interested in talking. Observation and interview on 11/6/23 at 9:07 a.m. with resident 32 revealed: *She was lying flat on her bed, her eyes were open, and the television was on. *She started a conversation with this surveyor about not getting to have a regular glass of chocolate milk and being on fluid restrictions but her doctor has not told her that. *She requested assistance getting her phone from the overbed table beside her bed, and one stuffed bear and three dolls from the chair in the corner of her room. *At 09:14 a.m., she asked this surveyor to raise the head of her bed and then got angry when told this surveyor could not help her raise the head of the bed but was able to help her turn on the call light. After the touch pad call light was placed in her hand, she turned on the call light. *While wafting, resident 32 asked this surveyor to retrieve several make-up items from the purse that was setting on the overbed table. *At 9:16 a.m., CNA I answered the call light and raised the head of the bed so that she was sitting in a mostly upright position, then helped her retrieve her make-up items. *After CNA I left the room, resident 32 answered a few questions including: -How safe do you feel while being transferred? Scared. Not when I like the staff who are doing it. Don't like the black CNAs, I was raped by a black person years ago. They come in to change my pad without telling me. -Have you noticed an odor in your room and in the hallway? Yes. I'm the source of the foul odor. When I have a bowel movement. -Do they clean you well when they change your pad? She did not answer this question. *Resident 32 agreed to let this surveyor observe the staff transfer her when she was ready to get up. Observation on 11/6/23 at 11:30 a.m. of CNA I and CNA KK get resident 32 out of bed revealed: *They changed her brief first, rolling her back and forth onto each side to remove the soiled brief, clean her, and then position the clean brief. *Neither CNA responded to her complaints of rolling too far, that was scary and Oh, it hurts, *CNA KK pushed the transfer sling under her and then they rolled her over so that CNA I could finish positioning the sling underneath her. *Resident 32 said, This is no fun. CNA KK said, I can see where it's no fun. *Resident 32 asked about lunch and CNA KK said, Don't know what they are having for lunch. *After positioning resident 32 in her wheelchair, and while CNA KK was taking the sling loops off the lift hooks, resident 32 exclaimed, Ow, that hurt. CNA KK did not respond. Interview on 11/6/23 at 11:46 a.m. with CNA KK revealed she replied, This is my second day, when asked how she knew level of assistance to provide for residents using a mechanical lift. She walked away without asking the question. Interview on 11/6/23 at 12:02 p.m. with LPN LL revealed: *She did not believe she could answer questions about resident 32 as she was an agency LPN even though she had worked here for a couple of months, it had been off and on, and she had worked on different units. Review of the 9/7/23 annual MDS for resident 32 revealed: *Her BIMS score was 10, which indicated she had moderately impaired cognition. *There were no indicators coded for mood disorder, *No behavior indicators were coded. *She was totally dependent for bed mobility and transfer. *She was always incontinent of bowel and bladder. Review of the 12/28/21 admission and the 6/7/22 readmission Lift Evaluation V.1 UDA for resident 32 revealed: *A. 3. Can Resident stand, pivot, & walk with no assistance or with limited assistance from the staff with no risk of falling or injury to staff? was marked No. *A. 4. Level of Assistance was marked Dependent. *B. 1. Is the resident able to bear at least 50% [percent] weight on at least 1 [one] leg? was marked No. *B. 2. Can the resident sit upright without Physical Assistance? was marked No. *B. 3. Is the resident able to follow simple directions? was marked Yes. *B. 4. Resident has upper extremity strength to grip with at least one hand? was marked Yes. *B. 5. Is Resident able to tolerate moderate pressure to mid to lower back? was marked No. *C. 1. Can resident tolerate being in a semi-reclined position? was marked as Yes. *D. 1. Type of lift required: Total Dependent (Full Body Lift). *D. 2. Sling Size: xl Review of the 12/3/22 quarterly OBRA MDS UDA - V3 Lift Evaluation section for resident 32 revealed the following differences in coding from the 12/28/21 admission Lift Evaluation V.1 UDA. *B. 2. Can the resident sit upright without Physical Assistance: was marked Yes. (Sit to Stand). *B. 4. Resident has upper extremity strength to grip with at least one hand? was marked No. *D. 2. Sling Size: [blank] Review of 10/31/23 quarterly Lift Evaluation V.1 UDA for resident 32 revealed: *All of the sections were answered the same as on the 12/3/22 quarterly OBRA MDS UDA - V3 Lift Evaluation except D.2. Sling Size: was large. Review of the care plan completed on 10/2/23 for resident 32 revealed: *Focus: Assistance with ADL's [activities of daily living] (bed mobility, transfers, .personal hygiene, .and toileting), initiated 9/3/20, revised 7/13/22. -Intervention: Bed mobility- extensive assist of two staff members, initiated 1/26/23. -Intervention: Uses a Hoyer lift with assistance of two staff members with transfers. She often yells out during transfers with Hoyer. Take time and explain next steps to reassure her during transfers, initiated 1/9/22, revised 1/26/23. -Intervention initiated on 11/1/23: Uses total mechanical lift with a large [emphasis added] divided leg sling.,. Review of the visual bedside Kardex report for resident 32, as of 11/6/23, revealed: *Under Safety, Hoyer lift for transfers. Sling size extra large [emphasis added]divided leg. *Under Transferring, Uses a Hoyer lift with assistance of two staff members with transfers. She often yells out during transfers with Hoyer. Take time and explain next steps to reassure her during transfers. Review of the undated T-Wing rounding sheet revealed for resident 32 revealed, Hoyer - divided leg large [emphasis added] sling. Interview on 11/6/23 at 3:53 p.m. with LPN/unit manager Y about resident 32 revealed: *She can make choices but needs support making appropriate ones. *Reliability of any allegations reported by resident 32 was 50/50. *There had been no injuries or accidents related to transfers. Sometimes [resident 32] will comment that staff don't know what they are doing. *Resident 32 says 'Ow' a lot when she is rolled from side to side. Her complaints are subjective. It depends on who is doing the transfer. *They communicate as a group during daily huddles or one-on-one depending on the priority of the change in the Kardex. *We keep an eye on each other through walking rounds and weekly interviews with residents. 4. Observation on 10/31/23 at 4:02 p.m. of resident 33, while restorative aide (RA) TT and LPN/unit manager Y transferred him, revealed: *Resident 33 was seated on a sling in his wheelchair in his room. *RA TT and LPN/unit manager Y fastened the loops of the sling onto the hooks on a full-body mechanical lift. *Resident 33's position in the sling, as they lifted him from the wheelchair, was leaning to the left. *After they lowered him onto the bed, LPN/unit manager Y commented, You went a little wonky. *The head of the bed was raised about 45 degrees. *Resident 33 was leaning far to the left. RA TT and LPN/unit manager Y physically repositioned him to sit more centered on the mattress. *When asked about the location of information regarding sling size for a resident, LPN/unit manager Y replied it is in each resident's care plan or on the lift assessment. Observation and interview on 11/6/23 at 3:41 p.m. of resident 33 revealed he: *He was in sitting semi-reclined position in bed in his room with the television on. *The flat sheet between him and the mattress was all bunched up behind him exposing the upper and bottom right corners of the mattress. *His bed was lower to the floor than the standard height, and a fall mat was on the floor next to the bed. *He said he was not ready to get up yet. *There was a bowel odor in his room. Review of the 10/13/23 annual MDS for resident 33 revealed: *His BIMS score was 6, which indicated he had severely impaired cognition. *There we only behavior coded was rejection of care. *He had impairment of both lower extremities. *He needed a helper to do all of the transfer activity. *The activity of sitting to standing was not attempted. *He was always incontinent of bowel and bladder. Interview on 11/6/23 at 4:26 p.m. with CNA KK revealed she replied, Don't know, when asked about the bowel odor in resident 33's room, then she walked away. Interview on 11/6/23 at 4:28 p.m. with LPN LL revealed today was the first time she had worked with CNA KK. Review of the 7/14/23 quarterly OBRA MDS UDA - V3 Lift Evaluation section for resident 33 revealed: *A. 3. Can Resident stand, pivot, & walk with no assistance or with limited assistance from the staff with no risk of falling or injury to staff? was marked Yes-No Lift Needed (STOP HERE) Review of the 10/31/23 quarterly Lift Evaluation V.1 UDA for resident 33 revealed: *A. 3. Can Resident stand, pivot, & walk with no assistance or with limited assistance from the staff with no risk of falling or injury to staff? was marked No *A. 4. Level of Assistance was marked Partial Assist. *B. 1. Is the resident able to bear at least 50% [percent] weight on at least 1 [one] leg? was marked Yes. *B. 2. Can the resident sit upright without Physical Assistance? was marked No. *B. 3. Is the resident able to follow simple directions? was marked Yes. *B. 4. Resident has upper extremity strength to grip with at least one hand? was marked Yes. *B. 5. Is Resident able to tolerate moderate pressure to mid to lower back? was marked Yes. *C. 1. Can resident tolerate being in a semi-reclined position? was marked as Yes. *D. 1. Type of lift required: Total Dependent (Full Body Lift). *D. 2. Sling Size: large Review of the care plan for resident 33 revealed: *Focus: assistance with ADL's due to right arm weakness and BKA [below knee amputation], initiated 1/3/22, revised 6/5/22. -Intervention: transfers using Hoyer lift with 2 person assist, initiated 3/3/22, revised 10/17/23, then revised further on 11/1/23 to transfers using total mechanical lift with 2 person assist, size Large divided leg sling. *Focus: altered skin integrity issues r/t [related to] PVD [peripheral vascular disease], left heel (pressure), left ankle, left medical calf, left TMA site, and left dorsal foot (all vascular), initiated 1/30/22, revised 11/1/23. -Intervention: prosthetic leg to the right leg. WHC [wound healing clinic] orders to not wear prosthetic until rash and wound are healed .not always compliant with this, please educate me why I am not to wear, initiated 1/30/22, revised 11/11/22. Review of the visual bedside Kardex report for resident 33, as of 11/6/23, revealed: *Under Transfers, Using total mechanical lift with 2 person assist, size Large divided leg sling. Review of the undated T-Wing rounding sheet revealed for resident 33, Hoyer - full body large sling. Interview on 11/06/23 at 4:03 p.m. with LPN/unit manager Y revealed: *Resident 33 is currently using a total lift because of the wounds on his left leg. *He is pushing his wound doctor to let him stand on his leg again. *We might be able to transition to the sit to stand. *He was admitted with the wounds, but his wounds are healing. Interview on 11/09/23 at 10:48 a.m. with director of rehabilitation (DOR) Z revealed: *She was involved with the lift training that was conducted last week. *When residents come in for rehabilitation, the therapy department works towards the highest level of function and lowest level of staff support needed before transferring them to long term care. *She conducted quarterly screenings for all residents in accordance with the MDS schedule. *She was also involved in Patient At Risk meetings, and communicated with unit managers and other staff through emails or one to one conversations. 5. Observation on 10/31/23 at 11:29 a.m. of CNAs X and U getting resident 9 out of bed using the mechanical full-body lift: *Resident had a blue divided leg sling under her. *CNA X attempted to raise the resident out of the bed and the resident slide out of the sling and onto her bed the straps had been crossed between her legs. *CNA X identified that sling was too large for the resident. *CNA X retrieved a different sling that one is green colored and full body for the mechanical full-body lift. *Staff are assisted with rolling the resident from left to right to place the new sling under her. *They hooked the sling to the mechanical full-body lift. *Resident 9 was then lifted into her wheel chair. Interview with CNA X following the transfer regarding what type of sling to use with residents revealed: *She would have decided what type of sling to use while transferring a resident. *She would have changed the type of sling to use on a resident if she had not felt safe while performing the transfer with the full-body lift. Interview on 10/31/23 at 2:53 p.m. with CNA U regarding the type and color sling to be used with residents using the full-body lift revealed: *They would be able to find that information in the resident's chart. *She had tried to locate that information but was unable to find that. Interview on 10/31/23 at 3:38 p.m. with CNA X regarding her training for the full-body lift use revealed: *She had not completed any competency for the full-body lift use. *She stated this is her fourth time working here. *If she does not feel comfortable using a type of sling, she will get a different one. *She does not know where in the chart the type of sling or sling size to be used on each resident that requires full-body lift use. Review of resident 9's care plan revealed: *She was dependent on staff for transfers. *She had required assistance of two with the use of the full-body mechanical lift. 26632 6. Observation and interview on 10/31/23 at 2:21 p.m. of CNA X and CNA OO who transferred resident 1 from her bed to her wheelchair using the full body lift. A full body sling size large was used. CNA OO was not sure who chose which size or type of sling a resident was to have used. She thought it might be licensed practical nurse (LPN)/unit manager J. They were not sure where to find the sling sizes for the residents. Review of resident 1's 9/19/22 care plan focus area for activities of daily living (ADL) revealed: *A 10/31/23 revised intervention Transfers: Full body lift for transfers with assist of 2. *There was no information of what type of size of lift sling was to have been used. 7. Observation and interview on 10/31/23 at 3:45 p.m. of resident 77 during a transfer with a full body lift from her wheelchair to her bed. CNAs P and OO assisted with the transfer. A full body sling size large was used. That sling was soiled, and a clean sling was brought into the room. Resident 77 stated she was glad the new, clean sling was not a split kind. She stated it had hurt and pinched her inner thighs when it was used. Review of resident 77's revised 10/23/22 care plan focus area for ADLs revealed: *A 10/23/22 intervention Transfers: Total Dependence of 2 staff with Hoyer (full body lift) lift. *There was no information of what type of size of lift sling was to have been used. 8. Observation on 10/31/23 at 3:15 p.m. with CNA OO and CNA P transferring resident 79 from her wheelchair to her bed using the mechanical lift revealed: *A blue sling was placed underneath resident 79 in her wheelchair. *When asked how CNA OO knew what sling size to use transferring resident 79, CNA OO was unaware of what sling size resident 79 should have been using or where she would find that information. Interview on 10/31/23 at 4:03 p.m. with CNA P and CNA/activities director C revealed: *The resident transfer information was found in the Kardex. *Both staff were unable to locate the Kardex in PCC to find out how resident 79 was transferred and the appropriate sling size to have used. Interview on 10/31/23 at 4:06 p.m. with LPN/Wound Nurse R revealed that she was unable to locate where Kardex was located to find out how resident 79 was transferred. Interview on 10/31/23 at 4:08 p.m. with LPN/unit manager M revealed: *She was able to locate the Kardex for Resident 79, but the Kardex only indicated that the resident used a full mechanical lift with 2 staff assist with transfers. The style and the size of sling that was to have been used was not documented in the Kardex. *She stated that all the residents who use a sling have their own but was unable to communicate what sling size resident 79 used or where she would find the information regarding transferring resident 79. *She stated that the sling size was not included in the care plan but agreed that it should have been in the resident's care plan. *When asked how staff would know which sling to use, she stated that the CNAs would ask the nurse or a seasoned CNA which sling they should have used. *She stated that rehabilitative services staff were responsible for evaluating residents for proper sling size and transfer recommendations. Interview on 10/31/23 at 4:49 p.m. with DOR Z revealed: *The rehabilitation staff did not assess residents for sling size or lift recommendations on admission to the facility, and they would have used the recommendation the resident had from the hospital provided. *Physical therapy would assess a resident for sling size when a referral was made by the nursing staff or the resident. Interview on 10/31/23 at 5:33 p.m. with DON B revealed that the CNA lift competency form that was used for new staff was not completed consistently and that temporary and contracted direct care staff were able to sign up for shifts without having to complete the CNA lift competency before providing care to the residents. Review of the CNA Legacy Health Care (LGHC) Lift Evaluation UDA (User def [TRUNCATED]

Based on observation, interview, record review, and policy review, the provider failed to ensure interventions that had been put in place were consistently implemented and documentation was consistent for four of four sampled residents (3, 37, 39, and 193) who developed pressure ulcers after admission to the facility. Findings include: 1. Interview on 10/31/23 at 10:30 a.m. with resident 193's wife revealed she had found a large blister on his right heel the previous night. She was surprised staff had not found it. She had informed the nurse at that time. The nurse had placed a foam dressing over his right heel the morning of 10/31/23. They had given him heel protector boots. He had told her his heels were causing him pain. Observation and interview on 10/31/23 at 10:30 a.m. with resident 193 revealed: *He was seated in his wheelchair. *He had bilateral heel protector boots on. *The back part of his heels on both of his feet rested against the outer edge of the foot pedals. *He stated his heels hurt and liked to keep his feet off of the foot pedals. Observation and interview on 11/2/23 at 9:19 a.m. with licensed practical nurse (LPN)/wound nurse R and registered nurse (RN) L of resident 193's heels after his shower revealed: *A large intact blister on his left heel. *A large opened area with the skin from the blister attached to his right heel. *LPN/wound nurse R would be measuring and placing dressings on his heels after she had clarified the treatment order. *No dressing was applied to his heels at that time. Observation on 11/2/23 at 11:30 a.m. of resident 193 revealed he was seated in his wheelchair. He had slipper socks on both feet. He did not have his heel protector boots on. Review of a 11/2/23 11:10 a.m. progress note by LPN/Wound nurse R revealed: *She had contacted the dermatologist office on 11/1/23 regarding his bullous phemigoid (a rare skin condition that causes large, fluid-filled blisters. They develop on areas of skin that often flex such as the lower abdomen, upper thighs, or under the arms.) and the blisters on his heels. *The dermatologists nurse reported back to her that their team felt the blisters on his heels were a manifestation of his bullous pemphigoid due to recently finishing prednisone. *Resident 193 will see the dermatologist on 11/15/23 for a full review at that time. Observation and interview on 11/2/23 at 3:00 p.m. of a dressing change for resident 193 by LPN/wound nurse R and RN/Minimum Data Set (MDS) coordinator E revealed: *He was lying in bed without his heel protector boots on. *He had no dressing on either of his heels. *An Optifoam Gentle EX dressing was placed on each of his heels. *His left heel blister was intact and measured 3.0 centimeters (cm) in length by 3.8 cm in width. *His right heel had an open blister that was reddened and had no drainage. The measurements were 3.1 cm in length by (X) 4.8 cm in width X 0.1 cm in depth. *LPN/wound nurse R stated a new service My Wound Care Plus would be making an initial visit on 11/13/23. Either a physician or a nurse practitioner would come and assess resident's wounds and order treatments. *LPN/wound nurse R stated the blisters on his heels were from his bullous phemphigoid. *She agreed the dermatologist had not seen the blisters to ensure they were not pressure ulcers. *She agreed the blisters were full skin thickness and looked different than the other blisters he had. *She agreed she did not know a lot about bullous phempigoid. Observation on 11/6/23 at 9:35 a.m. revealed resident 193: *Seated in his wheelchair in his room and he was wearing his regular shoes. *His heel-protector boots were lying on his bed. Interview on 11/6/23 at 10:00 a.m. with certified nursing assistant (CNA) T revealed: *She was a traveling CNA and picked up shifts at the facility and was under contract for thirteen weeks. *She had not worked on the yellow hall, where resident 193's room was located, prior to today. *Shift change rounds were completed with the night CNA. *Used a report sheet when making rounds and could write more information on the sheet regarding the care of the residents. *Stated she had given her report sheet to someone else. *Found a report sheet for the yellow hall and agreed the information for resident 193 only included his code status and how he was to have been transferred. *Stated it had not been reported to her that he had pressure ulcers to his heels, was to wear heel protectors, and was not to wear regular shoes. *Observations on 11/6/23 at 11:00 a.m. and again at 12:01 p.m. revealed resident 193 was in the hallway by his room and then in the dining room. He was not have wearing his heel protector boots. Continuous observation on 11/6/23 from 4:15 p.m. through 4:49 p.m. of resident 193 revealed he was lying in bed on his back. He did not have the heel protector boots on. His feet were slightly elevated on a pillow, but his heels were still touching the bed. He was only wearing socks. Interview on 11/6/23 at 4:57 p.m. with LPN D regarding resident 193's heel protector boots revealed: *She stated that resident 193 had his heel protector boots on today. *When she was informed of the above observations and the interview with CNA T she stated she was surprised by that. She was sure she had observed him with them on. *Report in the mornings for the CNA's was the off-going CNA would give report to the on-coming CNA. *The nurse would inform the CNAs if there had been any changes with the residents. *She would not review the residents conditions with the CNAs if they had not worked in the halls. *She thought the off-going CNA would have informed them of what care the residents required. Interview on 11/6/23 at 6:00 p.m. revealed LPN/unit manager J and RN/MDS coordinator E stated they had given CNA T education regarding resident 193's need for his heel protector boots. Observations on 11/7/23 at 8:05 a.m. and again at 10:00 a.m. revealed resident 193 did not have his heel protector boots on. He had regular shoes on and was seated in his wheelchair. The first observation in the dining room and the second one was in his room. The heel protector boots were observed lying on the floor between his bed and his bedside table. Interview on 11/7/23 at 11:16 a.m. with CNA W regarding resident 193 revealed: *When asked why he did not have his heel protector boots on earlier. She stated she had initially been told he did not need them and then was told he did when she laid him down in bed. *She was not sure who had told her he did not need the heel protector boots. *She had not worked on the yellow hall prior to today. *She was a traveling CNA. *She had access to the resident Kardex but had not looked at it to check what each resident needed. Review of resident 193's electronic medical record (EMR) revealed: *He was admitted on [DATE] after a hospitalization . *His diagnoses included: Parkinson's and mild cognitive impairment. *A previous diagnosis of bullous pemphigoid disorder was added on 10/27/23 from his dermatologist. Review of resident 193's 10/24/23 nursing admission assessment revealed he had: *Bruising to the top front of his left hip, right shin, and left shin. *He had complaints of feeling pins and needles sensation in his feet. Review of resident 193's 10/24/23 admission Braden Scale (assessment used for the risk for developing pressure ulcers) and clinical evaluation documentation revealed his score was a 5 which placed him at high risk for developing a pressure ulcer. Review of resident 193's 10/24/23 baseline care plan revealed: *Skin integrity had been triggered from his initial nursing assessment. *The interim focus area was Resident has (Specify: potential for/an actual) impairment to skin integrity. Potential for or an actual skin impairment had not been specified. *Goals included: -Resident will continue to have skin intact. *Interventions included: -LOW RISK - Skin weekly. Report changes to the nurse. *Off load heals as ordered and turn and reposition every two hours and as needed had not been chosen as interventions. Review of resident 193's skin alteration evaluation's revealed: *On 10/27/23 he had a blister to the shin of his left leg and a skin tear to his right elbow. *On 10/29/23 closed blisters to his bilateral heels had been added. *On 11/5/23 the only documentation was for other. Scattered blisters due to bullous pemphigoid diagnosis. Review of resident 193's 11/1/23 Braden Scale and clinical evaluation documentation revealed his score was a 13 which placed him at high risk for developing a pressure ulcer. Review of resident 193's 11/2/23 wound assessment for his right and left heel blisters revealed: *His left heel blister was intact and had not been classified as a pressure injury or staged. *His right heel blister was open and had not been classified as a pressure injury. It's clinical stage was listed as Partial Thickness. *Both were facility acquired. Review of resident 193's care plan for skin impairment revealed: *Focus revised on 11/2/23. -[Resident] has an actual impairment to skin integrity skin tear to right hand and bulbous [bullous] pemphigoid. This is a chronic skin issue and will continue to develop blister to all areas of my skin and it is unpreventable. I am seen by [name of dermatology clinic]. *Goal had not been updated since 10/27/23. *Interventions: -Revised 11/2/23 Coordinate care with [name of dermatology clinic] and primary care provider and determine plan of care and any treatment needed. -Revised 11/2/23 High Risk-Skin weekly. Report abnormalities to the nurse. *There had been no interventions added to specify the treatment for his bilateral heel blisters. *There had been no interventions added to specify any preventative skin interventions for other skin conditions other than his bullous phemphigoid. Review of a 11/3/23 physician's order revealed resident 193's primary care physician deferred any wound care to Dakota Dermatology. Review of a 11/7/23 faxed communication to the dermatologist revealed Resident has light bleeding to blister at right heel, ok to use collagen one a day until resolved or until seen by you clinic? There had been no reply from the dermatologist by the end of the survey on 11/9/23. Review of resident 193's Kardex as of 11/6/23 revealed under resident care: *Assist with application of appliances if needed. *High-risk skin inspections weekly, Report abnormalities to the nurse. *There were no specific instructions for his heel protector boots. Review of the CNA skin monitoring observation documentation from 10/25/23 through 11/6/23 for the question Does the resident have a skin alteration? Yes was only documented on 10/29/23, 10/31/23, 11/4/23, and 11/6/23. Interview on 11/8/23 at 3:59 p.m. with director of nursing (DON) B and regional nurse consultant HH revealed: *Wound rounds were done weekly. *DON B stated LPN/wound nurse R would be taking a wound care course. *Had not been aware resident 193's intervention for bilateral heel protector boots had not been consistently followed. *They were not aware LPN/unit manager J had provided education to CNA T regarding resident 193's heel protector boots. *Agreed after LPN/unit manager J had provided education to CNA T The intervention should have been entered on the Kardex. Review of the provider's 3/23/23 Pressure Injury Prevention policy revealed: *General preventative measures included: -Repositioning, need for a specialized mattress, wheelchair cushion, reducing friction, and shear. *Interventions and preventative measures would be implemented for resident with risk factors of moisture, friction and shear, bed-fast resident, chair-fast residents, immobility, bowel and/or bladder incontinence, poor nutrition, and impaired cognitive status. *Additional clinical conditions, treatments, and abnormal laboratory values could also indicate a resident was at risk for a pressure injury. Those included: -Impaired/decreased mobility and decreased functional ability. -Conditions, such as end stage renal disease, terminal cancer, or diabetes. -Medications that could affect would healing. -Blood flow impairment. -Cognitive impairment. -A healed ulcer. The history of a healed pressure injury and its stage is important since areas of healed stage 3 or 4 pressure injuries are more likely to have recurrent breakdown. 49395 2. Observation on 11/2/23 at 11:20 a.m. of resident 37 revealed: *The resident was sitting in her recliner with a walker next to the recliner and she was watching TV. The call light was attached to the recliner. *The resident was able to respond to questions asked appropriately but was confused as to why she was being asked questions. Interview on 11/2/23 at 11:25 a.m. with CNA I regarding resident 37's care revealed: *The resident was able to reposition herself. *Resident 37 would ambulate with a gait belt and assist of 1 staff member and a walker. *CNA I thought the pressure ulcer on the coccyx was healed. *Staff would attempt to assist the resident to the bathroom every 2 hours, but the times could be inconsistent from 1.5 hours to 2.5 hours dependent on staff availability. Review of resident 37's 10/2/23 care plan revealed the following interventions: Apply a moisture barrier to the peri-area after an incontinent episode. The call light should be in reach. Remind, offer, and assist the resident with toileting as needed. Review of resident 37's EMR revealed: *The resident had diagnoses of the following: -Unspecified dementia. -Mild protein-calorie malnutrition. -Iron deficiency anemia. -Type II diabetes mellitus. *Resident was on a constant carbohydrate diet. *The November 2023 Medication Administration Record (MAR) for resident 37 revealed resident 37 was taking Preservision multivitamin 2 caps once daily for a supplement. No other supplements for the pressure ulcer had been ordered. *A 10/11/23 Braden scale and clinical evaluation indicated resident 37 was at low risk for developing pressure ulcers with a score of 22. *A 10/14/23 progress note revealed the following: -A CNA reported a skin alteration for resident 37. -The note reported a blanchable red area measuring 0.5 cm x 0.5 cm, intact area on the coccyx. -The progress note also reported redness to the bilateral groin area. -The area was cleansed with soap and water, patted dry, and barrier cream was applied. -The resident's physician and family were notified. -The manager on call was also notified. *A 10/19/23 progress note revealed a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed without slough or bruising) coccyx pressure ulceration, which was previously thought to have been MASD (Moisture Associated Skin Damage). -The area of redness/MASD measured 9.2 cm x 5.8 cm. -The opened pressure ulcer area measured 1 cm in length x 1 cm width x 0.01 cm depth. -Intervention for the coccyx area included cleansing with normal saline or soap and water then covering with a bordered foam dressing every 3 days or as needed if soiled or removed. Review of resident 37's 10/2/23 care plan revealed: *The resident had a pressure ulcer to her L (left) lateral ankle and coccyx area. *Interventions included: -The wound treatment mentioned above. -Keep skin clean and dry. -Pressure relieving mattress. -Reposition at least every 2 hours. -Heel protection boots at bedtime. Review of the October 2023 Treatment Administration Record (TAR) revealed: *Wound care to the coccyx started on 10/19/23. *Wash the area with soap and water or normal saline and cover with bordered foam dressing every three days and as needed if soiled or removed. Telephone interview on 11/2/23 at 12:08 p.m. with resident 37's daughter revealed: *She stated that she believed the pressure ulcer on her mother's coccyx was a result of not being toileted regularly. *She stated that family had concerns about staff providing proper care to their mother specifically on the weekends. Observation on 11/6/23 at 11:24 a.m. of LPN/wound nurse R completing skin monitoring on resident 37 revealed the area on the coccyx was healed. Interview on 11/9/23 at 09:21 a.m. with LPN/would nurse R regarding resident 37 revealed: *The initial pressure ulcer prevention interventions that were started on the 10/2/23 admission included the following: -Two-hours bathroom checks. -Pressure relieving mattress. *The resident had a blanchable reddened area on right side of the coccyx that was identified on 10/14/23 related to MASD due to incontinence. *A 10/16/23 wound round form revealed, that resident 37 had a reddened area on the coccyx measuring 9.2 cm in length x 5.8 cm in width x 0.01 in depth. *A moisture barrier cream was ordered on 10/16/23 to have been applied during bathroom changes. *New interventions and care changes were communicated to CNAs through morning stand-up huddles, the resident's care plan, and the Kardex. Review of resident 37's Kardex revealed there was no moisture barrier cream listed. *LPN/Wound nurse R stated that the barrier cream was best practice and stated she had no concerns that the intervention was getting done. Barrier cream use for the resident was not documented by the staff. *A 10/19/23 wound round form revealed a stage 2 pressure ulcer with an open area pressure ulcer measuring 1 cm x 1 cm x 0.01 cm. *The wound healed on 11/4/23. Interview on 11/9/23 at 11:05 p.m. with DON B, LPN unit manager J, and regional nurse consultant HH revealed: *A grievance was filed by the resident's daughter-in-law on 10/13/2023. The grievance report indicated a concern that the family had not felt that the resident had been changed regarding her incontinence all morning and that she had not received breakfast. *When asked how interventions for bath rooming every 2 hours was being completed, regional nurse consultant HH stated they could not ensure that residents were toileted every two hours. 3. Observation on 10/31/23 from 11:09 a.m. through 2:11 p.m. revealed: *Resident 39 was lying in bed with a foot cradle supporting the blankets off of her feet. *Heel protector boots were lying on the sink counter in the resident's room. Observation and interview on 10/31/23 at 2:21 p.m. of CNA U performing personal care for resident 39 revealed: *CNA U stated that resident 39 stayed in bed much of the time throughout the day and night. *She was supposed to have been repositioned every 2 hours while she was in bed. *When asked about the heel protector boots, CNA U was not aware when resident 39 was to wear those heel protector boots. *CNA U used a rounding sheet to provide care for those residents she had been assigned to care for. *The rounding sheet that was used for resident 39's care had not listed the heel protector boots. Observation on 10/31/23 at 4:54 p.m. revealed resident 39 was lying in bed and was still not wearing those heel protector boots. Review of the October 2023 TAR revealed that LPN MM had documented that resident 39's heel protector boots were on during the day of 10/31/2023. Review of resident 39's 7/11/23 care plan revealed: *The resident had the potential for impairment to skin integrity. *The intervention included heel protection boots should have been on at all times. Interview on 11/3/23 at 3:09 p.m. with LPN/unit manager M revealed CNAs would use the Kardex and the rounding sheet to provide care and implement interventions for the residents from the information listed on the Kardex and the rounding sheets. Review of resident 39's EMR revealed: *A 10/24/23 Braden scale and clinical evaluation indicated the resident scored a 12 and was categorized at high risk for skin breakdown. *A 06/22/23 Skin Evaluation indicating that resident 39 had a stage I pressure ulcer (a reddened, painful area on the skin that does not blanch when pressed) on her R (right) great toe measuring 0.8 cm in length and 0.5 cm in width and a stage I pressure ulcer on her R second digit that measured 0.5 cm in length and 0.3 cm in width. *A foot tent was ordered to keep the blankets off of her feet, heel lift boots were to be worn, and a low-loss air mattress to the bed. Interview 11/6/23 8:53 a.m. with CNA W was employed with a contract agency revealed: *She stated that today was her first shift on her assigned wing. *When asked how she would know what the care needs were for resident 39, she stated that she was given a rounding sheet with their resident's code status and how the resident's transfer. *When asked about the heel protector boots sitting in the resident's wheelchair. She had no knowledge about them or if they needed to have been placed on the resident's feet. *CNA W admitted she did not known much about the resident and was going to assist the resident out of bed until she was stopped by another staff member that explained to her that the resident stays in bed. Observation on 11/6/23 at 9:58 a.m. revealed resident 39 lying in bed and the heel protection boots were still sitting in the resident's wheelchair in her room. Interview on 11/6/23 at 9:59 a.m. with RN NN regarding resident 39 revealed: *She had been employed for a month. *She had no knowledge as to when the heel protector boots were supposed to have been on but reviewed the resident's EMR and stated that those heel protector boots should have been on at all times. *When asked where that intervention was documented to ensure the heel protector boots were put on, RN NN reported that she had documented that the heel protector boots were on but acknowledged that she had not checked to ensure those heel protector boots were on prior to documenting in the EMR. Interview and review of resident 39's Kardex on 11/7/23 at 9:44 a.m. with LPN/wound nurse R revealed. *The heel protector boots should have been listed on the Kardex so that the CNAs caring for resident 39 knew those boots should have been on at all times. *It was confirmed by LPN/wound nurse R that the heel protection boots were not listed on the Kardex. *LPN/wound nurse R stated that she would have completed a teachable moment with the CNA. That would have been an informal reeducation for the CNA regarding the heel protector boots. Interview on 11/9/23 at 10:32 a.m. with LPN unit manager M regarding resident 39's pressure ulcers to her toes revealed: *The cause of the resident pressure ulcers on her toes were from the friction of the resident's sheets. The resident would wrap herself in the sheets and the heel protector boots still left the toes exposed to the friction of the bed sheets. *The foot cradle was ordered and the pressure ulcers to the toes have since healed. *They were starting to use the rounding sheet more by adding more interventions for the residents. *She agreed that communication was an issue with ensuring that direct care staff implemented resident's care plan interventions. Interview on 11/9/23 at 11:05 a.m. with director of nursing (DON) B, LPN unit manager J, and regional nurse consultant HH revealed: *Unit managers were responsible to ensure that interventions and changes to the resident's care plans were communicated to direct care staff. *That was completed through the Kardex, rounding sheets, and staff stand-up huddles. *All direct care staff were given access to Point Click Care (the provider's electronic medical record). *Managers would educate direct care staff on how to use Point Click Care and where to find the Kardex. -LPN unit manager J was attempting to develop a better system to communicate interventions to the direct care staff and was currently working with quality improvement on the issue. Review of the 3/23/23 Skin and Pressure Injury Prevention Program Policy revealed: *Nursing personnel who would have been providing care to the residents would have been instructed in the individual interventions for each resident. *Nursing personnel would monitor response to the resident's plan of care and ensure implementation of the resident's individualized plan of care. 06365 4. Interviews and observations on 10/31/23 at 4:15 p.m., 11/2/23 at 9:45 a.m. and again at 3:40 p.m. with resident 3 revealed she: *Was in her room seated in a recliner chair watching television. *Was not able to carry on an extensive conversation during each visit, but responded to questions that indicated she had no concerns. Review of the 10/22/23 quarterly Minimum Data Set (MDS) assessment for resident 3 revealed: *The Submission Information for MDS was listed as export ready, which indicated it had not yet been submitted. *Her Brief Interview for Mental Status (BIMS) was scored at 03, which indicated she had severe cognitive impairment. *No behaviors, mood indicators, or reports of pain were coded on the MDS. *She needed a helper to perform more that 50 percent of the effort with all mobility tasks. *She frequently incontinent of bladder but continent of bowel. *Skin conditions was marked as No pressure ulcer/injury and Yes for skin tears. Review of resident 3's care plan revealed actual impairment to skin integrity stage I [one] pressure ulcer to right buttock, date initiated: 10/09/2023, revision on: 10/17/2023. Review of the Order Summary for resident 3 revealed order dates of: *4/13/23, Pressure relieving mattress. *7/13/23, SKIN CARE: Apply bordered foam dressing for protection (sacrum) change q [every] 3 days or as needed every day shift every 3 day(s). *10/17/23, WOUND CARE: Cleanse open area to right buttock with wound cleanser and cover with bordered optifoam. Change dressing every 3 days and prn [as needed] if soiled. Reposition resident as frequent as possible and monitor area for any signs of infection and update provider if signs are present. Hospice nurse to assess weekly. one time a day every 3 day(s) for skin alteration AND as needed for skin alteration change prn if soiled. Review of the weekly Skin Evaluations revealed: *On 10/13/23, Resident has alteration in skin integrity was marked as Yes. Coccyx was listed as the Site with a description of redness under the heading for NON PRESSURE ULCER. There was no documentation in Additional Skin/Treatment Note. On 10/15/23, Resident has alteration in skin integrity was marked as Yes. Right gluteal fold was listed as the Site with the Type of open area under the heading for PRESSURE ULCER. The measurements for Length [L], Width [W], and Depth [D] were blank, and the Stage was not selected. Review of Skin/Wound notes for resident 3, written by LPN/wound nurse R, revealed: *On 10/9/23, the first note to acknowledge the wound, Reviewed open area to resident right buttock. Current measurement: 1.9 [centimeters (cm)] x [by] 1.7 x 1.01 cm. Applied wound care per current orders. *On 10/16/23, Current measurement: 1.8 x 1.5 x 0.02 cm. *On 10/17/23, Reviewed open area to resident right buttock with hospice nurse. Hospice nurse staged as a pressure I [one] injury ro right coccyx, continuing with plan of mepilex every 3 days. Amending wound rounds ot [to] show as stage I pressure injury. *On 10/23/23, Reviewed pressure ulcer to resident right buttock with [hospice] RN. Current measurement 1x1.1x0.02cm. Review of WOUND ASSESSMENT DETAILS REPORT for resident 3, completed by LPN/wound nurse R, revealed the wound decreased in size but was consistently labeled as a skin tear instead of a pressure ulcer, as follows: *On 10/9/23, right buttock, Type Skin Tear, Classification Type 3: Total Flap Loss, Source: Facility-acquired, Date identified: 10/3/23, Clinical Stage: Full Thickness, Size (cm): 1.90 x 1.70 x 0.01 (L x W x D). *On 10/16/23, Type and Classification the same as 10/9/23, Size (cm) 1.80 x 1.60 x 0.02 (L x W x D). *On 10/23/23, Type and Classification the same as 10/9/23, Size (cm) 1.10 x 1.10 x 0.02 (L x W x D). *On 10/30/23, Type and Classification the same as 10/9/23, Size (cm) 1.00 x 1.10 x 0.02 (L x W x D). *On 11/4/23, Type and Classification the same as 10/9/23, Size (cm) 0.40 x 0.30 x 0.01 (L x W x D). Interview on 11/8/23 at 4:18 p.m. with DON B and RNC HH revealed there was a discrepancy between the type and classification of skin tear or stage I pressure ulcer on the Skin Evaluations, Skin/Wound Notes, and the Wound Assessment Detail Reports. Interview on 11/8/23 at 5:04 p.m. with RN/MDS coordinator E revealed she: *Believed the coding of skin tear on the 10/22/23 export ready MDS was accurate. *The first note that identified it as a pressure ulcer was 10/23/23, which was after the assessment reference date (ARD) of 10/22/23 for the MDS. Interview on 11/8/23 at 5:32 p.m. with RN/MDS coordinator E and LPN/wound nurse R revealed they confirmed the wound was a pressure ulcer before the ARD and the MDS coding would have to be changed before it was submitted.

45383 Based on observation, interview, record review, and policy review, the facility failed to ensure sufficient nursing staff to provide care or complete/accurate documentation for 41 of 54 residents reviewed during the survey (1, 3, 5, 6, 7, 9, 10, 11, 12, 19, 23, 24, 26, 28, 32, 33, 36, 37, 38, 39, 46, 53, 58, 60, 62, 64, 67, 71, 72, 73, 74, 75, 77, 79, 81, 84, 87, 91, 193, 244, and 253). The census of the facility was 95 at the time of the survey. These failures placed residents at risk for unmet care needs and negative outcomes. Findings include: 1. The provider failed to ensure staff were provided with accurate information about each resident's transfer equipment needs, including sling size, and were competent to safely use the mechanical lift equipment for nine of twelve sampled residents (1, 9, 24, 32, 33, 60, 77, 79, 244). Refer to F689 Base A. 2. The provider failed to ensure staff provided adequate supervision, appropriate interventions, and adequately understood the door exit system to prevent unwitnessed elopements for two of two sampled residents (10 and 55). Refer to 689 Base B. 3. Interview on 10/31/23 at 10:30 a.m. with resident 6 regarding call light response time revealed: *It had taken an hour and an half [90 minutes] one time to answer her call light. *Staff would have answered her light then would have returned later to help her. Interview on 11/6/23 at 10:10 a.m. with sixteen residents (5, 7, 12, 19, 23, 28, 38, 46, 53, 58, 62, 67, 71, 73, 74, and 81) who attended resident council meetings replied with the following: *When asked if the residents received the help and care they needed without waiting a long time, the residents stated, -Call light buttons are not being answered. -It can be 3-4 [three to four] hours at night. -The staff stick their hand through the doorway and turn off the call light and walk away. *When asked about receiving snacks at bed time or when requested, the response was No. Refer to F809. *When asked if they felt the rights of the residents were respected and encouraged, the response was No. Examples provided by the residents included: -Not receiving timely meal trays when choosing to eat in the resident's room. -Not getting a bath or shower when requested, and having to take a bath or shower when staff offer to do it or it would be marked as a refusal. -Not getting enough opportunities to do restorative exercises. -Tired of being asked every shift if the resident had a bowel movement during the day when they should know because they had to help the resident use the toilet. Refer to F561 Review of the handwritten Resident Council Minutes for six months revealed concerns related to nursing services had been reported as follows: *On 6/14/23: -Call lights: Staff will shut off light and not come. Sometimes not getting them [bathes]. -Nursing: sometimes nurses dont [do not] help if CNA [certified nursing assistants] not around. -Snacks: Feels staff ignor [ignore] snacks - not getting. -Therapy: would like one more restorative. Walking programs - sometimes not happening. *On 7/12/23: -Call lights: Still shutting call light off and not answering, staff visiting at station instead of answering call lights. and -Nursing: some [staff] good, some not so good - set at desk, grumpy. -Snacks: Some [residents] state [they are] getting (East) [snacks], some [residents] state [they are] not getting. *On 8/9/23: -Call lights: Under Resolved column - better, but still some' -Nursing: would like to walk outside of therapy - restorative. *On 9/13/23: -Call lights: Same concerns - too long. Shutting light off and not returning -Nursing: some say they [staff] are going to do something - didn't come back. *On 10/11/23: -Activities: snacks [-] if [activity coordinator C] not here dont [do not] always get done. -Call lights: Still issue [,] turn off and waiting long times over an hr [hour]. Residents are missing activities cause of it. -Kitchen: Late w/meals [with meals] - room trays, nurses aides not willing to warm up food. -Nursing: Nurses & [and] aides [CNAs] still issues with saying come back and dont [do not]. Snacks at night late. Issues with water pass during day. Refer to F565. Interview on 11/06/23 at 9:03 a.m. resident 64's response to call lights revealed: *CNA not very good, she stands outside my door but doesn't come in to help me. *No shower since last Friday *No help here, no shower given on Monday. Observation and interview on 11/06/23 at 11:04 a.m. with CNA W from Clipboard Health-while transferring resident 64 revealed: *CNA W had picked up shifts the last two months. *Did not get orientation. *She learns as she goes. Interview on 11/8/23 at 2:20 p.m. RN F revealed: * Responsible for 23 or more residents,. *One nurse in the building on night shift when another nurse goes home sick,. *One nurse is responsible for 17 skin assessments, medication administration, physician orders, CNA's and phone calls. Interview on 11/6/23 at 4:48 p.m. with Administrator (ADM) A revealed they have been conducting call light audits since call light reports are not available with the call light system in the building. Review of fifteen (15) call light audit forms provided by ADM A completed between July 18, 2023 and November 5, 2023 revealed: *The quantity of audit forms did not meet the expected Instructions stated on the form, Daily x [times] 4 weeks. *Call light observations recorded 61 times included: -36 observations were noted with a.m. (morning) times. -3 observations were noted as p.m. (afternoon) times. -22 observations did not specify whether the observations were a.m. or p.m. *Recorded room locations included 4 on [NAME] (100 rooms), 28 on Center (200 rooms), 25 on East (300 rooms), and 3 rooms that were not specified by room number. *Of the 61 observations, 51 observations met the criteria for the acceptable call light time of answered in under 10 minutes. *Observations that did not meet the criteria included: -7/19/23, room [ROOM NUMBER] at 10:40 a.m. - 10:57 a.m. for 17 minutes and room [ROOM NUMBER] at 10:57 a.m. - 11:30 a.m. for 33 minutes. Comments were noted as 1:1 [one to one] caretaker hired by family had to request help and [staff name] on break until 10:55 a.m. -9/3/23, room [ROOM NUMBER] at 9:50 a.m. - 10:02 a.m. for 12 minutes. There were no Comments or Summary of findings recorded. -9/9/23, room [ROOM NUMBER] at 8:32 - 8:53 (a.m. or p.m. not specified) for 21 minutes. The Summary of findings noted, Center aides cannot seem to work together. -9/10/23, room [ROOM NUMBER] at 8:09 - 8:37 (a.m. or p.m. not specified) for 28 minutes and 307 at 8:12 - 8:23 (a.m. or p.m. not specified) for 11 minutes. The Summary of findings noted, 329 took a while due to 2 CNA's in 2 assist room & 1 CNA in [resident initials] room. -9/30/23 - 10/1/23, room [resident initials] at 8:00 a.m. - 8:21 a.m. for 21 minutes. There were no Comments or Summary of findings. -10/7/23, room [ROOM NUMBER] at 9:00 a.m. - [call light time turned off had a dash mark]. Comments noted Aid [CNA] never shut light off. -10/28/23, room [ROOM NUMBER] at 9:39 - 9:52 (a.m. or p.m. not specified) for 13 minutes. There were no Comments or Summary of findings. -11/4/23 - 11/5/23, room [ROOM NUMBER] at 9:05 - 9:30 (a.m. or p.m. not specified) for 25 minutes and room [ROOM NUMBER] at 9:02 - 9:12 (a.m. or p.m. not specified) for 10 minutes, and room [ROOM NUMBER] at 5:38 -5:51 (a.m. or p.m. not specified) for 13 minutes. There were no Comments or Summary of findings. Interview on 11/9/23 at 10:40 a.m. with ADM A and review of Weekend MOD [manager on duty] Checklist, MOD schedule, and November 2023 On Call nurse schedule revealed: *The MOD is expected to be in the building for three to four hours on the weekend, and should include being present for at least one meal. *The MOD is also on call for the weekend. *The on call nurse is scheduled to be the evening manager on weekdays in the building through the evening shift change and available every weekend. *The MOD checklist listed general duties to be addressed included: -Any staffing issues -Door alarms working -Wanderguard system working -Any customer complaints -Meals served timely (7:15 a.m., 11:15 a.m., 5:15 p.m.) -Ensure water pass occurs (10:00 a.m., 2:00 p.m., 10:00 p.m.) -Snack pass (2:00 p.m., 8:00 p.m.) -Call lights answered timely (Less than 5-8 minutes) 4. The provider failed to ensure interventions that had been put in place were consistently implemented and documentation was consistent for four of four sampled residents (3, 37, 39, and 193) who developed pressure ulcers after admission to the facility. Refer to F686. Review of the provider's Facility Assessment revealed: *It had updates of 10/23/22, 4/16/23, 6/30/23, and 7/13/23. *It had been reviewed with the quality assurance/performance improvement (QAPI) committee on 10/25/22 and 8/16/23. *Staff that had been involved in completing the assessment included: Administrator A, DON B, Governing Body Representative/regional director of operations, medical Director social service designee Q, business office manager H, dietary manager N, licensed practical nurse/unit managers J, M, and Y, human resource director GG, and Minimum Data Set coordinator E. *The provider is licensed for 110 residents with an average daily census of 90 residents with approximately 15% being short-term residents (13-14 residents). *Pertinent facts considered when determining staffing and resource needs are the residents sleep schedule, bathing schedule, dietary needs, weekend activities, community outings, and religious preferences. Based on the provider's resident population and resident needs for care and support, their approach to staffing was ensure they had sufficient staff to meet the needs of the residents at any given time and to simultaneously meet the requirements of Centers for Medicare and Medicaid Services regulations F725, F741, F802, and F839. their staffing plan included: -One full-time DON. -The ratio of registered nurses (RN) and LPNs to certified nursing assistants (CNA) shall be sufficient to assure professional guidance and supervision in the nursing care of the residents. Facility retains sufficient staffing to maintain a 24-hour licensed nurse (8-hours are a RN, 7 days a week). -CNAs and Restorative Aides [RA] are scheduled based on resident needs and current census. The typical staffing level for each shift as follows: --CNAs and RAs: Day shift 9-10 scheduled Night shift: 5-6 scheduled. --CNAs and RAs are scheduled for 12, 8, or 4 hours shifts. --Qualified Medication Aides (QMA) are scheduled to support the nurses and CNAs. QMAs are scheduled 12, 8, or 4 hour shifts. QMAs are scheduled 1-3 per day depending on resident needs and current census. -The facility provides enough support personnel to safely and effectively carry out the functions of the food and nutrition service. The minimum staffing consists of one cook and one dietary aide per meal. Based upon the licensed occupancy , the Dietary Manager may serve as a member of the line staff to meet this requirement. Interview on 11/9/23 at 1:31 p.m. with DON B and RNC HH revealed they agreed there was a need to address sufficient staffing and competencies related to the repeated pattern of concerns of timeliness to call lights and room trays and snack delivery. Refer to F561, F565, F802, and F809. 49238 49395 26632

Based on observation, interview, record review, review of provider policy and Facility Assessment, the provider failed to ensure nursing staff were verified as competent to perform tasks in accordance with the provider's policies prior to performing them and had adequate knowledge and access to resident information to meet resident needs for 41 of 54 residents reviewed during the survey (1, 3, 5, 6, 7, 9, 10, 11, 12, 19, 23, 24, 26, 28, 32, 33, 36, 37, 38, 39, 46, 53, 58, 60, 62, 64, 67, 71, 72, 73, 74, 75, 77, 79, 81, 84, 87, 91, 193, 244, and 253). Findings include: 1. Interview on 10/31/23 at 5:32 p.m. with director of nursing (DON) B revealed: *When asked how they verified the competencies of agency staff, he replied, Good question. *He understood that agency staff who picked up shifts through the [name of agency] app (an electronic recruitment and scheduling app) were their own independent contractor. *The agency app made it possible for agency staff to pick up a shift on a moment's notice. *He confirmed there was a need to determine how they would verify competencies at the time the agency contractor showed up for the shift they picked up. Observation and interview on 11/6/23 between 6:00 p.m. and 6:30 p.m. at East nurses desk, with dietary manager (DM) N while room trays were being delivered, revealed: *A cart with wheels was setting across from the nurses desk with mugs on the top tray of the cart that were filled with water. *When asked about the mugs -Agency certified nursing assistant (CNA) KK replied that she did not know the reason for the cart of water mugs. She explained this was the second day she had worked there. -Agency licensed practical nurse (LPN) LL replied she had not been aware the cart was there. She confirmed it looked like the water mugs were new since there were no straws in them. -DM N confirmed the water mugs had been filled by dietary staff for the 3:00 p.m. water pass, and it appeared they had not been passed. Observation and interviews on 11/9/23 between 8:45 a.m. - 9:10 a.m. revealed: *An overhead announcement was heard for all staff to Center for daily huddle. *Housekeeping supervisor AA confirmed the routine practice had been for daily stand-up in the conference room for managers followed by an all staff huddle at Center during the weekdays. *LPN/unit manager J reported that ADM A prepared the daily huddle information on a typed sheet, staff would sign-off on the Staff In-Service Sheets, and that information and the sign off sheets were kept in a binder at the Center nurses desk. *LPN/unit manager Y reported the daily huddle today was earlier than usual and it worked better when the breakfast meal was done. Interview on 11/9/23 at 9:19 a.m. with DON B revealed: *The Daily Stand Up Meeting sheet was reviewed during the daily huddles on weekdays. *Nursing department staff used the unit sheets that listed the residents in two columns for shift to shift report. Review of the unit sheets for East and T-Wing revealed the only resident specific information listed included each resident's advance directive code status and the assistance and equipment needs for transferring each resident between surfaces. Review of daily huddle reports for two weeks from the Center binder revealed Staff In-Service Sheets with signatures and Daily Stand-Up Meeting typed sheets that included the following topics: *10/26/23 Night shift, topics: admissions, discharges, room and dining changes, resident appointments, MDS [Minimum Data Set] interviews due and care conferences, influenza vaccine, dining room to chart meals, bathing preferences, sling and Hoyer [mechanical lift] use *10/30/23 at 10:00 a.m., topics: admissions, discharges, room and dining changes, resident appointments, MDS [Minimum Data Set] interviews due and care conferences *10/30/23 NOC [night] shift, topics: Hoyer [mechanical lift] use, bath preferences, and walkie-talkies. *10/31/23 at 10:00 a.m., topics: discharges, pending admissions, room and dining changes, resident appointments, MDS [Minimum Data Set] interviews due and care conferences, and a separate typed page that listed 6 bulleted items: 1 bullet addressed a specific resident, 2 bullets addressed operational topics, 1 bullet addressed a policy, and 2 bullets addressed care needs including, Please attempt to complete some baths today per schedule. *11/8/23 at 6 p.m., topics: discharge, change of conditions, and Misc [miscellaneous] that included elopement and Wanderguard training, mechanical lift training, new flooring being installed on East . *11/9/23 with no time listed, topics: discharge, room and dining changes, resident appointments, care conferences, risk events, change of conditions, and the same Misc [miscellaneous] as 11/8/23 with the addition of Fire Watch initiated this morning. Interview on 11/9/23 at 9:37 a.m. with ADM A confirmed there were gaps in the daily huddle documentation because we were doing one on one trainings related to the survey team findings. Interview on 11/9/23 at 1:31 p.m. with DON B and regional nurse consultant (RNC) HH agreed there was a need to address sufficient and competent staffing in nursing and/or dietary. Review of the Facility Assessment, last updated on 7/13/23 and last reviewed by the QAPI (quality assurance and performance improvement) committee on 8/16/23, revealed: *Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies .Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical., and psychosocial well-being. *Guidelines for Conducting the Assessment: 4. The facility assessment should serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources and may include the operating budget necessary to carry out facility functions. *Part 1: Our Resident Profile: -1.1. Licensed number of residents: 110 total with possibility of 110 maximum. -1.2. Average daily census: 90 residents, of which approximately 15% [percent] are short-term. -1.5. Major Rug-IV [resource utilization groups-four] Categories that give an overall picture of acuity levels. --Major Rug-IV Categories: Percent of population Rehabilitation: 19%, Extensive Services 47%, Special Care 32%, Clinically Complex 34%, Behavioral Symptoms and Cognitive Performance 35%, Reduced Physical Function 98%. --Special Treatment and Conditions: number of residents with behavioral health needs - 17 --Assistance with Activities of Daily Living: number of resident needing assist of 1-2 staff plus dependent for transfer 73 + 6 = 79, toilet use 79 + 3 = 82. -1.6. We strive to maintain a respectful and neighborly environment for our staff and residents. in response to this diversity, we strive to maintain activities, traditions, meals, and an environment that is reflective of many cultures .We strive to ensure residents have a choice in their activities of daily living. Our dietary staff regularly solicit input from the resident council regarding menu and food preparation. -1.7. Other pertinent facts we consider when determining staffing and resource needs are our resident's sleep preferences, bathing schedules, dietary needs, weekend activities, community outings and religious preferences. *Part 2: Services and Care We offer Based on our Residents' Needs -Activities of daily living: bathing, showers .eating, support with needs related to hearing/vision/sensory impairment, supporting resident independence . -Mobility and fall/fall with injury prevention: transfers, ambulation, restorative nursing . -Skin integrity: pressure ulcer prevention and care, skin care, wound care .with repositioning, w/c [wheelchair] cushions and pressure relieving mattresses. -Mental health and behavior: manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individual with depression, trauma/PTSD [post traumatic stress disorder] . -Nutrition: individualized dietary requirements, liberal diets, specialized diets .culture or ethnic dietary needs . -Provide person centered/directed care: --Build relationship with resident/get to know him/her; engage resident in conversation. --Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. --Make sure staff caring for this resident have this information. --Provide culturally competent care: learn about resident preferences and practices regarding culture and religion, stay open to requests and preferences and work to support those as appropriate. --Identify hazards and risks for residents. *Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies -3.1. The following is a list of staff/services that are typically provided for our residents. Some of these services are covered by multiple staff members . --Nursing Services: Director of Nursing (DON), Assistant Director of Nursing, Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA), Certified Medication Assistant, CCN [??] Nurse, Treatment Nurse --Food and Nutrition Services: Dietary Director, Dietary Aide, Cook, Registered Dietitian --Hospitality aide -3.2. Staffing plan --Licensed nurses: DON (1 FTE [full-time equivalent]) .RN or LPN charge nurse: Minimum of 2-4 [two to four] for each shift based [on] resident needs and current census. Nurses are scheduled for 12, 8, or 4 hour shifts always with no less than 2 licensed nurses on duty per shift. --Direct care staff: The typical staffing level for each shift is as follows . CNAs and restorative aides: Day = 9-10 scheduled, Night = 5-6 scheduled. Nurse aides and Restorative Aides are scheduled for 12-, 8-, or 4-hour shifts. Qualified Medication Aides (QMA) are scheduled to support the nurses and CNAs. QMAs are scheduled 12,8,or 4- hour shifts. QMA are scheduled 1-3 per day depending on resident needs and current census. --Dietary: The minimum staffing consists on one cook and one dietary aide per meal. Based upon the licensed occupancy, the Dietary Manager may serve as a member of the line staff to meet this requirement. -3.3. Avantara [NAME] nursing schedule is reviewed by nursing leadership on a weekly/daily basis to ensure adequate staffing and consistent assignments. Avantara [NAME] utilizes a consistent staffing model to coordinate staffing assignments for the facility. -3.4. All employees complete training and competencies on the following upon hire: --Company policies regarding effective communication for direct care staff .problem resolution procedure .cell phones and cameras. --Environmental Services: *hazard communication .Preventing Slips; Trips and Falls . --Clinical Services: .*elopement, .caring for visually .impaired; caring for depression / delirium and dementia; *dietary and hydration needs of residents; resident rights; *person-centered care/management for persons with dementia, depression, delirium, and trauma, 45383 Interview on 10/31/23 at 3:38 p.m. with CNA X regarding her orientation for working at the facility revealed: *She had not received any orientation at the facility prior to working. *She had not completed any competency for the full-body lift use. *She stated this is her fourth time working here. *She does not know where in the chart to find the resident care plans. *Rounding sheets had been provided and used as a patient care guide. 43021 Interview on 11/9/23 at 8:33 a.m. with human resource director GG regarding orientation of agency staff revealed she and staffing coordinator WW coordinated the agency staff orientation. Interview on 11/9/23 at 9:12 a.m. with staffing coordinator WW revealed: *She had been staffing coordinator since August/September 2022. *She assembled an orientation packet with an agency orientation checklist on top along with the user's EHR log-in credentials and would leave the packet at the center nurses station. *The charge nurse was responsible to have the agency staff complete the orientation packet before starting their shift. *She would then sign the orientation packet as completed and gave the packet to human resource director GG. *When asked about LPN LL's agency orientation checklist, she could not locate her agency orientation checklist. Interview on 11/9/23 at 9:56 a.m. with staffing coordinator WW confirmed that LPN LL had not completed an agency orientation checklist.

A. Based on closed record review, interview, and policy review, the provider failed to monitor and assess resident for frequency of bowel movements and constipation as well as identify and assess resident with significant weight loss for one of one sampled resident (2). Findings include: 1.Review of resident 2's closed medical record revealed: *He had originally been admitted on [DATE]. *His diagnoses included the following: unspecified ileus (inability of the intestine to contract normally and move waste out of the body), bowel obstruction, influenza A, history of malignant neoplasm of the large intestine, hypertension, and chronic obstructive pulmonary disease. *A [DATE] physician's progress note had report of constipation and to continue: -Bisacodyl suppository rectally daily as needed. -Milk of Magnesia 30 milliliters (ml) orally daily as needed. -Miralax 17 grams (gm) orally daily as needed. -Magnesium Oxide 400 milligrams (mg) orally twice a day. -Senna-S two tablets orally nightly. -Encourage adequate water intake. -Continue to monitor and adjust as needed. *From [DATE] through [DATE], he had only one large bowel movement (BM) in those seven days. *From [DATE] through [DATE], he received one dose of Milk of Magnesia 30 ml on the [DATE], the day he was admitted to the hospital. *From [DATE] through [DATE], there was no nursing documentation addressing his constipation or having a bowel assessment completed by nursing. *From [DATE] through [DATE], he had been hospitalized for an ileus versus small bowel obstruction. *From [DATE] through [DATE], there was no BM recorded between [DATE] and [DATE] and only one medium BM in the eight days between [DATE] and [DATE]. *From [DATE] through [DATE], there was no nursing documentation addressing his constipation or having a bowel assessment competed by nursing. *On [DATE], he had been transferred to a hospital and had not returned to the facility. 2.Continued review of resident 2's medical record revealed: *A [DATE] physician's progress note reflected he had lost more than forty pounds since his [DATE] admission and had lost almost twenty pounds since [DATE]. -He had a poor appetite and complaints of nausea. -Labs had been ordered to evaluate his weight loss. -He was started on Mighty Shake supplement three times daily. -It's not clear whether his poor appetite and nausea is from the side effect of the sertraline or from the recent intestinal obstruction. *Recorded weights from [DATE] through [DATE] were: -On [DATE], his weight was 178 pounds. -On [DATE], his weight was 180 pounds. -No weights were documented for [DATE]. -On [DATE], his weight was 169 pounds. -On [DATE], his weight was 165.6 pounds. -On [DATE], his weight was 162 pounds. -On [DATE], his weight was 151 pounds. -From [DATE] through [DATE], he had a 15 percent weight loss. *Meal intake documentation from [DATE] through [DATE] and from [DATE] through [DATE] had not been documented for 104 of the 174 meals he should have been offered. *From [DATE] through [DATE], his weight loss had not been addressed in nursing documentation until [DATE] when the physician had assessed him, that was 67 days after the first noted weight loss. -He was started on Mighty Shakes three times daily. *On [DATE] and [DATE], the registered dietician (RD) had evaluated him. -The [DATE] Dietary Evaluation reflected: --Resident 2 was on a regular National Dysphagia Diet (NDD) level 2 (foods that may be chopped or ground and were moist, soft-textured, and easier to swallow) and 4 oz Mighty Shake at each meal. --He had had an insidious weight loss due to decreased oral intake. --He was at risk of malnutrition. --Weight had been trending down over time, more recently with decreased appetite-stated food has been tasting the same, but just not feeling like eating. Added Mighty Shakes yesterday per his preference. Goals for wt [weight] in the ,d+[DATE]# [pound] range through next review. *His [DATE] care plan reflected: -He was at risk for altered bowel function. -He was at risk for alteration in nutritional status related to: Altered texture. I frequently refuse to follow the order. -He would have less episodes of constipation. -He would have been free of signs and symptoms of dehydration and malnutrition. -He would maintain his weight. Interventions included: --Monitor my bowel movements and document if I have not had a bowel movement in three days, or offer a laxative or stool softener as needed. ---I prefer to maintain a weight of ,d+[DATE] pounds. --Monitor for signs and symptoms of dehydration and weight loss. --Obtain weight as ordered. -His weight loss was not documented in his comprehensive individualized care plan. 3. Interview on [DATE] at 2:15 with dietary manager (DM) I regarding resident 2's weight loss revealed: *He ate most of his meals in his room. *She had noticed he was not eating as well because his food tray was coming back to the kitchen and the food had not been eaten. *He did have snacks in his room, but she did not know if he was eating them. *He was on a Mighty Shake three times a day, but he was not drinking them. *The registered dietician (RD) came to the facility every Tuesday. *There was a nutrition risk meeting held every Tuesday when the RD was in the facility and residents' weights were reviewed at that time. *The RD and nursing were required to monitor resident's weights. *The RD was the one who completed all the dietary evaluations. Interview on [DATE] at 2:26 p.m. with registered nurse H regarding resident 2's constipation and weight loss revealed: *He had been able to inform staff if he had not had a bowel movement. *He had been able to inform the nurse when he had not had a bowel movement and ask the nurse for a laxative. *If a resident had not had a bowel movement for two days, then she would have administered a laxative. *The floor nurses would get a list of resident names from one of the nurse managers for the residents who had not had a bowel movement and needed to have been administered a laxative. *He had snacks in his room he could eat independently. *He was not compliant with his diet and had not liked staff to assist him. *He ate his meals in his room. *She was not sure how often he would have eaten snacks or accepted an alternate if he had not liked what was served at scheduled mealtimes. Interview on [DATE] at 3:25 p.m. with RD J regarding resident 2's weight loss revealed: *She came to the facility weekly on Tuesdays. *Since he had returned from the hospital on [DATE] she had been looking at resident 2's weights and intakes weekly. *Initially he had refused to try a dietary supplement and then in February 2023 he had agreed to try the Mighty Shakes three times a day with meals. *His intakes were 75 to 100 percent at meals times, when they were documented. *She was responsible to complete all dietary assessments, the nutritional section of the Minimum Data Set assessment, update the resident care plans, reviewing residents' menus, educating staff, and reviewing all residents' nutritional status' in the facility. *Had not been aware his weight loss was not addressed in his comprehensive individualized care plan. *She organized and ran the monthly nutrition risk meetings where residents who were at risk or had a nutritional problem had been discussed by the interdisciplinary team. -Her Nutrition Risk meeting notes about resident 2 reflected: --On [DATE] his weights from [DATE] through [DATE]; he had been on Lasix 40 mg (a medication used to remove extra fluid from the body) daily; and his diet order with meal consumption of 75 to 100 percent. Then, --On [DATE], her notes only indicated his diet order was not entered into his electronic medical record. --On [DATE], her notes reflected his weight was 151 pounds and he had been down eleven pounds in one month, down sixteen pounds in three months, and down twenty-four pounds in six months. ---He was getting 4 ounces of Mighty Shake three times a day. ---He was on the NDD 2 diet. ---His meal intakes were at 75 percent. *She had not documented in the resident's medical record what was discussed at these meetings because she had not had the time. Continued interview on [DATE] at 8:29 a.m. with RD J regarding documentation of resident meal intakes revealed she: *Was aware meals had not been documented consistently. *Used what information was documented to complete her assessments. *Had informed administrator A and interim director of nursing (DON) B at the Nutrition Risk meetings about the missing documentation. Interview on [DATE] at 4:07 p.m. with administrator A, interim DON B, and DON C regarding resident 2's constipation and weight loss revealed: *Interim DON was training the current DON. *Resident 2 had been assessed on [DATE] by his physician and no changes had been made to his bowel regimen at that time. *The interdisciplinary team (IDT) had met each weekday morning and reviewed the dashboard on PointClickCare (the provider's electronic record keeping system). *The dashboard would have assisted the IDT by pulling information to show them which resident had not had a bowel movement in three days or if a resident had a weight loss. *They all had thought maybe the system was not working appropriately because resident 2 had only been on the list for not having a bowel movement on [DATE]. *Agreed he should have been offered a laxative on [DATE]. *They had expected the nurses to administer a laxative if the resident had not had a bowel movement in three days. *They all had not been aware meals were not being consistently documented. *Care plans were reviewed an updated when the MDS (Minimum Data Set) was completed. *His daughters had reported he might have had cancer but there was no documentation to support a cancer diagnosis. *Administrator B was aware RD J was not documenting in resident's medical records after Nutrition Risk meetings were held. *They all had agreed any member of the IDT could have documented in the resident's medical record what had been discussed in the Nutrition Risk meeting. 4. A policy had been requested from administrator A on [DATE] at 2:45 p.m. for a bowel policy or protocol. Interim DON B had brought in a printed page from a slide show used to educate staff after the provider's last survey in [DATE]. This printed page indicated: *Importance of Documentation of Bowel Movements -Identify Change of Conditions -Identify if resident is exhibiting signs and symptoms of dehydration or constipation *Bowel Movement Protocol -If a resident had not had a Bowel Movement in 72 hours Milk of Magnesium should be given and abdominal assessment should be completed for bowels sounds. -If not bowel movement after 24 hours of receiving Milk of Magnesium should be given a suppository. -If no bowel movement within 24 hours after suppository Primary Care Physician should be notified for further follow up. Review of the provider's [DATE] Weighing the Resident policy revealed: *The purpose of this procedure is to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident . *5. Report significant weight loss/weight gain to the nurse supervisor who will then report to the RD and physician. *7. The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria (where percentage of body weight loss = [equals] [usual weight - [minus] actual weight] / [divided by] [usual weight] x [times] 100): -1 month - 5% [percent] weight loss is significant, greater than 5% is severe. -3 months - 7.5% weight loss is significant, greater than 7.5% is severe. -6 months - 10% is significant, greater than 10% is severe. Review of the provider's [DATE] Care Planning policy revealed: *Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. *9. Care plans should be updated between care conferences to reflect current care needs of the individual resident as changes occur. B. Based on observation, interview, record review, and policy review, the provider failed to ensure timely physician notification after a fall, follow physical therapy recommendations for a restorative program, and ensure resident bathing was completed and documented for one of one sampled resident (1). Findings include: 1. Interview and observation on [DATE] at 2:58 p.m. with resident 1 and her daughter-in-law revealed: *Resident 1 had Steri-strips applied to the left side of her neck and a yellowish colored bruise extending from the left side of her forehead to below the outer area of her left eye. -There was what appeared to have been dried blood on her skin and the Steri-strips. *Her daughter-in-law stated she would be leaving soon and asked the surveyor to return to visit with resident 1 at that time. Observation and interview on [DATE] at 5:20 p.m. with resident 1 revealed she: *Got up from her bed and went into her bathroom without using her call light for assistance or her walker. *Was coming out of the bathroom, using a four-wheeled walker, and returned to her bed. *Was admitted for skilled rehabilitation therapy after a stay in the hospital. *Had cancer and was planning on returning to her home. *Had fallen on the [DATE] while getting ready to attend her care conference. -Her injuries from the fall included: --Hitting her head on the floor causing a goose egg and bruise to her forehead, that was a greenish yellow in color and extended from the left side of her forehead to below the outer side of her left eye with a dark purple colored area about the size of a dime in the left outer corner of her eye. --A skin tear approximately three inches long to her right arm forearm that had been closed together with Steri-strips. There was dried blood on and around those Steri-strips. --A skin tear approximately one inch long near her jugular vein on the left side of her neck that had been closed together with Steri-strips. There was dried blood on and around the Steri-strips. --Bruising to her left clavicle in an area that was approximately three inches by five inches. --Bruising to her left hip that extended down her leg and she stated it was painful. --She indicated her four wheeled walker and wheelchair had been sitting close together and her foot got caught in the walker, and that had caused her to fall. --She stated she was bleeding all over and had to wait for a while as the nurse called the doctor because she hit her head. --She was sent to the emergency department (ED) at the hospital on that day for the injuries from her fall. Review of resident 1's medical record revealed: *She was admitted on [DATE] and her diagnoses included cancer of the pancreas and kidney, adult failure to thrive, depression, and repeated falls. *Her [DATE] Brief Interview of Mental Status (BIMS) score was a 15, meaning her cognition was intact. Review of resident 1's physician admitting medication orders revealed she had been on Apixaban (a blood thinner) and sertraline (an antidepressant). Review of resident 1's [DATE] comprehensive individualized care plan revealed: *She was at risk for falls related to her poor safety awareness, decline in functional status, and history of falls. *A [DATE] goal was to prevent further falls. *She had poor insights to her deficits. *She used a walker as an assistive device during ambulation to prevent falls. *She was at risk for pain due to her cancer diagnosis. *Her discharge plan was to have completed rehabilitation and to have been discharged home. Review of resident 1's progress notes revealed: *On [DATE] she had a care conference scheduled. -She had fallen just prior to the care conference and was unable to attend. -Her son and daughter-in-law attended the conference. -Her discharge plan was to return home. --Her safety at home was a concern as she had multiple falls while in her home. Review of resident 1's fall records revealed: *She had numerous falls in her room prior to [DATE]. *She had fallen in her room on [DATE] at approximately 2:30 p.m. -The nurse on duty had faxed her physician on [DATE] at 2:35 p.m. and related she had a fall and had hit her head. --The nurse had not notified the physician on this fax that she was on a blood thinner. --The physician did not respond to this fax. -The nurse called another physician on [DATE] at 6:31 p.m. and received a physician's order for a non-emergent transfer to the hospital emergency department (ED) for treatment. --This was a three hour and 25-minute time span from when the fax had been sent to her physician and when the nurse called a different physician for an order to transfer to the ED. --Resident 1 left the facility at 7:10 p.m. for the ED and was seen there at 7:29 p.m. --The initial fax was responded to by that physician the next day, on [DATE] at 6:56 a.m. with an order to continue to monitor her. Interview on [DATE] at 9:00 a.m. with agency registered nurse K regarding resident falls revealed: *When a resident had a fall, she would assess them and if there was an obvious injury, she would have called the residents primary physician or the physician on call. --She would not have faxed the physician. *If a resident was on a blood thinner, fell , and hit their head she would have notified the physician right away. --She indicated if a resident was on a blood thinner, fell , and hit their head it might cause a brain bleed up to two weeks after the initial fall. Interview on [DATE] at 11:16 a.m. with administrator A, interim DON B, and DON C regarding resident 1's falls revealed: *She had a fall on [DATE] and hit her head on the floor while she had been getting ready for her care conference. -She had not used her call light for assistance. *Administrator A's expectations for when a resident fell were: -A fall with an injury would have required the nurse to notify the physician by telephone. -If there was not an injury related to the fall, the nurse could notify the physician by facsimile. -Interim DON B and administrator A would have expected the nurse to telephone the physician when resident 1 had fallen on [DATE] due to the extent of her injuries and the fact that she was taking a blood thinner. -Interim DON B would have expected the facsimile that had been sent to the physician to include that resident 1 had been taking a blood thinning medication, and it had not. -Administrator A was not sure why there had been a delay in resident 1 receiving emergency care on [DATE] after her fall as we don't have that documentation piece. -The nurse that faxed the physician had not been educated on calling versus faxing a physician after a fall with injury. Review of the provider's [DATE] Falls Management policy revealed: *Post Fall/Injury Resident Management: -9. Contact provider and resident representative and document in the medical record, including time and person spoken with. If transferred, document transferring agency/responders. -11. The Director of Nursing or designee will be notified immediately for falls resulting in major injury or transfer. 2. Continued review of resident 1's [DATE] comprehensive individualized care plan revealed the following: *A [DATE] intervention of Skilled Rehabilitation Therapy evaluation and treatment as indicated. -There was no documentation of a restorative nursing care program. *She was taking a psychoactive medication for her depression and to have been monitored for any ill effects related to the anti-depressant. *Her discharge plan was to have completed rehabilitation and to have been discharged home. Continued review of resident 1's progress notes revealed: *A [DATE] progress note from the certified nurse practitioner that indicated the following: -She had a [DATE] PHQ-9 Score (a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression) of 11 (she had moderate depression). -She attributes worsening of her depression symptoms for not participating with PT (physical therapy) and OT (occupational therapy) at this time. -Increase restorative activities. -May increase her sertraline dose in the future if moving to a different hallway and increased restorative activities do not help in improving her mood. -Continue Sertraline 50 mg daily. -No dose reduction at this time as patient is dealing with major health issues and high PHQ-9 score. *On [DATE] she had a care conference scheduled. -She had fallen just prior to the care conference and was unable to attend. -Her son and daughter-in-law attended the conference. -She would be starting restorative nursing therapy as her skilled therapy had ended. -Her discharge plan was to return home. --Her safety at home was a concern as she had multiple falls while in her home. Interview on [DATE] at 10:35 a.m. with interim director of nursing (DON) B regarding restorative program for resident 1 revealed: *Resident 1's restorative program had not been added to her electronic medical record. *She indicated the restorative nursing aide might have been documenting the restorative care on paper form. Interview and review of restorative medical records on [DATE] at 1:19 p.m. with restorative nursing aide F regarding resident restorative nursing care revealed: *She was the only restorative nursing aide employed at the facility. -She had one day off every two weeks. -She had 36 residents on her case load that day. -Her resident case load was assigned by the nursing department with recommendations from the skilled therapy department. *Resident 1's restorative nursing care started on [DATE], was to have been completed six times per week, and had included the following: --Walking 250 feet with stand by assist and a front wheeled walker. --Active range of motion with her upper extremities using dumbbells for 15 repetitions. --Upper extremity arm bike for 15 minutes. --Riding a NuStep bike for 15 minutes. ---Resident 1 liked to ride the NuStep bike. ---Resident 1 had not liked the other restorative programs and restorative nursing aide F had not been completing them with her. ---She would notify the nursing department if a resident had not liked to do a specific area of the restorative program. ---She had not notified anyone that resident 1 had not liked the other areas of her restorative program. *She documented resident 1's restorative nursing care on paper form. *She had received a [DATE] new nursing order transfer form from the nursing department for restorative nursing care that remained the same as the orders from [DATE]. Interview on [DATE] at 2:49 p.m. with physical therapist (PT) G regarding resident 1's therapy and restorative nursing care revealed: *Restorative nursing care was to assist residents in maintaining their current level of functioning. *When a resident was discharged from skilled nursing therapy, the therapist would develop a restorative program for the nursing department to implement for that resident. -Depending on the restorative program required, the program should have been started right away, within a couple of days, or a week. *Resident 1 had been discharged from skilled therapy on [DATE] as she had reached her highest level of functioning. -There had been a restorative nursing program written for her on [DATE]. --He would have expected her restorative nursing program to start within a week or 10 days after [DATE]. -Resident 1's restorative program started on [DATE] that was 11 days after PT G had written the restorative program. Interview on [DATE] at 11:16 a.m. with administrator A, interim DON B, and DON C regarding resident 1's restorative nursing care program revealed: *Administrator A's expectation was that: -Restorative nursing would have been set up within a week or two of a resident that was discharged from skilled therapy. -All areas of resident 1's restorative program should have been implemented. --If there had been any issues with resident 1's restorative program it should have been brought to someone's attention. -Interim DON B indicated when a physician order for restorative nursing was received, a nurse would enter the order in the computer, educate the restorative aide as to the order, and clarify the order if needed for frequency of visits or an increase of the restorative nursing care. -Both administrator A and interim DON B's expectations for resident 1's [DATE] physician ordered restorative nursing care should have been started on or about [DATE]. Review of the provider's [DATE], Restorative Nursing policy revealed: *Policy: -Generally restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech therapy. *Procedures: -3. Implementation of a Restorative nursing program may also occur following a course of physical, occupation or speech therapy. In these cases, the therapist will: provide resident specific training to the appropriate staff members; assist the Restorative team in establishing initial Restorative goals; and suggest interventions/approaches. -8. Measurable objectives and interventions must be documented in the resident's care plan and medical record. -10. Restorative nursing staff will document the program performed on the Point of Care Kiosks/computers. -11. A physician's order is not needed for a Restorative Nursing Program. Review of the provider's revised [DATE] Following Physician Orders policy revealed: *Policy: -To correctly and safely receive and transcribe physician's orders so correct order is followed/administered. *Procedure: -1. All physician's orders will be received by a licensed nurse, therapist, or dietitian. -2. Orders may be received through written communication in the resident's chart, verbally, by Fax, electronically entered into PCC, or per the telephone. -6. If the order is for a medication or treatment, it should be entered in the MAR/TAR [medication administration record/treatment administration record]. 3. Interview on [DATE] at 9:50 a.m. with resident 1 revealed she: *Had not had a bath for about ,d+[DATE] weeks and would prefer a bath over a shower. *Had not liked to complain. Review of resident 1's documented bathing records from [DATE] through [DATE] revealed: *She had received a shower on [DATE], [DATE], [DATE], [DATE] and a bed bath on [DATE]. -The next documented bathing record was on [DATE]. -That was 20 days between receiving a bath or shower from [DATE] until [DATE]. Interview on [DATE] at 12:25 p.m. with interim DON B and administrator A regarding bathing of resident 1 revealed: *They thought she had received one the week before [DATE] but could not find any documentation to support that. *They were not aware that her preference would have been for a bath rather than a shower. *They had started asking what preferences residents had upon their admission, they were unsure of the date of when that had started. -Resident 1 had no bathing preferences identified on her admission. Interview on [DATE] at 10:35 a.m. with director of nursing (DON) C and administrator A regarding bathing for resident 1 revealed: *Bathing documentation was completed in each resident's electronic medical record. *They had identified an issue with the bathing documentation not being completed. *Agreed there was no bathing documentation to support resident 1 had received a bath for 20 days. *When a resident refused a bath, it would have been documented. -There was no documentation to support resident 1 had refused a bath. Review of the provider's [DATE] Bathing policy revealed: *POLICY -The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The resident has the right to choose timing and frequency of bathing activity. Bathing preferences are asked upon admission and during quarterly care conference. C. Based on closed record review, interview, and policy review, the provider failed to ensure timely family/representative notification when resident had a change in condition for one of one resident (3). Findings include: 1. Closed record review for resident 3 revealed: *He had died in the facility on [DATE]. *On [DATE] he had become lethargic with complaints of not feeling well and hurting all over. *On [DATE] he was seen by his physician and a chest x-ray was ordered and completed. *On [DATE] he was started on Augmentin for right upper and left lower lobe infiltrates (pneumonia). *On [DATE] he became short of breath and his oxygen saturation was seventy-seven percent on room air (normal oxygen saturation is ninety-five to one hundred percent). *The physician had assessed him and wrote new orders to discontinue Augmentin, start Doxycycline, resume Duonebs, discontinue Tramadol, start Rocephin intravenously (IV) daily, and draw labs. *On [DATE] at 4:00 a.m. he was found in his bed with no vital signs present. *There was no documentation his family or representative had been notified of his change of condition until after his death. Interview on [DATE] at 2:44 p.m. with RN H regarding resident 3's change of condition revealed: *She had been working on [DATE] when his physician came to assess him. *She was not the nurse in charge of his care on [DATE] but had assisted with getting the IV started and mixed the Rocephin for administration. *She had not known if any of the nursing staff had attempted to contact his family when residents' condition changed. *It was an expectation nursing staff contact a resident's family or representative when a resident had a change of condition. *Resident 3 had a daughter who came to the facility after his death. Interview on [DATE] at 9:30 a.m. with Interim DON B regarding resident 3's change of condition revealed: *She was unsure if any of the nursing staff had attempted to contact resident 3's family or representative when he had a change of condition. *She expected nursing staff to document in the resident's medical record when they contacted residents' family or representatives. *After he died the facility initially could not get a hold of his representative because there had not been a working phone number in his medical record. *His daughter was contacted by social service director D on the morning of [DATE] via social media and was asked to call the facility. *The daughter then called the facility and was informed of his death. Review of the provider's [DATE] Notification of Change of Condition policy revealed: *The facility will provide care to residents and provide notification of resident change in status. *1. The facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: -b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); -c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . 43844

Based on observation, interview, record review, and policy review the provider fail to ensure nursing staff were competent and had sufficient training for: *Monitoring and assessing one of one sampled resident (2) for frequency of bowel movements and constipation. *Assessing one of one sampled resident (2) with significant weight loss. *Timely notification of a physician for one of one sampled resident (1) after a fall resulting in significant injury and requiring transportation to an emergency department. *Initiating a restorative nursing program timely for one of one sampled resident (1). *Timely notification of family/representative for one of one sampled resident (3) with a significant change of condition. Findings include: 1. Review of resident 2's closed medical record revealed: *On [DATE] he had reported complaints of constipation to his physician. *From [DATE] through [DATE] he had only one large bowel movement in those seven days. *There had been no nursing documentation addressing his constipation or having a bowel assessment completed by nursing. *From [DATE] through [DATE], he had been hospitalized for an ileus versus small bowel obstruction. Refer to F684, finding A1. 2. Review of resident 2's closed medical record revealed: *A [DATE] physician's progress note reflected he had lost more than forty pounds since his [DATE] admission and had lost almost twenty pounds since [DATE]. *Meal intake documentation from [DATE] through [DATE] and from [DATE] through [DATE] had not been documented for 104 of the 174 meals he should have been offered. *From [DATE] through [DATE], his weight loss had not been addressed in nursing documentation until [DATE] when the physician had assessed him, that was 67 days after the first noted weight loss. *On [DATE] and [DATE], the registered dietician (RD) had evaluated him. Refer to F684, finding A2. 43844 3. Review of resident 1's fall records revealed: *She had fallen in her room on [DATE] at approximately 2:30 p.m. *The nurse on duty had faxed her physician on [DATE] at 2:35 p.m. and related she had a fall and had hit her head. *The nurse had not notified the physician on this fax that she was on a blood thinner. -The physician did not respond to this fax. *The nurse called another physician on [DATE] at 6:31 p.m. and then received a physician's order for a non-emergent transfer to the hospital emergency department (ED) for treatment. -This was a three hour and 25-minute time span from when the fax had been sent to her physician and when the nurse called a different physician for an order to transfer to the ED. Refer to F684, finding B1. 4. Review of resident 1's medical records revealed the following: *Her [DATE] comprehensive individualized care plan included: -A [DATE] intervention of Skilled Rehabilitation Therapy evaluation and treatment as indicated. -There was no documentation of a restorative nursing care program. *A [DATE] progress note from the certified nurse practitioner that included, Increase restorative activities. *On [DATE] she had a care conference note that included she would be starting restorative nursing therapy as her skilled therapy had ended. Interview and review of restorative medical records on [DATE] at 1:19 p.m. with restorative nursing aide F regarding resident restorative nursing care revealed her restorative nursing care started on [DATE]. Refer to F684, finding B2. 5. Review of resident 3's closed medical record revealed: *He had died in the facility on [DATE]. *On [DATE] he had become lethargic with complaints of not feeling well and hurting all over. *On [DATE] he was seen by his physician and a chest x-ray was ordered and completed. *On [DATE] he was started on Augmentin for right upper and left lower lobe infiltrates (pneumonia). *On [DATE] he became short of breath and his oxygen saturation was seventy-seven percent on room air (normal oxygen saturation is ninety-five to one hundred percent). *The physician had assessed him and wrote new orders to discontinue Augmentin, start Doxycycline, resume Duonebs, discontinue Tramadol, start Rocephin intravenously (IV) daily, and draw labs. *There was no documentation his family or representative had been notified of his change of condition until after his death. Refer to F684, finding C1.

Based on observation, interview, and record review, the provider failed to ensure maintenance of hydration status for one of one resident (16). Findings include: 1. Observation and interview on 9/27/22 at 9:59 a.m. revealed resident 16: *Was in bed with the head of the bed raised and an overbed table on wheels positioned in front of her. A big water mug with a straw was on the overbed table. *Had patches of flaky skin on her lips and teeth appeared dull with yellow build-up and dry. *Moved her arms about in uncontrollable jerking movements. *Spoke with a muffled sound and moved her lips only slightly when she confirmed that she received enough to drink throughout each day. Observation on 9/27/22 at 12:10 p.m. revealed resident 16 was seated in a high back wheelchair in the dining room being fed by a certified nursing assistant (CNA). Interview on 9/28/22 at 3:51 p.m. with CNAs S and V revealed: *They were assigned to work on resident 16's wing that day for a twelve hour shift starting at 6:00 a.m. *CNAs were responsible for picking up water mugs from resident rooms and delivering fresh water in clean mugs to resident rooms. *They had not had time today to do that. Observation and interview on 9/28/22 at 4:26 p.m. with resident 16 revealed: *Her lips did not have flakes of skin but were pale in color and dry and her teeth remained dull and dry. *A smaller white plastic water mug full of water with a straw was in front of her on the overbed table. *She was unable to state what time it had been provided. Interview on 9/29/22 at 10:00 a.m. revealed the seven residents who attended a resident group meeting at that time agreed they received fresh ice water when they ask for it, but it was not routinely delivered without asking. Observation on 9/30/22 at 10:10 a.m. of resident 16 revealed: *She was in bed sleeping. *Her lips were pale, dry, and rough. *Eight ounces (oz) of water in a 9 oz white plastic water mug with a straw was on the overbed table. Interview on 9/30/22 at 10:12 a.m. with CNA S revealed: *She and the other CNA assigned to the wing had not passed fresh water yet. *She reported resident 16 was able to pick up her water mug and drink from the straw. Review of resident 16's electronic health record (EHR) revealed: *Her entry date was 1/26/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *The care plan included: -An intervention initiated on 2/10/21 to encourage adequate fluid intake that addressed the goal for no urinary tract infections related to her previous history of UTIs and use of a suprapubic (SP) catheter. -An intervention revised on 7/26/21 to report to the nurse any signs and symptoms of discomfort on defecation and frequency related to her risk for alteration of bowel .related to .always incontinent of bowel. -A focus for use of antidepressant medication, [MEDICATION(S)] ([MEDICATION(S)]), initiated on 9/17/20 and resolved [removed] on 8/2/21, with an intervention to monitor/document side effects .dry mouth, dry eyes, constipation, urinary retention. -Two focus areas revised on 6/15/22 that did not include interventions for how staff would ensure adequate hydration related to: --Required assistance with activities of daily living (ADL) due to [CONDITION(S)], including the ADL of eating. --Potential for altered nutritional status due to [CONDITION(S)]. One intervention stated, I like iced coffee with my meals with extra cream and sugar. *The September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -On 1/28/21, monitor for dry mouth, constipation . and other potential side effects related to antidepressant use. Both day and evening shifts were documented (except for three blank shifts) with a checkmark instead of as directed: Document: 'Y if monitored and any of the above observed. 'N' if monitored and not of the above was observed. -On 3/4/21, [MEDICATION(S)] 30 mg [milligrams] by mouth at bedtime for depression. -On 3/23/21, [MEDICATION(S)] powder 17 gram by mouth as needed every 24 hours for constipation. It was not recorded as being given on any day during the month. -On 11/4/21, [MEDICATION(S)] XL extended release 24 hour 15 mg, give 1 tablet by mouth one time a day to treat muscle spasms. According to Drugs.com, [MEDICATION(S)] is used to treat symptoms of an overactive bladder and may cause side effects including constipation, dehydration, and dry mouth. -On 11/13/21, [MEDICATION(S)] tablet delayed release 5 mg give 10 mg by mouth one time a day for constipation. *The most recent quarterly dietary evaluation, dated 2/2/22, noted: -She had functional problems and needed significant physical assistance to eat. -No evaluation of lab values. -An average intake of fluid at 1500-2000 milliliters (mL) daily. *Comparative review of the 11/2/21 annual Minimum Data Set (MDS) assessment and the 7/8/22 quarterly MDS noted the following declines: -The brief interview for mental status scored her as cognitively intact then moderately impaired. -The mood interview coded her as reporting no symptoms then feeling tired or having little energy nearly every day. -Her upper extremity range of motion limitation was coded as just one side then on both sides of her body. -Her bowel status was coded as occasionally incontinent with no constipation to having constipation present. Review of communication records in resident's 16's EHR over the past three months revealed ongoing concerns with irrigation of the catheter, urinary tract infections, and skin breakdown, as follows: *A discharge record dated 7/17/22 from the emergency room (ER) noted a clinical impression of obstructed SP and [CONDITION(S)] with instructions for an antibiotic twice a day for three days and push fluids. *Progress notes on 7/18/22, 7/22/22, and 8/2/22 addressed insurance denial, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *A urology consult on 8/3/22 at 3:49 p.m. ordered irrigate SP catheter PRN [as needed] with 60 cc's [cubic centimeter] of sterile water and a 60 cc cath [catheter] tip syringe if catheter is plugged. *A telemedicine consult on 8/3/22 at 4:28 p.m. noted the SP catheter was plugged and licensed practical nurse (LPN) L could not clear it with irrigation with an order request to send to the ER. *A nursing progress note on 8/21/22 at 4:24 p.m. reported, This am [before noon] prior to [MEDICATION(S)] Foley flush cna reported res [resident] peri [private] area very red with yellow discharge also reported res bypassing urine. Writer also observed res urine coming out of cath insertion site. Attempted to flush cath with [MEDICATION(S)] which was a very hard flush. Only small amount went through actual catheter. Flushed cath with ns, then repeated [MEDICATION(S)] clamped for 20 min. When disconnecting cath tubing for flush, res urine very thick like maple syrup, and slimy. Urine dark amber color, with very foul odor. Spoke with res about needing to increase fld [fluid] intake, and educated cna as well. *A faxed order on 8/22/22 directed 1500 cc [cubic centimeters] fluid per day, Please write a schedule & [and] make sure this is getting done and check UA [urinalysis] w/C&S [with culture and sensitivity]. *An order was entered on 8/22/22 to give 500 mL of fluids TID. *A note faxed on 8/23/22 to the physician reported an open area to L [left] buttock cheek crease with an order to treat. *Two progress notes on 8/25/22 at 10:39 a.m. and 2:50 p.m. reported, catheter flushes unsuccessful and continues to bypass urine followed by a clinic appointment with a new catheter inserted and orders for next SP catheter change on 9/22/22. *Two progress notes on 9/2/22 reported: -At 10:53 a.m., the urine was completely bypassing catheter and [resident] is lying in urine from shoulders to knees. Sediment packed into catheter tubing and unable to flush with [MEDICATION(S)] x 2. resident reports that catheter rarely flushed and has not been flushed in at least three days. some sediment loosened in catheter but unable to unpack. resident reports discomfort. -At 4:36 p.m., an order to obtain a UA and flush 2-3x [times] daily with renaciden (sic) to break down sediment. *A faxed note from the laboratory on 9/6/22 noted, urine sample contaminated. Is patient symptomatic? If symptomatic, collect urine sample again. *A progress note dated 9/8/22 reported urology orders related to UA for [MEDICATION(S)] [antibiotic] 100 mg [milligrams] bid [two times a day] for 3 weeks. *A progress note dated 9/21/22 reported MASD [moisture-associated skin damage] area to right gluteal [buttock] fold. Review of monitoring records in resident 16's EHR revealed: *The most recent basic metabolic laboratory (lab) report was dated 4/25/22. No further lab results were completed to evaluate her electrolyte balance. *No documentation to indicate a clinical review of her fluid intake was completed to ensure she was receiving adequate fluid intake. *The daily fluid intake records for August and September 2022 had multiple days and times of intake not documented making it difficult to determine actual fluid intake every day and verify that the 1500 cc per day had been met. On the days that were recorded, the intake averaged: -During meals, recorded on 15 days in August and 14 days in September, had an average of 397 mLs fluid per day. -Between meals, recorded 15 days in August and 15 days in September, had an average of 359.67 mLs fluid per day. *The daily bowel record noted bowel movements (BM) on only five days in August (8/2/22, 8/9/22, 8/15/22, 8/23/22, and 8/31/22) and five days in September (9/12/22, 9/13/22, 9/19/22, 9/26/22, and 9/28/22) with the condition of constipation on 9/13/22 and 9/19/22. *The September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -On 9/30/21, Flush supra pubic catheter with 10 mL normal saline TID PRN as needed for increased sediment. -On 10/31/21, Flush suprapubic catheter if not draining PRN as needed for flush. -On 11/19/21, Indwelling Catheter Type: Suprapubic, Catheter Size: 16F, 10 CC balloon. Change on the 23rd of the month and PRN as needed for leaking or dislodgement. -On 8/3/22, Irrigate SP catheter PRN with 60 CC of sterile water and 60 CC cath tip syringe if catheter is plugged. *The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 9/30/22 at 9:30 a.m. with dietary manager (DM) F, while reviewing resident 16's 9/30/22 dietary meal tickets revealed she would be offered: *No fluids for breakfast. That meal was marked in large bold letters, Do Not Serve DM F stated it was her preference to sleep in during the morning and not be served breakfast. *One cup, 8 fluid ounces (fl oz) or 237mL, of fluids at lunch *Two cups, 16 fl oz or 474 mL, of fluids at supper. IMMEDIATE JEOPARDY HARM Observations and interviews of resident 16 on 9/28/22 through 9/30/22 revealed she had dry, chapped lips with flakes of loose skin, dry mouth when she spoke, and her teeth were dull with yellow buildup. She required extensive assistance of one person to eat and drink. Her EHR revealed she has a suprapubic catheter that required two visits to theER on [DATE] and 8/3/22 due to complications from a blocked catheter tube and large amounts of sedimentation. A health status note from 8/21/22 indicated she was bypassing the catheter, urine was coming out of catheter insertion site, they attempted to flush [MEDICATION(S)] irrigation solution, very hard flush, they disconnected the catheter tubing for the flush, urine was very thick (like maple syrup, slimy, dark amber color, very foul odor). An order on 8/22/22 for a fluid goal of 1500 cc per day and to write a schedule and make sure that this is getting done was entered as an order to give 500mL of fluids TID; however, August and September 2022 fluid intake documentation was inconsistent with multiple days' worth of fluid intakes not documented making it difficult to determine actual fluid intake every day. The registered dietitian had not assessed her nutrition status since February 2022, and it did not include a fluid intake assessment. No other documentation was found in her record to indicate clinical review of fluid intake to ensure she was receiving adequate fluid intake. Lab results for the last six months revealed no labs had been obtained to evaluate her electrolyte balance. Bowel records showed she had only 5 movements in September 2022 with two times recorded as constipation. Random observations made by surveyors from 9/27/22 through 9/29/22 revealed staff do not pass fresh water to residents on a regular basis. Interviews with staff and residents confirmed those observation. IMMEDIATE JEOPARDY NOTICE On 9/30/22 at 11:15 a.m., administrator (ADM) A, director of nursing (DON) B, and regional nurse consultant (RNC) X were requested to provide a plan for removal of the immediate jeopardy that had been determined due to the provider's failure to have systems in place to monitor and ensure resident 16 received adequate hydration per orders placing her at increased risk for negative outcomes, including fluid and electrolyte imbalance, frequent ER visits due to thick urine, frequent UTIs, common symptoms of constipation, continued skin problems, and poor dentition. IMMEDIATE JEOPARDY REMOVAL PLAN On 9/30/22 at 1:21 p.m., ADM A, DON B, and RNC X provided an acceptable removal plan, Ad Hoc QAPI [quality assurance performance improvement], which included: 1. Immediate corrective action for those affected by the deficient practice: *9/30/22 at 11:55AM Resident #16 was assessed for signs and symptoms of dehydration by [name] DON. Suprapubic Site no evidence of urine leakage, no redness, no warmth. Dressing changed, clean, dry, and intact on 09/30/22. Urine amber colored, and dense. Oral membranes were moist, tongue was moist, eyes were moist, lips were dry and cracked. Skin turgor appropriate. Skin turgor did not show tenting. Resident #16 Primary Care Provider was contacted on 09/30/22 at 12:15PM, left message, returned call at 1:00pm and ordered basic metabolic panel and continue to monitor. *Reviewed Resident #16 Order for 1500mL per day fluid goal, schedule as follows, Morning water pass minimum of 200mL, Lunch minimum of 420mL, Afternoon water pass 240mL, Supper minimum of 420mL, NOC [night] shift minimum of 260mL. *Schedule posted on Dietary Wall, in C.N.A. and Nurse Communication book, and at Center Nurses station. *Resident #16 will be interviewed for preferences of beverages she prefer to consume. *Resident #16 Oral care will be provided 3x day by C.N.A. or Nurse. *Resident #16 Nurses will complete abdominal assessment for bowel sounds, and ensure abdomen is soft and non-tender 2x week to assist with signs and symptoms of constipation. Nurses will follow bowel protocol to ensure PRN medications are administered as ordered to assist with prevention of constipation and ensuring appropriate hydration status. *Resident #16 will be assessed by Dietitian on 10/04/2022. *Resident #16 Care Plan will be updated to reflect the above. 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: *All other residents will be assessed for signs and symptoms of dehydration. If not already on Intake monitoring will be implemented for hydration improvement. *Immediate Education will be provided to C.N.A.'s, Dietary Aides, Cooks, and Nurses regarding importance of hydration, and fluid intake of all residents, signs, and symptoms of dehydration, and on amount of mL's in each beverage container. They will be provided a list of high-risk residents to ensure awareness of fluid consumption. C.N.A.s and nurses will be educated regarding importance of bowel documentation and follow up. *Nurses will have a task on the TAR for monitoring fluid consumption of high-risk residents prior to end of shift, to ensure minimum goal of fluids has been consumed. *Water pass was implemented at 10:30AM on 09/30/22. 3. Measures put in to place/systematic changes to ensure the deficient practice does not reoccur *Nurse Manager will be assigned to observe, monitor, and ensure hydration schedules are being followed, and oral care is completed. *Will review fluid intake and BM documentation daily during morning clinical meeting. 4. Plan to monitor performance to ensure solutions are sustained *Audits 12 resident's intake, oral care, and bowels daily x 4 weeks, 3x week x 4 weeks, weekly x 4 weeks, monthly x 4 months. *Water pass audit daily x4 weeks, 3x week x4 weeks, weekly x4 weeks, and monthly x4 months. IMMEDIATE JEOPARDY REMOVAL REVIEW On 10/03/22 at 12:45 p.m., the survey team requested documentation to verify what was done for removal of the immediate jeopardy. Documentation provided by ADM A and RNC X and reviewed by the survey team revealed: *Resident 16 was interviewed on 9/30/22 at 4:30 p.m. (the name of the interviewer was blank), which revealed: -She reported she felt she got enough fluid. -Her preferences included water and chocolate milk. -She reported having a bowel movement 3 days ago when asked, Have you had difficulty with bowel movements? -She had no concerns with her catheter, going to the bathroom, or with staff. *A one page large print plan for resident 16's Fluid Expectations including: -AM Water Pass: 180mL per day -Lunch: 420mL per day -Afternoon Water pass: 360mL per day. -Supper: 420mL per day. -NOC shift: 360mL per day *Resident 16's care plan had not been revised to reflect these fluid expectations. *Hydration Documentation Education was completed with Hydration, Constipation, and Dehydration quizzes for numerous staff dated 10/1/22. *Audits had been started to monitor for: -Water pass completion through resident interviews and observation of three planned water pass times. -Fluids received, consumed, and documented at meal time and afternoon snack time for 12 random residents per day. -BM documentation completed, abdominal assessment when tree days had passed without a BM, and bowel protocol followed for 12 random residents per day. *A list of high risk residents was prepared for staff to ensure accurate and entered timely fluid documentation. *A Room Roster form that included all residents with rows and columns to record mL amounts of AM, PM, and NOC fluid intakes. Documentation on 10/2/22 and partial documentation on 10/3/22 were the same amounts for all residents. Observation and interview on 10/3/22 at 12:47 p.m. with resident 16 revealed: *She was sitting up in her chair in her room. *Her teeth were yellow but shiny. *Her lips were moist with a pale pink color. *Her speech sounded more fluid. Interview on 10/3/22 at 1:40 p.m. with ADM A and RNC X revealed: *They agreed that staff had documented on the Room Roster for all residents how much fluid was offered not consumed and the staff will need further education. *When asked about who was responsible to ensure the care plan was updated, they indicated -It was a team effort. -They thought DON B had updated the care plan to reflect the current changes for resident 16. -They were not aware it had not been updated. Interview and review of revised documents on 10/3/22 at 2:44 p.m. with ADM A and RNC C revealed: -A Staff In-Service Sheet documented attendance by staff on 10/3/22 for additional hydration education. -The Room Roster intake documentation sheet had been revised to record AM, PM, and NOC amounts offered and consumed. -Resident 16's care plan had been revised on 10/3/22 to include, Encourage and help the resident drink at least 1,500 cc's of fluid each day. 15cc's per pound of body weight is recommended (140 pound person should drink 2,100cc's per day). On 10/3/22 at 2:57 p.m., the survey team notified ADM A and RNC X that the immediate jeopardy was removed, and the remainder of the survey would continue.

Based on observation, interview, record review, policy review, and facility assessment review, the provider failed to ensure sufficient nursing staff were available to provide nursing services to meet residents' needs safely and in a manner that promoted each resident's rights and physical, mental, and psychosocial well-being for 79 residents. Findings include: 1. Interview on 9/27/22 at 4:02 p.m. with a resident who did not want to be identified revealed: *She did not get a bath regularly. *She had false teeth, staff did not usually brush them, they just put them in a denture cup at night with a denture cleaning tablet, rinse them off in the morning and give them back to her. *Hates the weekends because staff is always short and feels there is no one there to care for her. *Sometimes in the evening when she is ready to get into bed, she has to wait up to two hours for assistance. -She states usually because it takes two staff to transfer her and there is not always two available to help. *She stated the staff will tell her just a minute but then never come back. *Has been put to bed at night soiled and not changed until the next morning. 2. Interview on 9/27/22 at 4:53 p.m. with resident 45 revealed: *At times he has to go without a shower because there is not enough staff to assist him with the task. *He stated This [the provider] is a business and its about meeting the business standards, not taking care of people. *He did not think management listened to what the residents wanted or needed. 3. Interview on 9/27/22 at 4:21 p.m. with resident 61 revealed she: *Had been sitting in her wheelchair in her room. *Had to wait a long time to use the bathroom. *Had some accidents because she has to wait for someone to transfer her. Record review for resident 61 revealed she: *Was admitted on [DATE]. *Had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *Was assessed on the Minimum Data Set (MDS) dated [DATE] as one person physical assist with transfers. 4. Interview on 9/28/22 at 9:07 a.m. with resident 40 revealed he: *Had been sitting in his electric wheelchair in his room. *Had to wait 30 minutes in the morning for help sometimes. *Stated staff take other residents to the dining room to eat and then do not come back to help him. Record review for resident 40 revealed he: *Was admitted on [DATE]. *Had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *Was assessed on the MDS dated [DATE] as one person physical assist with transfers. 5. Interview on 9/27/22 at 3:15 p.m. with certified nursing assistant (CNA) M, who was assigned to give baths that day, revealed: *She did not know where she would be assigned until she arrived that morning, but she was okay with giving the residents baths, because she knew they would get done. *She had been full-time but worked just part-time now because of the concerns she had identified with poor quality of care, including: -Perineal care not getting done correctly leading to a high frequency of urinary tract infections. -Oral care not getting done at all. -Not all of residents were getting routine baths or showers. -Not using two staff when total lifts were used. *She was trying to get as many baths done as she could to get some of the missed residents done. *The tub room was a mess when she first walked into it that morning with soiled towels all over the place. *She named several residents who have had negative experiences related to staffing concerns. 6. Interview on 9/28/22 at 3:51 p.m. with CNAs S and V revealed: *CNA V had been working here for a few weeks, but CNA S started just on Monday, 9/26/22; both were already CNAs when they started. *CNA V reported she had received a little orientation when she started, but CNA S said she had received none. *They were assigned to work two halls together, blue [rooms 218-230, 20 residents as of 9/27/22] and red [209-217, 15 residents as of 9/27/22], but sometimes there was only one CNA for the blue wing. *No help was provided from other staff or nurses. *They did not know who leadership was. *There was no rounding between shifts with the off-going CNAs. *They try hard to do all personal cares. *The bath CNA doesn't do any baths outside of scheduled baths. *The CNAs have to pick up the water cups from each room and return with fresh water during the shift. CNA V reported there was no system for doing that when she first started so she started putting tape on the mugs so she could tell when fresh water was last delivered to each room. *Snack carts had to be done by CNAs if it was going to be done. *They had not had time yet to pass fresh water or snacks. Review of the employee files for CNAs S and V revealed: *CNA V started on 9/15/22 and there was a completed orientation checklist in her file. *CNA S started on 9/26/22 but there was not a completed orientation checklist in her file. Interview on 10/4/22 at 1:15 p.m. with human resource director (HRD) H revealed: *CNA S had not received orientation because she started working before she [HRD H] knew she was starting. *CNA V resigned effective immediately last week. 7. Interview on 9/28/22 at 4:16 p.m. with CNA N, while standing at the nurses desk with no residents in the area, revealed: *She had worked as a CNA here for a year. *The CNAs rotate wing assignments, and it took her two weeks to get to know every resident. *She was assigned as bath CNA that day, but they usually don't know who is assigned until they come on duty. She was the bath CNA maybe once a week out of three to four days. *The day shift CNAs will do walking rounds with the night CNAs if the night CNAs get here on time. *The CNAs do not get report from the nurses. *Regarding the bath schedule: -There is a schedule in the tub room. -The CNAs fill out a bath sheet to report the bath being done and any concerns observed during the skin check. -If scheduled bath is not done, a second CNA may see if the resident is willing to get a bath that day. -If the bath is not done, it may be done on another day if there is time and the bath CNA is aware of who was not done. -Sometimes, the nurse will write a note in the bath book. -We document the bath task in POC [point of care]. *Radios don't help with communication between staff. There was either not enough or they are not charged. *The CNAs are not able to hear call lights from one end to the next. *Most Hoyer [total] lifts are on blue [wing], and the CNAs have to pool together to get two person transfers done. *Mealtimes can be a challenge for assisting all the residents. -Today during lunch, there wasn't enough. Several people, including leadership, left while the surveyors were gone for lunch. -Supper is hardest for having enough staff to assist with the mealtime because we are changing shifts at 6:00 [p.m.] At the end of the interview with CNA N on 9/28/22 at 4:20 p.m., LPN L, who was charting while seated at the nurses desk, spoke up and reported there was never enough staff. She said, Management has asked the CNAs several times what would help, and nothing has changed. 8. Interview on 9/29/22 at 10:00 a.m. with 7 residents (9, 34, 36, 50, 52, 63, and 73) interviewed during the resident group meeting agreed: *They did not know who to go to when reporting a grievance. There had been so many changes in the last two months that they don't know what is happening. *The provider did not have sufficient staff to ensure care was provided in a timely manner: -They reported they have had to wait too long for call lights to be answered. -Staff get pulled away when providing care with a resident, sometimes several times, to help with other situations. -At times, there will be two staff when using a mechanical lift but usually only one. -The CNAs stand at the desk or in the hallway talking and laughing with each other while call lights are going off. -Resident 34 had reported that [when CNAs were not responding to call lights] to the nurse, but no changes in behavior have been seen. -Resident 73 reported he sat on toilet today for an hour before a medication aide arrived and then she did not want to take the time to get the sit-to-stand lift. When he refused, she said, I'm the boss, we'll do it [MEDICATION(S)]. (Refer to F600, finding 2.). -Resident 63 reported staff will not transfer me more than once a day so, when he wanted to attend morning and afternoon activities, he had to choose so he could get off his wheelchair during the day. -Residents 9, 34, and 63 all agreed they have had to help other residents get over a doorway threshold when stuck because there were no staff around to help. Then they get told they were not supposed to help other residents but do not get an explanation for why. -This should be our home, but it isn't. -They treat us as just a reason to get a paycheck. *They got fresh ice water when they ask for it, but it is not routinely distributed. *They had not seen a snack cart and had never been offered snacks at bedtime. 9. Review of the Facility Assessment revealed it was dated 5/24/21 and was based on an average daily census of 52 residents. *The facility census on the 9/27/22 Resident List Report had 79 residents total, with:. -20 residents on Unit: 218-230 Blue (Center). -16 resident on Unit: East-Wing [rooms 301-312]. -15 residents on Unit: 209-217 Red (Center) -12 residents on Unit: 201-208 Yellow (Center). -16 residents on Unit: [NAME] Wing [rooms 100-115]. *Comparative Review of the staffing numbers posted on the dry erase board in the conference room and the August and September 2022 nursing schedules revealed: *The current census was listed on the board as 80, 18 [short stay] residents. The goal census was 80, 20. *The CNA numbers on the board listed eight CNAs, without specifying which shift, assigned as: -CNAs Blue x [times] 2. -East x 2. -Red/Yellow [both wings] x 1. -Bath aid x 1. -[NAME] x 1. -[NAME]/Red x 1. *The August and September 2022 schedules revealed: -On 9/6/22 and 9/7/22, there was only one CNA. -On 9/13/22, there were only three CNAs. -On 8/28/22 - 9/1/22, 9/3/22, 9/11/22, and 9/26/22 [8 days], there were only four CNAs. -There were 13 days with only five CNAs, 17 days with only six CNAs, and 8 days with only seven CNAs. -Only 11 days were covered by eight or more CNAs, most of those days in August. -Only 2 days in September (9/28 and 9/30) had 8 CNAs on the schedule. *The nurse and certified medication aide (CMA) numbers on the board showed 3 and 2 respectively, each day, while the August and September 2022 schedules revealed shortages: -For nurses, three days in August and four days in September. There was only one nurse on 9/17/22. -For CMAs, seven days in August and four days in September. 10. Interview on 10/04/22 at 1:25 p.m. with administrator (ADM) A and regional nurse consultant X regarding staffing revealed: *They have trialed several changes in staffing from eight hour shifts to twelve hours shifts. The change to twelve hours started the end of July. *Residents have been interviewed about staffing concerns. *Staff have been interviewed to see where they felt the high acuity cares were in the building. *ADM A acknowledged that she had not had a chance to update the Facility Assessment to reflect current acuities. *Staff need to use the walkies [radios] to communicate with each other. *Staff have not been willing to cross-over to help each other and will only work on their assigned hallway. We are trying to change the culture. *Bath assignments were trialed two ways: -Had the CNAs give the baths assigned on their hallways each day instead of having an assigned bath aid. -After conducting a bath Ad Hoc quality improvement audit and discovered that baths did not get done that way, we now assign a bath aide every day to give all the baths. *We are working to hold some nurses accountable to make correct decisions about reassigning staff. *We are making progress moving away from having contract staff; we were at 80% [percent] contract staff and now it is 50/50 [50% contract to 50% hired}. 11. Refer also to F600, F677, F685, F686, F689, F692, and F809 for findings that demonstrate the impact that insufficient staffing had on unmet resident needs.

Based on interview, record review, and policy review, the provider failed to protect two of two residents (71 and 73) from mistreatment while receiving care from staff. Findings include: 1. Interview on 9/27/22 at 2:24 p.m. with resident 71 regarding her care revealed: *Resident 71 recalled on 9/25/22 after supper, but before bedtime, certified nursing assistant (CNA) W assisted her to go to the bathroom with the sit-to-stand aide. *CNA W did not put the sling on correctly and resident 71 slipped through the sling and landed hard onto the toilet. *Resident 71 said CNA W got upset with her and said, I'm not going to take care of you again, and abandoned her in the bathroom. *She had to wait a long time for another aide to help her off the toilet. *Resident 71 said she felt mad at CNA W for leaving her, helpless because she could not stand up on her own, and sad as she cried after the incident. *She thought she had mentioned this incident at her care conference. Interview on 9/29/22 at 11:11 a.m. with director of nursing (DON) B and social services designee (SSD) D revealed: *Neither of them were aware of the incident mentioned above. *SSD D indicated they had resident 71's care conference earlier in the week and she mentioned having to wait a long time for staff to answer her call light, however resident 71 had not mentioned anything about the incident mentioned above. Interview on 9/29/22 at 1:35 p.m. with SSD D revealed: *She talked with resident 71 to learn the full details of the incident. *Resident 71 told SSD D the same details of the incident mentioned above. *SSD D reviewed the working schedule from 9/25/22 and confirmed that CNA W had worked on that day and had been assigned to resident 71's hallway. *SSD D completed a grievance form, informed administrator A, and submitted reports to both adult protective services and the local police department. Interview on 9/29/22 at 2:22 p.m. with human resources director (HRD) H about CNA W's employee file revealed: *CNA W worked at the facility previously and was terminated from her position in January 2020 due to a substantiated allegation of abuse and neglect. *She was rehired in February 2021. *CNA W's employee file in the provider's electronic human resource software program indicated that she was terminated on 1/27/20 for the reason of employee misconduct. *The provider had access to this information of terminated for employee misconduct upon the rehire process in February 2021. *HRD H admitted they should have investigated further on why CNA W was previously terminated before rehiring her. *HRD H said she should have uploaded the corrective action form from January 2020 to their electronic human resource software program so that the leadership team could all have access to the form. -The corrective action form indicated CNA W had been terminated due to substantiated allegation of abuse/neglect. Interview on 9/29/22 at 2:47 p.m. with administrator A and regional nurse consultant (RNC) X revealed they: *Did not know that CNA W was previously terminated from the facility due to a substantiated allegation of abuse/neglect. *Would not have considered CNA W as a potential candidate for rehire if they knew about the previous termination. *Had not been aware of the incident between resident 71 and CNA W before 9/29/22. Interview on 10/3/22 at 3:36 p.m. with HRD H about her process for rehiring former employees revealed: *She reviewed the applicant's file in the provider's electronic human resource software program to learn why they previously left or why they were terminated from their position. *She confirmed again that she should have uploaded CNA W's termination papers from January 2020 into the program for easy access to review. *She was planning on conducting an audit of all employee files due to this incident. *She started to update the provider's do not rehire list. Interview on 10/4/22 at 11:17 a.m. with administrator A and RNC C regarding the incident revealed: *Administrator A interviewed the other staff members that worked on the evening of 9/25/22. -No other staff or residents voiced complaints about CNA W. -The other staff members were not aware that CNA W abandoned resident 71 on the toilet. *They were finishing their investigation to submit to the South Dakota Department of Health (SDDOH). *Due to learning one of their employees had previously been terminated due to abuse and neglect, they committed to improve their hiring practices by thoroughly checking potential applicant's references, looking at their employee files, and keeping their do not rehire list updated. Review of resident 71's electronic medical record revealed: *She was admitted on [DATE]. *She required extensive assistance with transfers. *Her brief interview for mental status score was 15, indicating she was cognitively intact. Review of CNA W's Corrective Action Form signed on 1/31/20 revealed: *The Facts section read, Resident filed complaint. Investigation completed. [Allegation] of abuse/neglect substantiated. [SDDOH] report completed. Last day worked 1/26/20. Review of the provider's Abuse and Neglect policy revealed: *Page one, 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, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. *Page one, Definitions of Abuse, Neglect, Exploitation, & Abuse Coordinator. -Abuse: abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertence or careless behavior done it deliberately that results in harm may be considered abuse. *Page one continued, Types of abuse . -2. Verbal. -3. Mental . -5. Neglect . -7. Involuntary Seclusion. *Page two, Verbal: verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing slash seeing distance. -Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc. *Page two continued, Mental: mental abuse includes but is not limited to humiliation, harassment, threat of bodily harm, punishment, isolation (involuntary, imposed or seclusion) or deprivation to provoke fear of shame. *Page two continued, Involuntary Seclusion: Isolation of a resident against his/her will (involuntary, imposed seclusion) . -Examples: statements to threaten or actually secluding, isolating or locking a resident in their room or a room or area by themselves; leaving a resident in their room all day who does not wish to be left alone in his/her room all day. *Page three, Neglect: 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. *Pages three and four indicated the screening process for potential applicants. There was no process mentioned for screening the facility's own personnel files for potential applicants who had worked at the facility previously. 2. Interview on 9/29/22 at 11:24 a.m. with resident 73 during the resident group meeting revealed: *He sat on the toilet today for an hour before a medication aide arrived. He did not give a name. *She did not want to take the time to get the lift equipment and was going to physically help him stand up off the toilet. *He said no, but she said, 'I'm the boss, we'll do it [MEDICATION(S)].' *He refused again, and said he asked her what she was smoking, with some added offensive words. *The lift equipment was used to get him off the toilet. *Another staff person came and told him to apologize to the medication aide about his statement to her. Interview on 9/29/22 at 4:34 p.m. with licensed practical nurse (LPN) L revealed: *When asked if she was aware of an incident that morning involving resident 73, she reported he had made a statement to the medication aide about her being on drugs. *She said, He exaggerates. Interview on 10/4/22 at 11:04 a.m. with DON B and RNC X revealed they agreed the incident should have been reported and investigated as an allegation of abuse and neglect. Follow-up interview on 10/4/22 at 11:09 a.m. with LPN L revealed: *The medication aide reported resident 73's refusal to let her transfer him off the toilet. *She went with the medication aide to his room and said to both that she did not want to hear their arguments about how he should be transferred. *She then asked resident 73 how he wanted it done, and he was transferred with the lift. *She did not report the incident for further investigation because it was he said, she said situation. Interview on 10/4/22 at 11:10 a.m. with SSD D revealed she agreed the incident should have reported as an allegation of abuse so it could be investigated. Review of resident 73's electronic health record revealed: *On 8/29/21, a lift evaluation required a sit to stand lift. *The care plan noted current interventions for assistance with activities of daily living (ADL) and risk for falls related to leg impairment due to post-polio plegia: -Revised on 2/18/22, Using stand-aid for transfers. Can get on to toilet per self, needs stand-aid to get off of toilet. -Revised on 4/8/22, Use of assistive device during transfers. Stand-aid. -Revised on 8/31/22 to assist with ADL's/mobility as needed. Stand-aid and motorized w/c [wheelchair]. *On 9/3/22, the annual minimum data set (MDS) coded him as cognitively intact, without behavior symptoms, and needing weight bearing assistance of one person to transfer on and off the toilet. *There was no progress note on 9/29/22 regarding the incident. *Transferring task documentation for 9/29/22 was not documented.

Based on observation, interview, record review, and procedure review, the provider failed to: *Follow up and monitor for signs and symptoms for a urinary tract infection ([CONDITION(S)]) resulting in hospitalization for one of one sampled resident (12). *Provide sufficient incontinence and peri care to avoid development of a [CONDITION(S)] for one of one sampled resident (55). *Provide ongoing educational opportunities for one of one sampled resident (40) who self-cares for his ostomy. *Provide fluids that were thickened to the correct consistency based on physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Address all aspects of a resident's pain and implement interventions for one of one sampled resident (15). Findings include: 1. Observation and interview on 9/27/22 at 10:54 a.m. of resident 12 in his room while certified nursing assistants (CNA) M and FF assist him to get ready for a shower. *CNAs M and FF used the mechanical total body lift to move him from his wheelchair and into bed. *They undressed him in the bed, emptied his catheter bag, set the catheter bag on his lap, and with the mechanical lift assisted him into the shower chair. *CNA M pushed him to the east shower room in the shower chair with the catheter bag on his lap. *When she got him in the shower, she then moved the catheter bag below the bladder and attached it to the side of the shower chair. Interview on 9/27/22 at 11:32 a.m. with CNA M regarding the above observation revealed: *She had been educated to empty the catheter bag prior to transferring a resident so then the bag could be placed in their lap so it would not get pulled out. *She had agreed there could still be urine in the tubing of the bag that could go back into the bladder. *Resident 12 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 9/27/22 at 11:52 a.m. with licensed practical nurse BB regarding resident 12's catheter revealed: *She had changed the resident's catheter recently with no issues. *He was not currently on antibiotics for [CONDITION(S)]. *Did have a history of UTIs. *Had not had an infection or hospitalization recently. *The CNAs put the catheter bag in his lap because resident 12 is nervous it will get pulled on. Review of resident 12's medical record revealed: *4/26/22 he had seen a urologist and a foley catheter was inserted. He was to have the catheter changed every 30 days. *There was an order on his treatment administration record (TAR) to change his catheter on 5/26/22. This had not been signed as completed. *A nurses note from 6/1/22 at 5:58 p.m.: Resident c/o [complaints of] Right side abdominal pain that started this morning et [and] gradually got worse thru out the day pain 6/10 per resident; writer emptied 300cc [cubic centimeter] of dark light brown urine per cath [catheter]bag. PRN [as needed] [MEDICATION(S)] given as ordered for pain PRN. VS [vital signs] 98.9-98-20-158/82. Will continue to monitor. *No other documentation regarding residents' abdominal pain until 6/3/22 at 5:10 p.m. and a nurses note indicated resident was sent to the emergency department for persistent abdominal pain that was not relieved with pain medications. *6/3/22 he was seen by Avel eCare via a two-way audiovisual telehealth system for evaluation of his abdominal pain. -Review of the note from this visit had indicated: --The pain had started the night before. --No mention of the symptoms he was having on 6/1/22. --His abdomen was distended and tender. --Plan was to transfer him to the emergency department to rule out appendicitis. Review of resident 12's 4/29/22 care plan revealed: *[Resident name] will show no signs and symptoms of urinary infection. *Change foley catheter per facility protocol or MD [medical doctor] order. Interview on 9/29/22 at 3:06 p.m. and on 10/3/22 at 3:41 p.m. with director of nursing (DON) revealed: *There had been no other documentation between 6/1/22 when the pain first presented until 6/3/22 when he was sent to the hospital. *Had expected a nurse to notify a doctor with his complaints on 6/1/22. *Had expected nurses to monitor and document in his medical record after his change on 6/1/22. *His catheter should have been changed and signed out on the TAR on 5/26/22. 2. Interview on 9/27/22 at 2:06 p.m. with resident 55 revealed she: *Was in her room in a bariatric bed. *Stated she had gone to the hospital this summer for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . *Could not remember exact date. Record review for resident 55 revealed: *She had been admitted on [DATE]. *She had a brief interview of mental status (BIMS) of 10, meaning she was moderately impaired. *Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *She was sent to the emergency roiagnom on [DATE] after a sudden change in condition. -diagnosed with [CONDITION(S)] (acute), acute [CONDITION(S)], E. coli bacteremia and acute alteration in mental status. -Returned to the provider on 6/7/22. *Her revised care plan dated 6/9/22 revealed interventions for monitoring resident 55 for: -Risk for alteration of bowel and bladder functioning related to: --Foley catheter use. --Obesity. --Impaired mobility. --Diuretic use. --Bowel incontinence. --History of [CONDITION(S)]. -Catheter related trauma. -Catheter care every shift and as needed. -Change Foley catheter per facility protocol or MD order. -Monitor urine/catheter output every shift. -Monitor for pain/discomfort due to catheter use. Interview on 10/04/22 at 9:09 a.m. with regional nurse consultant X and DON B regarding resident 55's [CONDITION(S)]/[CONDITION(S)] hospitalization revealed: *Her change in condition was a sudden onset of slurred speech and slow response. *The physician evaluated her while doing rounds and ordered her to be transferred to the emergency department. *The provider did update the care plan after this hospital stay to provide more guidance to staff. *Staff need to do a better job with peri care and re-education. 3. Observation and interview on 9/28/22 at 9:32 a.m. with resident 40 in his room revealed: *He had been sitting in his electric wheelchair. *A catheter bag had been hanging off a garbage can and the tubing had been lying on the floor of his bathroom. *The toilet had urine remaining in the bowl, and fecal matter spattered around the back half of the toilet and the toilet seat. *Stains had been noted on his bed mattress. *The front of his electric wheelchair had a thick layer of dirt. *His ostomy bag had been hanging below his shirt on the outside of his pants. *Multiple bottles of personal hygiene products and empty boxes cluttered up his room. *He did not like people coming into his room to organize his stuff. Review of resident 40's electronic medical record revealed: *He had been admitted on [DATE]. *He had a brief interview for mental status (BIMS) of 15, meaning he was cognitively intact. *His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *His revised care plan dated 7/13/21 revealed: -He preferred to provide his own ostomy cares. -He did not follow infection protocols as he has done this for many years. *He had been diagnosed with a [CONDITION(S)] on 8/4/22. Interview on 9/28/22 at 3:39 p.m. with administrator A regarding observations of resident 40 revealed: *She had agreed his room does need to be reorganized. *He will only allow housekeeping in his room once a month. *She had agreed the catheter tubing laying on the floor would be an infection control issue. Interview on 9/28/22 at 4:21 p.m. with DON B regarding observations of resident 40's bathroom revealed she: *Had not been aware that his catheter bag and tubing had been stored in his bathroom. *Agreed that would have been an infection control issues. *Did not find any documentation that the provider tried to re-educate resident 40 on ostomy care. 4. Review of the provider's September 2019 Catheter Care procedure revealed: *The purpose of the procedure was to prevent catheter-associated infections. *The catheter bag was to be positioned lower than the bladder to prevent urine from flowing back into the bladder. *To keep the catheter tubing and bag off the floor. *Residents who wanted to perform their own catheter care should be assessed to ensure they knew how to do it safely. *To notify the physician immediately with any signs or symptoms of urinary tract infection. 5. Observation on 9/28/22 at 5:40 p.m. of CNA R during supper service in the [NAME] dining room revealed she served coffee to resident 277 without thickening the beverage. Interview at that time with CNA R about resident 277 revealed she: *Did not know resident 277 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] *Did not really know the residents on the [NAME] unit. *Had seen resident 277's wife give him thin fluids previously, so she thought he could have thin fluids. *At that time, she retrieved the coffee, thickened it, and returned it to resident 277. Interview at that time with resident 277's wife revealed she: *Wondered why CNA R served coffee to resident 277 because both she and her husband were active Seventh-Day Adventists. *Discussed that Seventh-Day Adventists practiced certain dietary restrictions, such as refraining from drinking caffeinated beverages. Please refer to tag F656, finding 6 for additional information regarding resident 277's religious dietary preferences. Review of resident 277's order summary report revealed: *He had a 9/12/22 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 6. Observation and interview on 9/27/22 at 11:27 a.m. with resident 15 revealed: *Sleeping in the wheelchair is not good, it hurts my tailbone. *He was supposed to be getting a recliner and the social service designee was working on it. *His right leg had an open area that was wrapped, and he reported he went to a wound doctor for it. *He had pain that was increasing, and he received two pills for pain, but he needed more. Review of the 7/12/22 admission Minimum Data Set (MDS) assessment for resident 15 revealed: *The pain interview assessment coded him as having occasional pain at a rating of five that limited his day-to-day activities. *He had shortness of breath when lying flat. Review of resident 15's care plan revealed: *No interventions to obtain a recliner in his room to address his preference and need for comfort. (Refer to F656, finding 1.) *Pain focus area related to his leg wound, revised on 7/14/22, with interventions of: -Resident will report complaints of pain or requests for treatment. -The medication will have the intended effect or the nurse will notify the physician if interventions are unsuccessful. Review of the September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *Three [MEDICATION(S)] 300 milligrams (mg) capsules at bedtime for the non-pressure chronic ulcer on his lower leg, started on 9/2/22, (a medication used to manage pain due to damaged nerves). *Two [MEDICATION(S)] 300 mg capsules two times a day for chronic venous hypertension with ulcer of his lower leg, started on 9/2/22. *Two acetaminophen 325 mg tablets every 4 hours as needed for pain, not to exceed 100 mg a day, started on 7/6/22. *One [MEDICATION(S)]-acetaminophen 5-325 mg tablet every 6 hours as needed for moderate pain for non-pressure chronic ulcer of lower leg, started on 7/19/22. It was administered only on 9/28/22. An additional order on the September MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *Staff were to remind resident to elevate legs above the heart 3-4 times a day for 30-45 minutes and at night when in bed after meals and at bedtime related to generalized [CONDITION(S)]. *Documentation was present 4 times a day on 9/1/22 - 9/30/22 except for: -The 9:00 p.m. time on 9/2/22. -The 9:00 a.m. and 1:00 p.m. times on 9/26/22. Review of progress notes between 7/19/22 and 10/3/22 revealed: *No notation regarding an effort to obtain a recliner for resident 15. *A 9/2/22 progress note reported: -The order for three [MEDICATION(S)] at bedtime was an increased dose. -The resident wants a different mattress - he feels like hes [sic] going to fall out of bed. Interview on 10/4/22 at 11:10 a.m. with SSD D revealed: *Resident had used a recliner at his previous long-term care location. *He did not have a bed in his room at that location. *She knew he wanted a recliner and was working on it but confirmed she had not written a progress note.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (20) with a facility acquired pressure ulcer had received necessary care and interventions to prevent her wound from developing and worsening. Findings include: 1. Observation and interview on 9/27/22 at 4:02 p.m. with resident 20 revealed: *She had gone several weeks without a bath or a shower. *She could not recall the specific date but stated recently a staff person had assisted her into bed for the evening without changing her brief or removing her clothing. When she woke up in the morning, she was still in the same brief soiled with urine and stool and clothing. *She had been in her wheelchair since they had gotten her out of bed that morning around 10:00 a.m. *It was her normal routine to get up later in the morning around 10:00 a.m. and then be in her chair until the staff assisted her to lay down in the late afternoon or early evening. -She indicated staff usually would not check to see if she was dry, change her brief, or reposition her while she was up in her wheelchair. *In the evening when she was ready to lay down, at times it took up to two hours for staff to come assist her. She was often told 'just a minute' and then no one would come back to assist her. *After she was assisted into bed for the evening, the staff would usually come in between 9:00 p.m. and 10:00 p.m. to ensure her brief was dry, and then she did not get checked again until between 4:00 a.m. and 5:00 a.m. *Staff did not reposition her at night. *She did have a sore on her bottom and the nurses would put cream on it. Observation and interview on 9/28/22 at 3:39 p.m. with resident 20 revealed: *Staff had come in to change her soiled brief around 5:00 a.m. and then was not checked or changed again until she was assisted into her wheelchair for the day around 10:00 a.m. *She had not been changed or moved since they put her into the wheelchair. *She did not know if her brief was soiled or not. Observation on 9/28/22 at 10:51 a.m. of resident 20 in her bed laying on her side while certified nursing assistants (CNA) N and AA performed perineal cares revealed: *Her coccyx was reddened with pinpoint open areas to her lower back on her coccyx. *Licensed practical nurse had come into the room with [MEDICATION(S)] cream and instructed CNA AA to apply a thin layer to the reddened open area. Review of resident 20's 7/16/22 significant change MDS revealed: *Her BIMS was 13, indicating her cognition was intact. *She was dependent on two staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. *She was dependent on one staff for locomotion. *She could not walk and used a wheelchair. *She was always incontinent of bowel and bladder. *She was at risk for developing a pressure ulcer. *She did not currently have a pressure ulcer. *She did have moisture associated skin damage (MASD). *There had been a pressure reducing device for her chair and her bed. Review of resident 20's medical record revealed: *She had been admitted on [DATE]. *She had been admitted with a stage II pressure ulcer to her right buttock that was healed on 7/29/22. *An order to apply [MEDICATION(S)] ointment to buttocks twice a day due to incontinence of bowel and bladder. *6/19/22 at 12:11 p.m. a progress note indicated: small of back with a indented are [area] with redness surrounding the indention no visible open are [area] applied [MEDICATION(S)]. -It had not indicated whether the physician was notified. *She had been hospitalized from 7/8/22 through 7/12/22. *She had returned from the hospital with fractures to both legs and an elbow. *Wound summary documentation indicated: -She had a stage I pressure ulcer on her low back: --6/22/22, measuring 4 centimeters (cm) x 5 cm. --7/8/22, measuring 3.8 x 4 cm. --7/22/22 and 7/29/22, measuring 2.5 cm x 1 cm. --8/19/22, measuring 2.2 cm x 1 cm. -On 9/19/22 the pressure ulcer was documented as healed. *On 7/12/22 in her readmission user defined assessment (UDA) had indicated she had no: -History of a pressure ulcer. -Existing pressure ulcer. *One 7/12/22 she had refused a skin assessment upon readmission due to complaints of pain. *The first skin assessment was completed on 7/25/22 and stated she had a red groin. *Her skin assessment on: -8/2/22 stated she had an alteration in skin integrity but did not indicate what it was or where it was located. -8/9/22 and 8/16/22 she had redness under breasts, left inner thigh, groin folds, and coccyx. -8/23/22 the skin on her coccyx was pink and irritated. [MEDICATION(S)] cream was applied. -8/30/22 her groin is red. -9/6/22 stated she had an alteration in skin integrity but did not indicate what it was or where it was located. -9/14/22 stated she had an alteration in skin integrity but did not indicate what it was or where it was located. *No documentation of how often she was being repositioned. Review of resident 20's bathing documentation between 8/1/22 through 9/28/22 revealed she had: *Received a bath on 9/1/22 and 9/5/22. *Refused a bath on 9/22/22. -There had been no documentation of why or if another time had been set up to make up the missed bath. Review of resident 20's revised 7/21/22 care plan revealed: *She had an actual impairment in skin integrity r/t CKD [related to [CONDITION(S)]]. *It had not indicated what the skin impairment was or where it was located. *Had a goal for her wound to not develop infection. *Apply wound treatment as ordered by the physician. *Encourage good nutrition and hydration in order to promote healthier skin. *Keep skin clean and dry. Use lotion to dry skin. *Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD [medical doctor]. *Pressure reduction mattress and w/c [wheelchair] cushion. This was initiated on 2/25/22. *Turn and reposition as needed. *It had not indicated she was at risk for pressure ulcers or that she currently had a pressure ulcer. Interview on 9/28/22 at 3:54 p.m. with CNA AA regarding resident 20 revealed: *She usually worked a twelve hour day shift. *When she was working, they would get resident 20 up into her wheelchair around 10:00 a.m. or when she called for assistance. -This was the first time she had been changed or repositioned on the day shift. *Resident 20 would then stay in her wheelchair until she was ready to get into bed for the evening. *They did not check to ensure she was dry during the time she was in her wheelchair or reposition her. *Resident 20 was always incontinent of bowel and bladder and did not use the toilet. *Resident 20 did have a sore on her bottom. Interview on 9/28/22 with LPN BB regarding resident 20 revealed: *Resident 20 did have a pressure ulcer to her coccyx area and the nurses were putting cream on it. *She had thought all wounds in the building were measured weekly. *Had not been aware staff did not ensure resident 20's brief was clean and dry while she was up out of bed in her wheelchair. Interview on 9/29/22 at 4:11 p.m. with regional nurse consultant X revealed: *There was not a nurse designated as the wound nurse. *Director of nursing and Minimum Data Set nurse shared the role. *All pressure ulcers were to be measured weekly. Interview on 10/3/22 at 4:00 p.m. with director of nursing B regarding resident 20's pressure ulcer revealed: *Interventions put into place were an air mattress, wheelchair cushion, keep skin clean and dry, and to turn and reposition as needed. *She thought the resident should have been repositioned every two hours. *She had not been aware resident 20 was not checked to ensure she was clean and dry while up in her wheelchair. *She had expected the staff at night to ensure she was clean and dry. *The pressure ulcer and her risk of developing a pressure ulcer should have been included in the care plan. *Resident 20's skin impairment was probably not related to her [CONDITION(S)] but from not being repositioned and being clean and dry. *They had not had a dedicated wound nurse, so the measurements of wounds were not getting done weekly. Review of the provider's April 2021 Skin Program revealed: *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. *A skin assessment should have been completed at time of readmission. *When a pressure ulcer was identified it was to be reassessed weekly, and provider was to be updated if not improving within two or three weeks. *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 into place to prevent. *Skin checks to be completed at least weekly by a Licensed Nurse. Review of the provider's September 2019 Care Planning policy revealed each resident's care plan should be updated to reflect their current needs.

Based on observation, interview, and record review, the provider failed to ensure: *Diets were followed as ordered resulting in a choking episode for one of one resident (4). *A care plan had been updated to identify goals and interventions to prevent further choking episodes for one of one resident (4). *A resident (4) was supervised for potential of choking during one of three observed meal services. *A process was in place for meal delivery to identify the correct diet for each resident who received their meals in the dining room. *A documentation process was in place to accurately capture meal and oral intake for residents. Findings include: 1. Review of the provider's online self-report to the SD DOH on 3/15/22 revealed: *On 3/14/22 resident 1 had a choking episode during the supper meal. *The resident was able to expel the food on his own and had not required outside treatment. *The resident had a piece of regular bread on his plate. *The resident had not been given the correct diet. *The resident had a diet order for a regular diet, dysphagia [difficulty swallowing] mechanically altered (level 2) texture, thin liquids. *Educated staff on duty on 3/15/22 at 10:00 a.m. need to look at diet card prior to serving trays, to ensure correct diets are being given, to all residents. A conclusionary summary to the provider's self-report had indicated:*Resident 4 had been evaluated by the speech therapist (ST) last on 7/22/21 and a NDD (National Dysphagia Diet) 2/IDDSI (International Dysphagia Diet Standardisation Initiative) 5 (a mechanical diet that altered the texture - chopped, very soft foods, ground meat, and minced/moist food. Breads were to have been pureed.) His liquids could remain thin. *The dietitian had audited all the diet textures on 3/15/22 and her audit indicated: -Resident 4 had a correct diet on the meal ticket (a diet card specific to what diet he was to have). --His care plan had not been updated with his current diet but had been updated on 3/15/22. -All other residents with altered textures had matching diet and care plan on their meal ticket and care plan. *The dietitian was to have provided mandatory education on diets for all staff on 3/24/22. *A binder had been placed at the serving window in the kitchen for all staff to reference. It lists all current residents, diets, textures, thickened fluids, supplements, serving sized and descriptions of what the meals should look like. This binder will be updated every Tuesday and the nutrition risk meeting. Staff are being provided education on the binder at the beginning of each meal service and additional education be provided at the all staff on 3/24/22 by DON [director of nursing]. Review of the 3/14/22 at 8:11 p.m. interdisciplinary progress note by licensed practical nurse (LPN) I revealed:*Resident 4 had a choking episode at the evening meal. *The kitchen aide had noticed the resident with his head laid back in his wheelchair and trying to clear his throat. She leaned him forward and he began to clear his throat. *LPN I was summoned to the dining room to assist and noted a regular piece of bread on his plate. *Resident 4 was not given the correct diet. *The kitchen staff and CNA's [certified nursing assistants] were counseled to ensure correct diet is given. *He was taken to the nurses station and monitored. Observation of the noon meal on 4/5/22 at 12:00 p.m. revealed: *Dietary manager F was plating food and handing the plate to a CNA to deliver to the residents. *The CNA would pick up the plate and place the meal ticket upside down in a pile of meal tickets. -That CNA would then take the plate to a resident in the dining room and set it down in front of the resident. *There were no binders at the serving window for staff to review as stated in the provider's self-report. *Dietary manager F had picked up a black binder from the kitchen table behind him one time and then placed it behind him again. Interview on 4/5/22 at 12:15 p.m. with registered dietitian (RD) D regarding resident 4's choking episode on 3/14/22. RD D stated: *The kitchen staff have had a large staff turnover over the last several months. *The provider has had difficulty maintaining a dietary manager. *The previous dietary manager had resigned and she did not think the new dietary manager F had started working. *On the day of the choking episode the person cooking and dishing up plates had been a temporary CNA. *RD D stated there had been times there were no cooks to fill empty slots. *The DON and others filled in when there was no cook. *On the day of the choking episode CNA J's focus was making sure every resident had food. -The focus was not on diets. *The current dietary manager had no experience in healthcare when he started but he was learning the diets. *When asked about the meal tickets RD D stated the provider stopped placing each resident's meal on the ticket because residents became upset when they were not served what was on the ticket. -The staff did not want to bring the meal ticket to the table because the residents became upset. -The fill-in staff had chosen easy foods to cook rather than follow the menu. -She confirmed the provider now had the menu on their meal ticket with the diet to be served and the amount and type of food to be served. -She was not sure why the ticket was not brought to each resident to confirm accuracy of the diet. *When asked about the binder for staff to reference she stated all questions about the binder needed to go to the DON because she was the one to put the binder together. I had nothing to do with that. *When asked if the binder was for the cooks or the CNA servers she stated it was probably for the cooks. Observation on 4/6/22 at 8:25 to 9:00 a.m. of the center dining room revealed: *Resident 4 was sitting in a wheelchair facing the far west wall. -He had slid down in the chair and held an empty glass of water. No food or other drinks had been present. He was the only resident at the table. *CNA E sat on the east wall with three other residents who were receiving supervision or assistance. *CNA E would not have been able to see resident 4's face from where she was sitting. *This surveyor approached resident 4 and asked if he had already eaten. *The resident stated he had not and wondered if he was going to get breakfast. *This surveyor approached CNA E asked and if resident 4 could get his breakfast. -CNA E approached cook G and asked about his breakfast: *Cook G placed corned beef hash and scrambled eggs on a plate (that was part of his mechanical soft diet). *CNA E told the cook the resident was at risk for choking. *Cook G dished up two bowls of oatmeal and this was brought to the table. *A meal ticket had not been brought to the resident's table. *CNA E returned to the residents across the room and resident 4 sat alone facing the wall, and holding the oatmeal bowl to his chest to eat. He remained slightly slumped down in the wheelchair. *This surveyor questioned CNA E about resident 4's need for assistance with his meal. She stated: -He was capable of feeding himself. -He did not allow staff to feed him. -There were no available staff to sit with him. -She could see him from across the room. -She did not know why he was not given the plate of food that was dished up for him. *CNA E then sat with resident 4 and supervised him. Further interview with CNA E regarding resident 4 and the dining process revealed: *The CNAs did not bring meal tickets to the residents with their meal. *Only those residents who received meals eaten in their room received the meal tickets. *When asked about documenting the meal intakes after each meal she stated: -CNAs were supposed to document the meals of the residents down the halls they were assigned to but they did not come to the dining room to check their intakes because they were busy cleaning, removing garbage, and making beds on the unit. Interview on 4/6/22 at 9:00 a.m. with cook G revealed:*He did not know why resident 4's plate of food had not been given. *When asked what happened to the meal tickets after he dished up the residents' food he stated: -He threw them away. -Confirmed the meal tickets had an area to document meal intakes, but they had not been filled out. -He was not sure who was supposed to document the meal intakes. *When asked about a binder that was supposed to have been placed at the serving window, he brought this surveyor a menu book. Interview on 4/6/22 at 12:25 through 1:10 p.m. with assistant dietary manager H revealed: *She had: -Been an employee for approximately one year. -Worked as the dietary manager for approximately two months. *On the day of resident 4's choking event he had been served a french dip sandwich on regular bread. -The diets were not followed. *The binder: -Was supposed to be kept on the serving window. -Had been developed for the CNA's to refer to regarding each residents diet order and what foods were allowed and not allowed in each diet order. *The cooks were to have referred to the diet menu book for information. *The CNA's were supposed to bring the residents' meal tickets to their tables with their food to make sure the meal and diet were correct. *She did not know who was supposed to be documenting meal intakes. *The dietitian had updated the CNA binder on 4/5/22 and it was to be updated weekly with dietary orders for the residents. *She was not sure who was to have updated the dietary care plans. Review of resident 4's medical record revealed:*A current order summary indicated: -A 7/22/21 diet order for: 'Regular diet, dysphagia [difficulty swallowing] mechanically altered (level 2) texture, thin liquids consistency. -A 3/16/22 order for ST to evaluate and treat. *A previous 5/18/21 therapy note by speech language pathology (SLP) K for a swallowing screen referral indicated resident 4 had been found cheeking 10+ peanuts in mouth over the weekend. Pt [patient] unable to chew. Resident 4 refused to participate in an assessment. SLP K recommended the use of universal swallow precautions for decreased pocketing episodes:-To sit upright in his wheelchair for all oral intake. -Cueing to eat and swallow at a slow rate. -Cueing to take small bites and sips. -Encouraging alternating liquids and solids. -Assessing the oral cavity following oral intake to ensure his mouth had been cleared. -Oral care following meals. *A 7/22/21 SLP K evaluation provided recommendations for: -IDDSI 5/0 thin liquids (minced moist foods with thin liquids). -Oral care following all meals. -Caregiver assistance/supervision as needed with feeding. The SLP indicated he required supervision/assistance due to significant history of food pocketing twenty-six to forty-nine percent of the time. -Caregivers were to provide cueing for using small bites, slow rate of intake, alteration of foods and liquids, and use of a mouth sweep to monitor for clearing food. -There was a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Dietitian notes had been requested from the DON on 4/6/22. This surveyor received only a 1/11/22 Dietary Evaluation. That evaluation indicated his diet: -Was a concentrated carbohydrate diet with regular consistency and thin liquids. -The resident did not have functional problems that affect his ability to eat. -He had no behavioral problems. -He was independent with set-up and eating. Review of resident 4's revised 4/1/22 care plan related to his swallowing problems and choking event revealed:*He had dementia which resulted in the need for an altered texture diet due to swallowing problems related to dementia progression. -A 12/6/19 Activities of Daily Living (ADL) care plan indicated he required assistance with eating. *The goal was that he would not experience weight changes. *He could choose his own food choices at meal and snack times. *There were no interventions on the care plan to guide the staff for prevention of safe eating as recommended by the SLP. Interview on 4/6/22 at 2:20 p.m. with DON B and occupational therapist registered (OTR)/director of rehabilitation (DOR) L and regional nurse consultant C revealed:*Resident 4 had a 3/16/22 order for speech therapy but it was decided that the choking episode was not a resident problem but a staff issue due to the resident receiving the wrong diet. -He will be receiving SLP therapy to work on communication due to his verbal outbursts including at mealtime. *They: -Stated the previous SLP recommendations for assisting the resident with eating safely were just universal guidelines and not specific for the resident. -Confirmed: --Those guidelines had not been added to his care plan. --The care plan was not specific and did not address interventions to prevent choking. --Education was provided for use of the binder for the aides to use, but had not been utilized by the staff. *Regarding the lack of consistent meal intake documentation the DON stated before the pandemic the dietary aides were documenting the meals but that had stopped when residents were not eating in the dining rooms. -The provider planned to have the dietary aides document intakes again. *Regarding dietitian evaluations for resident 4 the DON stated she was unable to locate further documentation. *Head of therapy L stated resident 4 could be observed for choking from across the room. *Nurse consultant confirmed: -The meal tickets should have been brought to each resident during meals to monitor for correct diets. -The diets had not been followed on 3/14/22, but should have been followed. Review of the provider's September 2019 clinical management policy revealed:*Care planning was to have been constantly in process. *The physicians' orders in conjunction with the care plans constitute the total plan of care. *The DON would be responsible for holding the team accountable to initiating and updating the care plan. *Each staff member working with the individual resident is responsible to read, utilize, and offer input to improve the care plan. *Care plans were to have been updated between care conferences as changes occur. Requests for policies regarding safe feeding, monitoring for choking, documentation of oral intakes, and the use of the new binder protocol had been made to the DON. No policies had been provided.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure that professional standards were followed for: *One of one closed sampled resident (380) who had been identified with a significant change in condition. *One of one sampled resident (38) who had ongoing assessment and treatment for [REDACTED]. Findings include: 1. Review of the medical record for resident 380 revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED]. *The 7/22/19 admission Minimum Data Set (MDS) assessment showed: -A Brief Interview of Mental Status (BIMS) assessment score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. *He had sustained a fall without injury on 8/30/19. Review of the 9/20/19 to 10/30/19 care plan for resident 380 revealed: *An effective date of 7/25/19. *Problems/Strengths: At risk for falls related to balance problems during transfers. *Goals: -No falls. -Will be free from injury related to fall. *Interventions: -Will receive assist of one with transfers and locomotion. -Provide safe, clutter free environment. -Call light within reach, with prompt response to all requests. -Prompt to attend and engage in activities while awake. -Ensure the resident wears appropriate and well fitting footwear. -Ensure glasses are clean in good repair and worn. -Uses a wheelchair for locomotion. -Complete a rehabilitation evaluation and follow-up as ordered. -Prompt him to ask for assistance. -Hi/Low bed. *No new or different interventions were put into place after his fall on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: *At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose and a skin tear on his left elbow. -Resident was partly assessed by the nurse while on the floor. -He was unable to follow commands. -The on-call medical provider was contacted by phone. -He was transferred to his bed for a full assessment. -He was placed in a wheelchair at the nurses' station following the assessment. -Resident is comfortable, will monitor. *At 10:58 a.m.: -He was unresponsive. -Was unable to eat breakfast. -The nurse had been unable to reach the resident's wife by telephone. -His primary care provider was asked to see him while in the building on rounds. -An order was received from his primary care provider to send him to (hospital name) emergency department for evaluation. -The non-emergency number was contacted, and resident left the faciity on a stretcher. Review of the 9/22/19 fall report for resident 380 revealed: *It had occurred at 7:00 a.m. on 9/22/19. *He was unable to give an explanation of the event that had occurred and was unresponsive. *He had a history of [REDACTED]. *The area of the form for physician signature of notification had been left blank. Review of the 9/22/19 Neuro (neurological) flow sheet for resident 380 revealed: *The directions on the form indicated: -Neuro checks were to be taken after a blow to the head or unwitnessed fall. -They were to be repeated every thirty minutes for two hours, then every hour for four hours, then every eight hours for a total of twenty-four hours. -Areas to be evaluated included level of consciousness (L[NAME]), pupil response to light, hand grip strength, vital signs, and response to verbal directions. *On 9/22/19 at 7:00 a.m.: -He was alert. -His pupil response was not verified due to his eyes being shut. -The grip strength on his right hand was weak, and his left hand was strong. -The vital signs included: blood pressure (B/P) 139/68, temperature (T) 98.5 degrees, pulse (P) 78, and respirations (R) 18. -He was not responding to verbal directions. *On 9/22/19 at 7:30 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -The vital signs included: B/P 135/72, T 96.9, P 68, and R 20. -He was not responding to verbal directions. *On 9/22/19 at 8:00 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -The vital signs included:B/P 148/79, T 95.4, P 79; and R 24. -He was not responding to verbal directions. *On 9/22/19 at 8:30 a.m.: -He was alert. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -The vital signs included: B/P 158/86; T 95.8; P 88; and R 22. -No response was listed with the following of verbal directions. *On 9/22/19 at 10:00 a.m.: -He was unresponsive. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -The vital signs included: B/P 199/85, T 97.0, P 63, and R 22. -No response was listed for following verbal directions. -The PCP was present. *All flow sheet entries had been completed by LPN K. Review of the 9/22/19 physician's order sheet for resident 380 revealed: *9/22/19 - Head Injury with poor responsiveness- Recommend evaluate in (hospital name). *It was signed by the resident's PCP. *It was noted by LPN K and dated 9/22/19. *There was no time listed by physician or LPN K signatures. Interview on 10/15/19 at 2:36 p.m. with certified nursing assistant/certified medication assistant (CNA/CMA) L regarding resident 380 on 9/22/19 revealed: *Her shift began at 6:00 a.m. on the above date. *He was sitting by the nurses' station when she had arrived that morning. *He had a history of [REDACTED]. *She was assisting another resident when CNA M called for assistance. *He was laying on the floor near his roommate's bed and was face down. *There was blood that appeared to be coming from his nose, and his dentures had fallen out. *He was transferred with the mechanical lift from the floor to his bed to be assessed and then into his wheelchair. *He was taken to the dining room to eat. -He would not eat any food. -When he attempted to drink it would fall out of his mouth. He was not swallowing. *He was brought back to the nurses' station following the attempt to eat breakfast. *She observed the staff being unable to reach the resident's spouse by telephone. Interview on 10/15/19 at 2:48 p.m. with CNA M regarding resident 380 on 9/22/19 revealed: *She heard LPN K calling out for assistance. *She obtained the vital sign machine and mechanical lift as instructed by LPN K. *He was observed laying on the floor with some bleeding, and his dentures falling out. *Vital signs were obtained while he was laying on the floor. *She stayed with the resident while LPN K telephoned the on-call medical provider. *The nurse returned and instructed them to move him to his bed. *He was then transferred to his wheelchair to sit at the nurses' station since staff were always present. *He was not talking, and she described him as groggy and zombie-like. -His baseline was to be verbally responsive and talkative. *She acknowledged she felt something was going on with his health. Interview on 10/15/19 at 3:02 p.m. and again at 3:56 p.m. with the director of nursing (DON) regarding the events on 9/22/19 revealed: *There were to be two CNAs and a medication aide scheduled that day, but the medication aide had called in. *The census was approximately thirty residents in that part of the building. *She acknowledged the fall report stated he was unresponsive at 7:00 a.m. but clarified he was only in that state upon initial observation. Interview by telephone on 10/15/19 at 3:38 p.m. with resident 380's primary care provider regarding the events of 9/22/19 revealed: *He had arrived later than his normal time frame to make rounds on residents but did not give a time-frame. *He was in the building doing rounds on other residents when staff alerted him resident 380 needed to be assessed. *Verbalized it was approximately 10:30 a.m. to 11:00 a.m. when he saw the resident. *Had observed him in the wheelchair rocking and slightly incoherent. *The information shared with him by the nursing staff indicated: -They had telephoned the on-call provider immediately following the fall. -The on-call provider did not feel he had been significantly injured from the fall. *He was surprised the staff had not called the on-call provider back regarding his change in condition. -He felt they might not have done that since they knew he would be in the facility for rounds. *He thought the resident was likely experiencing a stroke or a bleed when he was assessed. *It would be his expectation the resident should have been transferred to the emergency department (ED) for evaluation for his acute change in condition. *There was no written progress note of his assessment of that resident. Interview by telephone on 10/15/19 at 3:44 p.m. with registered nurse (RN) N regarding resident 380 on 9/22/19 revealed: *She had worked the overnight shift on another unit but was still in the building. *She was asked to assist for a fall that she was told looks weird. *Her observation indicated: -There was no facial droop, but something seemed off. -His hand grip strength was weak on both sides. -He was responding slower than his normal, and his speech was garbled. -One arm appeared to be flinching or cringing, and she was not sure if he was in pain. *She had told LPN K, He's not right. *His baseline was he would not always answer questions appropriately but would respond. *LPN K addressed her feedback with, I am assessing him and I'll take care of it. *In her nursing judgement of that day she stated she would have sent him in to be evaluated right away. Interview on 10/15/19 at 4:20 p.m. and again on 10/16/19 at 8:25 a.m with the administrator regarding resident 380 on 9/22/19 revealed: *She was the supervisor on-call when the incident had occurred. *LPN K had stated he was found on the floor, would not eat, and was fussy and resistive. -Encouraged her to visit with the physician but that had already been done. *She acknowledged the preferred hospital was not listed on the resident's face sheet and should have been. *It was her expectation a resident experiencing a drastic change in condition should have been transferred to the ED for evaluation. *There was no professional standard in place at the time that event had occurred. -They would be using Lippincott with their new process. Interview on 10/16/19 at 9:46 a.m. with LPN K regarding resident 380 on 9/22/19 revealed: *He had been dressed for the day and was sitting in his wheelchair at the nurses station when she arrived to work at 6:00 a.m. -He would frequently propel himself in the wheelchair around the facility. -She had encouraged him to stay at the nurses' station, but he chose to go back to his room. *She entered his room to complete a blood sugar check around 7:00 to 7:15 a.m. *He was laying on the floor and was slightly on his right side. -His nose was bleeding, and he was fumbling with his dentures that had fallen out. *She summoned the assistance of several other staff to assist. *She placed a call to the on-call physician. -The vital signs and range of motion had been completed but neurological checks had not been completed. -The physician asked if he was comfortable or in any pain. She felt he was not in any pain. -He requested the resident be moved from the floor and receive a full assessment. If there was any concerns he was to be called back. -Acknowledged she had not told the provider she thought he should be transferred to the hospital for evaluation. *He was moved from the floor to his bed for a complete assessment. -Neuro checks were completed. Attempted to use the pen light to his eyes, but he had them shut tight. *The second set of vitals completed at 7:30 a.m. were acceptable, but he was not following commands. -Verbalized that was not abnormal, as he was sometimes stubborn. *She made the decision to bring him out to the nurses' station. -She was the only nurse assigned to that unit. -She wanted to be able to observe him. *Staff had decided to take him to the dining room. -He was unable to eat or drink. -She felt that action might have accounted for the gap between 8:30 a.m. to 10:00 a.m. with his vital signs and neuro assessments. *She felt the resident had a change in condition and needed to be transferred around 9:00 to 9:30 a.m. -She was not able to locate his preferred hospital in the medical record. -She telephoned the facility administrator and nurse back. -She was not able to reach the resident's spouse by telephone following the event. *She was not sure when the resident's provider had arrived but thought it was after 9:00 a.m. -He had ordered the resident to be transferred to the emergency department for evaluation. *She acknowledged her actions were done using her own nursing judgment and not based on a facility policy or procedure. -The policy and procedures had been given to her upon being hired, but she was not sure where they were currently located. *She could not recall completing any recent skill competencies. *Acknowledged he had been sent to the emergency department by non-emergent transfer. -Was not able to give a rationale for a non-emergent transfer and stated, It just happened that way. Review of the 9/22/19 to 9/24/19 hospital medical record for resident 380 revealed: *He arrived at the emergency department at 11:21 a.m. *A physician's note on 9/22/19 at 2:31 p.m. indicated: -Patient (resident) is a level I stroke code upon arrival .Initial last normal time is not clear however this was verified to be at 6:30 a.m., and unfortunately he is past the TPA (tissue plasminogen activator -a protein used to breakdown blood clots) window. -We did call the nursing home to verify last known well. At 6:30 a.m. he was able to get up in his chair and was acting normal per the nurse. It is not clear why there was a delay before he was brought to the ED. -On arrival the patient is not moving his left side he does have complete [MEDICAL CONDITION] and is nonverbal and looking to the right. *His [DIAGNOSES REDACTED]. *A physician's note on 9/24/19 at 12:36 p.m. indicated: -R MCA (right middle cerebral artery) stroke with large volume hemorrhage within the stroke zone, with the development of uncal herniation. Per discussion with the patient's family, decision made to transition to Comfort/Hospice. *He passed away in hospice care on 9/24/19. Review of the provider's (MONTH) 2013 Job Description for Charge Nurse (RN or LPN) revealed: *Monitors and documents changes in health status through continuing assessment of the resident. *Observes, records and reports to supervisor or physician resident's conditions and reactions to drugs, treatments and significant incidents. *Knows and is is able to carry out approved emergency procedures. Review of the provider's 4/3/18 Change in a Resident's Condition or Status policy revealed: *The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A significant change in the resident's physical/emotional/mental condition *A 'significant change' of condition is a decline or improvement in the resident's status that .will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Review of the provider's 8/15/19 Neurological Assessment policy revealed, Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately. Review of [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis., (YEAR), p. 176, revealed: It is important to recognize early indicators of acute illness in older adults .A key principle of providing age-appropriate nursing care is timely detection of these cardinal signs of illness so early treatment can begin. 2. Review of resident 38's medical record revealed:*She had been admitted on [DATE]. *She had a BIMS score of ninety-nine indicating she was unable to complete the interview. *Her [DIAGNOSES REDACTED].>-Unspecified dementia with behavioral disturbance. -Localized [MEDICAL CONDITION]. -Unspecified [MEDICAL CONDITION], unspecified site. -Unspecified sensorineural hearing loss. -Constipation. -[MEDICAL CONDITION]. -History of falling. Interview and observation on 10/15/19 at 2:56 p.m. with CNAs D and J regarding resident 38 revealed: *She required two staff assist to transfer into the bed. *She had two pink colored bandages to the outside of her left leg below the knee. -They had a date of 10/7/19 written on them. *She had been admitted from another long term care facility with a pressure ulcer to her right buttock which had been healed. *The CNAs applied [MEDICATION NAME] ointment that was kept at her bedside to her buttocks when they changed her brief. *The wounds on her leg had been there since she was admitted . Interview and observation on 10/15/19 at 3:23 p.m. with registered nurse (RN) I regarding resident 38 revealed: *The wound on the left leg had been there prior to admission. *She was not sure what kind of wound it was. *She did not know when the dressing was changed. *She had looked to see when the dressing was scheduled to be changed and what type of dressing was used. -She could not find an order. *She then went into the resident's room and removed two pink foam type dressings that were about four inches by four inches. -That revealed two superficial opened areas about the size of a nickel with a scant amount of red drainage to the dressings. *She then covered the wounds with two large bandaids dated 10/15/19. Review of resident 38's non-pressure skin condition reports dated 7/27/19 through 10/10/19 had not addressed the opened areas on her left leg. Review of resident 38's skin assessment notes dated 8/29/19 through 10/10/19 revealed there was no documentation of opened areas on her left leg. Review of resident 38's medication and treatment administration records for (MONTH) 2019 revealed: *No documentation of opened areas on resident's left leg. *No order for or documentation of [MEDICATION NAME] ointment to be applied to the resident. Interview on 10/17/19 at 11:00 a.m. and at 2:35 p.m. with RN I regarding resident 38 revealed: *If she found a wound she would notify the doctor and get an order for [REDACTED].>*She: -Would have documented on the skin assessment sheet along with measurements of the wound. -Agreed there was not an order for [REDACTED]. -Had thought another nurse had applied those bandages. -Agreed the wounds should have been looked at, and the dressings should have been changed regularly. -Agreed she should have notified the physician and asked for orders on 10/15/19. -Had not called the physician to notify him of the wound or ask for orders by 10/17/19 at 2:35 p.m. Review of the physician's orders in Point Click Care on 10/17/19 at 2:09 p.m. revealed: *RN I had entered a written physician's order at 11:06 a.m. that read: Resident has two small superficial wounds to Left leg. Need to change bandages one time a day for wounds related to [MEDICAL CONDITION], UNSPECIFIED (I73.9). *No order for [MEDICATION NAME] Ointment. Interview on 10/17/19 at 4:15 p.m. with the DON regarding resident 38 revealed: *She would have expected if a nurse had found an opened wound the nurse would have: -Measured the area upon finding it and then weekly until it was healed. -Notified the physician. -Entered a risk management note. -Asked the physician for dressing change orders if needed. *The nurses used fax communications when communicating with a physician. -Those communications were kept in a basket at the nurses station until they were answered. -If not answered they would fax them again the next day. *Nurses kept a communication book at the nurses station to communicate residents with wounds. *The policy was to call a physician and get an order for [REDACTED].>*[MEDICATION NAME] needed to be ordered by a physician. *[MEDICATION NAME] ointment was a medication and should have been kept in the medication cart and administered by the nurse. Review of resident 38's 6/20/19 care plan revealed: *She was at risk for developing pressure ulcers related to impaired mobility and incontinence. *She would not develop pressure ulcers. *Keep skin clean, dry. *Monitor skin integrity while providing care and every week by licensed nurse. *Turn and reposition every two hours. *Pressure reducing mattress. *Pressure relieving device when in chair: cushion *It did not address the opened areas on left leg. Review of the provider's undated Wound Care policy revealed: *The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. *Verify that there is a physician's order for this procedure. *Review the resident's care plan to assess for any special needs of the resident. *It indicated to document in the medical record when wound care was given along with the assessment of the wound and the type of wound care given.

Based on record review, job description review, interview, and policy review, the provider failed to ensure one of one closed sampled resident (380) received appropriate care and services following an unwitnessed fall. Findings include: 1. Review of resident 380's closed medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED]. *The 7/22/19 admission Minimum Data Set (MDS) assessment showed: -A Brief Interview of Mental Status assessment score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. *He had sustained a fall without injury on 8/30/19. Review of the information face sheet for resident 380 revealed the preferred hospital line had been left blank. Review of the 9/20/19 to 10/30/19 care plan for resident 380 revealed: *An effective date of 7/25/19. *Problems/Strengths: At risk for falls related to balance problems during transfers. *Goals: -No falls. -Will be free from injury related to fall. *Interventions: -Will receive assist of one with transfers and locomotion. -Provide safe, clutter free environment. -Call light within reach, with prompt response to all requests. -Prompt to attend and engage in activities while awake. -Ensure the resident wears appropriate and well fitting footwear. -Ensure glasses are clean in good repair and worn. -Uses a wheelchair for locomotion. -Complete a rehabilitation evaluation and follow-up as ordered. -Prompt him to ask for assistance. -Hi/Low bed. *No new or different interventions were put into place after his fall on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: *At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose, and there was a skin tear on his left elbow. -Resident was partially assessed by the nurse while he was on the floor. -He was unable to follow commands. -The on-call medical provider was contacted by phone. -He was then transferred to his bed for a full assessment. -He was placed in a wheelchair at the nurses' station following the assessment. -Resident is comfortable, will monitor. *At 10:58 a.m.: -He was unresponsive. -Was unable to eat breakfast. -The nurse had been unable to reach the resident's wife by telephone. -His primary care provider (PCP) was asked to see him while in the building on rounds. -An order was received from his PCP to send him to (hospital name) emergency department (ED) for evaluation. -The non-emergency number was contacted, and the resident left the faciity on a stretcher. Review of the 9/22/19 fall report for resident 380 revealed: *It had occurred at 7:00 a.m. on 9/22/19. *He was unable to give an explanation of the event that had occurred and was unresponsive. *He had a history of [REDACTED]. *The area of the form for physician signature of notification had been left blank. Review of the 9/22/19 Neuro (neurological) flow sheet for resident 380 revealed: *The directions on the form indicated: -Neuro checks were to be taken after a blow to the head or an unwitnessed fall. -They were to be repeated every thirty minutes for two hours, then every hour for four hours, then every eight hours for a total of twenty-four hours. -Areas to be evaluated included level of consciousness (L[NAME]), pupil response to light, hand grip strength, vital signs, and response to verbal directions. *On 9/22/19 at 7:00 a.m.: -He was alert. -His pupil response was not verified due to his eyes being shut. -The grip strength on his right hand was weak, and his left hand was strong. -The vital signs included: blood pressure (B/P) 139/68, temperature (T) 98.5 degrees, pulse (P) 78, and respirations (R) 18. -He was not responding to verbal directions. *On 9/22/19 at 7:30 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -The vital signs included: B/P 135/72, T 96.9, P 68, and R 20. -He was not responding to verbal directions. *On 9/22/19 at 8:00 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -The vital signs included: B/P 148/79, T 95.4, P 79; and R 24. -He was not responding to verbal directions. *On 9/22/19 at 8:30 a.m.:-He was alert. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -The vital signs included: B/P 158/86; T 95.8; P 88; and R 22. -No response was listed with the following of verbal directions. *On 9/22/19 at 10:00 a.m.: -He was unresponsive. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -The vital signs included: B/P 199/85, T 97.0, P 63, and R 22. -No response was listed with the following of verbal directions. -The PCP was present. *All flow sheet entries had been completed by LPN K. Review of the physician's orders [REDACTED]. *9/22/19 - Head Injury with poor responsiveness- Recommend evaluate in (hospital name) ED. *It was signed by the physician. *It was noted by LPN K and dated 9/22/19. *There was no time listed by the physician or LPN K signatures. Interview on 10/15/19 at 2:36 p.m. with certified nursing assistant/certified medication assistant (CNA/CMA) L regarding resident 380 on 9/22/19 revealed: *Her shift began at 6:00 a.m. on the date of the fall. *He was sitting by the nurses' station when she had arrived that morning. *He had a history of [REDACTED]. *She was assisting another resident when CNA M called for assistance. *He was laying on the floor near his roommate's bed and was face down. *Blood appeared to be coming from his nose, and his dentures had fallen out. *He was transferred with the mechanical lift from the floor to his bed to be assessed and then into his wheelchair. *He was taken to the dining room to eat. -He would not eat any food. -When he attempted to drink it would fall out of his mouth. He was not swallowing. *He was brought back to the nurses' station following the attempt to eat breakfast. *She observed LPN K being unable to reach the resident's spouse by telephone. Interview on 10/15/19 at 2:48 p.m. with CNA M regarding resident 380 on 9/22/19 revealed: *She heard LPN K call out for assistance. *She obtained the vital sign machine and mechanical lift as instructed by LPN K. *He was observed laying on the floor with some bleeding, and his dentures had fallen out. *Vital signs were obtained while he was laying on the floor. *She stayed with the resident while LPN K telephoned the on-call physician. *The nurse returned and instructed them to move him to his bed. *He was then transferred to his wheelchair to sit at the nurses' station since staff were always present. *He was not talking, and she described him as groggy and zombie-like. -His baseline was to be verbally responsive and talkative. *She acknowledged she felt something was going on with his health. Interview on 10/15/19 at 3:02 p.m. and again at 3:56 p.m. with the director of nursing regarding the events on 9/22/19 revealed: *There were to be two CNAs and a medication aide scheduled that day, but the medication aide had called in. *The census was approximately thirty residents in that part of the building. *She acknowledged the fall report stated he was unresponsive at 7:00 a.m. but clarified he was only in that state upon initial observation. *Verbalized the medical records department was responsible for placing the preferred hospital on the information face sheet. Interview by telephone on 10/15/19 at 3:38 p.m. with resident 380's primary care physician regarding the events of 9/22/19 revealed: *He had arrived later than his normal time frame to see residents but did not give a time frame. *He was in the building seeing other residents when staff alerted him that the resident needed to be assessed. *Verbalized it was approximately 10:30 a.m. to 11:00 a.m. when he saw the resident. *Observed him in the wheelchair rocking back and forth and slightly incoherent. *The information shared with him by the nursing staff indicated: -They had telephoned the on-call physician immediately following the fall. -The on-call physician did not feel he had been significantly injured from the fall. *He was surprised the staff had not called the on-call physician back regarding his change in condition. -He felt they might not have done that since they knew he would be in the facility for rounds. *He thought the resident was likely experiencing a stroke or a bleed when he was assessed. *It would be his expectation the resident should have been transferred to the emergency department for evaluation for the acute change in condition. *There was no written progress note of his assessment of the resident. Interview by telephone on 10/15/19 at 3:44 p.m. with registered nurse (RN) N regarding resident 380 on 9/22/19 revealed: *She had worked the overnight shift on another unit but was still in the building. *She was asked to assist for a fall she was told looks weird. *Her observation indicated: -There was no facial droop, but something seemed off. -His hand grip strength was weak on both sides. -He was responding slower than his normal, and his speech was garbled. -One arm appeared to be flinching or cringing, and she was not sure if he was in pain. *She told LPN K, He's not right. *His baseline was he would not always answer questions appropriately but would respond. *LPN K addressed her feedback with, I am assessing him, and I'll take care of it. *In her nursing judgement of that day she stated she would have sent him in to be evaluated right away. Interview on 10/15/19 at 4:10 p.m. with the director of medical records regarding the information face sheet for resident 380 revealed: *She would enter the preferred hospital in the appropriate field if it was known. *The process at the time of the resident's admission involved the social worker forwarding that information to her. Interview on 10/15/19 at 4:15 p.m. with social worker W regarding the information sheet for resident 380 revealed: *He initially verbalized it was a duty of the medical records department. -He was provided information regarding the above interview with medical records. *He described the absence of a preferred hospital on the form as a data-entry error, and there was no good reason why it had occurred. *The process in place at the time of the resident's admission and the above event indicated: -He would collect and send out the resident's information to the appropriate departments approximately two days prior to admission. -It had been his responsibility, but there was no policy and procedure in place. Interview on 10/15/19 at 4:20 p.m. and again on 10/16/19 at 8:25 a.m. with the administrator regarding resident 380 on 9/22/19 revealed: *She was the supervisor on-call when the incident had occurred. *LPN K had stated he was found on the floor, would not eat, and was fussy and resistive. -Encouraged her to visit with the physician, but that had already been done. *She acknowledged the preferred hospital should have been on the information sheet. *It was her expectation a resident experiencing a drastic change in condition should have been transferred to ED for evaluation. *There was no professional standard in place at the time that event occurred. -They would be using Lippincott with their new process. Interview on 10/16/19 at 9:46 a.m. with LPN K regarding resident 380 on 9/22/19 revealed: *He had been dressed for the day and was sitting in his wheelchair at the nurses station when she arrived to work at 6:00 a.m. -He would frequently propel himself in the wheelchair around the facility. -She encouraged him to stay at the nurses' station, but had chosen to go back to his room. *She entered his room to complete a blood sugar check around 7:00 a.m. to 7:15 a.m. *He was laying on the floor and was slightly on his right side. -His nose was bleeding, and he was fumbling with his dentures that had fallen out. *She summoned the assistance of several other staff to assist. *She placed a call to the on-call physician. -The vital signs and range of motion had been completed, but neurological checks had not been completed. -The physician had asked if he was comfortable or in any pain. She felt he was not in any pain. -He requested the resident be moved from the floor and receive a full assessment. If there was any concerns he was to be called back. -Acknowledged she did not tell the provider that she thought he should be transferred to the hospital for evaluation. *He was moved from the floor to his bed for a complete assessment. -Neuro checks were completed. Attempted to use the pen light to his eyes, but he had them shut tight. *The second set of vitals completed at 7:30 a.m. were acceptable, but he was not following commands. -Verbalized that was not abnormal as he was sometimes stubborn. *She made the decision to bring him out to the nurses' station. -She was the only nurse assigned to that unit. -She wanted to be able to observe him. *Staff had decided to take him to the dining room. -He was unable to eat or drink. -She felt that action might have accounted for the gap between 8:30 a.m. to 10:00 a.m. with his vital signs and neuro assessments. *She felt the resident had a change in condition and needed to be transferred around 9:00 a.m. to 9:30 a.m. -Was not able to locate his preferred hospital in the medical record. -Telephoned the facility administrator and nurse back. -Was not able to reach the resident's spouse by telephone following the event. *She was not sure when the resident's provider had arrived but felt it was after 9:00 a.m. -He had ordered the resident to be transferred to the emergency department for evaluation. *She acknowledged her actions were done using her own nursing judgment and not based on a facility policy or procedure. -The policy and procedures had been given to her upon being hired, but she was not sure where they were currently located. *She could not recall completing any recent skill competencies. *Acknowledged he had been sent to the emergency department by non-emergent transfer. -Was not able to give a rationale for a non-emergent transfer and stated, It just happened that way. Review of the hospital medical record for resident 380 revealed: *He arrived at the emergency department at 11:21 a.m. *A physician's note on 9/22/19 at 2:31 p.m. indicated: -Patient (resident) is a level I stroke code upon arrival .Initial last normal time is not clear however this was verified to be at 6:30 a.m., and unfortunately he is past the TPA (tissue plasminogen activator -a protein used to breakdown blood clots) window. -We did call the nursing home to verify last known well. At 6:30 a.m. he was able to get up in his chair and was acting normal per the nurse. It is not clear why there was a delay before he was brought to the ED. -On arrival the patient is not moving his left side he does have complete [MEDICAL CONDITION] and is nonverbal and looking to the right. *His [DIAGNOSES REDACTED]. *A physician's note on 9/24/19 at 12:36 p.m. indicated: -R MCA (right middle cerebral artery) stroke with large volume hemorrhage within the stroke zone, with the development of uncal herniation. Per discussion with the patient's family, decision made to transition to Comfort/Hospice. *He passed away in hospice care on 9/24/19. Review of the (MONTH) 2013 Job Description for Charge Nurse (RN or LPN) revealed: *Monitors and documents changes in health status through continuing assessment of the resident. *Observes, records and reports to supervisor or physician resident's conditions and reactions to drugs, treatments and significant incidents. *Knows and is is able to carry out approved emergency procedures. Review of the 4/3/18 Change in a Resident's Condition or Status policy revealed: *The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A significant change in the resident's physical/emotional/mental condition *A 'significant change' of condition is a decline or improvement in the resident's status that .will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Review of the 8/15/19 Neurological Assessment policy revealed, Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (74 and 235) who were at risk for developing pressure ulcers had ongoing assessments and implemented individualized interventions in place to prevent skin breakdown. Findings include: 1. Review of resident 235's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had orders for a diabetic renal diet. Review of the 9/25/19 admission Minimum Data Set (MDS) assessment for resident 235 revealed: *He was able to understand what others said and make himself understood. *The Brief Interview for Mental Status assessment score was thirteen indicating he was cognitive. *He required: -Extensive assistance of one staff person for dressing and toilet use. -Limited assistance of one staff person for bed mobility, transfer, ambulation, and personal hygiene. *He had limited range of motion to his lower extremity. *He used a walker or wheelchair. *Nutritional approaches had not been coded indicating he required a therapeutic diet. *He was at risk for developing pressure ulcers or injuries. *He had one stage two pressure ulcer. *He was coded as having: -A pressure device for the chair and bed. -Pressure ulcer/injury care. *The Care Area Assessment Summary was coded for pressure ulcer area triggered and care planning decision. Review of the Braden Scale for Predicting Pressure Sore Risk from 9/18/19 through 10/8/19 for resident 235 revealed a score of fifteen. -A score of twelve or less represented a high risk. Observation and interview on 10/15/19 at 4:21 p.m. with resident 235 in his room revealed: *He was in the facility, because he had broken his left leg a few weeks ago. *He had been receiving physical therapy. *He had been laying on the bed, had his shoes on both feet, and his heels were not off-loaded. *There was a Prevalon boot laying on the floor. Observation on 10/15/19 at 6:00 p.m. in the[NAME]Wing dining room regarding resident 235 revealed: *He had regular shoes on both feet and no socks on. *He had not been wearing the Prevalon boot. *His heels had not been off loaded. Observation and interview on 10/16/19 at 4:20 p.m. with registered nurse (RN) R in resident 235's room revealed: *He had been laying on the bed. -The Prevalon boot was on the floor. -He had a shoe on his left foot. -There was a shoe and sock on the bed next to his right foot. -The right foot had not been off-loaded off the bed. *RN R: -Removed a dressing to the resident's right foot bunion area. -There was a small opened area to the right side of the great toe on the bony prominence. --The area was opened. *There was a white message board on the wall next to the bathroom. -A note on the message board stated: Family is concerned about draining sore on right bunion. ? cultures needed. Interview at the above time with RN R regarding resident 235 revealed: *He had a stage two pressure ulcer to his left heel that had started out as a water filled blister. *The certified nurse practitioner had seen the resident that day and had written an order for [REDACTED]. Review of the following physician's orders [REDACTED]. *9/18/19: -Complete weekly skin assessment. -Skin prep (preparation) to left heel blister daily, Prevalon boot to [MI] (left) heel. DAY SHIFT -House supplement per registered dietitian. *10/8/19: -Discontinue Prevalon boot to left heel twice a day. -Saline to clean area to right great toe daily and with soilage and covering with dry dressing until healed. *10/14/19: -The nurse informed the physician per fax that the area to his great right toe measured 0.5 centimeters (cm) by 1.0 cm. --Physician's response was, Will see on rounds. *10/16/19: -Send pt (resident) wound care clinic for treatment right foot wound. -Pt to wear Rook (Prevalon) boot at all times to prevent further breakdown of heel wound on left foot. Review of the 9/22/19 Weekly Pressure Ulcer Record for resident 235 revealed: *The left heel pressure ulcer had occurred on 9/22/19. -They had not documented on that area weekly. *The body diagram to identify sites for non-pressure skin condition dated 9/18/19 had a circle drawn around the anterior right foot. -There was no documentation to explain what the area had revealed. Review of the nursing progress notes from 10/7/19 through 10/14/19 for resident 235 revealed on: *10/7/19: -Reported to writer this AM that family member of resident noted an area to right great toe, when touched the area began draining. Upon writer assessment, yellow drainage coming from side of right great toe, small amount, no odor. PCP (primary care provider) aware and will be out to facility to assess on 10/8/19. *10/14/19: -Resident has an area 0.5 x 1 cm on right great toe that has eschar present. Surrounding area is reddened. This is on bony prominence of bunion. Await PCP order as she was notified per fax. Review of the 9/18/19 through 10/5/19 skin assessment documentation for resident 235 revealed on: *9/18/19: There was no documentation regarding the right great foot wound. *9/24/19: There was no documentation regarding the right great foot wound. *10/5/19: He has a small red, swollen area on the side of right foot. Review of the 9/24/19 registered dietitian (RD) progress note for resident 235 revealed: *Resident has a blister to left foot measuring 3.5 x 4.0. -Resident's BMI (body mass index) is 23.8, which is slightly below recommended range for older adults of 25-30. -Resident reports weight loss of 5 pounds and attributes it to exercise and anorexia. -Nutrition care plan added. Review of the 10/8/19 physician's progress note for resident 235 revealed:*Has stage one [MEDICAL CONDITION] on lateral right great toe. *[MEDICAL CONDITION] associated with diabetes mellitus due to underlying condition. -Will use saline to wound every day and with spoilage dressed with 4 x 4. -Daily dressing change and as needed. *Lateral right great toe with stage one ulcer, no exudate. Review of the current care plan with the following dates listed for problems/strengths for resident 235 revealed: *10/10/19: -Problem: Resident has stage 2 pressure ulcer on left heel. -There was no documentation regarding the right foot diabetic ulcer. -RD consult. -Refer to weekly pressure ulcer sheet for weekly measurements and staging. *9/24/19: -Problem: At risk for weight loss/dehydration due to leaves 50% + food uneaten at most meals related to anorexia. -Dietary supplements as needed. -Between meal snacks. -There was no documentation regarding what the RD was doing regarding nutrition for the stage two pressure ulcer on the left foot or the right foot diabetic ulcer. Interview on 10/17/19 at 4:15 p.m. with the director of nursing (DON) regarding resident 235's right foot diabetic ulcer revealed:*They should have done more with assessing it. *There usual routine for pressure ulcers was to measure the area, notify the physician, and do risk management. *There should have been further documentation for the right foot diabetic ulcer. *She would have expected the body diagram to identify sites for the non-pressure skin condition dated 9/18/19 to have further documentation than just a circle drawn around the anterior right foot. *The care plan should have been updated to reflect his right foot diabetic ulcer. 2. Observation and interview on 10/15/19 at 1:34 p.m. of resident 74 revealed he: *Had: -Been in his room sitting in a wheelchair (w/c) watching television (TV). -A urinary catheter collection bag hanging underneath the w/c. -Pressure relieving Una boots on both of his feet. *Stated: -I'm getting ready to go see the doc, I have a lot of fluid. -Yes, I have wounds on my feet because of all the fluid. -They said they were blisters then just opened up. Interview on 10/15/19 at 3:28 p.m. with RN Q regarding resident 74 revealed she: *Confirmed he a pressure injury on his left heel. *Was not sure if he had: -Acquired the pressure injury during his stay and while receiving care at the facility. -Required a dressing change for that pressure injury. *Had to look on the computer to check to confirm the dressing change. *Stated: -He does have a dressing change on that heel tomorrow. -I'm not sure of the time. -I haven't had time to do it yet today. -I float to all areas and different shifts, so I'm just not quite sure of some things. Review of resident 74's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He had: -Good memory recall and was capable of making his needs known. -Been dependent upon the staff to assist him with all activities of daily living (ADL). --That had included bed mobility, transfers, personal hygiene, and dressing. -Not been able to walk and required the use of a w/c to go from place-to-place in the facility. *He was to be repositioned every two hours. -There was no documentation to support he required the use of positioning devices. *On 7/30/19 he had acquired a stage 2 pressure injury to his left heel. -That injury measured 1.3 centimeters (cm) by (x) 2.0 cm and had a scant amount of exudate draining from it. The skin around that wound was intact and pink in color. The wound bed was pink. -He had acquired that injury twenty days after his admission to the facility. -The staff were directed to use pressure relieving heel boots on his feet. --That intervention had not been put into place until after the identification and assessment of the pressure injury. *On 8/3/19 the documentation supported his pressure injury had worsened and increased in size. --That pressure injury measured 2.0 cm x 3.0 cm and continued to have a scant amount of exudate draining from it. The wound bed was now pale in color with the surrounding tissue boggy (soft) and white in color. --The nursing staff had documented the wound had worsened due to the bogginess of the surrounding tissue. The opened area had remained the same size. --That wound had worsened within four days from the initial identification of it. *The physician and family had been informed of the wound. *The nursing staff had sent a faxed request on 7/30/19 to the physician requesting a treatment for [REDACTED]. *There was no documentation to support: -Preventative measures were put in place in a timely manner to ensure he had not acquired a pressure injury to his left heel. -He had been admitted with that pressure injury. Review of resident 74's Braden Scale for Predicting Pressure ulcers score from 7/10/19 through 9/26/19 revealed: *On 7/10/19: he was admitted with a score of twenty indicating he was at low risk for skin breakdown. *On 7/13/19: -His score was a sixteen indicating he was now at risk for skin breakdown. -That score had dropped four points within four days of his stay in the facility. *On 7/20/19: -His score was a fifteen indicating he was still at risk for skin breakdown. -That score had dropped five points within ten days of his admission to the facility. *On 7/27/19: his score was a fifteen indicating he remained at risk for skin breakdown. *On 8/3/19, there was no score calculated for him. *On 9/26/19: -His score was a thirteen indicating his level of risk for skin breakdown had increased. -That score had dropped seven points from when he was initially assessed and admitted to the facility on [DATE]. Review of resident 74's initial nursing assessment tool revealed: *It had been completed on 7/18/19. -That had been eight days after his admission to the facility. *His skin was: -Warm and dry to the touch. -Swollen with 2+ [MEDICAL CONDITION] observed to both of his lower extremities. Review of resident 74's following interdisciplinary progress notes revealed: *On 7/10/19: he had been admitted to the facility with 2+ [MEDICAL CONDITION] to his left lower extremity. -That was the only skin concern identified and documented on. *On 7/23/19: Minimum Data Set (MDS) assessment coordinator T had written a summary supporting his admission assessment of 7/17/19. *She had documented: -He has no pressure related skin concerns. -He had a pressure reducing mattress on his bed and cushion in his w/c. *On 7/30/19 the nursing staff had documented: -Resident complaining of bilateral heel pain. Upon assessment (R) (right) heel is red blanchable to entire heel. (L) (left) later heel has 1.3 x 2 cm [MEDICATION NAME] tissue with intact edges, draining scant amount of drainage. -Area was cleansed per facility protocol and [MEDICATION NAME] applied for protection. Heel boots applied. -Explained to resident that to relieve pressure from both heels, that heel boots need to warn (be worn) instead of shoes; voiced understanding. Appropriate paperwork completed. -Wife, (name), notifies via phone. Fax sent to PCP (personal care provider) requesting orders for daily dressings, awaiting response. *On 10/7/19: MDS assessment coordinator T had written a summary supporting his quarterly assessment of 9/26/19. She had documented: -He had a stage II pressure ulcer with treatments. There was no documentation to support where that was located. -He wears heel boots at all times. -He had a pressure reducing mattress on his bed and cushion in his w/c. Review of resident 74's 7/17/19 admission MDS assessment revealed he: *Was at risk for skin breakdown/injuries. *Had pressure relieving devices for his bed and w/c. *Had no repositioning program in place. Review of resident 74's 9/26/19 quarterly MDS assessment revealed he: *Had the same documentation as reviewed above on his admission assessment. *Had acquired a stage 2 pressure injury. Review of resident 74's undated pocket care plan revealed no documentation to support he: *Was at risk for skin breakdown and required staff support to be repositioned every two hours. *Required the use of pressure relieving devices to ensure no skin breakdown had occurred. *Had a pressure injury to his left heel, and he required the use of heel boots to relieve pressure for them. Review of resident 74's comprehensive care plan revealed: *It had different initiation and revision dates for all the focus areas developed for him. *On 7/23/19: a focus area was initiated and identified him at risk for developing pressure ulcers related to requiring assistance with bed mobility, decreased mobility, and having bowel incontinence. -He currently has zero pressure ulcers. -Goals and interventions had been put in place to promote prevention and healing of wounds. -The staff were to have repositioned him every two hours, and he had a pressure relieving mattress. *There had been no interventions put in place to support he required repositioning devices such as pillows and heel boots. *There was a Plan of Care Comments sheet containing multiple lines attached to the care plan. -On 7/30/19: a handwritten note stated, (L) lateral heel ulcer was on the top line of that comments sheet. --No interventions were written for that left lateral heel ulcer to promote healing of it. Review of resident 74's 7/10/19 admission orders [REDACTED]. Review of resident 74's 7/1/19 through 7/10/19 treatment administration record (TAR) from the admitting facility revealed no documentation to support he had a left heel pressure injury that had required assessments and treatments. Observation on 10/16/19 at 10:39 a.m. with RN R with resident 74 revealed: *The resident was in his room sitting in his w/c watching TV. *He had the Una boots on both of his feet. *RN R: -Had prepared to complete the dressing change to the resident's left heel pressure injury. -Removed the resident's Una boot and sock from his left foot. *There had been no dressing on the resident's left heel/foot for protection. *With those dirty gloves on RN R: -Touched and felt the wound prior to showing it to the surveyor. --The pressure injury was located on the lateral aspect of his left heel. --The wound was approximately 1.0 cm x .5 cm with a red base. -Opened a package of 4x4 gauze and moistened it with wound cleanser from a bottle. -Cleaned the wound with that 4x4 gauze. -Put the resident's foot back down to rest on the Una boot. --The pressure injury came into direct contact with the outside surface of that Una boot. *RN R: -Removed his gloves and without sanitizing or washing his hands put on another pair of gloves. -Opened the package containing the Sorbact gel gauze, removed it from the package, and placed it on the resident's opened wound. -Opened another package and placed a protective dressing over it. -Removed his gloves and put the resident's sock and Una boot back on. Interview on 10/16/19 at 10:55 a.m. with RN R regarding the above observation with resident 74 revealed he: *Stated: -He had a shower this morning, so that is why there was no dressing on his foot. -Yes, the staff should have told me the dressing was off or removed, so I could have replaced it soon. -I was disappointed there wasn't a dressing covering the wound. -I typically don't work down here, so I wasn't even sure what I was going to find, I didn't even know he had a dressing change until you asked about it. -I have no idea how he got the wound. *Agreed: -The dressing change was completed in an unsanitary manner. -A treatment completed in an unsanitary manner would have created the potential for poor healing and infection to have occurred. *Had not realized: -All the surfaces he touched would have been considered dirty until reviewed with him. -He had touched and assessed the resident's wound with dirty gloves. Interview on 10/16/19 at 4:50 p.m. with MDS assessment coordinator T regarding resident 74 revealed she: *Confirmed the stage 2 pressure injury to his left heel, and he was at risk for skin breakdown. *Was not sure how or when he had acquired that injury. *Stated: -I'm sure he was not admitted with it, it was just crazy. -They were taking two admissions a day from (facility name) and before you know it we had ten admissions in one week. -Yes, the staff use the pocket care plans to help them with cares for the residents and yes, it's considered a part of the comprehensive care plan. *Would not have: -Assisted with determining those residents who had been at risk for skin breakdown. -Assisted the staff with determining pressure relieving measures for the residents at risk for skin breakdown. -Updated the comprehensive care plans in-between their assessments. *Was not: -Responsible for the overall completion of the comprehensive care plans and was unsure who was. -Sure who updated the pocket care plans and comprehensive care plans between resident assessments. *Would not have: -Assessed the residents and been proactive with determining any type of preventative measures for them. All her information for the residents had been data driven. -Attended care conferences to assist the interdisciplinary care team with reviewing the care plans on the residents and with their representatives. -Been a part of the care conference to ensure the care plan was accurate and true to support care for the residents had occurred. -Been a part of determining processes and preventative measures for their residents to ensure proper care and services were delivered. *She had completed her interviews as directed by the MDS document, but there was nothing further to support her information for that assessment was accurate. *She stated: -The other MDS nurse attends all the care conferences, I don't. -I just came back to help them with the MDSs, and here I am still here after all this time. Interview on 10/17/19 at 11:23 a.m. with the director of nursing and the administrator regarding resident 74 revealed they: *Would have expected a team approach on determining preventative interventions for the high risk residents. *Had been uncertain as to when and where the resident had acquired the pressure injury to his left heel. *Agreed: -He was at high risk for skin breakdown, and preventative measures should have been put in place to ensure that did not occur at the time of his admission. -The dressing change was not completed in a sanitary manner and created the potential for the wound to acquire an infection and slow down the healing process. *Were positive he had been admitted with that wound but could not find the documentation to support it. *Agreed all the documentation had supported: -He acquired a pressure injury while receiving care and services from them. -The preventative measures and interventions were not timely and appeared to be reactive versus proactive. *Were aware the MDS assessment nurse was not: -Involved in determining preventative measures to ensure skin breakdown had not occurred. -A part of care conferences and should have been to ensure the necessary care and services the residents required had occurred. *Had not considered the pocket care plans as a part of the resident's comprehensive care plan. -Those were used by the staff to guide them with care for the residents. -The information on them should have been on the comprehensive care plans. -They were updated as needed and reviewed everyday in their morning stand-up meetings. *Confirmed and agreed: -The admission nursing assessment of the resident had not been completed until eight days after his admission. -The admission nursing assessment should have been completed at the time of his admission and sooner then eight days. -If there was no documentation it did not happen. 3. Review of the provider's (MONTH) (YEAR) Pressure Ulcers/Skin Breakdown - Clinical Protocol policy revealed: *The nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). *The physician and staff will examine the skin of a new admission for ulcerations or indications of a stage I pressure area that has not yet ulcerated at the surface. -There was no documentation to support how soon a skin assessment should have been completed upon the admission to the facility. *The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces. *The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. There were no other policies or procedures on pressure ulcers and the prevention of them given to the surveyor upon request from the DON and administrator prior to exit of the facility on 10/17/19. Review of the provider's (MONTH) 2013 Charge Nurse (RN or licensed practical nurse (LPN)) job description revealed: *The charge nurse performs the primary functions of an LPN or RN including assessing, planning, implementing and evaluating the care of a designated group of residents in a designated time frame. *Performs and documents resident assessments on admission and on a continuing basis. *Develops and updates the nursing care plan. Meets with an interdisciplinary team quarterly to review the plan of care on primary residents. *Implements the plan of care, using appropriate nursing actions. Review of the provider's (MONTH) (YEAR) Clinical Coordinator job description revealed: *The MDS (Minimum Data Set) Clinical Coordinator is a registered nurse (RN) that conducts federally mandated assessments for the residents at (facility name). *The MDS Clinical Coordinator: -Is responsible to formulate and implement individual care plans for residents. -Will gather information from residents and their families during initial and periodic interviews. -Is to know the residents extremely well, have a good rapport with them and with their family (as well as the staff). -Are responsible to know what is going on in the facility, who is declining, med (medication) changes that are significant, etc. -Assesses, plans, implements, and coordinates the nursing care in conjunction with the Director of Nursing to ensure the highest quality of resident care is maintained at all times. -Supervises the day to day nursing activities in accordance to compliance with current Federal, State, and local standards, guidelines, and regulations that govern our facility as well as responsible to support, mentor, and empower the nursing staff.

Based on interview, record review, personnel record review, job description review, and policy review, the provider failed to ensure one of two licensed nurses (K) was competent in recognizing the signs and symptoms of a significant change in condition for one of one closed sampled resident (380). Findings include: 1. Review of resident 380's closed medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED]. *The 7/22/19 admission Minimum Data Set (MDS) assessment showed: -A Brief Interview of Mental Status assessment score of seven indicating severe cognitive impairment. -He used a wheelchair for mobility. *He had sustained a fall without injury on 8/30/19. Review of the 9/22/19 interdisciplinary progress notes for resident 380 by licensed practical nurse (LPN) K revealed: *At 7:37 a.m.: -He was found on the floor of his room at approximately 7:00 a.m. -Blood was coming from his nose, and he had a skin tear on his left elbow. -Resident was partly assessed by the nurse while on the floor. -He was unable to follow commands. -The on-call medical provider was contacted by phone. -He was transferred to his bed for a full assessment. -He was placed in a wheelchair at the nurses' station following the assessment. -Resident is comfortable, will monitor. *At 10:58 a.m.: -He was unresponsive. -Was unable to eat breakfast. -The nurse had been unable to reach the resident's wife by telephone. -His primary care provider was asked to see him while in the building on rounds. -An order was received from his primary care provider to send him to (hospital name) emergency department for evaluation. -The non-emergency number was contacted, and the resident left the faciity on a stretcher. Review of the Neuro (neurological) flow sheet for resident 380 revealed: *The directions on the form indicated: -Neuro checks were to be taken after a blow to the head or unwitnessed fall. -They were to be repeated every thirty minutes for two hours, then every hour for four hours, then every eight hours for a total of twenty-four hours. -Areas to be evaluated included level of consciousness (L[NAME]), pupil response to light, hand grip strength, vital signs, and response to verbal directions. *On 9/22/19 at 7:00 a.m.: -He was alert. -His pupil response was not verified due to his eyes being shut. -The grip strength on his right hand was weak, and his left hand was strong. -His vital signs included: blood pressure (B/P) 139/68, temperature (T) 98.5 degrees, pulse (P) 78, and respirations (R) 18. -He was not responding to verbal directions. *On 9/22/19 at 7:30 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -His vital signs included: B/P 135/72, T 96.9, P 68, and R 20. -He was not responding to verbal directions. *On 9/22/19 at 8:00 a.m.: -He was alert. -His pupil response was equal. -The grip strength with his right and left hands was strong. -His vital signs included: B/P 148/79, T 95.4, P 79; and R 24. -He was not responding to verbal directions. *On 9/22/19 at 8:30 a.m.: -He was alert. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -His vital signs included: B/P 158/86; T 95.8; P 88; and R 22. -No response was listed with the following of verbal directions. *On 9/22/19 at 10:00 a.m.: -He was unresponsive. -His pupil response was unequal. -The grip strength with his right and left hands was weak. -His vital signs included his B/P at 199/85, T of 97.0, P of 63, and R of 22. -No response was listed for following of verbal directions. -The primary care provider (PCP) was present. *All flow sheet entries had been completed by LPN K. Interview by telephone on 10/15/19 at 3:38 p.m. with resident 380's primary care physician regarding the events of 9/22/19 revealed: *He had arrived later than his normal time frame to see residents but did not give a time frame. *He was in the building seeing other residents when staff alerted him the resident needed to be assessed. *Verbalized it was approximately 10:30 a.m. to 11:00 a.m. when he saw the resident. *Observed him in the wheelchair rocking and slightly incoherent. *The information shared with him by the nursing staff indicated: -They had telephoned the on-call provider immediately following the fall. -The on-call provider did not feel he had been significantly injured from the fall. *He was surprised the staff had not called the on-call provider back regarding his change in condition. -He felt they might not have done that since they knew he would be in the facility for rounds. *He thought the resident was likely experiencing a stroke or a bleed when he was assessed. *It would be his expectation the resident should have been transferred to the emergency department for evaluation for his acute change in condition. *There was no written progress note of his assessment of the resident. Interview by telephone on 10/15/19 at 3:44 p.m. with registered nurse (RN) N regarding resident 380 on 9/22/19 revealed: *She had worked the overnight shift on another unit but was still in the building. *She was asked to assist for a fall she was told looks weird. *Her observation indicated: -There was no facial droop but something seemed off. -His hand grip strength was weak on both sides. -He was responding slower than his normal, and his speech was garbled. -One arm appeared to be flinching or cringing, and she was not sure if he was in pain. *She told LPN K, He's not right. *His baseline was he would not always answer questions appropriately but would respond. *LPN K addressed her feedback with, I am assessing him, and I'll take care of it. *In her nursing judgement of that day she stated she would have sent him in to be evaluated right away. Interview on 10/16/19 at 9:46 a.m. with LPN K regarding resident 380 on 9/22/19 revealed: *He had been dressed for the day and was sitting in his wheelchair at the nurses station when she arrived to work at 6:00 a.m. -He would frequently propel himself in the wheelchair around the facility. -She encouraged him to stay at the nurses' station, but he had chosen to go back to his room. *She entered his room to complete a blood sugar check around 7:00 a.m. to 7:15 a.m. *He was laying on the floor and was slightly on his right side. -His nose was bleeding, and he was fumbling with his dentures that had fallen out. *She summoned the assistance of several other staff to assist. *She placed a call to the on-call physician. -The vital signs and range of motion had been completed, but neurological checks had not been completed. -The physician asked if he was comfortable or in any pain. She felt he was not in any pain. -He requested the resident be moved from the floor and receive a full assessment. If there was any concerns he was to be called back. -Acknowledged she did not tell the provider she thought he should be transferred to the hospital for evaluation. *He was moved from the floor to his bed for a complete assessment. -Neuro checks were completed. Attempted to use the pen light to his eyes, but he had them shut tight. *The second set of vital signs completed at 7:30 a.m. were acceptable, but he was not following commands. -Verbalized that was not abnormal as he was sometimes stubborn. *She made the decision to bring him out to the nurses' station. -She was the only nurse assigned to that unit. -She wanted to be able to observe him. *Staff had decided to take him to the dining room. -He was unable to eat or drink. -She felt that action might have accounted for the gap between 8:30 a.m. to 10:00 a.m. with his vital signs and neuro assessments. *She felt the resident had a change in condition and needed to be transferred around 9:00 a.m. to 9:30 a.m. -Was not able to locate his preferred hospital in the medical record. -Telephoned the facility administrator a second time. -Was not able to reach the resident's spouse by telephone following the event. *She was not sure when the resident's provider had arrived but felt it was after 9:00 a.m. -He had ordered the resident to be transferred to the emergency department for evaluation. *She acknowledged her actions were done using her own nursing judgment and not based on a facility policy or procedure. -The policy and procedures had been given to her upon being hired, but she was not sure were they were currently located. *She could not recall completing any recent skill competencies. *Acknowledged he had been sent to the emergency department by non-emergent transfer. -Was not able to give a rationale for a non-emergent transfer and stated it just happened that way. Review of the hospital medical record for resident 380 revealed: *He had arrived at the emergency department at 11:21 a.m. *A physician's note on 9/22/19 at 2:31 p.m. indicated: -Patient (resident) is a level I stroke code upon arrival .Initial last normal time is not clear however this was verified to be at 6:30 a.m., and unfortunately he is past the TPA (tissue plasminogen [MEDICATION NAME] - a protein used to breakdown clots) window. -We did call the nursing home to verify last known well. At 6:30 a.m. he was able to get up in his chair and was acting normal per the nurse. It is not clear why there was a delay before he was brought to the ED. -On arrival the patient is not moving his left side he does have complete [MEDICAL CONDITION] and is nonverbal and looking to the right. *His [DIAGNOSES REDACTED]. *A physician's note on 9/24/19 at 12:36 p.m. indicated: -R MCA (right middle cerebral artery) stroke with large volume hemorrhage within the stroke zone, with the development of uncal herniation. Per discussion with the patient's family, decision made to transition to Comfort/Hospice. *He passed away in hospice care on 9/24/19. Review of LPN K's personnel file revealed: *Her hired date was 5/18/16. *She had completed a nurse competency checklist on 5/18/16. -It included the policy and procedure related to incident and fall reports. -There was no indication the emergency and change in condition policies and procedures were reviewed. *No additional competencies were found in her employee file. Review of the (MONTH) 2013 Charge Nurse (RN or LPN) job description revealed essential functions included: *Observes, records, and reports to supervisor or physician resident's conditions and reactions to drugs, treatments and significant incidents. *Knows and is able to carry out approved emergency procedures. Review of the 8/15/19 Neurological Assessment policy revealed: Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure one of one sampled resident (50) who was socially withdrawn and unhappy with her placement in the facility received any social services or behavioral health services. Findings include: 1. Interviews and observations on 10/15/19 at 3:00 p.m. and on 10/16/19 at 9:45 a.m. of resident 50 revealed she: *Was alert and oriented to person and place. *Laid on her bed with no clothes on except a disposable brief. -Showed no discomfort with how she was dressed in the surveyors presence. *Stated loudly, This place sucks and went on to say how unhappy she was there. -Felt like she was just put in the facility to die, and all the staff cared about was getting her money. -Did not care how she got out of this place, but she thought it would take dying to get out. -Did not go to any activities and emphatically stated she did not care to go. -Did not know who the social worker was or that she had a social worker to visit with. -Had a computer she thought she should bring into her room but did not know where it was. -Went to the dining room for breakfast and lunch but not supper. --Did not visit with any peers and was unhappy with the other residents in the dining room. Review of resident 50's 9/10/19 Minimum Data Set (MDS) assessment revealed she: *Was cognitively intact. *Felt down and depressed. *Was tired and had little energy. Interview on 10/16/19 at 10:16 a.m. with certified nursing assistant C regarding resident 50 revealed she had: *Known her from the previous nursing home she was at. -A history of failure to thrive. Interview on 10/17/19 at 7:48 a.m. with certified medication aide D regarding resident 50 revealed she: *Did not like to get dressed, and laid in bed without any clothes on. *Got upset about being here and cried. *Could get upset about wanting to get a can of pop. *She was not always cooperative with her bath. *She had never seen any visitors. Review of resident 50's social services notes revealed: *6/25/19: She scored a 6/27 on the pHQ9 (an assessment of depression) indicating depression concerns at this time. She expressed that she feels this is as she has no control of her situation and has no one as intelligent that she is able to interact with her. -No noted moods or behaviors during that look back period. -Length of stay was long term. *7/2/19: Care conference summary: -Resident refused to participate in the care conference. -She refused every attempt to weigh her. -Her food intake varied depending on her mood. -Refused all structured activities but did like one-to-ones. -A medication for her mood and anxiety had been increased by her physician since her admission. -She continued to be unhappy with multiple things but was unwilling to give specifics. -She made general statements like nothing works and thought the food was terrible. *7/24/19: Social worker (SW) went to speak with her about her emotional state offering a mental health counselor. -She declined. -She became tearful and stated she did not want to be there anymore. -Discharge was discussed with her, but she stated she had no where to go. *There was no further weekly visits or follow-up with her on barriers to her adjustment to the facility or the possibility of other placement. Review of resident 50's 6/26/19 care plan revealed: *Problem/Strengths: She had signs and symptoms of depression. *Interventions: -Administer medications. -Monitor for signs of depression. -Involve in activities daily. -Notify MD immediately of suicidal ideation, self harming. -Social services to encourage resident to verbalize feelings, provide validation and reassurance as needed. -Social services and activities: In room visits for social stimulation if resident could not attend activities. -Psych (psychiatric) consult as indicated. Interview on 10/17/19 at 9:30 a.m. with the director of nursing regarding resident 50 revealed: *She liked to be in her room undressed and did not want the door closed. -Had a blanket that was with her to pull up over her. *She had a call light but did not always use it. *She stayed in bed as much as possible and had snacks in her room. *It was all about the approach with her, smile and soft tones. *She complained about being in the facility, and it depended on how she felt whether she would cooperate with staff. *She said herself she was racist and did not like the staff of color. So they always tried to have a white staff person with her when care was given to her. Interview on 10/17/19 at 8:31 a.m. with SW W regarding resident 50 revealed: *He had not visited with her for emotional support, and he really had not spent any time with her. *The SW that recently quit had completed the MDS. *Counseling had been offered, but she had refused. *He agreed nothing had been done with her, and he really did not know her well. *He confirmed she was a resident who had psychosocial issues and could have benefited from more frequent contact. Review of the provider's (MONTH) (YEAR) Social Worker job description revealed: *The role of the SW in a long term care facility is to enable each individual to function at the highest possible level of social and emotional wellbeing and to act as the resident advocate in all circumstances. *Essential functions: -Assisting residents in voicing and obtaining resolution to grievances about treatment, living conditions, visitation rights, and accommodation of needs. -Assisting or arranging for a resident's communication of needs through the resident's primary method of communication or in a language that the resident understands. -Making arrangements for obtaining items. *Ensure that the facility provides social services or obtains needed services from outside entities include, but are not limited to: -Expressions or indications of distress that affect the resident's mental and psychosocial well-being , resulting from depression, chronic diseases, difficulty with personal interaction and socialization skills, and resident to resident altercations. -Difficulty coping with changes or loss (e.g. change of living arrangement). -Need for emotional support.

Based on observation, record review, interview, and policy review, the provider failed to ensure an effective quality assurance and performance improvement (QAPI) program had been implemented to identify and address concerns related to residents' care within the facility. Findings include: 1. Interview on 10/17/19 at 2:59 p.m. with the administrator regarding their QAPI program revealed: *She was the QAPI coordinator. *They would like to do monthly meetings but had been meeting quarterly. -They were due for their next quarterly meeting in October. *They currently had a medical director. -They were in the process of finding a new medical director. *Their last QAPI meeting was in (MONTH) or July. *The medical director had not attended all of the quarterly meetings. -They would email information to the medical director if they were unable to attend. *They used the Casper report for their QAPI meetings. *Each department reported on what they had been working on. *The pharmacist had attended the quarterly QAPI meetings. *They were not working on any performance improvement plans (PIPS). -They knew they had issues. -They had not had the resources or staff to initiate PIPS or to follow through on the PIPS. Review of the QAPI Sign-In Sheet from (MONTH) 11, (YEAR) through (MONTH) 26, 2019 revealed the medical director had attended the QAPI meetings in (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019. Review of the provider's 2019 QAPI Plan revealed: *Purpose: -To promote the highest quality of life for our residents while providing quality care. *The QAPI plan included policies and procedures used to:-Identify and use data to monitor our performance. -Establish goals and thresholds for our performance measurements. -Utilize resident, staff and family input. -Systematically analyze underlying causes of systemic problems and adverse events. -Develop corrective action or performance improvement activities. *(Facility name) will conduct Performance Improvement Projects that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention. -We will conduct PIPS that will lead to changes and guide corrective actions in our systems, which cross multiple departments, and have impact on the quality of life and quality of care our residents. *The QAPI committee will review data and input on a monthly basis to look for potential topics for PIPS. *QAPI committee will prioritize topics for PIPS based on the current needs of the residents and (facility name). Refer to F550, F565, F584, F604, F610, F641, F657, F658, F679, F684, F686, F698, F726, F740, F803, F842, and F880.

Based on record review, interview, and policy review, the provider failed to: *Provide necessary care in services resulting in neglect and resident-to-resident altercations for two of two sampled closed resident record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit (MCU). *Implement a resident-specific care plan that included evaluations and revisions of interventions to prevent abuse and neglect for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. *Provide supervision and monitoring of the delivery and implementation of care for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. *Ensure effective communication between nursing and direct care staff and health care providers regarding physical and verbal abuse for two of two sampled resident closed record reviews (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment residing in the secured memory care unit. *Contact the primary physician at the time of an acute change in condition that required the plan of care to be revised to meet the residents' needs in a timely manner for two of two sampled resident closed record reviews (1 and 2) with cognitive impairment who had resided in the secured memory care unit. *Ensure staff responded professionally to medical and psychiatric emergencies for two of two sampled resident closed record reviews (1 and 2) with cognitive impairment who had resided in the secured memory care unit. *Ensure thorough orientation upon hiring for one of one licensed nurse (B) and one of one certified nursing assistant (CNA)/unlicensed assistive personnel (UAP) (D). Findings include: 1. Review of a South Dakota Department of Health (SD DOH) initial Required Healthcare Event Reporting form completed by the director of nursing (DON) regarding resident 1 that had been sent to the SD DOH on 2/23/18 revealed: *The type of event being reported was Suspicion/allegation of abuse/neglect on 2/22/18 at 5:40 p.m. *The allegation type was Physical harm/injury. *Under the heading Suspicion/Allegation of Abuse/Neglect: Resident to resident /Patient to patient. Both Names and Cognition. (Resident 1) (Resident 2) Both residents have dementia and live in our memory care unit (MCU). * A brief explanation of the event indicated: (CNA/UAP E) was in the medication room when she heard a loud bang. She immediately went to investigate to find (resident 1) laying on the floor bleeding from her nose and mouth. (Resident 2) was standing beside (resident 1) mocking her when (CNA/UAP E) found them. Large bump to the back of (resident 1's) head when assessed by nurse. Resident was sent to ER. Social worker notified at the time of the fall but unaware of the circumstances. Management staff are made aware of the situation after reading notes this morning. *The law enforcement had been notified on 2/22/18 at 6:00 p.m. due to Assault of resident. *The Department of Social Services had not been notified. Review of the SD DOH final Required Healthcare Event Reporting form for resident 1 sent to the SD DOH on 2/23/18 revealed the conclusionary statement: *The initial SD DOH facility event report statement was included. *On 2/23/18 at 8:30 a.m.: Staff development nurse called (the medical director/Resident 2's primary physician) regarding incident and requested a return call ASAP. 8:45 a.m. DON, infection control nurse (LPN J), staff development nurse (LPN A) spoke with CNA/UAP E about the events that occurred the previous day. CNA/UAP E had reported: *She had been in the medication room when the event occurred. *CNA/UAP H had been in the common room with all nine residents present. *CNA/UAP E heard a loud thud and came out to investigate the noise. She found: -Resident 1 on the floor in the hallway between the door of her room and the common area, bleeding from her nose. She was lying on her back and attempting to roll to her side to get up. -Resident 2 was standing over resident 1, Mocking her for crying and verbally berating her. -As CNA/UAP E was assisting her to sit up, she began bleeding from her mouth. -CNA/UAP E laid her on her back on the floor to redirect resident 2 away from resident 1, and contacted the nurse by phone. -Once CNA/UAP E had notified the nurse CNA/UAP H: --Exited the bathroom. --Attempted to redirect resident 2 away from the area as he continued to mock resident 1. -At that time LPN B entered the MCU. -She attempted to obtain resident 1's vital signs but was unsuccessful. -She contacted 911 for transport. -Family was notified, and PCP (primary care physician) was faxed about the incident. -Resident 1 was transported by ambulance to the emergency room at 6:17 p.m. -CNA/UAP E reported she had not been gone from the common room for more than two minutes when the event had occurred. The above report went on to document: *On 2/23/18 at 10:30 a.m. the infection control nurse had attempted to contact the medical director/resident 2's physician's personal cell phone. *At 11:30 a.m. the infection control nurse had contacted the medical director/resident 2's physician's office and spoke to the receptionist. Message left with the receptionist regarding the severity of the situation and the urgency of needing to speak with the physician. *At 11:40 a.m. the infection control nurse had received a phone call from another doctor, and they discussed resident 2's background and behavioral history. -She received a verbal order to send resident 2 to the emergency room for an evaluation. *At 11:45 a.m. the staff development nurse contacted resident 2's wife and notified her he was being transported to the emergency room . *At 12:15 p.m. he was transported to the emergency room . *Documentation at the end of the conclusionary summary stated: In conclusion abuse/neglect has not been substantiated at this time due to lack of proof of any wrong doing. -The police department was investigating the incident. *Documentation below the conclusionary summary stated: -Was abuse/neglect allegation substantiated? was marked N/A. There was no proof/witness to substantiate. Police are investigating at this time. -Action taken by the facility: Resident that possibly caused harm was removed from the facility and transferred (to a) facility that can meet his behavioral needs. Interview on 3/7/18 at 8:10 a.m. with CNA/UAP E regarding the above event on 2/22/18 revealed she confirmed the above conclusionary report and added: *She had worked as a restorative aide until 3:30 p.m. that day. *She had worked on the MCU from 3:30 p.m. until 6:30 p.m. with CNA/UAP H. *Supper was finished between 5:15-5:30 p.m. *CNA/UAP H had wheeled the MCU supper cart to the kitchen and returned to the MCU. *CNA/UAP E then went to the medication room next to the common area to finish setting up the supper medication. *Residents 1 and 2: -Had been placed at separate tables. -We always sat them at different tables. -Resident 1 had frequent repetitions of the word Kay, Kay, Kay that would cause resident 2 to become upset with her. -CNA/UAP H was in the bathroom when the event occurred. -She came out of the bathroom at the time LPN B entered the MCU. -LPN B was unable to get vital signs, but resident 1 was resisting. -After resident 1 had been transported to the ER resident 2 had stated, They called the cops at me. -Resident 2 had remained on the MCU. -CNA/UAP E had left the MCU at approximately 6:35 p.m. -CNA/UAP H remained on the MCU to care for the residents alone. -Resident 2 was still on the MCU when CNA/UAP E returned to work the following day. *Resident 2's behaviors: -Were OK when he had been admitted to the MCU. -Became worse and worse over the last couple months. -Had received medication changes due to his worsened behaviors, but the behaviors had not changed. -Because of his worsened behavior CNA/UAP E had not been comfortable working on the MCU alone. -When asked if she had discussed her discomfort with his behavior, she stated Not really. Interview on 3/7/18 at 8:57 a.m. with LPN B regarding the above event on 2/22/18 revealed she: *Worked as day shift charge nurse on the Warren and MCU units. *Went to the MCU at 1:00 p.m. to administer a medication. *Returned again at around 5:40 p.m. after she received the phone call from CNA/UAP E. *Confirmed the events on the SD DOH event report conclusionary summary statement. *Had not known resident 2 had behavior issues until that day. *Entered the unit to find resident 2 standing over resident 1 mocking her. *Instructed CNA/UAP H to get CNA I. *Lifted resident 1 by the pants from the floor to her wheelchair with CNA/UAP I's assistance and wheeled her to her room. *Used a flashlight to find the cause of the bleeding in her mouth. *Was unable to obtain vital signs. *Did not attempt to obtain neurological checks. *Left the CNAs on the MCU while she went back to the Warren unit to call the ambulance. *Did not know how to call out for 911, so called the other nurse in the building for instructions. *Informed the emergency medical system (EMS) person of resident 1 possibly being pushed or hit and answered yes when the EMS person had asked if the other person remained in the building. *Had not known how to fill out paperwork for a transport, so the oncoming LPN C assisted her. *Stated: -There was no written instruction on how to handle emergency situations. -She had not received orientation regarding emergency situations. -LPN C was her only contact to assist her to handle the situation. *Stated the licensed social worker (LSW) was still in the building, and he told LPN C to tell LPN B to: -Fax the physician about the fall. -Get a fax order from resident 2's physician to get resident 1 moved. *LPN B stated the LSW: -Wanted to wait for the fax order follow-up for resident 2. -Did not enter the MCU during the event or after resident 1 had been transported to the ER. *LPN B: -Called resident 1's power of attorney to notify him of the injury and transport to the ER. -Faxed resident 1's primary physician regarding the event. -Did not notify the director of nursing or the administrator of the event. -Did not notify resident 2's family about the event. -Did not immediately phone resident 1 or 2's physicians about their significant change in status. When asked if LPN B had observed any other aggressive incidents by resident 2 she stated: *She had been called back to the MCU on the evening of 2/21/18 by CNA D to check resident 1's chest. *CNA D had told her resident 1 had been Punched in the chest. -LPN B stated she: -Did not think it had occurred at that time. -Had not asked who punched resident 1 or when it had occurred. -Thought it happened earlier and the aide wanted her to follow up on it. -Had looked at her chest and placed a note in her chart. -Had not completed an event report. -Had not reported it to other nursing staff. Interview on 3/7/18 at 10:15 a.m. with CNA/UAP H regarding the 2/22/18 event revealed: *She came to work at 10:30 a.m. *CNA/UAP E came to work in the MCU at 3:30 p.m. *After the supper meal was done CNA/UAP E went to the medication room to get medications ready. *The residents were fine, so she went into the bathroom. When she came out of the bathroom she saw resident 1 on the floor. *She confirmed the events according the SD DOH conclusionary report and added that after resident 1 was transported to the ER: -Resident 2 was agitated and mentioned he was going to jail. -He had threatened to harm other residents and her. -She confirmed she was scared by his threats. -She immediately told the nurse (LPN C) about his threats to harm others. -Sometimes he would become verbally aggressive, but she had never seen him harm anyone before. -Later that evening he went to his room and stayed there. -CNA/UAP H left the MCU at around 9:00 p.m. Interview on 3/7/18 at 10:12 a.m. with CNA F regarding the event on 2/22/18 revealed she: *Came to work on MCU at 6:00 p.m. and worked there until 6:30 a.m. the following morning. *Thought resident 2 was already in bed when she reported to the MCU. *Stated he slept all night getting up one time to the bathroom. *Was not afraid of him. *Checked all residents every two hours, and thought the nurse had told her to check on resident 2 every hour. *Did not recall having worked with CNA/UAP H that evening. *Did not remember resident 2 raising a fist at her. *Had never seen resident 2 hit or push other residents. *Did observe resident 2 become verbally aggressive with residents. *Used the pocket care plan to guide her care of the residents. Interview on 3/7/18 at 11:11 a.m. with the LSW regarding the 2/22/18 resident-to-resident altercation revealed he: *Had clocked out and was walking through the facility at 6:00 p.m. when LPN C informed him I think (resident 2) may have pushed someone down, and they need to go to the hospital. *Instructed LPN C to let the administrator or the director of nursing know. *Denied he had recommended to LPN C to fax resident 2's primary care physician (PCP) regarding a behavioral health referral. *Stated It was more hearsay than reportable so I left. *Stated, I thought it was being handled. *Had heard of other occasions that resident 2 had pushed others, but he did not get involved. *Was not involved with reviewing event reports. *Did not assess resident 2's behavioral problems and said, I did not actively think about how (resident 2) would act after the situation. Further interview at the above time with the LSW revealed: *The interdisciplinary team gathered daily at 9:00 a.m. for a stand-up meeting to review any resident's concerns. -They reviewed falls. -Resident behaviors were not reviewed routinely. *The CNAs documented resident's behaviors. *He: -Imported resident behavior reports to review for the seven-day look back at the time of each residents' Minimum Data Set assessment. -Did not review the days that were not in their seven-day look back. -Was more involved with missing money or elopements. -Was not involved with resident-to-resident behavior. -Was not aware the CNAs attempted to keep residents 1 and 2 separated in order to prevent resident 2 from becoming aggressive toward resident 1. Interview on 3/7/18 at 2:20 p.m. with infection control/staff development LPN J regarding altercations between residents 1 and 2 revealed: *She had been aware of resident 2's episodes of verbal aggression but had not been aware of physical aggression. *She was aware of the 12/14/17 event but did not remember the altercation had been intentional.*She vaguely remembered the 1/24/18 event when resident 1 had been pushed. *She had recalled reviewing the 1/24/18 event at a stand-up meeting, but had not put it together to report the event to the SD DOH. *The LSW would not have been involved with that type of event. *The LSW would talk to a resident if their behavior was inappropriate such as touching but not for physically aggressive behaviors. Interview on 3/7/18 at 4:35 p.m. with LPN C regarding the 2/22/18 resident-to-resident altercation revealed she: *Worked the 6:00 p.m. to 6:30 a.m. shift. *Was scheduled as the charge nurse on Warren and memory care units that date. *Was aware of resident 2's aggressive behaviors. *Was informed by LPN B of the fall event in the memory care unit. *Reported to LSW on 2/22/18 at approximately 6:30 p.m. that she heard two different stories: resident 2 hit resident 1 or they suspected he hit her. *Was instructed by the LSW to fax resident 2's doctor to get an order to send him to behavioral health. *Was not instructed by the LSW to call the administrator and/or the director of nursing. *Stated the LSW left the facility and did not assess the situation to ensure the safety of other residents. *Acknowledged on 2/22/18 at approximately 8:00 p.m.: -CNA/UAP H had reported to her resident 2 raised his fist at her and tried to hit her. -She had instructed CNA/UAP H to ignore resident 2 and leave him alone. -She told her she would go back to memory care to check on him. *There was no communication to the PCP regarding resident 2's behaviors. *She had not documented in the interdisciplinary progress notes (IPN) regarding having monitored resident 2's behaviors. When asked if there was protocol for notifying the DON or administrator about incidents LPN C stated: *I think we are supposed to notify the DON or administration if a resident was hospitalized . *She probably should have followed up with LPN B regarding what resident reporting she had done before she left. *She had not known what LPN B completed for notification before she left the building. *I didn't really think of calling. *Interventions for resident 2's aggressive behavior was to redirect/steer other residents away from him and hope he did not follow. Review of resident 1's medical record revealed:*She had been admitted on [DATE]. *She resided on the memory care unit. *A 12/12/17 physician's progress note indicated: -[DIAGNOSES REDACTED]. -No longer even to do social chatter. -[MEDICATION NAME] had been helpful for anxiety and agitation. -She was quickly declining cognitively. -She walked with a shuffled gait, head held down. *A 12/27/17 order to change [MEDICATION NAME] from three times daily to as-needed. *A 1/31/18 fax to the primary physician to discontinue the as-needed [MEDICATION NAME], because she had not used the prescription in the last fourteen days. That order was approved. *A 2/13/18 physician's progress note revealed:-She was seen at the Veteran's Administration (VA) Hospital. -The VA physician had changed her [MEDICATION NAME] from a scheduled dose to as-needed. -The same physician had also added [MEDICATION NAME] (to treat depression and anxiety). -Really no improvement. -Still attempts 'exit-seeking'. -Gait now more shuffle than walking. -Echolalia (word repetition)-unable to formulate words otherwise. *A quarterly memory care unit assessment form completed 5/19/17, 8/18/17, 11/17/17, and 2/14/18 had indicated on each assessment she: -Required a calm and structured environment to maintain comfort and dignity. -Exhibited pacing and agitation. -Was known to wander. Review of the 2/22/18 at 10:53 a.m. care conference note completed by the LSW in the IPN revealed:*A care conference was held on that day. *The clinical coordinator/Minimum Data Set (MDS) nurse, dietary manager, LSW were present. *The resident's power of attorney was present by phone. *Resident 1 was on a list to have received one-to-one activity once every week. *She had lost thirteen pounds in the past six months. *The physician saw her 2/13/18, and States she is tolerating her medication well. *She was needing more assistance with her activities of daily living. *She could not formulate words and continued to have echolalia. *No concerns noted during care conference. Review of the IPN for resident 1 revealed: *A 2/22/18 at 6:20 p.m. note by LPN B revealed at 5:40 p.m.: -The memory unit called me no one witnessed it and (resident 1) was on the floor bleeding on her left side, she was crying out, she could move all of her limbs freely, she was bleeding from her mouth and nose had has a huge knot on the back of her head. -She coughed up a huge clot. -The staff were unable to obtain her vital signs, because She was too worked up. -She may have fallen or she was punched by or pushed by another resident. *At 6:17 p.m. she left by ambulance to the emergency room . *LPN B had notified the power of attorney of the event. *LPN C who was coming on duty had talked to the LSW about the event. *LPN B indicated she was Sending a fax to her Dr (doctor) about the incident, and the other Dr about his behavior. The other resident was mocking her the whole time she was on the floor. Laughing at her too. A 2/23/17 at 3:59 p.m. note by the DON indicated she had contacted the hospital for an update on resident 1. She was instructed the resident had a fracture to her skull and a subdural hemorrhage. A 3/2/18 at 2:18 a.m. late entry by LPN C: Late entry for 02/23/18. Resident sent to the ER after falling and hitting her head. Hospital said has 2 bleeds in her head. There were no further entries in the IPN notes. Review of the provider's 2/22/18 at 5:30 p.m. fall report by LPN B for resident 1 revealed:*The fall was not witnessed. *Memory care called her. *She entered memory care and found the resident on her left side. She was bleeding from her nose and mouth. *There was a Huge lump the size of a golf ball on back of her occipital bone. *Patient (resident) could move all 4 of her limbs freely, we then got her off the floor and sat her in a wheelchair where we tried to get vitals, but she was so shook up. Patient was then take via ambulance to (hospital name) ER. *Patient did cough up a large clot and spit it out. *The primary physician had been faxed at 6:00 p.m. *The power of attorney had been notified at 6:00 p.m. *Under the heading Was first aid administered, LPN B had written Yes/ambulance. *The physician signature of notification had not been signed. *A Post Fall Investigation form attached to the fall report revealed:-Resident 1 had been walking away from the supper table, To do her normal wandering at the time of the fall. -No assistive devices were in use at the time of the fall. -Resident may have hit, pushed, punched her to make her fall. -Staff members present at the time of her fall were CNA/UAP E, CNA/UAP H, and LPN B. -Is fall suspicious for abuse, mistreatment, or neglect (failure to follow care plan) of resident? had been marked Yes. -Police came here also on 2/22/18 at 6:00 p.m. -Under the heading Nursing assessment regarding the cause of the fall and interventions added to care plan to prevent further fall, including education given to resident/staff. LPN B had documented Yes - 2/22/18. -There was no documentation of any investigation of the event or interventions. -The form had been signed by LPN B, the director of nursing (DON), The Minimum Data Set (MDS) coordinator, and the administrator. Review of resident 1's 9/1/17 through 11/15/17 Behavior Detailed Entry Reports revealed: *The 9/1/17 through 9/30/17, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-six of thirty days. On the above days the wandering behavior had: -Placed her at significant risk for twenty-six of thirty days. -Significantly intruded on the privacy or activities of others for twenty-five of twenty-six days. *The 9/1/17 though 9/30/17, 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behaviors. *The 10/1/17 through 10/31/17 (YEAR), 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-three of thirty-one days. On the above days the wandering behavior had: -Placed her at significant risk for twenty-one of thirty-one days. -Significantly intruded on the privacy or activities of others for twenty-three of thirty-one days. *The 10/1/17 through 10/31/17, 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. *The 11/1/17 through 11/15/17, 6:00 a.m. through 6:30 p.m. entries revealed: -She had wandered in hallways or other residents' rooms for nine of fifteen days. *On the above days the wandering behavior had: -Placed her at significant risk for eight of fifteen days. -Significantly intruded on the privacy or activities of others for seven of fifteen days. *On 11/13/17 at 1:30 p.m. she was Physically abusive. Hit others. -There was no further documentation in the medical record regarding who she had hit or what had prompted the behavior. *The 11/1/17 through 11/15/17, 6:00 p.m. through 6:30 a.m. entries revealed on 11/7/17 at 3:45 a.m. she had screamed at staff. -There was no further documentation in the medical record regarding what had prompted the behavior. Review of resident 1's 11/15/17 quarterly Minimum Data Set (MDS) assessment for resident 1 revealed: *She had exhibited physically aggressive behavior symptoms toward others one-to-three days per week. *She had not exhibited behavioral symptoms directed toward others such as pacing, rummaging, hitting or scratching, or disruptive sounds in the seven day look-back period. *She had overall presence of behavioral symptoms. *The above symptoms put her and others at risk for physical illness or injury. *She wandered one-to-three days per week. -It significantly intruded on the privacy or activity of other residents. -It also placed the resident at significant risk of getting to a potentially dangerous place. *Her behavior had worsened compared with the prior MDS assessment on 8/16/2017. Review of resident 1's 11/16/17 through 2/14/18 Behavior Detailed Entry Reports revealed: *The 11/16/17 through 11/30/17, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for seven of fifteen days. *On the above days the wandering behavior had: -Placed her at significant risk for seven of fifteen days. -Significantly intruded on the privacy or activities of others for seven of fifteen days. *The (MONTH) 15 through (MONTH) 30,2017, 6:00 p.m. through 6:30 a.m. entries revealed she did not display any behavior. *The 12/1/17 through 12/31/17, from 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for twenty-one of thirty-one days. *On the above days the wandering behavior had: -Placed her at significant risk for seventeen of thirty-one days. -Significantly intruded on the privacy or activities of others for eighteen of thirty-one days. *The (MONTH) (YEAR) 6:00 p.m. through 6:30 a.m. entries revealed: -On 12/10/17 at 8:00 p.m. she had refused assistance with dressing. -On 12/11/17 at 10:00 p.m. she was Physically abusive. Hit staff. -There was no further documentation of behavior. *Review of the 1/1/18 through 1/31/18, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for ten of thirty-one days. *On the above days the wandering behavior had: -Placed her at significant risk for four of thirty-one days. -Significantly intruded on the privacy or activities of others for five of thirty-one days. *The 1/1/18 through 1/31/18 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. *Review of the 2/1/18 through 2/22/18, 6:00 a.m. through 6:30 p.m. entries revealed she had wandered in hallways or other residents' rooms for six of twenty-two days. *On the above days the wandering behavior had: -Placed her at significant risk for three of twenty-two days. -Significantly intruded on the privacy or activities of others for three of twenty-two days. *The 2/1/18 through 2/22/18, 6:00 p.m. through 6:30 a.m. entries revealed she had not displayed any behavior. Review resident 1's interdisciplinary progress notes (IPN) revealed: *An 11/24/17 LSW quarterly MDS note indicated a history of wandering and physical behavior as well as wandering and exit seeking. *A 12/8/17 entry by LPN N indicated resident 1 had been grabbed on the arm by another resident (3) and was trying to shake her hand off. -When resident 3 would not let go resident 1 forcefully shoved her. Upon request for more information of the 12/8/17 incident from the DON: -There was no resident-to-resident altercation event report completed. -An investigation had not been completed to identify the cause of the above altercation. -There was no notification to the physician or either family regarding the event. -A SD DOH event report had not been completed and sent to the SD DOH. *A 12/24/17 incident regarding a fall with a head injury. Review of the 12/24/17 fall report by RN O revealed CNA D had observed resident 2 threaten to back into resident 1 if she did not move. RN O had documented, Report is that he did back into her then backed into her causing her to lose her balance. Resident 1 fell hitting her head. *Upon request for more information from the DON: -Resident 1's physician and power of attorney had been notified. -There was no documentation in resident 2's record of the resident-to-resident altercation. -There was no notification to resident 2's physician or family about the event. -An investigation had not been completed to identify the cause of the altercation. -A SD DOH event report had not been completed and sent to the SD DOH. *A 1/15/18 note by LPN P at 5:29 p.m. indicated the resident was found on the floor with both legs in one pant leg. The fall was not witnessed. Another head injury was noted. *Upon request for more information from the DON: -An investigation had not been completed to identify the cause of the above fall. -A SD DOH event report had not been completed and sent to the SD DOH. *A 1/24/18 note by RN O at 9:48 p.m. indicated the resident had a fall at 3:15 p.m. Caused by aggressive behavior of another resident. -Resident 1 received another head injury after being pushed by resident 2. -The LSW was made aware of verbal and physical aggression of the other resident. Upon request for more information from the DON: -A fall report had been completed for resident 1. -Resident 1's physician and power of attorney had been notified. -An resident-to-resident altercation report had not been completed for resident 2. -There was no notification to resident 2's physician or family about the event. -An investigation had not been completed to identify the cause of the above altercation. -A SD DOH event report had not been completed and sent to the SD DOH. Two other resident-to-resident altercations had occurred between residents 1 and 2 that were not documented in resident 1's medical record. Those events were recorded in resident 2's behavior tracking record: *On 1/28/18 CNA D had documented resident 2 hit resident 1 in the back. Upon request for more information from the DON: -A resident-to-resident report had not been completed for residents 1 or 2. -Residents' 1 and 2's physicians and families or power of attorney had not been notified. -An investigation had not been completed to identify the cause of the altercations. -SD DOH event reports had not been completed and sent to the SD DOH. *On 1/31/18 CNA G had documented resident 2 hit resident 1 in the left upper chest shoulder, witness by (CNA K) and housekeeper and he was mocking (resident 1), making crying sound after hitting her. *Upon request for more information from the DON: -Resident-to-resident reports had not been completed for residents 1 and 2. -Residents' 1 and 2's physicians' and family or power of attorney had not been notified. -An investigation had not been completed to identify the cause of the altercation. -SD DOH event reports had not been completed and sent to the SD DOH. Review of resident 1's 2/14/18 annual MDS assessment revealed: *She displayed no physically or verbally aggressive behavior symptoms toward others in the seven day look-back period. *No behavioral symptoms directed toward others such as

Based on record review, interview, and policy review, the provider failed to ensure a thorough investigation had been completed and documented for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who were cognitively impaired and had been subject to resident-to-resident altercations. Findings include: 1. Review of resident 1, 2, 3, 4, and 5's medical records revealed: *They had been subject to resident-to-resident altercations. *Thorough investigations had not been documented and maintained. *The South Dakota Department of Health (SD DOH) had not been notified of all but one event (2/22/18). Refer to F600, F609, F657, F658, F726, F744, F745, and F842.

Based on observation, interview, record review, policy review, and job description review, the provider failed to: *Provide the necessary care and services for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) with cognitive impairment to reach his/her highest practicable level of physical, mental, and psychosocial well-being. *Develop policies and procedures for all residents residing on the memory care unit (MCU). *Develop a care plan with measurable goals and interventions to address the care and treatment for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) who had cognitive impairment. *Identify, document, and communicate specific targeted behaviors for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5) residing on the MCU. *Ensure staff had the skills and qualifications to assess residents' with behaviors for two of two closed resident records (1 and 2) and three of three sampled residents (3, 4, and 5). Findings include: Surveyor: 1. Interview on 3/13/18 at 10:46 a.m. with the director of nursing (DON) and the administrator regarding policies and procedures revealed the provider had: *A policy regarding admission criteria for the MCU. *No policies and procedures specific for the care of the residents residing on the MCU. Surveyor: Review of the provider's (YEAR) Dementia - Clinical Protocol policy revealed: *Assessment and Recognition: -1. The physician will help identify individuals who have been diagnosed as having dementia or otherwise irreversibly impaired cognition. -5. The staff and physician will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. -6. The staff and physician will review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. -8. The staff and physician will jointly define the decision-making capacity of someone with dementia, including the extent to which the individual can participate in making everyday decisions and considerations about healthcare treatment choices, including life-sustaining treatment. *Treatment/Management: -1. For the individual with confirmed dementia, the staff and physician will identify a plan to maximize remaining function and quality of life. -2. The physician and staff will identify and address ethical issues and related treatment options. *Monitoring and Follow-up:-1. The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician. -2. The physician will help staff adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, etc. Refer to F600, F609, F610, F657, F658, F679, F726, and F745.

Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure two of two closed resident records (1 and 2) who had cognitive impairment and resided on the memory care unit (MCU): *Had notified the residents' (1 and 2) physicians of significant changes as required. *Had provided appropriate emergency response for one of one sampled resident (1) with a fall with a major injury. *Had identified, assessed and documented specific targeted behaviors for both residents. *Reviewed and modified the interdisciplinary care plans to identify specific interventions to address behavioral and mood-related symptoms for both residents. Findings include: 1. Observation on 3/8/18 at 1:00 p.m. of an undated and unsigned note posted at the Warren unit nurses' station revealed: *(Medical director's name) and his team DO NOT want to receive faxes!!! *If it is important and needs to be addressed right away you need to call him. *If it can wait, then write out a fax and put it in the medical records folder (at each nurses station) and (medical records staff name) will get it to him when he comes out that week. Observation on 3/8/18 at 1:00 p.m. of an undated Charting guidelines posted at the Warren unit nurses' station revealed: *Chart any behaviors as an IPN note. *If behavior needs to continue to be monitored put on pass along to chart for two to three days. *Event report: front and back fully completed, call family, fax MD, IPN Note. Surveyor: 2. Review of resident 1's 2/22/18 resident transfer form had indicated: *The resident's name. *She was a female. *Date of the transfer was 2/22/18. *Payment source was Other. *Under vitals at time of transfer: Could not. Too worked up. *Speech and mental impairments had been checked. *Additional pertinent information indicated Has dementia on locked unit. *The above form had not indicated: -The name of the physician or facility transferring from. -The name of the facility transferring to. -The name of the guardian. -Her diagnoses. -The time of the injury. -Her condition at the time of the transfer. -The reason for the transfer. -A signature of the nurse providing the information. Surveyor: 3. Review of resident 2's 2/23/18 resident transfer form had indicated: *The resident's name. *He was a male. *Date of the transfer was 2/23/18. *Payment source was Other. *Under vitals at the time of transfer: N/A. *Mental and hearing impairments had been checked. *Important medical information: NKDA. *Under advance directives yes and copy attached had been checked. *Code status: DNR. *Additional pertinent information indicated, He was suspected of hurting, hitting, punching, or pushing another resident multiple times. *The form had not indicated: -The name of the guardian and contact information. -[DIAGNOSES REDACTED]. -His condition at the time of the transfer. -A signature of the nurse providing the information. -The date the nurse completed the resident transfer form. 4. Interview on 3/7/18 at 8:57 a.m. with LPN B regarding the 2/22/18 at 5:40 p.m. resident-to-resident altercation revealed she: *Had not received any orientation on how to complete a hospital transfer form for resident 1. *Did not receive any event report checklists and/or guidelines to follow to complete a resident-to-resident altercation. *Had to call the other two night nurses working that date for directions on how to: -Contact the emergency response system. -Complete the required mandatory reporting forms. *Had faxed resident 2's event report form to the primary care physician (PCP) at 6:00 p.m. Interview on 3/7/18 at 12:43 p.m. with the medical director regarding the 2/22/18 resident-to-resident altercation revealed he: *Thought the MCU was an appropriate placement for resident 2. *Stated resident 2's Behaviors were ramped up just recently. *Had seen resident 2 on 2/2/18 for aggressive behaviors, anger and aggression, and had ordered an antipsychotic medication. *Stated in his own professional opinion it was Hard to say if they should have moved resident 1, probably should of stabilized her neck with a bump to her head. *Agreed it was a problem if LPN B had no formal orientation to the emergency response protocol. *Assisted with writing the MCU admission criteria. *Deferred to the director of nursing for the protocols on wandering, pacing, agitation, and aggressive behavior. Interview on 3/7/18 at 4:04 p.m. with the administrator and the director of nursing (DON) regarding MCU policies and protocols revealed the facility did not have: *Policies and procedures for the MCU. *Protocols for wandering, pacing, agitation, and aggressive behavior. Interview on 3/7/18 at 4:35 p.m. with LPN C regarding the 2/22/18, 5:40 p.m. resident-to-resident altercation revealed she had: *Came on duty at 6:00 p.m. *Notified the LSW and supervisor on duty at 6:00 p.m. of the event. *Not notified the PCP of resident 2's continued aggressive behaviors. *Felt the fax was sufficient notification to the medical director since it: -Was so late the doctor would not do anything with it. -Would be taken care of in the morning. -Stated she would call if a situation was very serious. Further interview on 3/8/18 at 2:38 p.m. with the administrator and the DON regarding immediate notification of significant changes for residents 1 and 2 revealed: *LPN B had made multiple phone calls and should have known how to call the emergency response system for resident 1. *LPN B or C should have notified resident 2's doctor by a phone call versus a fax. 5. Review of the provider's undated MCU admission criteria revealed: *Individuals who are being considered for admission will exhibit at least two of the following characteristics: -a. Primary [DIAGNOSES REDACTED]. -b. Displays impaired judgement. -c. Requires a calm and structured environment. -d. Exhibits pacing, agitation, and/or aggressive behavior. -e. Resident is known to wander. *The individual is able to participate in and benefit from consistent, daily programming in a therapeutic environment. 6. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis, Mo., (YEAR), revealed professional standards in nursing practice for: *p. 316, communication includes: -Communication is the key to nurse-patient relationships and the ability to deliver patient-centered care. -Patient safety also requires effective communication among members of the health care team as patients move from one caregiver to another or from one care setting to another. *pp. 356 to 358, written documentation includes: -Documentation is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses in a health record. -Nursing documentation needs to be accurate and comprehensive. -To enhance communication and promote safe patient care, document assessment findings and patient information as soon as possible after you provide care. -Record all facts. -Begin each entry with date and time and end with your signature and credentials. *p. 367, incident reports includes: -When an incident occurs, document an objective description of what happened; what you observed: and the follow-up actions taken, including notification of the patient's health care provider in the patient's medical record. -Remember to evaluate and document the patient's (resident) response to the incident. *p. 382, nursing assessment for falls includes: -Apply ANA (American Nurses Association) and TJC (The Joint Commission) standards of providing interventions in a safe and appropriate manner. *Evidenced based clinical practice guidelines for a post fall assessment of a witnessed suspected fall includes: -Do not move a resident who was experiencing neck pain, abnormal neurological check, altered mental status, and poor historian. -A nursing assessment should include vital signs, injuries, loss of consciousness/neuro checks, range of motion, resident activity, and resident behavior. -Communication to the MD, nursing leadership, and appropriate interdisciplinary care team members. 7. Refer to F600, F609, F610, F657, F658, F679, F726, and F745.

Based on interview, personnel file review, job description review, and policy review, the provider failed to ensure an orientation program had been completed for one of one licensed nurse (B) and one of one certified nursing assistant (CNA)/unlicensed assistive personnel (UAP) (D). Findings include: 1. Interview with the DON, infection control nurse (ICN)/staff development, and licensed social worker (LSW) on 3/6/18 at 2:30 p.m. revealed: *The current census for the memory care unit (MCU) was nine. *They could have up to thirteen residents in the MCU. *The usual staffing pattern for the MCU consisted of: -Two staff on the day shift from 6:00 a.m. through 2:30 p.m. -One staff on the evening shift from 2:00 p.m. through 6:00 p.m. -One staff member on the night shift from 6:00 p.m. through 6:30 a.m. -They usually worked twelve hour shifts. -Someone from the Warren wing would go back to cover breaks for the MCU person. -One nurse covered the Warren wing and MCU. -They usually had an UAP for the MCU. 2. Review of licensed practical nurse (LPN) B's personnel file revealed: *A hired date of 1/17/18. *There was no documentation of a competency checklist in her file. Interview on 3/7/18 at 8:57 a.m. with LPN B regarding her orientation revealed: *She had started on 1/17/18. *She worked the day shift from 6:00 a.m. through 6:30 p.m. *She mostly worked on the Warren wing and the MCU. *Her orientation had consisted of medication pass, documentation, and had not sat down side-by-side with the other nurse training her. *If she had issues she could have called another nurse. *She had received a little training on dementia. *She had the orientation competency checklist in her backpack in her car. *She had three days of orientation on the floor. *She had been hired to work on Center but was on Warren. *She thought she had been hired to replace LPN A to get her off the floor and into an office job. *LPN A had been her mentor. *She had learned about the residents on the MCU by herself. *She had requested more orientation to the administrator and the director of nursing (DON). Further interview on 3/7/18 at 3:15 p.m. with LPN B regarding her orientation revealed: *She had received three to four days of training with LPN A. *She had carried the orientation checklist with her, but no one had asked to see it or sign off items she had completed. *She had: -Filled in on another wing for a nurse -Not been oriented to that wing. *Who were they going to put with me, there weren't any nurses, two nurses had quit. *On her third day or orientation she was by herself down Center wing and was instructed by LPN A to let her know if she needed anything. *No one had told her when she needed to have the orientation checklist completed. *No one had followed up on her to see if she had completed the orientation checklist. Review of LPN B's nurse competency checklist and medication administration observation checklist provided by LPN B revealed: *There was no documentation on either sheets indicating it had not been completed. Interview on 3/7/18 at 2:27 p.m. with LPN/staff development J regarding new employee general orientation revealed: *She had been employed three years ago. *March (YEAR) she started in the position of staff development and infection control. *General orientation consisted of: -The first day was spent going over mandatory topics. -They completed the general orientation checklist on the first day of orientation. -The competency checklist was done with whoever their mentor was. -New hires were given ten shifts. If they needed more or less shifts they were to let her know. -The competency checklist should have been completed by the end of the ten days. -As the staff development nurse she should have been following up with the new hires. *LPN A had been LPN B's mentor. *LPN A had: -Provided the education. -Had done most of LPN B's orientation. Interview on 3/13/18 at 10:46 a.m. with the DON regarding general orientation revealed: *New employees were to complete the general orientation checklist by the end of their orientation. *The time frame for the general orientation was around ten shifts depending on how comfortable the person felt. *The mentors were to have signed off the general orientation checklist as tasks had been completed. Interview on 3/8/18 at 1:50 p.m. with the administrator confirmed there was no orientation checklist in LPN B's personnel file. 3. Review of CNA/UAP D's personnel file revealed: *A hired date of 10/23/17. *The general orientation checklist was dated 3/9/18. *There was no documentation of a CNA competency checklist in her file. *The medication technician competency checklist was dated 3/9/18. Interview on 3/8/18 at 9:45 a.m. with CNA/UAP D regarding her general orientation training revealed: *She had transferred from another sister facility around (MONTH) 1, (YEAR). *She did have general orientation consisting of going over different topics. *She had been hired to work in the MCU. *She had watched the Hand in Hand video. *She had no other training on dementia. *That had been her first exposure for working with residents with dementia. *She did not remember getting a competency checklist when she had started employment. Interview on 3/13/18 at 10:15 a.m. with the administrator regarding CNA/UAP D's personnel file revealed: *Her expectations would have been to complete the orientation checklist and competency checklists sooner. *They should have been done by the time she was through with orientation. Interview on 3/13/18 at 1:39 p.m. with LPN A regarding orientation of new employees revealed: *She had done orientation with new employees. *She oriented them to computer use, electronic medical records, charting and documentation, phone numbers, and what to do in emergency situations. *The new employees would be oriented to ten shifts. If the new employee: -Was comfortable with less shifts they would allow them to work independently. -Wanted more than ten shifts for orientation they would honor that also. 4. Review of the provider's (YEAR) Employee Handbook revealed: *Training and Professional Development: -(Facility name) recognizes the importance of encouraging and supporting employees in professional development activities that are related to their employment. -(Facility name) is responsible for identifying, creating, and providing opportunities for professional development and training to enhance and build the capacity, skills excellence and professionalism of employees to enable them to contribute effectively creatively encouraging and supporting appropriate learning experiences. -Individual employees are responsible for assessing their job related skills and knowledge, for maintaining a high level of performance throughout their employment and for seeking approval for appropriate professional development and training opportunities in consultation with their supervisors. -Supervisors are responsible for working with their employees to identify needs and for creating a professional development and training plan that will benefit the unit as well as the individual. Review of the provider's (MONTH) 2013 LPN job description revealed: *General description: -Are responsible for assessing, planning, implementing, and evaluating the care of a designated group of residents in a designated time frame. -Demonstrates knowledge of gerontology residents physical, social, emotional and psychological needs based upon the residents care needs. *Essential functions: -Monitors and documents changes in health status through continuing assessment of the resident. -Implements the plan of care, using appropriate nursing action. -Transcribes and carries out physician's orders [REDACTED]. -Observes, records and reports to supervisor or physician resident's conditions and reactions to drugs, treatments and significant incidents. -Directs and supervises non-licensed staff in resident care. -Works closely with nursing assistants. Assures the CNA has appropriate information to provide care to the residents. -Knows and is able to carry out approved emergency procedures. -Follows and enforces back safety precaution for lifting and moving residents and other items. Review of the provider's (MONTH) 2013 CNA job description revealed: *General description: -Responsible to provide direct, hands-on care to residents to ensure residents attain or maintain the highest possible physical, mental and emotional well-being possible for each resident without declines in status unless the decline is documented as unavoidable. Review of the provider's undated Director of Staff Development job description revealed: *A. Staff Development/Education: -Assures that staff receive sufficient training and orientation to perform his/her duties. -Develops/coordinates/assists with instruction in general orientation. -Assures all staff complete required orientation topics before they begin work in their departments. -Assures all employees receive a comprehensive orientation that covers all required topics per facility policy, procedures, orientation checklists and law. -Assures that all employees training checklists and on-the-job orientation is completed within 30 days after starting work in their area. -Trains others to coach and mentor knowledge and skills. Review of the provider's (MONTH) 2013 DON job description revealed: *Is responsible for the daily direct care services. *Supervises the nursing department and makes sure (name of facility) is in compliance's with all nursing related rules and regulations. *Observes, mentors, and trains new and current staff to facility's programs, policies and procedures and holds staff accountable for duties assigned. Review of the provider's (YEAR) Staff Development Program revealed: *All personnel must participate in initial orientation and regularly scheduled in-service training classes. *The primary purpose of the in-service training program is to provide our employees's with an in-depth review of our established operational policies and procedures, their positions, methods and procedures to follow in implementing assigned duties, and to provide up-to-date information that will assist in providing quality care. Refer to F600, F609, F610, F657, F658, F679, F744, F745, and F842.

Surveyor: A. Based on observation, record review, interview, and policy review, the provider failed to perform tasks of daily living (toileting), implement individualized interventions, and appropriately assess and document skin breakdown for three of three sampled cognitively impaired residents (10, 18, and 25) resulting in skin breakdown. Findings include: 1. Interview on 6/10/15 between the timeframe of 2:30 p.m. and 3:30 p.m. with resident 25's daughter revealed she: *Visited almost everyday. *Felt her mother was taken to the bathroom too late sometimes. *Purposely did her mother's laundry to see how wet her clothes were from being incontinent. *Had a system where staff were to put wet clothes into one laundry bag and dry clothes into the other but staff had not followed it. *Stated the clothes were consistently very wet. *Stated her mother had skin breakdown on her bottom which healed about one month ago. Review of resident 25's skin assessment report revealed on 2/18/15 she had developed a superficial skin abrasion to her bottom. The contributing factor was incontinence. Review of resident 25's 4/30/15 Minimum Data Set (MDS) assessment revealed she was frequently incontinent of bladder (urine). She needed extensive assistance of two plus staff members for toileting. Her mental status score (thinking ability) was 0 meaning her thinking was severely impaired. Review of resident 25's 2/11/15 care plan revealed: *Urinary incontinence had been identified as a focus area on 8/26/14. *Interventions included: -Assist me to the toilet before and after meals, at bedtime, and every couple of hours at night. -If I am anxious, ask me if I need to use the toilet. -On 11/16/14 toilet every two hours while awake, at 12:01 a.m. and between 5:00 a.m. and 6:00 a.m. had been added. -On 11/19/14 I want to be kept clean and dry throughout our next meeting had been added. *There were no other interventions added for urinary incontinence after 11/19/14. *There had been no documentation on the care plan regarding the documented 2/18/15 skin abrasion. Interview on 6/10/15 between the timeframe of 2:30 p.m. and 3:30 p.m. with certified nursing assistant (CNA) G revealed some residents who needed assistance with toileting were soaked in the morning when she got to work. She defined soaked as meaning the bed and her clothes had been wet. She stated the overnight staff did not always toilet residents, especially those that may have behaviors or are more difficult. Interview on 6/16/15 at 2:30 p.m. with CNA H regarding resident 25 revealed: *The resident was dependent on staff for most care. *She was to have assistance from one staff person for toileting. *Sometimes when she arrived at work in the morning the resident was really wet. -When asked to explain what really wet meant she replied, The bed, her clothes, and everything. *She did not think the overnight staff always toileted her. *She felt they did not change her because they were short staffed or because sometimes the resident would fight with staff. Interview on 6/16/15 at 2:15 p.m. with the director of nursing revealed: *CNAs did not document every time they assisted the resident with toileting. They would document one time during their shift. *There was no documentation to verify staff had been toileting her before and after meals, at bedtime, every couple of hours at night or every two hours while awake, at 12:01 a.m., and between 5:00 a.m. and 6:00 a.m. *There had been no updated interventions on the care plan. A toileting policy had been requested on 6/11/15 but had not been received by the time the survey team had exited on 6/17/15. Review of the provider's 11/13/14 Bowel and Bladder Assessment Policy revealed: *Residents would achieve their highest possible level of bowel and bladder function. *Each resident would be assessed for bowel and bladder incontinence upon admission, re-admission, annual review, and with significant changes. *The bladder screening sheet should have been completed by staff for three days to provide information on potential patterns of incontinence. *The nurse was to implement an individualized toileting plan based on the information obtained. *The care plan should have included goals and interventions. Surveyor 2. Observation and interview on 6/10/15 at 1:00 p.m. with CNA G during resident 10's care after toileting with assistance from CNAs G and I revealed: *Both sides of his buttocks were bright pink and dry with cracks in the skin at the outer edges of the bright pink area. *There was a small open area (top layer of skin was gone) on the upper right buttock. *There was an area the size of a quarter on the back side of the upper left thigh with small dark brown scabbed areas throughout. -CNA G stated she had not known of the scabbed area on the upper left thigh. *There were several small open areas on the back side of the scrotum. Those areas were open, red inside, and about half the size of a pencil eraser. -CNA G stated these were from his constant dribbling of urine. -He had dribbling of urine during the time of the assessment. *When asked how those areas were being cared for CNA G replied they were to use a cream on the scrotum and buttocks. -The [MEDICATION NAME] cream (a moisture barrier) that had been in the resident's room was applied in a thick layer over both sides of the buttocks, the back side of the upper left thigh, and the back side of the scrotum. Review of resident 10's complete medical record revealed: *From 2/28/15 to 4/11/15 the skin was documented as intact with no areas of concern. *On 4/13/15 the groin area was pink. *On 4/14/15 there was an open area on the right upper buttocks and the family and the physician were notified. -Moisture cream applied to area. -No time was documented. *On 4/14/15 the Skin Assessment Report had documented an open area on the upper right buttocks with sitting in urine listed as a causal or contributing factor. -The diagram to identify the location of the skin concern had an X over the left groin. *On multiple dates the wound was tracked on a Non-Pressure Skin Condition Report form and was identified as a skin tear. -The intervention started was listed as a moisture barrier. *On 4/27/15 the left ischial crease (skin fold at bottom of buttocks and top part of thigh) was documented as a new area of concern. *On 4/27/15 the Skin Assessment Report identified friction from briefs as a causal or contributing factor. -Skin was described as sheared. *On 5/4/15 there were no new areas of concern noted; wounds to buttocks not improving much. *No physician's order or nursing order for the use of [REDACTED] *[MEDICATION NAME] cream was not documented on the treatment administration record. Review of the undated manufacturer's instructions stated to apply [MEDICATION NAME] in a thin layer. Interview and record review including surveyor on 6/16/15 at 5:00 p.m. with the director of nursing (DON) and administrator revealed the DON: *Had not seen resident 10's open skin area. *Was not aware a barrier cream was being used on resident 10's open skin areas. Surveyor 3. Review of resident 18's closed medical record revealed an admission skin assessment had been completed on 7/3/14 with no skin concerns noted on buttocks, coccyx, or heels. Review of his 7/4/14 nursing note revealed he had been a total assist for all ADLs (activities of daily living), was incontinent of both bladder and bowel, and wore incontinent products. Further review of the Interdisciplinary Progress Notes revealed on: *7/11/14 - Admission MDS (Minimum Data Set is an assessment tool) revealed a: -Braden (a skin assessment tool) score of 13 (at risk for skin breakdown). -Pressure reducing mattress was to have been on his bed at all times. -Pressure reducing cushion was to have been in the wheelchair when he was in it. *9/9/14- At 11:15 a.m. the nutrition documentation revealed a Braden score of 13 and coccyx may be red. A nursing note on that same day at 5:16 p.m. stated a half-dollar size red area was noted on the lower coccyx, but was not open. *9/24/14 - A nutrition note indicated his skin did not have a pressure ulcer per nurse and the skin team notes had been reviewed. *10/7/14 - The care plan conference record revealed the family was concerned the resident was not getting a bath 3 times a week as expected. *11/6/14 - A new skin concern of an open area 1 centimeter (cm) x 1 cm on the inner aspect of butt cheek had been documented. The physician was notified and an order received for [MEDICATION NAME] (moisture barrier ointment). The area was also documented on a non-pressure skin condition report and was noted as incontinence skin break down. *11/7/14 - On a weekly pressure ulcer record the coccyx was noted to have been a stage II ulcer (an open sore in the top layer of the skin) measuring 1.0 cm x 1.0 cm. Risk factors/cause were noted to have been diabetes and incontinence. *11/14/14 - On the weekly pressure ulcer record the coccyx was noted to be a stage I (reddened area without being open) and was 0.5 cm x 0.5 cm. *11/21/14 - The weekly pressure ulcer record stated the coccyx area was healed but a new area was observed. The non-pressure skin condition report stated the inner buttocks cheek area was healed. *11/21/14 - The skin assessment revealed a new open area on the inner lower aspect of buttocks cheek measuring 2 cm x 2 cm. Incontinence had been listed as a causal or contributing factor. *11/29/14 - The nutrition notes indicated nursing assessments had documented an open area from incontinence; the nutrition team discussed it was a closed area; but a voice mail message left for dietary by nursing stated it was an open area. There was no change regarding extra protein until clarification of the skin condition had been received. The resident's family had been made aware of the open areas. *12/8/14 -Licensed Nurses Notes stated the DuoDerm (type of wound dressing) had been replaced on the coccyx when there was no documentation of a start date for the DuoDerm. *12/21/14- Licensed Nurses Notes stated the DuoDerm dressing had been reapplied to the reddened coccyx. *12/23/14 - The nutrition notes indicated the pressure area was healed. *1/5/14 (should have been 2015) - Licensed Nurses Notes stated the coccyx area was pink and intact and DuoDerm had been used for protection of fragile skin. Surveyor B. Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled residents (3), 1 randomly interviewed resident (29), and 8 randomly reviewed residents (9, 16, 22, 23, 24, 26, 28, and 30) that resided in Center hall had received scheduled baths/showers and accurate documentation was maintained for when baths/showers had been given. 1. Review on 6/10/15 of resident 3's Bath Type Detail Report revealed she had not had a bath since 5/31/15. Review of resident 3's May 2015 care plan for activities of daily living function/incontinence revealed: *She is always incontinent of bowel and bladder. *She would like to be kept clean and dry. Interview on 6/10/15 at 9:45 a.m. with CNA J who is also a full-time bath-aide revealed: *There were usually three CNA's including the bath-aide that worked on Center Hall. *She would get pulled from giving baths to help the other CNA's *3 CNA's were not enough for this many residents. *There were more than forty residents on Center hall. *Sometimes there was only one CNA on night shift. *Baths do not get done everyday. *Some of yesterdays baths had not been done. *Last nights scheduled baths had not been done. *There were a lot of wet beds and urine soaked residents in the mornings. Interview on 6/9/15 at 11:40 a.m. with CNA K revealed there were two to three CNA's during the day to approximately forty-seven residents. Sometimes baths did not get done and they got moved to the next day. They usually had nine baths on Mondays, and about twelve to thirteen on Wednesdays and Thursdays. Sometimes they would have to change three to four urine soaked beds in the mornings when they got to work. Interview on 6/10/15 at 1:55 p.m. with CNA K revealed the bath logs that were kept in the bath house were inaccurate. The bath log in the computer should have been more accurate. When a resident was given a bath even if it was after their scheduled bath day, they would still document that the bath was given on their scheduled day. Sometimes they would put the correct date of the bath behind the residents names on the bath logs that were kept in the bath house. There was not consistent documentation. Review of the Center bathing log from 6/8/15 through 6/11/15 revealed: *On 6/9/15 resident 22 was scheduled for bath. *Resident 22 was moved to the next day on 6/10/15. *On 6/9/15 resident 23 was scheduled for a bath. *There was no documentation for resident 23 on 6/9/15 they had received a bath. *On 6/10/15 resident 9 was moved to 6/11/15. Review of the Bath Type Detail Report from 6/8/15 through 6/11/15 revealed: -Resident 22: -On 6/9/15 at 10:16 a.m. it was documented she received a shower. -On 6/10/15 at 2:27 p.m. it was documented she received a whirlpool bath. *Resident 23: -On 6/10/15 at 8:27 a.m. it was documented she received a shower. -On 6/11/15 at 9:51 a.m. it was documented she received a whirlpool bath. -On 6/11/15 at 10:28 a.m. it was documented she received a shower. *Resident 24: -On 6/11/15 at 10:01 a.m. it was documented he received a shower. -On 6/11/15 at 11:18 a.m. it was documented he received a whirlpool bath. *Resident 16: -On 6/8/15 at 5:49 a.m. it was document he received a whirlpool bath. -On 6/8/15 at 6:50 a.m. it was documented he received a shower. *Resident 26: -On 6/9/15 at 10:10 a.m. it was document he received a shower. -On 6/10/15 at 2:27 p.m. it was documented he received a whirlpool bath. *Resident 28: -On 6/11/15 at was documented she received a shower at 9:06 a.m. and 9:46 a.m. *Resident 30: -On 6/9/15 at 10:15 a.m. it was documented she received a shower. -On 6/10/15 at 2:27 p.m. it was documented she received a shower. Surveyor: Interview on 6/11/15 at 9:00 a.m. with resident 29 revealed there was no time for my shower this morning. Maybe I will get it this afternoon. Otherwise I will have to wait until tomorrow. That happens all the time. Surveyor: Interview on 6/16/15 at 9:05 a.m. with CNA J who was also a full-time bath aide revealed: *The bath detail reports were not accurate. *Instead of just the bath aide documenting that a resident would get a bath or shower all the CNA's would document it. *The charting would be inaccurate. *There was no way to know from their documentation if or when a resident received a shower or whirlpool bath. *There was just not enough staff to get all the cares done. Interview on 6/16/15 at 2:25 p.m. with the director of nursing and administrator revealed: *They would have expected baths and showers to have been completed the day they were scheduled. *They would have expected documentation to have been accurate and timely. Review of the revised October 2010 Shower/Tub policy/procedure revealed: *The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the residents skin. *The following information should have been recorded on the residents activities of daily living and/or in the medical record: -The date and time the shower/tub bath was performed. -The name and title of the individual who assisted the resident with the shower/tub bath. -All assessment data obtained during the shower/tub bath. -How the resident tolerated the shower/tub bath. -If the resident refused the shower/tub bath, the reason why, and the intervention taken. -The signature and title of the person recording the data. -Notify the supervisor if the resident refuses the shower/tub bath. Surveyor C. Based on record review, interview, and policy review, the provider failed to combine the hospice plan of care with the provider's plan of care to specify who was responsible for care for two of three sampled hospice residents (14 and 15). Findings include: 1. Review of resident 14's medical record revealed an admission on 8/9/14. Hospice care had started 5/22/15. Review of resident 14's current 2/12/15 provider's care plan revealed: *It was located in a Care Plan binder with the hospice agency's care plan placed behind it. *No mention was made on the provider's care plan to show who was responsible for what care the resident was to receive. Interview on 6/16/15 at 3:30 p.m. with the DON and administrator revealed they were unaware of the need to specify provider and hospice care for residents. No hospice specific policy on resident care plans existed. Surveyor 2. Review of resident 15's medical record revealed: *She had been admitted on [DATE]. *She was currently on hospice care and had been receiving hospice services at another facility. *A 6/3/15 physician's order for hospice care for No change in level of care at this time only change of location. Review of resident 15's undated care plan revealed: *No interventions that had included hospice care. *It had not: -Addressed why she was on hospice. -Identified the services and what care was to have been provided by the provider and by hospice. Interview on 6/10/15 at 2:40 p.m. with registered nurse (RN) A regarding resident 15 revealed: *The provider had not combined hospice care plans into her care plans. *She had been unaware the hospice care plans needed to have been combined into the provider's care plan. *She agreed the hospice care plan needed to have been combined into the provider's care plan. Interview on 6/10/15 at 2:55 p.m. with certified nursing assistant (CNA) B regarding resident 15 revealed: *She had been unaware she was on hospice. *She had not known what services hospice were to have provided. Interview on 6/10/15 at 3:00 p.m. with the director of clinical services at the hospice agency regarding resident 15 revealed: *They had not combined hospice care plans into the provider's care plans. *It was the responsibility of the provider to integrate the care plan provided by the hospice agency into the provider's care plan. *She stated there was a hospice plan of care for her, and that she would send it to the facility. *She agreed the plan of care needed to have been available and combined into the provider's care plan. Interview on 6/10/15 at 4:10 p.m. with CNA Q regarding resident 15 revealed she: *Had been aware she was on hospice because she had assisted with her admission on 6/4/15. *Stated It would have been nice to have had more information regarding her hospice care. *She was not aware what services hospice was to have provided. Interview on 6/10/15 at 4:40 p.m. with the DON regarding resident 15 revealed she: *Agreed they did not have her facility care plan combined with the hospice one. *Confirmed the provider's care plan needed to have been combined with the hospice one and followed. 3. Review of the provider's January 2009 Care Plans - Preliminary policy revealed to ensure the resident's immediate care needs were met and maintained a short-term care plan was to have been developed on admission. Review of the provider's January 2009 Care Plans-Comprehensive policy revealed: *The provider developed a comprehensive care plan for each resident to meet the resident's medical, nursing, and psychological needs. *The above comprehensive care plan had been designed to: -Incorporate identified problem areas. -Incorporate risk factors associated with identified problems. -Build on the resident's strengths. -Reflect treatment goals and objectives in measurable outcomes. -Identify the professional services responsible for each element of care. -Prevent decline in the resident's functional status and levels (the measure and levels of a person's ability to perform activities of daily living independently). Review of the provider's revised 7/25/12 Agreement for Nursing Home Services revealed: *The provider and hospice were to have developed a combined care plan for each hospice resident. *Hospice was to have provided the facility with a copy of any existing care plan upon admission. *If a care plan had not been developed prior to that admission: -Hospice was to have prepared a care plan for that resident within two working days. -And have delivered a copy to the provider. *The provider and hospice were to have worked together to: -Facilitate cooperative efforts between the provider and hospice in providing appropriate care for residents admitted to hospice. -Ensure that care for hospice residents was in compliance with the hospice plan of care.

Based on observation, interview, record review, and policy review, the provider failed to ensure interventions and safety measures were in place for: *Three of three sampled residents (17, 18, and 19) who had falls and had been discharged from the facility. *Two of eight sampled residents (25 and 27) who had falls. Findings include: 1. Review of resident 17's closed medical record with a [DATE] post fall risk assessment that was to be completed immediately after a fall revealed: *She was in the bath chair in the bath house. *As the nurse entered the room the resident lifted the arm of the chair and slid out onto the floor. *She hit her head on the floor. *The environmental factors that contributed to the fall were it was wet, and there was no safety belt on the chair. *The resident's cognitive (mental) status was alert and confused. *No available safety belt on the bath chair. Review of resident 17's interdisciplinary progress notes revealed: *A nursing note on [DATE] at 11:00 a.m. noted the following: -The nurse was called into the bath house to do a skin assessment on the resident. -Upon entering the room the resident lifted the side arm on the bath chair and fell out onto the floor landing face first. -The resident was rolled to her back. -Small amount of blood noted on her nose. -Left eye was swollen and bruised. -Bruising noted to right hand. -No complaints of pain noted. -Two staff returned the resident to bed. *A post-fall nursing note on [DATE] at 2:00 p.m. noted: -Vital signs (basic indicators of body function) and neurological (neuro) assessments noted to be completed. -No change to left eye bruising, and no further injury noted. -Will continue to monitor for any changes in level of consciousness (awareness) (LOC) or any further injuries. *A post fall nursing note on [DATE] at 9:00 p.m. noted: -Vital signs were taken and documented. -Left eye was bruised, but no other injuries noted. -Resident denied pain. -Would continue to monitor for any changes in LOC. *A post fall nursing note on [DATE] at 10:45 p.m. noted: -Continued to have bruising to left eye and right hand. -PEARL (PERRLA (pupils equal, round, and reactive to light, accommodate)) neuro assessments WNL (within normal limits). -Vital signs were taken and noted. *A nursing note on [DATE] at 9:46 a.m. noted: -The resident's lung sounds did not sound good. -A fax was sent to the doctor to see what he would like them to do. -The resident was on 2 liters of oxygen and a nebulizer treatment was completed with no change to lung sounds. *A nursing note on [DATE] at noon noted a fax received from the physician that it was ok to send the resident to the emergency room (ER). *A nursing note on [DATE] at 12:05 p.m. revealed Sioux Falls wheel chair express picked up the resident and took her to Avera ER. *A nursing note on [DATE] at 3:00 p.m. written by MDS care manager L noted: -She reviewed the resident's fall from [DATE]. -The resident was in the shower room in the bath chair. -The resident lifted the side arm on the bath chair and fell out onto the floor. -The resident landed face first onto the floor. -Her left eye was bruised and swollen, and her right hand was bruised. -The resident was instructed not to lift the arm on the chair. -The staff were instructed not to leave the resident unattended during her bath. -After further review it was determined there was not evidence of abuse or neglect with the above fall. *A late entry nursing note on [DATE] at 10:00 p.m. revealed: -The resident was admitted to Avera. -Her [DIAGNOSES REDACTED]. -She had a hospice consult on [DATE]. *A nursing note on [DATE] at 12:35 p.m. noted: -Two broken vertebrae (bones in the spine) that are old! -She stated she is not upset with anyone. *A readmission to the facility nursing note on [DATE] stated: -Readmission [DIAGNOSES REDACTED]. *A nursing note on [DATE]: A fax was sent to the physician asking for a hospice order. *A nursing note from [DATE] stated the resident was found at 5:45 p.m. without vital signs. Review of Avera Mckennan Hospital and University Center's medical records for resident 17 revealed: *emergency room visit notes: -Date of service was [DATE]. -Her chief complaint was difficulty breathing. -The report from her daughter was she was sitting after getting out of the shower, she slipped out of her chair, falling onto her left side. -That had happened four days ago. -The nursing home had noticed she has had breathing difficulty since then. -She did complain of pain to her left shoulder. *The emergency department course and plan: -She had a fall four days ago with now difficulty breathing and some significant chest wall tenderness. -An x-ray was obtained. -The resident was noted to have multiple left rib fractures. -She also had a clavicular fracture. *She was admitted on to the trauma service on [DATE]. -She presented in the emergency department from the nursing home with shortness of breath and wheezing. -In the transfer information it did not mention anything about a recent fall. -Upon evaluation it was evident the resident had some sort of trauma with bruising to her left shoulder, chest, and eye. -Further discussion demonstrated was she might have fallen either yesterday versus three days ago. -Reports were inconsistent. -She described she felt very confused and that was not normal for her. -She described diffuse (widespread) pain. -The chest x-ray showed multiple displaced rib fractures on the left side, and the left clavicle fracture. -It was unclear of the events that lead up to this, with a left clavicle fracture, multiple left rib fractures, on 3 liters of oxygen, bruising to the left eye, and some pelvic tenderness. *On [DATE] diagnostic test results showed the left second, third, fourth, fifth, sixth, seventh, ninth, and tenth ribs were fractured both anteriorly and posteriorly forming a flail segment. *She was discharged back to the nursing home on [DATE] with the following [DIAGNOSES REDACTED]. -Fall from standing height. -Multiple left rib fractures. -Left clavicle fracture. -Hypoxia (inadequate oxygen supply). Review of resident 17's [DATE] care plan for falls/psychotropic (mind-altering) drug use revealed: *It had been updated on [DATE] with her fall from the bath chair. *She was reminded not to lift her arm up while she was in the bath chair. *She was not to be left unattended while in the bath. *She had a history of [REDACTED]. Observation and interview on [DATE] at 11:00 a.m. with CNA D who was the bath aide that day revealed: *She was not using a seat belt on the bath chair. *There was no seat belt for the bath chair, she did not use anything to secure the residents in the bath chair. *Most residents could support themselves in the bath chair. *She remembered there being a seat belt probably back in [DATE], but she had not used one since then. *She worked at the facility as needed. Interview on [DATE] at 12:05 p.m. with Minimum Data Set care manager L revealed she had not seen a seat belt for the bath chair. Interview on [DATE] at 12:35 p.m. with CNA J who usually worked full-time as a bath-aide (but not on [DATE]) revealed she had been using a seat belt when she bathed residents. The seat belt was ordered because of resident 17's fall out of the bath chair. Review of the [DATE] Penner Patient Care, Incorporated invoice revealed a seat belt had been ordered for the bath chair. Review of the Penner Manufacturing Cascade Patient Transfer Lift System Safe Operations and Daily Maintenance Instructions revealed on page 9 for the bath chair WARNING Failure to secure the resident properly with the seat belt could result in injury to the resident or operator. Review of the revised [DATE] Shower/Tub bath policy revealed: *Never leave the resident unattended in the tub or shower. *No mention of the use of the seat belt for the bath chair. Interview with the director of nursing and administrator on [DATE] at 2:25 p.m. revealed: *They had ordered a seat belt after resident 17's fall from the bath chair. *They would have expected the CNAs that were giving baths to have used the seat belt for all baths. Surveyor 2. Review of resident 19's complete medical record revealed: *He was admitted on [DATE]. *He was at high risk for falls. *His fall risk assessment score was sixteen. *His fall risk assessment report stated any score ten or greater to initiate the following: -Initiate falling star program. -Write on nursing Kardex, care plan, and pocket care plan. -Initiate other safety measure as appropriate. *His [DATE] nursing Kardex revealed no mention of falls or interventions for falls. *On [DATE] he had a fall with the following noted: -Nursing heard someone yelling for help. -He was found on his floor by his bed. -He complained of left hip pain and was unable to move his left leg. -He was sent by ambulance to the emergency department. -He was admitted to the hospital with [REDACTED]. Review of the provider's addendum to their final report for resident 19's [DATE] event revealed on [DATE] staff noted an obituary for him. He had died on [DATE]. 3. Review of resident 18's closed medical record revealed: *An admission date of [DATE] with [DIAGNOSES REDACTED]. *The [DATE] Fall Risk Assessment showed a score of 12 (score greater than 10 = high risk for falls). *The [DATE] care plan stated he had used a wheel chair for mobility and wanted it tilted. *The [DATE] care conference note indicated the family was concerned the resident would slide out of the wheelchair. He had his own wheelchair with a seat belt. The resident unable to release the seat belt and is thus considered a restraint. *A [DATE] faxed request from therapy to the resident's physician requested OT, PT, and ST (Occupational Therapy, Physical Therapy, and Speech Therapy) evaluations and treatment orders to address seating safety. *On [DATE] at 11:15 a.m. the Interdisciplinary Progress Notes stated the resident was found by a certified nursing assistant (CNA) setting on floor in room in front of assistive chair - no injury noted on assessment. Assistive chair not tilted appropriately - res (resident) slid out of chair onto floor. *On [DATE] at 1:30 p.m. the Interdisciplinary Progress Notes stated the resident's fall of [DATE] had been reviewed. It was noted the assistive chair was not tilted appropriately. Staff were reminded to place the assistive chair in the appropriate position. No injuries were noted and no evidence of abuse. *On [DATE] at 10:00 a.m. a fax was sent to the physician stating the resident had a scratch to the left side of his nose. An antibiotic ointment was ordered to use on the nose, and an antibiotic via the [DEVICE] (a tube inserted directly into the stomach to provide nutrition) was also ordered. *On [DATE] at 1:00 p.m. on the Interdisciplinary Progress Notes by nursing stated Resident's sister was here and noticed bridge of nose is swollen and left eye sclera (whites of eye) is red and yellow. *A [DATE] Sanford Hospital dictation stated the patient reported a fall with bleeding. A large scratch across the left bridge of nose and a little bit of ecchymosis (reddening) right at the corner of his eye so it suggests that there was probably a fall or injury. An X-ray showed no fracture. *A documented interview on [DATE] with the resident's sister revealed the physician had stated the resident had facial trauma. When she had asked the provider what had happened to his face, the administrator and DON told her they did not know, and that they were short staffed. 4. Review of resident 25's [DATE] care plan revealed: *From [DATE] through [DATE] she had forty falls. *The following interventions had been implemented: -On [DATE] Attempt to engage in activities when up, and they had obtained a floor mat to place beside her bed. -On [DATE] Will do frequent observations. -On [DATE] Let resident wake up on own accord in AM. -On [DATE] Offer food monitor freq (frequently). -On [DATE] keep around nurse's station when out of room for easier observation, and toileting every 2 hours while awake and prn. -On [DATE] Will ambulate with restorative (therapy to help restore function) daily. -On [DATE] Toilet between ,[DATE] (5:00 a.m.-6:00 a.m.) Q (every) AM. -On [DATE] New cushion for w/c (wheelchair) per O.T. (occupational therapy). -On [DATE] Will add toilet at 0001 (12:01 a.m.). Ambulate at least two times per day and prn (as needed). -On [DATE] Will start toileting program. -On [DATE] Start falling stars program and toileting program. Monitor every 15 minutes. -On [DATE] Trial of new voice activated bed/chair alarm. -On [DATE] Pommel cushion (helps prevent forward sliding) applied to chair. -On [DATE] Try music therapy with headphones. -No other interventions had been documented after [DATE]. Interviews and record review revealed resident 25 had skin breakdown to her bottom due to incontinence. There was no documentation the toileting interventions above had been followed. Refer to F309, finding A1. Interview on [DATE] at 8:15 a.m. with the director of nursing revealed she did not know resident 25 and directed me to speak with Minimum Data Set (MDS) case manager X. MDS case manager X stated they put several interventions in place and referred to the care plan. All of the documentation regarding the fall interventions was requested. Interview and record review on [DATE] at 10:20 a.m. with the director of nursing after she had brought the above requested information revealed: *The activities documentation for resident 25 had only included information from [DATE] through [DATE]. *There was no documentation regarding the frequent observations and monitoring every fifteen minutes. *There were no other interventions put in place. 5. Record review of resident 27's medical record revealed: *He had a Brief Interview for Mental Status (BIMS) assessment score of fifteen out of fifteen indicating no cognitive impairment. *Three falls had been documented since [DATE]. *A fall occurred on [DATE] with the following noted: -Resident found on floor -He had leaned over to reach for an object and slid out of the wheelchair. -He was not injured in the fall. -Staff encouraged him to use the call light when he needed assistance. -No documentation was provided that indicated additional interventions were put into place to prevent future falls. *A fall occurred on [DATE] and noted: -The resident used the call light to request staff assistance after he had fallen. -He attempted to transfer himself from the wheelchair to bed with no staff assistance. -He was not injured in the fall. -Staff encouraged the resident to ask for assistance and use the call light. -Follow-up documentation stated the resident would like to have physical and occupational therapy reevaluate him. -There was no documentation a physical or occupational therapy consultation had been ordered after it was requested. -No additional documentation was provided up to the end of survey that indicated additional interventions were put into place to prevent future falls. *A fall occurred on [DATE] and noted: -Resident was found on the floor -He had slid out of his wheelchair while trying to place his urinal on a table. -He was not injured in the fall. -Education was provided regarding the use of the call light for assistance. -No documentation was provided up to the end of the survey that indicated additional interventions were put into place to prevent future falls. Interview on [DATE] at 3:50 p.m. with resident 27 regarding the above falls revealed: *He acknowledged he wasn't thinking prior to each of the falls. *Staff frequently reminded him to use the seatbelt on his motorized scooter. -He demonstrated he was able to unbuckle the belt without assistance. -Verbalized he had been using the seatbelt for approximately one month. *He had a tool that allowed him to grasp objects that were out of arms reach. -The facility had replaced the tool sometime during the winter, because the old one was broken. *Staff frequently reminded him to use his call light when he needed assistance while in his room. Interview on [DATE] at 4:15 p.m. with registered nurse (RN) Y revealed: *Staff had been instructed to keep items including his call light within reach. *Safety was reinforced with the resident after each fall. *Staff observed the resident more often and estimated it was at an interval of approximately every hour. *No documentation was provided to support the statement the resident had been observed at regular intervals. 6. Review of the provider's 2001 Falls and Fall Risk, Managing policy revealed: *Initial approaches could have included exercise or balance training, rearrangement of room furniture, or medication adjustments. *If falling reoccurred despite initial interventions staff should have implemented additional or different interventions, or indicated why the current approach remained relevant. Review of the provider's revised [DATE] Falls and Fall Risk, Managing policy revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure sufficient nursing services were provided to meet all aspects of resident care needs. Findings include: Surveyor: 1. Group interview on 6/9/15 at 3:15 p.m. with fifteen residents in attendance revealed it was a group consensus: *They were short staffed. *The staffing shortage was mostly in the evenings and overnights. *Sometimes there was only one CNA on duty in a wing to answer the call lights. *Sometimes there was only one nurse for center hall and east hall. *It had taken an hour or an hour and a half to answer call lights. *Resident 24 said he has had to lay in bed and wait to get up in the mornings because there was not enough staff to assist him. Surveyor: 2. Interview on 6/16/15 at 1:15 p.m. with the administrator revealed they were unable to provide call light logs from 5/13/15 to the present. The computer that had the call light software installed on it had been accidently turned off. He had been getting an error message for approximately the past 3 weeks and was unable to get any reports. They had realized it had been turned off after this surveyor had requested the data earlier that morning. Surveyor: 3. Interview on 6/9/15 at 9:20 a.m. with Dr. V revealed: *He had no access to the electronic medical record (EMR) nursing notes or dietary notes. *He had been waiting a long time for my access from the facility. *He had to hunt down a nurse if I want to know about my residents. *No nurse was available to assist him when he made rounds. *He would have to do my best with the information he had received. *They don't have enough staff for that. in regards to sending a nurse with him when he visited residents. *I will be here until 12:30 I bet. It is slow without a nurse. 4. Interview on 6/16/15 at 9:38 a.m. and at 2:35 p.m. with the staff coordinator revealed: *She was responsible for coordinating the nursing staff schedule. *She prepared a new nursing schedule every six weeks. -There were many changes to that above schedule after it had been posted. *The day of each week that had been the hardest to fill was on Sunday. *The evening shift from 2:00 p.m. until 6:30 p.m. and until 10:30 p.m. were the more difficult ones to have filled. *There were many changes to the schedule after it had been posted. *She stated there were challenges with the staffing schedule. Interview on 6/16/15 at 5:15 p.m. with the administrator and the director of nursing revealed they both agreed there were challenges with the staffing schedule. Surveyor: 5. Review of the provider's April 2013 director of nursing (DON) job description revealed she: *Monitors the nursing staff to maintain sufficient staff to provide quality care for the residents. *Was Responsible for making sure that there is adequate staff in number and ability to maintain the highest practicable level of physical, mental, and psychosocial well-being for each resident that meets the state and federal regulations. 6. Interviews, observations, record review, and policy review throughout the course of the survey from 6/8/15 through 6/11/15 and from 6/16/15 through 6/17/15 revealed the provider failed to ensure resident needs were met. Refer to F309, F314, F323, F325, and F441.

Based on observation, interview, record review, and job description review, the provider failed to ensure its resources were used effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: 1. Review of the provider's October 2012 Administrator job description revealed: *The administrator is responsible to lead and direct the overall operations of (provider name) in accordance with customer needs, government regulations and (corporate name) policies. *The administrator is responsible to maintain a focus in excellent care for the residents while achieving the facility's business objectives. *Manages overall facility operations and leading by example with regards to customer service, employee relations, and quality assurance. *Complies with, supporting, and enforcing company safety and infection control policies. *Promotes, understands, and complies with rules regarding residents' rights. Review of the provider's April 2013 director of nursing (DON) job description revealed: *The DON is responsible for the daily direct care services of (provider name) in a professional manner using its resources effectively and efficiently to attain and maintain the highest level of care to residents/patients in accordance with regulatory standards. *Keeps the facility in compliance with applicable federal, state, and local standards and regulations. *Monitors the nursing staff to maintain sufficient staff to provide quality care for the residents. *Responsible for making sure that there is adequate staff in number and ability to maintain the highest practicable level of physical, mental, and psychosocial well-being for each resident that meets the state and federal regulations. Refer to F151, F159, F176, F223, F311, F366, F367, and repeated deficiencies from previous recertification survey on 9/11/14: F166, F224, F226, F241, F248, F252, F253, F278, F280, F281, F309, F314, F323, F325, F353, F368, F371, F441, F490, F493, F514, and F520.

Based on observation, interview, record review, job description review, and policy review, the governing body failed to ensure the facility was managed in a manner that ensured the safe management and overall well-being for all ninety-five residents in the facility. Findings include: 1. The following deficiencies were repeated deficiencies from the previous recertification survey on 9/11/14: F166, F224, F226, F241, F248, F252, F253, F278, F280, F281, F309, F314, F323, F325, F353, F368, F371, F441, F490, F493, F514, and F520. The following were newly cited for the current survey: F151, F159, F176, F223, F311, F366, and F367.

Based on observation, interview, record review, and policy review, the provider failed to ensure freedom of movement for one of one sampled residents (10). Findings include: 1. Observation and interview on 6/10/15 from 12:40 p.m. to 1:00 p.m. in the East wing, far East hallway revealed: *At 12:40 p.m. resident 10 was seated in his wheelchair, his knees were up against the bed, his head was down. *At 12:45 p.m. resident 10 put his call light on. It stayed on for several minutes, and then went into a faster beeping and flashing mode. The resident made his way into the hall with his wheelchair and stayed just outside of his doorway. *At 12:53 p.m. three certified nursing assistants (CNA) came to answer the call light. The resident was pushed back into his room, the television was turned on, and one CNA asked him if the channel was okay. I heard no response from the resident. *At 12:55 p.m. the resident turned his light on again and went out into the hallway in his wheelchair. *Two of the above three CNAs returned to his room, CNAs G and I pushed him backwards into his room. CNA G told him he needed to wait ten more minutes then they would move him into his recliner, then they closed the door to his room. *When the two CNAs were asked why the resident had to wait ten minutes. CNA G responded he wanted to know his weight, and they had not had time to get it. *This surveyor had previously identified the door to his room stuck and was difficult to open. *On previous random observations when the resident had been in his recliner and watching television, the door had been left open a few inches and the resident could have been seen in the recliner. After the CNAs had closed the resident's door and left the following occurred: *The resident was heard trying to open the door. *The door knob was moving, but it was not opening. *After knocking on the door, this surveyor opened it slowly to find the resident was right in front of the door. *He motioned with his hands he wanted to move to the recliner. -His call light was not seen. *At 1:00 p.m. the resident's light was back on. *The two CNAs returned with an EZ Stand (device to assist in lifting a person into the standing position) to move the resident. Interview and record review including surveyor on 6/16/15 at 5:00 p.m. with the director of nursing (DON) and the administrator, revealed they were: *Unaware of the event. *Wanting to know if the event needed to be reported to the Department of Health office in Pierre at this time. Review of the provider's June 2014 Reporting Abuse to Facility Management policy revealed: *Involuntary seclusion was listed as a type of abuse. *The definition for involuntary seclusion included a resident being confined to his room against his will. *Employees, facility consultants, and or attending physicians were to report abuse or suspected abuse to the administrator or DON.

Based on observation, interview, record review, plan of correction review from the survey on 9/11/14, job description review, and policy review, the provider failed to appropriately identify, notify, assess, provide treatment, and care plan a pressure ulcer for one of one sampled resident (2) who was at risk for pressure ulcers. Findings include: 1. Review of resident 2's complete medical record revealed: *She was admitted on [DATE]. *There was multiple documentation of pressure ulcers since her admit. *There was multiple conflicting documentation of pressure ulcers on different areas of her body. *Her most recent documented pressure ulcer had been identified on 3/12/15. *On 5/21/15 there was a nursing note that the area was healed. *There was no way to know if the resident had a pressure ulcer currently or not because of conflicting documentation. Random observations on 6/9/15 of resident 2 from 8:45 a.m. through 10:33 a.m. while she was seated in the center dining room revealed: *At 8:45 a.m. she was sitting in her wheelchair at the dining room table with her breakfast in front of her on the table. *At 9:49 a.m. she was seated at the dining room table in her wheelchair with her head down. *At 10:00 a.m. she called out Someone help me please several times with no staff response. *At 10:10 a.m. she called out I need to use the toilet with no staff response. *At 10:33 a.m. she was still seated in her wheelchair at the dining room table with her head down. *Dietary staff had been in and out of the dining room while she was calling for help. *No nursing staff were present in the dining room. Observation on 6/9/15 at 10:45 a.m. of resident 2 in her room revealed certified nursing assistant (CNA) K and C were helping her use the toilet. Interview on 6/9/15 at 10:55 a.m. with resident 2 while she was in her recliner in her room revealed: *The questions asked were written due to her hearing impairment with some of her answers being verbal. *She stated I have a sore on my bottom (left buttock) and it hurts. *When asked if she was toileted enough she wrote on a piece of paper It depends on who is working. Interview on 6/9/15 at 11:15 a.m. with CNA K regarding resident 2 revealed: *After meals they were supposed to toilet the resident and lay her down. *She had a reddened area on her bottom, but it was not opened. *She complained her bottom was sore when she was toileted. Interview on 6/9/15 at 11:15 a.m. with CNA C regarding resident 2 revealed there was no reddened areas on her bottom. Interview on 6/9/15 at 11:20 a.m with registered nurse (RN) P revealed she had not heard that resident 2 had a sore on her bottom nor had she heard of any reddened areas on her bottom. Review of resident 2's 6/7/15-6/9/15 bowel and bladder detail report revealed: *On 6/7/15 she was toileted at: -12:31 a.m. -10:18 a.m. -2:51 p.m. *On 6/8/15 she was toileted at: -12:48 a.m. -1:41 p.m. -8:48 p.m. *On 6/9/15 she was toileted at: -11:52 p.m. -9:47 a.m. (The observation of resident 2 being toileted was 10:45 a.m. on this date). -9:30 p.m. Record review on 6/10/15 of resident 2's medical record revealed no documentation regarding her 6/9/15 complaints of a sore on her bottom or a pain assessment. Observation and interview on 6/10/15 at 9:00 a.m. while CNA K toileted resident 2 revealed: *She had a reddened area on her left buttock (bottom). *The CNA stated she would notify the nurse on duty. Observation and interview on 6/10/15 at 11:00 a.m. with MDS case manager X and L of resident 2's left buttock revealed: *A reddened area with several pinpoint open areas. *A scant amount of blood was noted on her incontinence (loss of bowel and bladder control) brief. *They stated they were unsure if it was a pressure ulcer or an incontinence ulcer. *The resident does sit in her chair a lot. Interview on 6/10/15 at 11:25 a.m. with the director of nursing (DON) and licensed practical nurse (LPN) O regarding resident 2's left buttock assessment revealed: *LPN O stated Its just red when asked if she had assessed the resident's bottom. *LPN O had not documented the assessment yet. *There was no wound care nurse at the facility, however MDS coordinator L used to be the wound care nurse. *LPN O had asked the CNAs to apply a barrier cream on her bottom. Review of the following documentation on 6/11/15 regarding resident 2 revealed: *A nursing note on 6/10/15 at 7:30 p.m. stated New skin concern on bottom see NPSCR (Non-pressure skin condition report). *NPSCR: -Left buttock redness. -The size was documented as pinpoint. -Provon (skin barrier cream) was placed. *Review of resident 2's 6/10/15 skin assessment report revealed: -The location of the new skin concern was on the left buttock. -The contributing factor was incontinence. -The skin concern was redness and a pinpoint area open. *Review of resident 2's 6/10/15 interdisciplinary progress (IDP) notes revealed New skin concern found on left side of residents bottom. There is one pinpoint area on bottom that is open, the rest of her cheek is red with no other open areas noted at this time. PCP (primary care provider) faxed r/t (related to) this reoccurring skin issue. Family notified of skin concern. CNA instructed to put on Provon for time being until PCP faxes back with treatment. No other skin concerns at this time. Call light within reach. Will continue to monitor. Interview on 6/10/15 at 3:55 p.m. with MDS coordinator L regarding the above noted IDP note revealed: *It was not how she would have documented the assessment of what she observed resident 2's skin concern. * She would have measured the reddened area. *Resident 2's cheek (entire left buttocks) was not all reddened. *LPN O should have assessed the resident for pain and documented it. *She confirmed the assessment was inaccurate. Review of resident 2's entire medical record revealed: *There was no documentation on 6/9/15 of her complaint of the sore on her bottom or her complaints of pain. *There had been no pain assessment documented. *There had been no accurate measurement of her reddened area on her left buttock. *The only documentation for measurement stated pinpoint. Review of resident 2's skin assessment report faxed to the physician on 6/10/15 and then physician response on 6/11/15 revealed it was okay to start with barrier cream and to keep it as clean as possible. Review of a fax sent to the physician on 6/11/15 to clarify the above order revealed: *RN Y asked the physician Do you want the barrier cream as a PRN (as needed) order or daily? Please clarify. *The physicians response was If incontinent daily. Review of resident 2's bowel and bladder detail report from 6/12/15 through 6/16/15 revealed she had been incontinent on: *6/12/15 at 12:51 p.m. and 7:54 p.m. *6/13/15 at 12:24 a.m. and 8:05 p.m. *6/14/15 at 12:19 a.m. and 4:40 p.m. *6/15/15 at 10:09 a.m. and 3:35 a.m. *6/16/15 at 12:44 a.m. Review on 6/16/15 of resident 2's June 2015 treatment administration record revealed: *6/12/15 Barrier cream to area on buttocks if incontinent daily. *The time listed to apply the barrier cream was PRN. *There was no documentation that the barrier cream had been applied. Interview on 6/16/15 at 9:50 a.m. with RN Y regarding resident 2 revealed: *She was incontinent more than usual. *The nurse should have been putting on the barrier cream. Interview on 6/16/15 at 10:05 a.m. with CNAs M and N regarding resident 2 revealed: *She was always incontinent. *She had been incontinent that day at 9:45 a.m. Review of resident 2's care plan revealed: *Two focus areas documented as pressure ulcers. *One of the pressure ulcer focus areas updated 3/12/15 was the following: -She was at risk for pressure ulcers, because she was frequently incontinent of urine and she had [MEDICAL CONDITION] (swelling). -During care observe skin and notify the nurse if there were any areas of concern. -Notify the nurse, family and physician with any areas that were reddened, opened, or with any unexplained bruising. -Remind the resident to reposition when sitting or lying in one place. -On 3/12/15 her care plan was updated Area to buttock crease open again. -3/12/15 was the last time her care plan had been updated. *Another focus area documented as pressure ulcers updated on May 2015 revealed the following: -I have a pressure ulcer. -Progress toward the healing of the residents pressure ulcer. -If there were no changes to wound in two weeks seek a different treatment. -If there were no changes in four weeks, seek a consult to the wound clinic. *She had a focus area for pain with the following interventions: -Nursing should assess pain and document it. -Encourage the resident to change positions if she is in the same position for more than two hours. Her care plan had not been updated to reflect when her pressure ulcer identified on 3/12/14 was healed. Review of her care plan on 6/16/15 it had not been updated to include her new skin concern. * A May 2015 focus area of urinary incontinence. -Please take me to the toilet when I get up in the morning, before and after meals, at bedtime and PRN. -Please take me every couple hours at night as well. -I take a diuretic that makes me have to go often. Review of resident 2's pocket care plan revealed CNAs were to check skin daily. Interview on 6/16/15 at 2:45 p.m. with the DON and administrator regarding resident 2 revealed: *The nursing staff should have assessed her for her complaints of a sore on her bottom and pain. *They would have expected the physician's orders [REDACTED]. *They would have expected the nurse to have done accurate measurements and accurate assessments of the resident's impaired skin integrity (skin break down). *They would have expected the resident's care plan to have been updated. *The DON would not expect toileting to be real time (actual time it was done). *The DON agreed there was no way to know when the resident was being toileted. *The administrator asked the DON during this interview to have nursing staff go do an accurate assessment to get a baseline of the resident's impaired skin integrity. Review on 6/17/15 of resident 2's requested by the administrator skin assessment revealed a stage II pressure ulcer (open sore) measuring 2 centimeters by 0.8 centimeters. Review of the provider's 9/11/14 last survey results revealed the provider failed to appropriately assess, intervene, and care plan for three of four residents with pressure ulcers. Review of the provider's plan of correction for their 9/11/14 recertification survey regarding pressure ulcers revealed: *All nursing staff would be re-educated on pressure ulcer prevention, care planning, and treatment including contributing factors. *A certified wound care nurse would be hired within the next sixty days. *A weekly wound care committee was started to include the MDS case managers, DON, the certified wound care nurse, and the consultant registered dietician to review all residents at risk for weight loss and or wound management needs. *At monthly quality assurance and performance improvement meetings, the certified wound care nurse would provide a report, on a continuous basis, on pressure ulcer incidence, and effectiveness of current treatments and prevention program. Surveyor: Interview on 6/17/15 at 8:15 a.m. with the administrator regarding audits performed as part of the plan of correction from the 9/11/14 survey related to pressure ulcer prevention revealed: *A certified wound care nurse will be hired within the next sixty days. *There was no certified wound care nurse hired as directed. *He was unsure why that had not been done. *He agreed they had not followed the plan of correction as stated by hiring a certified wound care nurse. Surveyor: Review of the provider's revised March 2013 CNA's job description revealed: *Provides, completes and documents, if applicable, resident care as assigned in a timely and accurate manner. *Examples of resident care included provides personal care in eating, dressing, hair and body care, communication, toileting, bathing, and oral care. *Reports changes in resident's condition immediately to the Staff Nurse. *Responds to request from residents for assistance in a respectful and timely fashion. Answers call lights promptly. *Communicates suggestions or concerns from residents, other staff, visitors or others to the Staff Nurse in a timely, factual and accurate manner. Review of the provider's undated LPN job description revealed: *Assesses, plans, implements, evaluates plan of care for residents. *Make changes on the plan of care as necessary. Review of the provider's undated RN job description revealed Assesses, plans, implements, evaluates plan of care for residents. Review of the provider's September 2011 Standard Operating Procedure Skin Assessments revealed: *To monitor residents known to have history of or be at risk of pressure ulcers or have skin breakdown. *All staff are aware of need to notify a nurse concerning any resident's skin concerns. *Staff nurse will perform skin assessments with measurements on a weekly basis.

Based on observation, record review, and interview, the provider failed to ensure adequate staff on a twenty-four hour period to ensure all the residents' basic needs were met according to their plan of care. Findings include: 1. Interview on 9/4/14 at 10:30 a.m. with business manager O regarding staffing revealed she: *Had been doing scheduling for about a month and one-half to two months. *Had been put in the position the end of July 2014 after the human resource staff person who had been doing the scheduling left. She had received minimal training for the position. *Had been trying to cover open nursing shifts with the staff they had. *Had been calling three staffing agencies in conjunction with the administrator to fill open nursing spots with little success. *Stated two staffing facilities had not been able to supply them with any staff. *Stated one staffing facility had sent them a certified nursing assistant (CNA) on 8/27/14 and on 9/9/14. They had sent them a licensed practical nurse on 9/7/14 that had been utilized as a CNA. *Knew there were shifts that were not fully covered with nurses and CNAs. *Stated the nurses usually worked twelve hour shifts 6:00 a.m. to 6:30 p.m. or 6:00 p.m. to 6:30 a.m. *Stated the medication technicians (MT)/CNA usually worked the same twelve hour shifts. Some of the MT/CNAs worked eight hour shifts. *Stated the CNAs also usually worked twelve hour shifts. Some CNAs would work eight hour shifts or any amount of hours that would help fill in hours. *Stated the adequate amount of nursing staff for the twenty-four hour period would be as follows: -One nurse on each wing from 6:00 a.m. to 6:30 p.m. and from 6:00 p.m. to 6:30 a.m. (Warren wing, east wing, and center wing). -Usually a med tech/CNA would staff the memory care unit instead of a nurse for a twelve hour shift from 6:00 a.m. to 6:30 p.m. and from 6:00 p.m. to 6:30 a.m. -Four CNAs would work the center wing from 6:00 a.m. to 6:30 p.m. twelve hour shifts. -Three CNAs would work the east wing from 6:00 a.m. to 6:30 p.m. twelve hour shifts. -One CNA would work the Warren wing from 6:00 a.m. to 6:30 p.m. a twelve hour shift. -One CNA would work in the memory care unit from 6:00 a.m. to 6:00 p.m. a twelve hour shift. -Two to three CNAs would work the center wing from 6:00 p.m. to 6:30 a.m. twelve hour shifts. -Two CNAs would work the east wing from 6:00 p.m. to 6:30 a.m. twelve hour shifts. -One CNA would work in the memory care unit from 6:00 p.m. to 6:30 a.m. a twelve hour shift. -One MT/CNA on both the east wing and the center wing from 6:00 a.m. to 6:30 p.m. a twelve hour shift. -One MT/CNA on both the east wing and the center wing from 6:00 p.m. to 6:30 a.m. a twelve hour shift. *If there was not a nurse in the Warren wing from either 6:00 a.m. to 6:30 p.m. or from 6:00 p.m. to 6:30 a.m. they would leave the doors to the unit open, and the nurse from the east or the center wings would cover that area too. Review of the 8/18/14 through 9/7/14 nursing schedules revealed deviations from the above adequate staffing on the following dates: *8/18/14, Two CNAs worked 6:00 a.m. to 6:30 p.m. on the center wing instead four CNAs. Two CNAs worked from 6:00 a.m. to 6:30 p.m. on the east wing instead of three. One CNA worked the east wing from 6:00 p.m. to 6:30 a.m. instead of two. *8/19/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. *8/22/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. *8/23/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three twelve hour shift nurses. One nurse worked 6:00 p.m. to 10:00 p.m. (short an 8 hour nurse). *8/24/14, Two CNAs worked from 6:00 a.m. to 6:30 p.m. on the center wing instead of four. Two CNAs worked from 6:00 a.m. to 6:30 p.m. on the east wing instead of three. There was not a CNA in the Warren wing from 6:00 a.m. to 6:30 p.m. One CNA worked from 6:00 p.m. to 6:30 a.m. on the center wing instead of two. *8/25/14, Two nurses worked from 6:00 a.m. to 6:30 a.m. instead of three. Two CNAs worked from 6:00 a.m. to 6:00 p.m. on the east wing instead of three. One CNA worked on the center wing from 6:00 p.m. to 6:30 a.m. instead of two. *8/26/14, Two CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. Two CNAs worked the east wing from 6:00 a.m. to 6:30 p.m. instead of three. One CNA worked the center wing from 6:00 p.m. to 6:30 a.m. instead of two. *8/27/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. Three CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. *8/28/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. One MT/CNA worked from 6:00 p.m. to 6:30 a.m. instead of two. *8/29/14, Three CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. *8/30/14, Three CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. *8/31/14, Two CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. Two CNAs worked the east wing from 6:00 a.m. to 6:30 p.m. instead of three. Two CNAs worked the east wing from 2:00 p.m. to 9:00 p.m. No CNAs were scheduled after 9:00 p.m. to 6:30 p.m. *9/4/14, Three CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. *9/5/14, Two nurses worked from 6:00 p.m. to 6:30 p.m. A licensed practical nurse also worked from 6:00 p.m. to 6:30 a.m. but was in orientation. One CNA worked from 2:00 p.m. to 10:00 p.m. Two CNAs worked from 6:00 p.m. to 6:30 a.m. to cover the whole facility. *9/6/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. Four CNAs worked from 6:00 p.m. to 6:30 a.m. to cover the facility instead of six. *9/7/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. Observation on 9/5/14 from 10:48 a.m. through 11:50 a.m. concerning staffing for the days shift of 6:00 a.m. to 6:00 p.m. revealed: *Had been schedule changes since yesterday afternoon. *On center wing:for forty-six residents -Had had two CNAs scheduled for the two hours between 2:00 p.m. and 4:30 p.m. -Had had one CNA scheduled for the two hour period between 4:30 p.m. and 6:30 p.m. which would include getting residents to dinner and back to room after dinner. -Had pulled the MT/CNA from east wing for 5:00 p.m. to 6:00 p.m. to help. *On the east wing there were thirty-two residents: -A new orient was found with the scheduled MT/CNA. *On Warren wing with five residents: -Had one CNA scheduled for eight hour shift. At time of observation scheduled had changed and this person was staying for a total of eleven hours. -Had one nurse scheduled for a twelve hours shift. No nurse was present at time of observation and no one had been found to fill in for the nurse. Observation on 9/5/14 from 9:00 p.m. through 10:00 p.m. concerning staffing for the night shift of 6:00 p.m. to 6:00 a.m. revealed: *On the center wing with forty-six residents: -Evening/bedtime snack cart was sitting at nurses station. The food bin with snacks and food had some ice remaining. More than half of the bin was full of food items. -They had pulled another MT/CNA from the east wing to work on center between 6:00 p.m. and 8:00 p.m. -At 9:00 p.m. there were four residents' call lights on and two residents were in wheelchairs against a wall by the nurses station waiting to be assisted to bed. -Had one CNA scheduled for an eight hour shift. This person was present until 10:30 p.m.. - After 10:30 p.m. there would be one nurse and one MT/CNA for 58 residents from 10:30 p.m. to 6:30 a.m. to answer lights, administer medications, meet all resident needs. *On the east wing: to care for thirty-two residents -Evening/bedtime snack cart was sitting at nurses station. The food bin with snacks and food had some ice remaining. The food bin looked full of food items. -One CNA had been scheduled from 6:00 p.m. to 8:00 p.m. -They had pulled one MT/CNA from the Warren wing for 6:00 p.m. to 6:30 a.m. --One nurse for 6:00 p.m. to 6:30 a.m. *On the Warren wing there was one nurse for five residents from 6:00 p.m. to the 6:30 a.m. shift. Interview on 9/6/14 at 11:45 a.m. with resident 35 revealed: *She required two staff to assist her in transferring using the Hoyer lift. *"Only had one CNA on last night." "I need two people to help me." "Had to wait forever to go the the bathroom." Observation on 9/6/14 from 11:18 a.m. through 1210 p.m. concerning staffing for the days shift of 6:00 a.m. to 6:00 p.m. revealed: *Had been schedule changes since yesterday afternoon. *On east wing to care for thirty-two residents: -One licensed practical nurse (LPN) had been on assignment schedule to come in, but was not scheduled to come in. This was an error. Observation and interview on 9/6/14 from 11:10 p.m. through 12:10 a.m. concerning staffing for the night shift of 6:00 p.m. to 6:00 a.m. revealed: *On the center wing with forty-six residents: -Evening/bedtime snack cart was sitting at nurses station. The food bin with snacks and food had very little ice remaining. More than half of the bin was full of food items. -The scheduled MT/CNA for center had to add the five residents from Warren wing to her patient list. -One CNA remained on the center wing as the second one was pulled to the east wing to assist until people were in bed. -One nurse was present on center wing. *On the east wing with thirty-two residents: -Evening/bedtime snack cart was sitting at nurses station. The food bin with snacks and food had very little ice remaining. More than half of the bin was full of food items. -Four residents were seated in the nurses station, two of these were asleep in their chairs or wheelchairs. The third was yelling for help. The fourth was wheeling back and forth. -One CNA had gone on break at 7:15 p.m. and never returned. The nurse had reported her as missing to the police. The police had checked and found her at home in bed. She did not intend to return to work. -A second CNA had not shown up for work, had not called, could not be reached. -One nurse and one CNA remained for the duration of the night shift. -A CNA from center wing was pulled to the east wing to assist until people were in bed. Once all were in bed she would be going home. -The nurse on duty had attempted to call all staff to assist. No one had agreed to come in. She then notified the manager on duty which had been the administrator at 11:55 p.m. She was instructed to call the LPNs and see if one would come in early tomorrow. *On the Warren wing: -Double doors to unit open. -All five call lights were on to identify where residents were located. If a resident put call light on these would flash all three colors and in a faster tone to identify need. -No staff was present in the Warren wing. Observation on 9/7/14 from 9:40 a.m. through 10:40 a.m. concerning staffing for the day shift of 6:00 a.m. to 6:00 p.m. revealed: *Front desk receptionist was going through mail. She stated the mail was from Saturday. She had not had time to go through the mail on Saturday. *On the center wing with forty-six residents: -Between 4:30 p.m. and 6:30 p.m. there were one MT/CNA and one nurse on duty. During this time residents would have to get to evening meal and be assisted following the meal. Interview on 9/7/14 at 7:59 p.m. with resident 35 revealed: *She had put her call light on at 6:30 p.m. following the evening meal for the assistance of one person to place a bedpan under her. *She finished and put her call light on at 6:40 p.m. to be taken off the bedpan. *She received assistance to get off the bedpan at 7:55 p.m. *She was in pain and was told there was a red area on her buttocks where the bedpan had been. Observation on 9/7/14 from 7:45 p.m. through 8:45 p.m. concerning staffing for the night shift of 6:00 p.m. to 6:00 a.m. revealed: *On the center wing with forty-six residents: -Evening/bedtime snack cart was sitting at nurses station. More than half of the bin was full of food items. -The MT/CNA had been pulled off center wing and sent to Warren wing. -One nurse remained on the center wing. -There were two CNAs until 10 p.m. and a second nurse from 6:00 p.m. to 9:00 p.m. *On the east wing with thirty-two residents: -One nurse and one CNA were scheduled for the entire night shift. -One MT/CNA was leaving at 9:00 p.m. -One other CNAs was leaving at 10:30 p.m. -At 8:10 p.m. there were six residents seated in the nurses station area. Four of these were asleep in their chairs or wheelchairs. The fifth one was yelling for help. The sixth one was wheeling back and forth. -At 8:20 p.m. the administrator was wheeling the east wing's evening/bedtime snack cart to the east wing *One nurse from a temporary staffing agency was working the night shift and floating between center and east wings. Observation on 9/5/14 from 10:48 a.m. through 11:50 a.m. concerning staffing for the days shift of 6:00 a.m. to 6:00 p.m. revealed: *Had been schedule changes since yesterday afternoon. *On center wing:for forty-six residents -Had had two CNAs scheduled for the two hours between 2:00 p.m. and 4:30 p.m. -Had had one CNA scheduled for the two hour period between 4:30 p.m. and 6:30 p.m. which would include getting residents to dinner and back to room after dinner. -Had pulled the MT/CNA from east wing for 5:00 p.m. to 6:00 p.m. to help. *On the east wing there were thirty-two residents: -A new orient was found with the scheduled MT/CNA. *On Warren wing with five residents: -Had one CNA scheduled for eight hour shift. At time of observation scheduled had changed and this person was staying for a total of eleven hours. -Had one nurse scheduled for a twelve hours shift. No nurse was present at time of observation and no one had been found to fill in for the nurse. Observation on 9/5/14 from 9:00 p.m. through 10:00 p.m. concerning staffing for the night shift of 6:00 p.m. to 6:00 a.m. revealed: *On the center wing with forty-six residents: -Evening/bedtime snack cart was sitting at nurses station. The food bin with snacks and food had some ice remaining. More than half of the bin was full of food items. -They had pulled another MT/CNA from the east wing to work on center between 6:00 p.m. and 8:00 p.m. -At 9:00 p.m. there were four residents' call lights on and two residents were in wheelchairs against a wall by the nurses station waiting to be assisted to bed. -Had one CNA scheduled for an eight hour shift. This person was present until 10:30 p.m.. - After 10:30 p.m. there would be one nurse and one MT/CNA for 58 residents from 10:30 p.m. to 6:30 a.m. to answer lights, administer medications, meet all resident needs. *On the east wing: to care for thirty-two residents -Evening/bedtime snack cart was sitting at nurses station. The food bin with snacks and food had some ice remaining. The food bin looked full of food items. -One CNA had been scheduled from 6:00 p.m. to 8:00 p.m. -They had pulled one MT/CNA from the Warren wing for 6:00 p.m. to 6:30 a.m. --One nurse for 6:00 p.m. to 6:30 a.m. *On the Warren wing there was one nurse for five residents from 6:00 p.m. to the 6:30 a.m. shift. Interview on 9/6/14 at 11:45 a.m. with resident 35 revealed: *She required two staff to assist her in transferring using the Hoyer lift. *"Only had one CNA on last night." "I need two people to help me." "Had to wait forever to go the the bathroom." Observation on 9/6/14 from 11:18 a.m. through 1210 p.m. concerning staffing for the days shift of 6:00 a.m. to 6:00 p.m. revealed: *Had been schedule changes since yesterday afternoon. *On east wing to care for thirty-two residents: -One licensed practical nurse (LPN) had been on assignment schedule to come in, but was not scheduled to come in. This was an error. Observation and interview on 9/6/14 from 11:10 p.m. through 12:10 a.m. concerning staffing for the night shift of 6:00 p.m. to 6:00 a.m. revealed: *On the center wing with forty-six residents: -Evening/bedtime snack cart was sitting at nurses station. The food bin with snacks and food had very little ice remaining. More than half of the bin was full of food items. -The scheduled MT/CNA for center had to add the five residents from Warren wing to her patient list. -One CNA remained on the center wing as the second one was pulled to the east wing to assist until people were in bed. -One nurse was present on center wing. *On the east wing with thirty-two residents: -Evening/bedtime snack cart was sitting at nurses station. The food bin with snacks and food had very little ice remaining. More than half of the bin was full of food items. -Four residents were seated in the nurses station, two of these were asleep in their chairs or wheelchairs. The third was yelling for help. The fourth was wheeling back and forth. -One CNA had gone on break at 7:15 p.m. and never returned. The nurse had reported her as missing to the police. The police had checked and found her at home in bed. She did not intend to return to work. -A second CNA had not shown up for work, had not called, could not be reached. -One nurse and one CNA remained for the duration of the night shift. -A CNA from center wing was pulled to the east wing to assist until people were in bed. Once all were in bed she would be going home. -The nurse on duty had attempted to call all staff to assist. No one had agreed to come in. She then notified the manager on duty which had been the administrator at 11:55 p.m. She was instructed to call the LPNs and see if one would come in early tomorrow. *On the Warren wing: -Double doors to unit open. -All five call lights were on to identify where residents were located. If a resident put call light on these would flash all three colors and in a faster tone to identify need. -No staff was present in the Warren wing. Observation on 9/7/14 from 9:40 a.m. through 10:40 a.m. concerning staffing for the day shift of 6:00 a.m. to 6:00 p.m. revealed: *Front desk receptionist was going through mail. She stated the mail was from Saturday. She had not had time to go through the mail on Saturday. *On the center wing with forty-six residents: -Between 4:30 p.m. and 6:30 p.m. there were one MT/CNA and one nurse on duty. During this time residents would have to get to evening meal and be assisted following the meal. Interview on 9/7/14 at 7:59 p.m. with resident 35 revealed: *She had put her call light on at 6:30 p.m. following the evening meal for the assistance of one person to place a bedpan under her. *She finished and put her call light on at 6:40 p.m. to be taken off the bedpan. *She received assistance to get off the bedpan at 7:55 p.m. *She was in pain and was told there was a red area on her buttocks where the bedpan had been. Observation on 9/7/14 from 7:45 p.m. through 8:45 p.m. concerning staffing for the night shift of 6:00 p.m. to 6:00 a.m. revealed: *On the center wing with forty-six residents: -Evening/bedtime snack cart was sitting at nurses station. More than half of the bin was full of food items. -The MT/CNA had been pulled off center wing and sent to Warren wing. -One nurse remained on the center wing. -There were two CNAs until 10 p.m. and a second nurse from 6:00 p.m. to 9:00 p.m. *On the east wing with thirty-two residents: -One nurse and one CNA were scheduled for the entire night shift. -One MT/CNA was leaving at 9:00 p.m. -One other CNAs was leaving at 10:30 p.m. -At 8:10 p.m. there were six residents seated in the nurses station area. Four of these were asleep in their chairs or wheelchairs. The fifth one was yelling for help. The sixth one was wheeling back and forth. -At 8:20 p.m. the administrator was wheeling the east wing's evening/bedtime snack cart to the east wing *One nurse from a temporary staffing agency was working the night shift and floating between center and east wings. 2. One hour observations were completed two times a day, each day, during the three days of 9/5/14,.9/6/14, and 9/7/14, for a total of six different observations. During each of these observations the staff that were present was compared to the daily staffing planned. This revealed that during each twelve hours shift: *There were numerous schedule changes from the staffing plan provided on 9/4/14. *The provider had not been able to secure the identified adequate number and type of staff needed each shift to provide for the basic needs of the residents. Observation on 9/5/14 from 10:48 a.m. through 11:50 a.m. concerning staffing for the day shift from 6:00 a.m. to 6:00 p.m. revealed: *Center wing: with forty-six residents: -There were two CNAs scheduled for the two hours between 2:00 p.m. and 4:30 p.m. -There was one CNA scheduled for the two hour period between 4:30 p.m. and 6:30 p.m. which would include getting residents to dinner and back to their rooms after dinner. -They had pulled a MT/CNA from east wing from 5:00 p.m. to 6:00 p.m. to help on the center wing during the dinner time period. *East wing with thirty-two residents: -The scheduled MT/CNA was now orienting a new staff person. *Warren wing with five residents: -There was one CNA scheduled for an eight hour shift. At the time of the observation the schedule had been changed, and that person was staying for a total of eleven hours. -There was one nurse scheduled for a twelve hour shift. No nurse was present at the time of the observation, and no one had been found to fill in for that nurse. There was no one assigned for the last hour. Center wing staff was to address the needs of Warren wing residents during that time. Observation on 9/5/14 from 9:00 p.m. through 10:00 p.m. concerning staffing for the night shift from 6:00 p.m. to 6:00 a.m. revealed: *Center wing with forty-six residents: -The evening/bedtime snack cart was sitting at the nurses station. The food bin with snacks and food had some ice remaining, and more than half of the bin was full of food items. -They had pulled a MT/CNA from the east wing to work on center between 6:00 p.m. and 8:00 p.m. -At 9:00 p.m. there were four residents' call lights on, and two residents were in wheelchairs against a wall by the nurses station waiting to be assisted to bed. -They had one CNA scheduled for an eight hour shift. That person was to be there until 10:30 p.m. - After 10:30 p.m. there would be one nurse and one MT/CNA for forty-six residents from 10:30 p.m. to 6:30 a.m. to answer lights, administer medications, and meet all resident needs. *East wing with thirty-two residents: -Evening/bedtime snack cart was sitting at the nurses station. The food bin with snacks and food had some ice remaining, and the food bin was full of food items. -There was one nurse present from 6:00 p.m. to 6:30 a.m. -One CNA had been scheduled from 6:00 p.m. to 8:00 p.m. -They had pulled one MT/CNA from the Warren wing for 6:00 p.m. to 6:30 a.m. to help on the east wing. *Warren wing with five resident had one nurse from 6:00 p.m. to the 6:30 a.m. shift. Interview on 9/6/14 at 11:45 a.m. with resident 35 revealed: *She required two staff to assist her in transferring using the Hoyer lift (mechanical device used to raise and lower residents). *"Only had one CNA on last night." "I need two people to help me." "Had to wait forever to go the the bathroom." Observation on 9/6/14 from 11:10 a.m. through 12:10 p.m. concerning staffing for the day shift from 6:00 a.m. to 6:00 p.m. revealed: *Center wing with forty-six resident: -There were no CNAs assigned and present for the entire twelve hour shift. Four CNAs were scheduled for parts of the twelve hour shift. One of those was only scheduled to be on center wing for two hours of the twelve hour shift. *East wing with thirty-two residents: -Two licensed practical nurses (LPN) had been assigned on the schedule to come in. One was an error. -One LPN was present during the twelve hour day shift. -Only one CNA was assigned and present for the entire twelve hour shift. Three other CNAs were assigned and present for part of the twelve hour shift. One of those was only scheduled for four hours of the twelve hour shift. *Warren wing with five residents had one nurse for the day shift. No CNA was scheduled on that wing. Observation on 9/6/14 from 11:10 p.m. through 9/7/14 at 12:10 a.m. concerning staffing for the night shift from 6:00 p.m. to 6:00 a.m. revealed: *Center wing with forty-six residents: -Evening/bedtime snack cart was sitting at the nurses station. The food bin with snacks and food had very little ice remaining, and more than half of the bin was full of food items. -The scheduled MT/CNA for center had to add the five residents from the Warren wing to her resident list. -One CNA remained on the center wing as the second one was pulled to the east wing to assist until people were in bed. -One nurse was present on the center wing. *East wing with thirty-two residents: -Evening/bedtime snack cart was sitting at nurses station. The food bin with snacks and food had very little ice remaining, and more than half of the bin was full of food items. -Four residents were seated in the nurses station, two of them were asleep in their chairs or wheelchairs. The third was yelling for help. The fourth was wheeling back and forth in the hall. -One CNA had gone on break at 7:15 p.m. and never returned. The nurse had reported her as missing to the police. The police had checked and found her at home in bed. She did not intend to return to work. -A second CNA had not shown up for work, had not called, and could not be reached. -One nurse and one CNA remained for the duration of the night shift to assist the residents. -A CNA from center wing was pulled to the east wing to assist until people were in bed. Once all were in bed she would be going home. -The nurse on duty had attempted to call all the off-duty staff to ask if if they would come in and assist on the night shift. No one had agreed to come in. She then notified the manager on duty who had been the administrator at 11:55 p.m. She was instructed to call the LPNs and see if one would come in early tomorrow morning to assist in getting residents up after the nights sleep. *Warren wing with five residents had no staff were present. Center wing staff were to cover this wing also. To do so they: -Opened the double doors to the Warren wing so the Warren wing residents' call lights could be seen from the center wing. -Turned on all five resident call lights to identify where the residents were located. -If a Warren wing resident put on their call light the light would change from a steady beam to all three colors (white, red, and green) flashing with a fast audible tone to identify the immediate need for assistance. Observation on 9/7/14 Sunday, from 9:40 a.m. through 10:40 a.m. concerning staffing for the day shift from 6:00 a.m. to 6:00 p.m. revealed: *The front desk receptionist was going through mail. She stated the mail was from Saturday. She had not had time to go through the mail on Saturday. *Center wing with forty-six residents: -Between 4:30 p.m. and 6:30 p.m. there were one MT/CNA and one nurse on duty. During that time residents would have to get to the evening meal and be assisted following the meal. *East wing with thirty-two residents: -There was only one CNA scheduled for the full twelve hour shift. Three others were scheduled for part of a twelve hour shift. Two of those were for four hours of the twelve hour shift. *Warren wing with five residents: -Had one nurse scheduled for the twelve hour shift. No CNA was present on the Warren wing. Interview on 9/7/14 at 7:59 p.m. with resident 35 revealed: *She had put her call light on at 6:30 p.m. following the evening meal for the assistance of one person to place a bedpan under her. *She had finished and put her call light on at 6:40 p.m. to be taken off the bedpan. *She received assistance to get off the bedpan at 7:55 p.m. *She was in pain and was told there was a red area on her buttocks where the bedpan had been. Observation on 9/7/14 from 7:45 p.m. through 8:45 p.m. concerning staffing for the night shift from 6:00 p.m. to 6:00 a.m. revealed: *Center wing with forty-six residents: -Evening/bedtime snack cart was sitting at the nurses station, and more than half of the bin was full of food items. -The MT/CNA had been pulled from the center wing and sent to the Warren wing. -One nurse remained on the center wing. -There were two CNAs until 10:00 p.m. and a second nurse from 6:00 p.m. to 9:00 p.m. *East wing with thirty-two residents: -One nurse and one CNA were scheduled for the entire night shift. -One MT/CNA was leaving at 9:00 p.m. -One other CNA was leaving at 10:30 p.m. -At 8:10 p.m. there were six residents seated at the nurses station area. Four of those were asleep in their chairs or wheelchairs. The fifth one was yelling for help. The sixth one was wheeling back and forth in the hall. -At 8:20 p.m. the administrator was wheeling the east wing's evening/bedtime snack cart to the east wing *One nurse from a temporary staffing agency was working the night shift and floating between the center and the east wings. *Warren wing with five resident: -Had one MT/CNA scheduled for the twelve hour shift. -A nurse had been listed on the Daily Employee Assignment Schedule form for that wing and shift, but that nurse was not present.

Based on observation, record review, and interview, the provider failed to ensure adequate staff on a twenty-four hour period to ensure all the residents' basic needs were met according to their plans of care. Findings include: 1. Interview on 9/4/14 at 10:30 a.m. with business manager O regarding staffing revealed she: *Had been doing scheduling for about a month and one-half to two months. *Had been put in the position the end of July 2014 after the human resource staff person who had been doing the scheduling left. She had received minimal training for the position. *Had been trying to cover open nursing shifts with the staff they had. *Had been calling three staffing agencies in conjunction with the administrator to fill open nursing spots with little success. *Stated two staffing facilities had not been able to supply them with any staff. *Stated one staffing facility had sent them a certified nursing assistant (CNA) on 8/27/14 and on 9/9/14. They had sent them a licensed practical nurse on 9/7/14 that had been utilized as a CNA. *Knew there were shifts that were not fully covered with nurses and CNAs. *Stated the nurses usually worked twelve hour shifts 6:00 a.m. to 6:30 p.m. or 6:00 p.m. to 6:30 a.m. *Stated the medication technicians (MT)/CNA usually worked the same twelve hour shifts. Some of the MT/CNAs worked eight hour shifts. *Stated the CNAs also usually worked twelve hour shifts. Some CNAs would work eight hour shifts or any amount of hours that would help fill in hours. *Stated the adequate amount of nursing staff for the twenty-four hour period would be as follows: -One nurse on each wing from 6:00 a.m. to 6:30 p.m. and from 6:00 p.m. to 6:30 a.m. (Warren wing, east wing, and center wing). -Usually a med tech/CNA would staff the memory care unit instead of a nurse for a twelve hour shift from 6:00 a.m. to 6:30 p.m. and from 6:00 p.m. to 6:30 a.m. -Four CNAs would work the center wing from 6:00 a.m. to 6:30 p.m. twelve hour shifts. -Three CNAs would work the east wing from 6:00 a.m. to 6:30 p.m. twelve hour shifts. -One CNA would work the Warren wing from 6:00 a.m. to 6:30 p.m. a twelve hour shift. -One CNA would work in the memory care unit from 6:00 a.m. to 6:00 p.m. a twelve hour shift. -Two to three CNAs would work the center wing from 6:00 p.m. to 6:30 a.m. twelve hour shifts. -Two CNAs would work the east wing from 6:00 p.m. to 6:30 a.m. twelve hour shifts. -One CNA would work in the memory care unit from 6:00 p.m. to 6:30 a.m. a twelve hour shift. -One MT/CNA on both the east wing and the center wing from 6:00 a.m. to 6:30 p.m. a twelve hour shift. -One MT/CNA on both the east wing and the center wing from 6:00 p.m. to 6:30 a.m. a twelve hour shift. *If there was not a nurse in the Warren wing from either 6:00 a.m. to 6:30 p.m. or from 6:00 p.m. to 6:30 a.m. they would leave the doors to the unit open, and the nurse from the east or the center wings would cover that area too. Review of the 8/18/14 through 9/7/14 nursing schedules revealed deviations from the above adequate staffing on the following dates: *8/18/14, Two CNAs worked 6:00 a.m. to 6:30 p.m. on the center wing instead four CNAs. Two CNAs worked from 6:00 a.m. to 6:30 p.m. on the east wing instead of three. One CNA worked the east wing from 6:00 p.m. to 6:30 a.m. instead of two. *8/19/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. *8/22/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. *8/23/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three twelve hour shift nurses. One nurse worked 6:00 p.m. to 10:00 p.m. (short an 8 hour nurse). *8/24/14, Two CNAs worked from 6:00 a.m. to 6:30 p.m. on the center wing instead of four. Two CNAs worked from 6:00 a.m. to 6:30 p.m. on the east wing instead of three. There was not a CNA in the Warren wing from 6:00 a.m. to 6:30 p.m. One CNA worked from 6:00 p.m. to 6:30 a.m. on the center wing instead of two. *8/25/14, Two nurses worked from 6:00 a.m. to 6:30 a.m. instead of three. Two CNAs worked from 6:00 a.m. to 6:00 p.m. on the east wing instead of three. One CNA worked on the center wing from 6:00 p.m. to 6:30 a.m. instead of two. *8/26/14, Two CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. Two CNAs worked the east wing from 6:00 a.m. to 6:30 p.m. instead of three. One CNA worked the center wing from 6:00 p.m. to 6:30 a.m. instead of two. *8/27/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. Three CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. *8/28/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. One MT/CNA worked from 6:00 p.m. to 6:30 a.m. instead of two. *8/29/14, Three CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. *8/30/14, Three CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. *8/31/14, Two CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. Two CNAs worked the east wing from 6:00 a.m. to 6:30 p.m. instead of three. Two CNAs worked the east wing from 2:00 p.m. to 9:00 p.m. No CNAs were scheduled after 9:00 p.m. to 6:30 p.m. *9/4/14, Three CNAs worked the center wing from 6:00 a.m. to 6:30 p.m. instead of four. *9/5/14, Two nurses worked from 6:00 p.m. to 6:30 p.m. A licensed practical nurse also worked from 6:00 p.m. to 6:30 a.m. but was in orientation. One CNA worked from 2:00 p.m. to 10:00 p.m. Two CNAs worked from 6:00 p.m. to 6:30 a.m. to cover the whole facility. *9/6/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. Four CNAs worked from 6:00 p.m. to 6:30 a.m. to cover the facility instead of six. *9/7/14, Two nurses worked from 6:00 p.m. to 6:30 a.m. instead of three. 2. One hour observations were completed two times a day, each day, during the three days of 9/5/14,.9/6/14, and 9/7/14, for a total of six different observations. During each of these observations the staff that were present was compared to the daily staffing planned. This revealed that during each twelve hours shift: *There were numerous schedule changes from the staffing plan provided on 9/4/14. *The provider had not been able to secure the identified adequate number and type of staff needed each shift to provide for the basic needs of the residents. Observation on 9/5/14 from 10:48 a.m. through 11:50 a.m. concerning staffing for the day shift from 6:00 a.m. to 6:00 p.m. revealed: *Center wing: with forty-six residents: -There were two CNAs scheduled for the two hours between 2:00 p.m. and 4:30 p.m. -There was one CNA scheduled for the two hour period between 4:30 p.m. and 6:30 p.m. which would include getting residents to dinner and back to their rooms after dinner. -They had pulled a MT/CNA from east wing from 5:00 p.m. to 6:00 p.m. to help on the center wing during the dinner time period. *East wing with thirty-two residents: -The scheduled MT/CNA was now orienting a new staff person. *Warren wing with five residents: -There was one CNA scheduled for an eight hour shift. At the time of the observation the schedule had been changed, and that person was staying for a total of eleven hours. -There was one nurse scheduled for a twelve hour shift. No nurse was present at the time of the observation, and no one had been found to fill in for that nurse. There was no one assigned for the last hour. Center wing staff was to address the needs of Warren wing residents during that time. Observation on 9/5/14 from 9:00 p.m. through 10:00 p.m. concerning staffing for the night shift from 6:00 p.m. to 6:00 a.m. revealed: *Center wing with forty-six residents: -The evening/bedtime snack cart was sitting at the nurses station. The food bin with snacks and food had some ice remaining, and more than half of the bin was full of food items. -They had pulled a MT/CNA from the east wing to work on center between 6:00 p.m. and 8:00 p.m. -At 9:00 p.m. there were four residents' call lights on, and two residents were in wheelchairs against a wall by the nurses station waiting to be assisted to bed. -They had one CNA scheduled for an eight hour shift. That person was to be there until 10:30 p.m. - After 10:30 p.m. there would be one nurse and one MT/CNA for forty-six residents from 10:30 p.m. to 6:30 a.m. to answer lights, administer medications, and meet all resident needs. *East wing with thirty-two residents: -Evening/bedtime snack cart was sitting at the nurses station. The food bin with snacks and food had some ice remaining, and the food bin was full of food items. -There was one nurse present from 6:00 p.m. to 6:30 a.m. -One CNA had been scheduled from 6:00 p.m. to 8:00 p.m. -They had pulled one MT/CNA from the Warren wing for 6:00 p.m. to 6:30 a.m. to help on the east wing. *Warren wing with five resident had one nurse from 6:00 p.m. to the 6:30 a.m. shift. Interview on 9/6/14 at 11:45 a.m. with resident 35 revealed: *She required two staff to assist her in transferring using the Hoyer lift (mechanical device used to raise and lower residents). *"Only had one CNA on last night." "I need two people to help me." "Had to wait forever to go the the bathroom." Observation on 9/6/14 from 11:10 a.m. through 12:10 p.m. concerning staffing for the day shift from 6:00 a.m. to 6:00 p.m. revealed: *Center wing with forty-six resident: -There were no CNAs assigned and present for the entire twelve hour shift. Four CNAs were scheduled for parts of the twelve hour shift. One of those was only scheduled to be on center wing for two hours of the twelve hour shift. *East wing with thirty-two residents: -Two licensed practical nurses (LPN) had been assigned on the schedule to come in. One was an error. -One LPN was present during the twelve hour day shift. -Only one CNA was assigned and present for the entire twelve hour shift. Three other CNAs were assigned and present for part of the twelve hour shift. One of those was only scheduled for four hours of the twelve hour shift. *Warren wing with five residents had one nurse for the day shift. No CNA was scheduled on that wing. Observation on 9/6/14 from 11:10 p.m. through 9/7/14 at 12:10 a.m. concerning staffing for the night shift from 6:00 p.m. to 6:00 a.m. revealed: *Center wing with forty-six residents: -Evening/bedtime snack cart was sitting at the nurses station. The food bin with snacks and food had very little ice remaining, and more than half of the bin was full of food items. -The scheduled MT/CNA for center had to add the five residents from the Warren wing to her resident list. -One CNA remained on the center wing as the second one was pulled to the east wing to assist until people were in bed. -One nurse was present on the center wing. *East wing with thirty-two residents: -Evening/bedtime snack cart was sitting at nurses station. The food bin with snacks and food had very little ice remaining, and more than half of the bin was full of food items. -Four residents were seated in the nurses station, two of them were asleep in their chairs or wheelchairs. The third was yelling for help. The fourth was wheeling back and forth in the hall. -One CNA had gone on break at 7:15 p.m. and never returned. The nurse had reported her as missing to the police. The police had checked and found her at home in bed. She did not intend to return to work. -A second CNA had not shown up for work, had not called, and could not be reached. -One nurse and one CNA remained for the duration of the night shift to assist the residents. -A CNA from center wing was pulled to the east wing to assist until people were in bed. Once all were in bed she would be going home. -The nurse on duty had attempted to call all the off-duty staff to ask if if they would come in and assist on the night shift. No one had agreed to come in. She then notified the manager on duty who had been the administrator at 11:55 p.m. She was instructed to call the LPNs and see if one would come in early tomorrow morning to assist in getting residents up after the nights sleep. *Warren wing with five residents had no staff were present. Center wing staff were to cover this wing also. To do so they: -Opened the double doors to the Warren wing so the Warren wing residents' call lights could be seen from the center wing. -Turned on all five resident call lights to identify where the residents were located. -If a Warren wing resident put on their call light the light would change from a steady beam to all three colors (white, red, and green) flashing with a fast audible tone to identify the immediate need for assistance. Observation on 9/7/14 Sunday, from 9:40 a.m. through 10:40 a.m. concerning staffing for the day shift from 6:00 a.m. to 6:00 p.m. revealed: *The front desk receptionist was going through mail. She stated the mail was from Saturday. She had not had time to go through the mail on Saturday. *Center wing with forty-six residents: -Between 4:30 p.m. and 6:30 p.m. there were one MT/CNA and one nurse on duty. During that time residents would have to get to the evening meal and be assisted following the meal. *East wing with thirty-two residents: -There was only one CNA scheduled for the full twelve hour shift. Three others were scheduled for part of a twelve hour shift. Two of those were for four hours of the twelve hour shift. *Warren wing with five residents: -Had one nurse scheduled for the twelve hour shift. No CNA was present on the Warren wing. Interview on 9/7/14 at 7:59 p.m. with resident 35 revealed: *She had put her call light on at 6:30 p.m. following the evening meal for the assistance of one person to place a bedpan under her. *She had finished and put her call light on at 6:40 p.m. to be taken off the bedpan. *She received assistance to get off the bedpan at 7:55 p.m. *She was in pain and was told there was a red area on her buttocks where the bedpan had been. Observation on 9/7/14 from 7:45 p.m. through 8:45 p.m. concerning staffing for the night shift from 6:00 p.m. to 6:00 a.m. revealed: *Center wing with forty-six residents: -Evening/bedtime snack cart was sitting at the nurses station, and more than half of the bin was full of food items. -The MT/CNA had been pulled from the center wing and sent to the Warren wing. -One nurse remained on the center wing. -There were two CNAs until 10:00 p.m. and a second nurse from 6:00 p.m. to 9:00 p.m. *East wing with thirty-two residents: -One nurse and one CNA were scheduled for the entire night shift. -One MT/CNA was leaving at 9:00 p.m. -One other CNA was leaving at 10:30 p.m. -At 8:10 p.m. there were six residents seated at the nurses station area. Four of those were asleep in their chairs or wheelchairs. The fifth one was yelling for help. The sixth one was wheeling back and forth in the hall. -At 8:20 p.m. the administrator was wheeling the east wing's evening/bedtime snack cart to the east wing *One nurse from a temporary staffing agency was working the night shift and floating between the center and the east wings. *Warren wing with five resident: -Had one MT/CNA scheduled for the twelve hour shift. -A nurse had been listed on the Daily Employee Assignment Schedule form for that wing and shift, but that nurse was not present. Interview on 9/9/14 at 2:45 p.m. with nursing assistant (NA) JJ regarding residents on the east wing revealed: *She was unsure when or if any of the residents of the east wing needed to be repositioned or why. *She had been unaware residents 12 and 13 had pressure ulcers. *She had been employed "about a month and a half" and was not certified yet. *She stated they were "short-staffed and residents were lucky to get good care." *She was placed on a weight restriction for muscle strain from lifting residents at the time of the survey from lack of additional staff to help. *She was "lucky to have another aide working on the wing today." *Stated both residents 12 and 13 were dependent on staff for fluid and nutrition. *She was unsure how she and the other CNA would be able to transfer residents requiring an assist of two safely or at all if she was unable to lift (with her 5 lb. weight restriction). *Average time to answer a call light on the east wing she estimated, had been twenty minutes at best. *Residents were not always given care at that time, but would be routinely be told someone would be there shortly to help and the light was then shut off. *Commonly residents had to push their light "multiple times" before their needs were taken care of. That had been happening regularly since she had been employed at the facility. Interview on 9/10/14 at 2:00 p.m. with registered nurse (RN) A regarding residents on the east wing revealed she: *Agreed the provider's and the hospice care plans were not updated or specific for staff to know how to care for residents. *Stated staff had not been repositioning residents by schedule or according to their current needs because they were understaffed. *Stated she had not performed any new interventions for resident 12 since the new unstageable pressure ulcers had been found that morning. "I just don't have time." *Stated "His (resident 12's) (pressure ulcer) will be worse by tomorrow I'm sure. We just don't have the staff or the time." *Stated residents who were dependent on staff for hydration had not been getting fluids between meals as staffing was poor. *Stated bedtime snacks were routinely not given or residents were often sleeping when staff had been offering them, which had been related to the lack of staff available. *Agreed more staff was needed in the facility and had been for a "very long time." *Stated she was doing her best but felt she "had no time." *Stated the monthly MDS assessments had not been getting filled out correctly as nursing staff had little extra time being short staffed so they had been completing them often "without looking at the residents." Refer to F314 findings 1, 2, and 3.

Based on observation, interview, record review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that attained or maintained the highest practicable physical, mental, and psychosocial well-being of all ninety-three residents. Findings include: 1. Interview on 9/9/14 at 9:00 a.m. with the administrator revealed: *He reported to the chief financial officer (CFO) any concerns or problems he had with the facility. *He usually informed the CFO on the phone or in e-mails of any concerns he had. He had not kept any of the e-mails he had sent to the CFO. *He had informed the CFO the end of July 2014 or first part of August 2014 of staffing issues. The CFO's response to him at that time had been "Figure it out with the staff you have." *He felt the CFO had a "bad taste" regarding the big financial bill that was run up last year from using the staffing agencies. *"Maybe I did a bad job explaining to him how dire we were." *He was told about two weeks ago when the previous director of nursing (DON) left he could use the staffing agencies. *He had called three staffing agencies on 8/21/14 and was told "We were too late in the game and all staff were on contract with another facility. It was going to be difficult to get us any staff. Someone that was on contract would have to cancel before we could get any staff. He had requested two day certified nursing assistants (CNA) twelve hour shifts and two night CNAs twelve hour shifts. *One staffing agency told them they had to establish a contract with them before they could provide staff. He developed a contract with them on 8/26/14. Their option with that facility was only nurses as the CNAs were not certified. *Two staffing facilities had not been able to supply them with any staff. *One staffing facility had sent them a CNA on 8/27/14 and on 9/9/14. They sent them a licensed practical nurse on 9/7/14 that they utilized as a CNA. *He or business manager A called the staffing agencies every two to three days after 8/21/14 and their response was always the same "They did not have any staff they could send us." *The second time we called the staffing agencies they changed their request to eight hour CNAs instead of twelve hour CNAs to increase their chances of getting help. Phone interviews on 9/9/14 at 9:30 a.m. with the three staffing agencies revealed: *None of the agencies were aware when the initial request from the facility had been for staff. *It was usually business manager A they had spoken to from the facility. *None of the agencies had documentation the facility had requested eight hour shift CNAs instead of twelve hour shift CNAs. *Only one of the staffing agencies had been able to supply them any staff as the administrator had confirmed. Interviews, observations, record reviews, and policy reviews throughout the course of the survey revealed the administration had not ensured all residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being. Refer to F221, F222, F225, F248, F309, F333, F353, and F356.

Based on observation, interview, record review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that attained or maintained the highest practicable physical, mental, and psychosocial well-being of all ninety-three residents. Findings include: 1. Interview on 9/9/14 at 9:00 a.m. with the administrator revealed: *He reported to the chief financial officer (CFO) any concerns or problems he had with the facility. *He usually informed the CFO on the phone or in e-mails of any concerns he had. He had not kept any of the e-mails he had sent to the CFO. *He had informed the CFO the end of July 2014 or first part of August 2014 of staffing issues. The CFO's response to him at that time had been "Figure it out with the staff you have." *He felt the CFO had a "bad taste" regarding the big financial bill that was run up last year from using the staffing agencies. *"Maybe I did a bad job explaining to him how dire we were." *He was told about two weeks ago when the previous director of nursing (DON) left he could use the staffing agencies. *He had called three staffing agencies on 8/21/14 and was told "We were too late in the game and all staff were on contract with another facility. It was going to be difficult to get us any staff. Someone that was on contract would have to cancel before we could get any staff. He had requested two day certified nursing assistants (CNA) twelve hour shifts and two night CNAs twelve hour shifts. *One staffing agency told them they had to establish a contract with them before they could provide staff. He had developed a contract with them on 8/26/14. Their option with that facility was only nurses as the CNAs were not certified. *Two staffing facilities had not been able to supply them with any staff. *One staffing facility had sent them a CNA on 8/27/14 and on 9/9/14. They had sent them a licensed practical nurse on 9/7/14 that they utilized as a CNA. *He or business manager O had called the staffing agencies every two to three days after 8/21/14, and their response was always the same "They did not have any staff they could send us." *The second time they had called the staffing agencies they changed their request to eight hour CNAs instead of twelve hour CNAs to increase their chances of getting help. Phone interviews on 9/9/14 at 9:30 a.m. with the three staffing agencies revealed: *None of the agencies were aware when the initial request from the facility had been for staff. *It was usually business manager O they had spoken to from the facility. *None of the agencies had documentation the facility had requested eight hour shift CNAs instead of twelve hour shift CNAs *Only one of the staffing agencies had been able to supply them any staff as the administrator had confirmed. Interviews, observations, record reviews, and policy reviews throughout the course of the survey revealed the administration had not ensured all residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being. Refer to F157, F164, F166, F204, F221, F222, F224, F225, F226, F241, F248, F252, F278, F279, F280, F281, F309, F314, F322, F323, F325, F327, F332, F333, F353, F356, F368, F371, F385, F425, F428, F431, F441, F505, F514, and F520.

Based on observation, record review, interview, and policy review, the governing body failed to ensure the facility was administered in a manner that ensured: *An antianxiety medication was appropriately administered to 1 of 1 sampled resident (5) to treat a medical condition instead of for staff convenience. *One of one sampled nursing staff (D) who had allegations of simple assault had been thoroughly investigated previous to hire. *One of one sampled resident (2) who was on hospice (end of life care) was assessed and monitored for pain management. *Acceptable parameters of nutritional status was maintained for 1 of 2 sampled residents (1) who received an enteral feeding. *Sufficient staff was on duty all shifts to provide basic resident care needs to all ninety-three residents. *The nursing staff information posted daily was accurate and reflected the current schedule. Findings include: 1. Interview on 9/8/14 at 11:00 a.m. with the chief financial officer regarding the above revealed: *He and the owner were the governing body of the facility. *The administrator reported to him, and he reported to the owner. *He was responsible for the accounting, the books, and the reporting. *He recently became aware of a lot of things but primarily staffing. He was told by the administrator that staffing was "challenged." He had told the administrator and the director of nursing (DON) about two weeks ago if they had exhausted all their staff for staffing to call a staffing agency. *He thought it was about the third week of August the administrator had informed him of the staffing issues, and he informed the owner. *He would have thought the administrator would have called the staffing agency at that time. *He thought the last time the administrator used a staffing agency was in August 2013. The facility had occurred a large bill with the staffing agency that took them awhile to pay off. *He and the owner had felt any information from the administrator "had been dwindling for awhile." *If the administrator informed him of anything it was usually on the phone, texts, or e-mails. *He was not sure if had kept any of the e-mails or texts but would provide them for the surveyor if he had. No texts or e-mails were provided to the surveyor by the end of the survey on 9/11/14. *He had usually come to the facility on ce a month, but the last month had come a couple of times a week. *He and the owner had concerns since the information provided by the administrator had been dwindling. *When they would ask the administrator how things were he would usually voice no concerns or that he had everything under control. *The facility had a lot of nursing students during the 2014 summer and had put no plan in place to replace them when they had returned to school. *When the previous director of nursing (DON) left about a month ago she had voiced no concerns to him. *The present DON had been hired to be the staff development person but had agreed to be the interim DON. *They had put cameras in the facility a couple months ago related to missing items. Interviews, observations, record reviews, and policy reviews throughout the course of the survey from 9/2/14 through 9/11/14 revealed the governing body had not ensured the safe management and overall well-being of all ninety-three residents. Refer to F221, F222, F225, F248, F309, F333, F353, and F356.

Based on observation, record review, interview, and policy review, the governing body failed to ensure the facility was administered in a manner that ensured: *Confidentiality of all ninety-three residents regarding influenza vaccinations was maintained and not stored on the Minimum Data Set door on the east hall. *Four of ten confidential residents' grievances regarding a staff member were resolved. *One of one sampled resident (31) was educated regarding skin needs upon discharge. *Three sampled residents (10, 14, and 16) had been assessed for the use of a physical restraint. *An antianxiety medication was appropriately administered to 1 of 1 sampled resident (2) to treat a medical condition instead of for staff convenience. *One of one sampled nursing staff (L) who had allegations of simple assault had been thoroughly investigated previous to having been hired. *Reference checks were completed for 8 of 9 employees (L, CC, DD, EE, FF, GG, HH, and II) prior to having been hired. *Allegations regarding missing money, missing jewelry, residents' burns, residents' elopements, and an unwitnessed fall with injury were investigated for six sampled residents (12, 13, 32, 33, 34, and 38). *Call lights were answered in a timely manner that enhanced resident dignity and respect for 2 of 2 random residents (35 and 42). *Nail care was done for 3 of 16 sampled residents (1, 6, and 9). *One of one sampled resident (12) who was dependent on staff was assisted to eat in a timely manner. *Interventions were in place to communicate with 1 of 1 sampled resident (7) who had a hearing impairment. *Activity intervention was provided for 1 of 1 sampled resident (10) who was on isolation due to a medical condition. *Activities were provided and documented for 1 of 4 sampled residents (3). *A homelike environment was provided for all the residents on 1 of 1 memory care unit. *One of one sampled resident (3) who had an acute skin condition was assessed. *A comprehensive care plan was developed for 1 of 1 sampled resident (30). *Twelve of fourteen residents' care plans were updated and revised to reflect their current needs. *Post-hospitalization physicians' orders were clarified with the physician for 2 of 2 sampled residents (7 and 12). *physician's orders [REDACTED]. *Physicians's orders for medication administration for four sampled residents (12, 16, 37, and 47) were appropriately followed. *Weights were consistently obtained for 1 of 1 sampled resident (15) who was on [MEDICAL TREATMENT] (artificial means of removing toxins from body). *Physicians' orders for obtaining weights was followed for 2 of 2 residents (9 and 14) who received enteral (tube into the stomach) feedings. *One of one sampled resident (3) who had an acute skin condition was assessed, monitored, and medical treatment was provided. *One of one sampled resident (17) who was on hospice (end of life care) was assessed and monitored for pain management. *The prevention or worsening of pressure ulcers did not occur from the lack of skin assessment and the lack of adequate hydration for 3 of 4 sampled residents (6, 12, and 13). *Outside doors were locked between the hours of 8:00 p.m. and 7:00 a.m. for resident safety for 4 of 4 sampled doors. *Crash carts were functioning and accessible in 2 of 3 sampled units (Warren and Center). *One of one sampled resident (5) on a therapeutic diet received the correct meal tray. *Acceptable parameters of nutritional status was maintained for 1 of 2 sampled residents (14) who received enteral feedings. *Sufficient hydration for 2 of 2 sampled residents (12 and 13) who were dependent on staff was provided. *A medication error rate of less than 5 percent (%) was met. The medication error rate was 9.5 %. *Four of four sampled residents (2, 40, 46, and 48) received their medications as ordered by the physician's. *Sufficient staff were on duty all shifts to provide basic resident care needs to all residents. *The nursing staff information posted daily was accurate and reflected the current schedule. *Bedtime snacks were offered to all residents on oral diets on a daily basis. *One of one sampled resident (12) received the breakfast meal within fourteen hours of the supper meal. *Sanitation was maintained at 2 of 2 meal services and at randomly observed times. *Milk that was served to the residents was not greater than 41 degrees Fahrenheit. *Seven of seven sampled residents (13, 32, 33, 34, 38, 43, and 45) who received as needed (PRN) medications for mood and behavior or pain had follow-up documentation as to the effectiveness of the medications. *Pharmacy consultations were signed by the consultant pharmacist for 16 of 16 sampled residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16). *An active infection control program had been maintained. *An effective quality assurance (QA) program had been maintained to identify concerns and to develop and implement corrective action. *Medication destruction had been completed in a timely manner in 3 of 4 medication rooms (Warren, east, and center). *Medication refrigerator temperatures were consistently documented in 2 of 3 medication rooms (center and east). *Medication and narcotic box keys were not accessible to unauthorized staff on 1 of 3 nursing units (Warren). *Controlled medication accountability was maintained for 13 sampled residents (10, 17, 24, 29, 31, 34, 49, 50, 51, 52, 53, 54, and 56). Findings include: 1. Interview on 9/8/14 at 11:00 a.m. with the chief financial officer regarding the above revealed: *He and the owner were the governing body of the facility. *The administrator reported to him, and he reported to the owner. *He was responsible for the accounting, the books, and the reporting. *He had recently became aware of a lot of things but primarily staffing. He was told by the administrator that staffing was "challenged." He had told the administrator and the director of nursing (DON) about two weeks ago if they had exhausted all their staff for staffing to call a staffing agency. *He thought it was about the third week of August the administrator had informed him of the staffing issues, and he informed the owner. *He would have thought the administrator would have called the staffing agency at that time. *He thought the last time the administrator used a staffing agency was in August 2013. The facility had occurred a large bill with the staffing agency that took them awhile to pay off. *He and the owner had felt any information from the administrator "had been dwindling for awhile." *If the administrator informed him of anything it was usually on the phone, texts, or e-mails. *He was not sure if had kept any of the e-mails or texts but would provide them for the surveyor if he had. No texts or e-mails were provided to the surveyor by the end of the survey on 9/11/14 *He had usually come to the facility on ce a month, but the last month had come a couple of times a week. *He and the owner had concerns since the information provided by the administrator had been dwindling. *When they would ask the administrator how things were he would usually voice no concerns or that he had everything under control. *The facility had a lot of nursing students during the 2014 summer and had put no plan in place to replace them when they had returned to school. *When the previous director of nursing (DON) left about a month ago she had voiced no concerns to him. *The present DON had been hired to be the staff development person but had agreed to be the interim DON. *They had put cameras in the facility a couple months ago related to missing items. Interviews, observations, record reviews, and policy reviews throughout the course of the survey from 9/2/14 through 9/11/14 revealed the governing body had not ensured the safe management and overall well-being of all ninety-three residents. Refer to F157, F164, F166, F204, F221, F222, F224, F225, F226, F241, F248, F252, F278, F279, F280, F281, F309, F314, F322, F323, F325, F327, F332, F333, F353, F356, F368, F371, F385, F425, F428, F431, F441, F505, F514, and F520.

Based on record review, interview, and policy review, the provider failed to follow physicians' orders for weight monitoring for one of two residents (1) on a tube feeding. Findings include: 1. Review of resident 1's medical record revealed he: *Was admitted on [DATE]. *Had been on a tube feeding since admission. *He had a physician's orders [REDACTED]." Review of resident 1's weight sheet from the first week in July 2014 through the first week in September 2014 revealed *The weekly weights were not completed for: -July 2014 week two and week four. -August 2014 week three and week four. Interview on 9/9/14 at 10:35 a.m. with the consultant registered dietitian regarding resident 1's weights revealed: *He had a physician's orders [REDACTED]. *Weekly weights had not been consistently obtained. *She would have expected the weights to have been obtained as ordered. Surveyor: Interview on 9/10/14 at 8:35 a.m. with certified nurse assistant (CNA) I revealed when asked how weights were to have been obtained stated: *Monthly weights were to have been obtained on all residents on the first seven days of each month. *Weekly weights were to have been obtained on Monday or Tuesday so they would have been available for staff meetings. *No one had been responsible for obtaining the weights, "Just whoever does it, does it." *The bath aide was never responsible for obtaining weights. Interview on 9/10/14 at 8:40 a.m. with nurse aide L revealed: *The nurses had been primarily responsible for obtaining residents' weights. *If the nurses had been too busy the nurse aides would obtain them. Interview on 9/10/14 at 8:45 a.m. with registered nurse (RN) J and medication technician (med tech)/CNA K revealed: *The CNA was responsible for obtaining resident weights. *Monthly weights were to have been obtained the first ten days of each month. *The nurses and med techs were not responsible for obtaining weights. *CNAs obtained weekly weights on Mondays. *There was no set time for obtaining the weights; the staff were to obtain the weights whenever they got the chance. It did not matter what time of day it had been done. Surveyor: Interview on 9/10/14 at 8:15 a.m. with the director of nursing regarding resident 1's weights revealed: *His weight had not been completed weekly. *She would have expected the weekly weights to have been obtained as physician ordered. Review of the provider's revised 12/11/12 Weight and Height policy revealed: *All new admissions would have had their weights taken weekly for one month. *Then monthly thereafter, unless otherwise indicated, during the resident's stay.

Based on record review, interview, and policy review, the provider failed to: *Follow physician's orders for a urinalysis (obtain a urine specimen) for one of one sampled resident (1). *Administer medications according to the physicians' orders for four of four sampled residents (12, 16, 37, and 47). *Advocate the medical needs and administer the prescribed treatment in a timely manner for one of one sampled resident (3) after an emergency room evaluation. *Clarify post-hospital orders with the physician for two of two sampled residents (7 and 12). *Follow physician's orders for one of one sampled resident (13) who was administered [MEDICATION NAME] (an antipsychotic medication). *Weights were consistently obtained and documented for one of one sampled resident (15) who was on [MEDICAL TREATMENT] (artificial means of removing toxins from the body). *Follow physicians' orders for weight monitoring for one of two sampled residents (14) who were on enteral (tube in the stomach) feedings. *Obtain a physician's order for the use of [REDACTED]. *Document a skin assessment for one of one sampled resident (31) who had an order for [REDACTED]. Findings include: 1. Review of resident 1's 9/2/14 through 9/9/14 interdisciplinary progress notes revealed: *9/2/14 at 10:15 a.m. "Denies nausea-is pale and lethargic (sleepy). No emesis (vomiting) since 8/28/14. Poor appetite. Pale in color." *9/2/14 at 5:15 p.m. "White blood count 16.0 (normal less than 11.0 and elevated is indicative of an infectious process). Unknown etiology (cause)." *9/2/14 at 5:40 p.m.- "Get urinalysis. Start intravenous (IV) 200 cubic centimeters (cc) at 200 cc per hour for 1000 cc. See in clinic on 9/3/14." Further review of 9/3/14 through 9/9/14 notes revealed no documentation a urinalysis had been obtained. Interview on 9/8/14 at 11:00 a.m. with registered nurse (RN) MM regarding resident 1 revealed: *She had transcribed the physician's order on 9/2/14 for the urinalysis. She had passed it on in report to obtain the urinalysis the next morning. Someone had written "Done" on their 24 hour communication sheet, so she thought it had been obtained. *On 9/6/14 the resident had told her she still did not feel well. *She realized on 9/6/14 the urinalysis had not been obtained, so she obtained an order from the physician to straight catheterize (tube directly into the bladder) the resident for the urine specimen. *She had sent the urine specimen to the laboratory on 9/6/14, and it had returned with abnormal results. *The physician was still waiting for the culture report before he ordered an antibiotic (medication for infection). 2a. Review of resident 12's August 2014 Medication Administration Record [REDACTED] *8/13/14- [MEDICATION NAME] (antidepressant medication) had not been given "Medication not here." *8/24/14- Senna Plus (stool softner) had not been given "Not given-no medication." b. Review of resident 16's September 2014 MAR indicated [REDACTED] *I-Vite (vitamin supplement) one twice a day (BID). *There was documentation all the doses had been administered. Observation on 9/10/14 at 10:45 a.m. of resident 16's bottle of I-Vite in the medication cart revealed: *There was documentation the bottle had been opened on 9/1/14 and contained sixty pills. *There were forty-nine pills left in the bottle. *There should have been forty-one pills in the bottle if the I-Vite had been administered 9/1/14 at 8:00 a.m. through 9/10/14 at 8:00 a.m. c. Review of resident 37's August 2014 MAR indicated [REDACTED]"No medication." Observation 9/10/14 at 11:00 a.m. of resident 37's Calcitonin nasal spray revealed: *The bottle had an open date of 7/22/14. *The manufacturer's instructions on the label read "Bottle to not be used past 30 days." d. Review of resident 47's June 2014 through September 2014 MAR indicated [REDACTED] *I-Vite one tablet daily. *[MEDICATION NAME] (urine frequency medication) one tablet daily. *There was documentation both the I-Vite and [MEDICATION NAME] had been administered as ordered. Observation on 9/4/14 at 8:00 a.m. and on 9/10/14 at 11:15 of resident 47's bottles of I-Vite and [MEDICATION NAME] in the medication cart revealed: *There was documentation on the bottle of I-Vite it had been opened on 6/22/14 and contained sixty pills. *There was six I-Vite pills left in the bottle on 9/10/14. *There should have been 80 I-Vite tablets administered since 6/22/14 instead of 54 if it had been administered as ordered by the physician. *On 9/4/14 there was a bottle of [MEDICATION NAME] tablets with an opened date of 8/19/14 and four pills remained in the bottle. *Seventeen pills of [MEDICATION NAME] should have been administered from 8/19/14 through 9/4/14. There should have been thirteen pills of [MEDICATION NAME] in the bottle on 9/4/14 instead of four. e. Interview on 9/10/14 at 11:45 a.m. with the DON regarding the above residents' medication discrepancies revealed she: *Was unaware of the medications not being available from pharmacy. *Confirmed the bottles of medication did not reconcile with what had been documented as administered on the residents' MARs. 3. Review of resident 31's medical record documentation regarding his coccyx revealed: *An 8/19/14 physician's order for DuoDerm (type of dressing) to be applied to "a red area on his bottom, at the top of the coccyx (tailbone) area." *The 8/15/14 through 9/2/14 Interdisciplinary Progress Notes indicated: -On 8/19/14 at 3:30 p.m. "New orders for DuoDerm to coccyx area Q (every) three days/PRN (as needed)." -On 9/2/14 at 1:15 a.m. "DuoDerm in place on bottom." The Skin Assessment documentation form indicated: *On 8/14/14 at 10:55 p.m. skin was warm, dry, and intact. *On 8/21/14 at 11:20 p.m. "Skin warm/dry/intact. DuoDerm to coccyx for prevention of skin breakdown. See NPSCR (non-pressure skin condition report) for concerns." -On 8/29/14 at 12:35 a.m. "Skin W/D/I (warm, dry, intact). DuoDerm to coccyx for prevention of skin breakdown. See NPSCR for concerns." *No documentation on 8/19/14 regarding the coccyx skin breakdown or orders for dressings. *No NPSCR form for the coccyx had been located in the medical record. *No documentation regarding skin measurements or current status had been located in the medical record. Interview on 9/10/14 at 11:00 a.m. with the DON revealed: *Her expectation was the nurse assessing resident 31's skin would document skin measurements on the NPSCR form. *She had been unable to locate the NPSCR form in the chart, in the Warren wing skin assessment book, or in the medical records. Interview on 9/10/14 at 12:20 p.m. with MDS coordinator QQ regarding resident 31's skin concerns revealed: *Skin concerns were to have been documented on the Skin Assessment form. *His coccyx had not been initially documented on the Skin Assessment form. *His skin assessments were to have been routinely documented on the NPSCR sheet. *She had been unable to locate the NPSCR sheet in the chart or in the skin assessment book in the Warren wing nurses station. *There would have been no way of knowing how his skin had looked as he had been discharged on [DATE]. Review of the provider's September 2011 Skin Assessments policy revealed: *The purpose was to monitor residents known to have a history of or be at risk of pressure ulcers or have skin breakdown. *Staff would perform skin assessments with measurements on a weekly basis. *The initial assessment and documentation of skin concerns/conditions were made on the Initial Skin Report by the staff nurse who identified the condition. *The form was then given to the nurse manager who placed it in the resident's medical record. *"Non-pressure related skin breakdown issues are documented weekly on the non-pressure skin condition report by the staff nurse." *Staff nurses were to use the skin assessment notebook to be aware of which skin concerns to follow-up on. 4a. Observation on 9/3/14 from 5:15 p.m. through 5:30 p.m. of resident 9 revealed: *His feeding tube (tube going directly into ) was not connected and the feeding pump was not infusing at 5:15 p.m. *His feeding tube was connected and the feeding pump was infusing at 5:30 p.m. *No one had entered his room during that time frame. *Resident had history of connecting and disconnecting his own feeding tube to the feeding pump. Review of resident 9's complete medical record revealed: *An interdisciplinary progress note on 6/15/14 at 5:00 p.m. that described the resident adjusting the rate of his feeding on his tube feeding pump. -Rate had been at 186 cubic centimeters (cc) per hour instead of the 85 cc per hour ordered. *Physician's orders to: -Check feeding tube placement before each feeding was dated 8/13/12. -Give a 200 cc flush of water through the feeding tube before and after each feeding was dated 8/12/13. -[MEDICATION NAME] (nutritional solution to go through feeding tube in place of meals) 1.0 was to have been infusing at 85 cc per hour for sixteen hours (5:00 p.m. to 9:00 a.m.) was dated 5/27/14. -[MEDICATION NAME] 1.0 was to have been infusing at 200 cc per hour for one and a half hours each noon was dated 6/23/14.-A 200 cc flush of water was to be one through the feeding tube every four hours was dated 7/23/14. Interview on 9/3/14 at 5:37 p.m. with RN B revealed she: *Was aware resident 9 had been starting and stopping his tube feeding himself. *Agreed there was no date or time documented on the [MEDICATION NAME] solution container. *Agreed he might not have been getting the correct amount of [MEDICATION NAME] or fluids ordered by the physician. *Agreed the assessments and water flushes might not have been done as ordered by physician. *Was not sure the date or time the current container of feeding solution had been hung. Observation on 9/8/14 from 12:00 p.m. (noon) to 1:07 p.m. of resident 9 revealed: *At 12:00 p.m. (noon), 12:21 p.m., and 12:40 p.m., his feeding tube was not connected or infusing. *At 12:44 p.m. his visitor left. The feeding tube was not connected or infusing at that time. *At 12:53 p.m. the feeding tube was connected to the solution and infusing at 250 cc per hour instead of the physician's ordered 200 cc per hour. *No one had entered the room since the visitor left. Interview on 9/8/14 at 1:08 p.m. with RN A regarding resident 9's feeding tube orders revealed she: *Believed his next feeding was at 5:00 p.m. *Stated he needed his every four hour 200 cc water flush done and proceeded to the resident's room. *Identified the feeding tube was infusing at that time. *She stopped the feeding pump and disconnected the feeding tube to administer the water flush. *She reconnected the feeding tube. *She restarted the feeding pump. *She asked the resident if he had connected his feeding tube and started his feeding. The resident stated he had. When asked why he stated no one came at noon to start it. *She was aware that resident 9 had been starting and stopping his feeding himself. *She agreed the resident had connected and started his own noon feeding without an assessment of the feeding tube placement or a water flush before starting it. *She agreed he might not have been getting the correct amount of water or [MEDICATION NAME] solution ordered by the physician. Review of resident 9's intake and output record from 6/12/14 to the present date revealed: *Inconsistent charting of feeding tube water flushes as ordered by the physician. *Occasional documentation of 300 cc 12:00 p.m. (noon) feeding tube fluid, but rare documentation of sixteen hour overnight feeding (from 5:00 p.m. to 9:00 a.m.) fluid which would have been 1,360 cc with the present physician orders. *No documentation of output had been kept. Interview on 9/10/14 at 1:40 p.m. with the director of nursing (DON) revealed she: *Was unaware resident 9 had been connecting, starting, adjusting the rate of flow, and stopping his feeding tube and nutritional fluid that had been administered through a feeding pump. *Agreed the ordered feeding tube placement assessments and water flushes were not being completed when the resident self-administered (did himself) his feeding solution. *Agreed there was no way to accurately account for the amount of feeding solution resident 9 received since he was stopping and starting the feeding pump at will. *Agreed times for water flushes on the Medication Administration Record [REDACTED]. The provider's 10/5/12 Enteral Nutrition/hydration policy and procedure revealed: *Prior to administering nutrition or hydration through a feeding tube there should have been an assessment and a check of the feeding tube placement. *Tubing should have been flushed with water before and after the feedings as ordered by the physician. *Intake and output were to have been recorded every shift while on the feeding tube. 4b. Observation on 9/2/14 at 6:00 p.m. in resident 9's room revealed two quarter bed rails in place on each side of the upper half of the resident's bed. Review of resident 9's complete medical record revealed: *The 6/3/14 care plan entry for activities of daily living and toileting identified one-half side rails for repositioning on the upper half of both sides of the bed. *A physician's order for "bed bars" (side rails) for repositioning was dated over two months later on 8/26/14. *There was no assessment on the use of the side rails in the medical record. 5. Observation on 9/2/14 at 6:00 p.m. in resident 9's room revealed two quarter bed rails in place on each side of the upper half of the resident's bed. Review of resident 9's completed medical record revealed: *The 6/3/14 care plan entry for activities of daily living and toileting identified bilateral one-half side rails for repositioning. *A physician's order for bed bars in bed for repositioning was dated over two months later on 8/26/14. *There was no assessment on use of side rails in the medical record. Review of resident 15's complete medical record revealed:*She was on [MEDICAL TREATMENT] three days a week. *She had a physician's order for daily weights dated 2/3/11. -From 6/12/14 to 6/30/14 two daily weights were not documented. -July 2014 seven daily weights were missing. -The August 2014 daily weight sheet could not be located at the time of the survey. -On a weekly weight chart for August there had been only one entry instead of four. *There was inconsistent notation as to if the weights were taken before or after [MEDICAL TREATMENT] treatment. *The pocket care plan used by the certified nursing assistants (CNAs) dated 8/17/14 identified her as needing weekly weights instead of daily weights as ordered by physician. Interview on 9/10/14 at 1:40 p.m. with the director of nursing revealed she agreed: *Weights should have been done daily as the physician ordered. *Weights should have included when they were done, as in before or after [MEDICAL TREATMENT] that could change weights. *There should have been a nursing assessment that included weights immediately before leaving for [MEDICAL TREATMENT] and upon return from [MEDICAL TREATMENT]. Review of the provider's 10/28/13 outpatient [MEDICAL TREATMENT] policy revealed: *A nursing assessment was to have been completed prior to be being transported to outpatient [MEDICAL TREATMENT] and immediately after returning from [MEDICAL TREATMENT]. *The assessment was to have included vital signs and a weight prior to and after returning from [MEDICAL TREATMENT]. 6. Review of resident 14's medical record revealed he: *Was admitted on [DATE]. *Had been on a tube feeding since admission. *He had a physician's order on 7/3/14 for "Weight Weekly." Review of resident 14's weight sheet from the first week in July 2014 through the first week in September 2014 revealed *The weekly weights were not completed for: -July, weeks two and four. -August, weeks three and four. Interview on 9/9/14 at 10:35 a.m. with the consultant registered dietitian regarding resident 14's weights revealed: *He had a physician's order for weekly weights. *Weekly weights had not been consistently obtained. *She would have expected the weights to have been obtained as ordered. Surveyor: Interview on 9/10/14 at 8:35 a.m. with certified nurse assistant (CNA) X revealed when asked how weights were to have been obtained stated: *Monthly weights were to have been obtained on all residents on the first seven days of each month. *Weekly weights were to have been obtained on Monday or Tuesday so they would have been available for staff meetings. *No one had been responsible for obtaining the weights, "Just whoever does it, does it." *The bath aide was never responsible for obtaining weights. Interview on 9/10/14 at 8:40 a.m. with nurse aide SS revealed: *The nurses had been primarily responsible for obtaining residents' weights. *If the nurses had been too busy the nurse aides would obtain them. Interview on 9/10/14 at 8:45 a.m. with RN EE and medication technician (med tech)/CNA TT revealed: *The CNA was responsible for obtaining resident weights. *Monthly weights were to have been obtained the first ten days of each month. *The nurses and med techs were not responsible for obtaining weights. *CNAs obtained weekly weights on Mondays. *There was no set time for obtaining the weights; the staff were to obtain the weights whenever they got the chance. It did not matter what time of day it had been done. Surveyor: Interview on 9/10/14 at 8:15 a.m. with the director of nursing regarding resident 14's weights revealed: *His weight had not been completed weekly. *She would have expected the weekly weights to have been obtained as physician ordered. Review of the provider's revised 12/11/12 Weight and Height policy revealed: *All new admissions would have had their weights taken weekly for one month. -Then monthly thereafter unless otherwise indicated, during the resident's stay. 7. Review of resident 12's medical record revealed: *He had a history of [REDACTED]. *Those medications had been discontinued on August 28, 2014. *No documentation was made by staff or the primary care physician in reference to the above medication discontinuance. Interview on 9/9/14 at 4:30 p.m. with LPN AA regarding resident 12 revealed she: *Was unaware his above medications had been discontinued. *Was unsure if the physician's orders to discontinue the medications had been clarified by staff. *Then placed a call to the physician to clarify the above medication orders upon request by this surveyor. *Agreed there had been no supporting documentation or rationale by the physician with regards to the above medications. *Stated clarification by nursing staff should have been obtained and documented for the above medication orders. Interview on on 9/10/14 at 2:00 p.m. with registered nurse (RN) A regarding resident 12 revealed she: *Confirmed he had been admitted to the Veterans hospital on [DATE] and discharged back to the facility on [DATE] with orders to continue the above medications. *Had been unsure who had discontinued the medication on 8/28/14. *Stated she readmitted the resident to the facility and had reviewed the orders from the hospital upon his return. *Was unaware the physician's orders stated the diabetes medication were to be continued. *Never clarified that section in the discharge summary. *Would only add new medications and therapies to a resident's medication or treatment record. *Agreed physicians' orders needed to be clarified with the primary physician and/or the discharging hospital if there had been discrepancies. *Stated "I should have called and clarified." *Agreed choosing what orders to follow instead of clarifying the orders had been out of her scope of practice as a nurse. 8. Review of resident 13's medical record revealed: *There were physician's orders to increase her daily dose of [MEDICATION NAME] (a medication used to treat mood disorders) received from hospice and signed by the primary care provider on 7/16/14. *The order was noted (transcribed) by the nursing staff on 7/17/14. *The above medication dose change had not been implemented as ordered. Interview on 9/10/14 at 2:00 p.m. with RN A regarding resident 13 revealed she: *Had written a note on 7/21/14 that read "Found PO (physician's order) from hospice that had not been processed. Changed doses of [MEDICATION NAME]." *Agreed that had been a medication error. *Had not contacted the physician to notify him of the omission of the increased dose for five days, and she should have made him aware of it. Review of the provider's undated Discontinued Drugs/Medications policy revealed nursing staff must record the following information in the resident's medical record: *Date and time the medication had been discontinued. *Name and strength of the medication. *Name of the physician. *Disposition of remaining medication. *Signature and title of person recording the information. *Other as necessary or appropriate. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St Louis, MO, 2013, page 358, revealed, "A registered nurse makes a telephone report when significant events or changes in a patient's condition have occurred." Review of Audrey Knippa et al., Fundamentals for Nursing, 7th Ed., October 2011, Safe Medication Administration and Error Reduction, page 488, revealed: *Question the provider if the prescription is unclear. *Report all errors and implement corrective measures. 9. Observation and interview on 9/3/14 at 9:15 a.m. with resident 3 revealed: *He was unshaven and had dried greenish nasal drainage in his mustache. *The hair was quite long and unkempt. He looked as though he had not had a haircut for several months. *His scalp was reddened and had a large amount of dry scaling skin noted. The dry skin was layered and thick on his scalp. *Both ears were very pink, had scabbed areas on the lobes of the ears, and were scaling and dry. *The back of his neck was quite pink and had dry scaly skin. *He was hard of hearing. *He stated his scalp, ears, and neck were "itchy." *He was uncertain as to how long he had that scaling and dryness to those areas. Interview on 9/3/14 at 10:20 a.m. with registered nurse (RN) B regarding resident 3's skin issues revealed: *She stated "He is a mess." *He had the skin issues to the scalp, neck, and ears since 7/10/14. *His primary physician had seen him, and there was a dermatology appointment made for September 16 through the Veteran's Administration (VA). *There had been no treatment ordered after the skin issues had been identified. *She was unsure as to the reason there had been no treatments attempted prior to his dermatology appointment. Telephone interview on 9/3/14 at 10:30 a.m. with VA Community Care coordinator G and RN H from the VA regarding resident 3 revealed: *He had a dermatology appointment scheduled for September 16 via telemedicine. *He had been seen on 7/3/13 at the VA. The provider called the VA on 7/11/14 and then that was when the dermatology appointment had been scheduled. *They both were unsure as to the reason there had been no medical treatment provided for resident 3's skin condition. Interview on 9/3/14 at 11:00 a.m. with MDS (Minimum Data Set) coordinator E regarding resident 3 revealed: *There had been no treatment provided for the resident's scalp that she had been aware of . *She was responsible for his MDS. *She would have gone by what the nurses charted, because she did not perform skin assessments on her residents. She only did pain assessments. Interview on 9/3/14 at 3:40 p.m. with RN B regarding resident 3 revealed: *There had been no medical intervention for his scalp, neck, and ears skin issues. *The VA had been contacted on 7/10/14. Review of resident 3's 2/14/14 individualized care plan revealed there had been no documentation that he had scalp, ear, and neck skin issues. There was no documentation regarding any scheduled appointments, or that a physician had been notified about his skin issues that had started on 7/10/14. Interview and observation on 9/3/14 at 3:50 p.m. with the director of nursing (DON) in resident 3's room revealed: *She was unaware of his skin issues. *She agreed the skin issues were severe. *She agreed there should have been some medical treatment intervention from the primary physician or the VA prior to his dermatology appointment on September 16, 2014. Review and interview on 9/8/14 at 11:30 a.m. of resident 3's September treatment administration record (TAR) with RN A revealed: *He had been seen on 9/4/14 at the emergency room . *He had an order for [REDACTED]. *The new medication order had not been placed on his current TAR. *RN A stated she had ordered the medication from the pharmacy on 9/4/14. *She had not noted the new physician's order for the [MEDICATION NAME] shampoo and had not transcribed the new physician's order on to resident 3's September 2014 TAR. *The new medication was found in the top drawer of the medication cart unopened. *He had not received the medicated shampoo that had been physician ordered four days ago. *She agreed the medicated shampoo ordered on [DATE] should have been started immediately. *She confirmed she had not appropriately transcribed the physician's order onto the TAR, and that had delayed resident 3 from obtaining his treatment for [REDACTED]. Interview on 9/8/14 at 11:45 a.m. with the DON regarding the above concerns regarding resident 3 revealed: *The physician's orders should have been transcribed onto the September TAR after the order had been received. That would have ensured timely treatment for [REDACTED]. *She confirmed the delay in the transcription of the physician's orders caused the resident unnecessary discomfort. *The treatment should have been started on 9/4/14. Review of resident 3's September 2014 TAR on 9/8/14 at 3:30 p.m. revealed the physician's order from 9/4/14 had been transcribed by RN A on 9/8/14 four days after the order had been received. Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing 8th Ed., St. Louis, Mo.,2013, p. 4, pp. 6 and 7, and p. 305 , revealed: *"The Standards of Practice describe a competent level of nursing care. The levels of care are demonstrated by the critical thinking model known as the nursing process, assessment, diagnosis, outcomes identification, and planning, implementation, and evaluation. The nursing process is the foundation of clinical decision making and includes all significant actions by nurses in providing care to patients." *"As a nurse, you are responsible for obtaining and maintaining specific knowledge and skills for a variety of professional roles and responsibilities. Nurses provide care and comfort for patients in all health care settings. Nurse's concerns for meeting the patient's needs remains the same whether care focuses on health promotion and illness prevention, disease and symptom management. Accountability means that you are responsible, professionally and legally, for the type and quality of nursing care provided." *The healthcare provider (physician or the advanced practice nurse) was responsible for directing medical treatment. Nurses follow health care provider's orders unless they believed the orders were in error or would harm patients (residents). 10. Review of resident 7's medical record revealed: *A form from the surgical center stated the suprapubic catheter (a tube into the bladder through a small hole in the belly which drains urine) placement surgery was scheduled for 8/27/14. *An interdisciplinary note dated 8/27/14 stated "OOF (out of facility) with daughter to VA for S/P (suprapubic) placement." *A patient instructions sheet for wound/incision care that was not signed and not dated. *There were no specific instructions on the patient instruction sheet regarding catheter care. *There was no documentation staff had contacted the primary physician for orders to care for the suprapubic catheter. Review of resident 7's September 2014 treatment administration records revealed no order for changing the suprapubic catheter dressing. Observation on 9/9/14 at 11:05 a.m. by surveyor of RN A completing suprapubic catheter care revealed the dressing had been dated and initialed on 8/31/14. The dressing had not been changed for nine days. RN A stated the expectation would have been to change the dressing daily. Interview on 9/9/14 at 11:15 a.m. with primary physician I regarding resident 7 revealed: *He had not been informed of the suprapubic catheter placement done on 8/27/14. *He had just learned of the suprapubic catheter placement during the interview with this surveyor. *The resident was a VA patient, but he was still his primary care physician. *He would have expected the dressing to be changed daily. *The staff never tell him what was going on with residents under his care. Interview on 9/9/14 at 3:15 p.m. with the administrator and the DON revealed: *The DON stated she would have to check their policy on catheter care to determine if going nine days without a dressing change had been okay. *At the time of the survey exit the DON had still not provided a response or policy relevant to the above discussion. Interview on 9/10/14 at 10:25 a.m. with RN EE revealed the provider did not have standing orders for catheter care. Review of the provider's 5/15/13 Dressings, Dry/Clean policy revealed staff were to verify there was a physician's order for the procedure. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., 2013, p. 305, revealed: *Nurses should follow health care providers' orders unless they believe the orders are in error. *If the nurse found an error further clarification from the health care provider should have been obtained.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (3) who had a significant [MEDICAL CONDITION] to his scalp, neck, and face had the prescribed physician's orders [REDACTED]. Findings include: 1. Observation on 10/21/14 at 1:00 p.m. of resident 3 revealed: *He had a very dry and scaly scalp. *There were visible layers of dry scaling skin on the back of his scalp. *His eyelids were scaly and reddened. *His neck was reddened and scaly. Review of his October 2014 Physician's Medication and Treatment Order sheet revealed: *He had a physician's orders [REDACTED]. -On 9/4/14 [MEDICATION NAME] 2% (percent) shampoo apply topically as directed two times weekly on Tuesday and Friday. -On 9/16/14 [MEDICATION NAME] 0.5% cream apply topically (skin) two times daily to the affected area of his scalp and neck. -On 9/17/14 [MEDICATION NAME] 0.025% cream apply topically two times daily as directed to his eyebrows, eyelids, mustaches, chin, and abdomen. Review of resident 3's September 2014 TAR revealed: *The [MEDICATION NAME] 0.05% cream apply twice daily had been started on 9/16/14. There was no documentation the cream had been administered three times during 9/16/14 through 9/30/14. *The [MEDICATION NAME] 0.025% cream apply twice daily had be started on 9/16/14. There was no documentation the cream had been administered four times during 9/16/14 through 9/30/14. *The [MEDICATION NAME] 2% shampoo apply twice weekly with bath had been started on 9/4/14 three days after the physician had ordered the shampoo. The was no documentation the medicated shampoo had been administered on 9/26/14 and 9/30/14. Review of resident 3's October 2014 TAR on 10/21/14 at 8:58 a.m. revealed: *There had been no documentation the [MEDICATION NAME] 2% shampoo had been administered on including 10/3/14. *The skin assessments that were to be done on Tuesday had no documentation that they had been completed. *There was an unsigned handwritten note taped to the TAR that read "Needs Bath STAT ( needs immediately) et (and) skin assessment." Interview on 10/21/14 at 9:20 a.m. with certified nursing assistant (CNA) DDD regarding bathing of resident 3 revealed: *She had just started her position on 10/5/14. *She was a CNA and had been giving baths to assigned residents for the day. *She felt as though she had not been given sufficient training in the bathing of residents. *She was given a pocket care plan to follow for her assigned care of the residents. She would refer to that pocket care plan as she was not familiar with the residents. *She was going to give resident 3 a whirlpool bath today. She was unaware that resident 3 had special medicated shampoo. She had referred to her pocket care plan, and there had been no information on that care plan regarding his medicated shampoo. Interview on 10/21/14 immediately following the above observation, interview, and record review of resident 3 with director of nursing II revealed: *She was sure the nurses had administered the medicated shampoo as order but had forgotten to initial after the shampoo had been administered. *She was going to call the nurses or medication aides that would have worked that day to have them intimal the October 2014 TAR. *The nurses should have documented on the TAR as soon as the treatment or assessment had been completed. *The nurse or medication aide on duty should have informed the CNA who had been giving a bath to resident 3 about the medicated shampoo. *She confirmed the pocket care plan provided to CNA DDD had not been updated to provide the most current information regarding his medicated shampoo. *She agreed resident 3 had a significant skin [MEDICAL CONDITION], and the treatments for that skin condition should have been followed as the physician had ordered. *The skin assessments scheduled for Tuesdays with his bath should have been completed in a timely manner. Review of resident 3's October 2014 TAR on 10/22/14 at 8:40 a.m. revealed: *The initials of staff had been filled in on the TAR where there had been blanks on 10/21/14 at 8:58 a.m. *One staff member had documented "10/3/14 forgot to sign off/late entry made." There was no time and no initial of the staff member that had made that entry. That entry had been made nineteen days after the medicated shampoo should have been administered. *One nurse had circled her initials on 10/7/14 and documented on the back of the TAR the shampoo had not been administered, because she was not aware he had an order for [REDACTED]. Review of the provider's August 2008 Charting and Documentation policy revealed: *All services provided to the resident, or any changes in the resident's medical or mental condition should have been documented in the resident's medical record. *All observations, medications administered, services performed, should have been documented in the resident's clinical record. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8 th Ed., St. Louis Mo., 2013, pp. 305 and 306, revealed: *The health care provider was responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders were in error or would harm patients. *Risk management was an organization's system to ensure appropriate nursing care by identifying potential hazards and eliminating them before harm occurs. *Risk management also required complete documentation. A nurses' documentation was often the evidence of care received by a patient and served as proof the nurse acted reasonably and safely. *Nurses were responsible for performing all procedures correctly and exercising professional judgement as they carried out health care provider's orders.

Based on record review and interview, the provider failed to ensure an anti-anxiety medication was administered to one of one sampled resident (5) for the appropriate indications. Findings include: 1. Review of resident 5's complete medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. -Dementia (loss of memory). -Anxiety state. -Right [MEDICAL CONDITION] on 3/8/14 related to a fall. *admitted to Hospice services on 8/28/14 related to his dementia. *On 8/28/14 he had a physician's orders [REDACTED]. Review of resident 5's Antipsychotic Monitoring Tool sheet revealed: *On 8/28/14 at 8:00 p.m. he had been given 1 ml of [MEDICATION NAME] sublingually for displaying "agitation with cares." *On 8/29/14 at 2:00 a.m. he had been given another 1 ml of [MEDICATION NAME] for displaying "agitation with cares." *[MEDICATION NAME] 1 ml was equivalent to 2 mg of [MEDICATION NAME], which would mean the resident had received twice the physician's orders [REDACTED]. Interview on 9/3/14 at 4:00 p.m. with the director of nursing (DON) regarding the above record review revealed: *She had been unaware there was an incorrect dose of [MEDICATION NAME] administered to resident 5. *She agreed the resident had been given twice the physician ordered dose of [MEDICATION NAME]. *The resident could have been severely injured with that incorrect dose of [MEDICATION NAME]. Interview on 9/4/14 at 10:30 a.m. with the DON regarding licensed practical nurse (LPN) D that had been involved in administering the incorrect dose of [MEDICATION NAME] to resident 5 revealed: *She had spoken to LPN D on the phone regarding the medication error. *LPN D had stated she had not been feeling well that night. *That had been LPN D's reason for the medication error. Anonymous interview on 9/10/14 at 3:00 p.m. regarding resident 5 revealed: *The next day after he had received the [MEDICATION NAME] he was hard to arouse. *He had gone all day without eating, because he had been too sleepy. *He had slept most of the next day after he had received the [MEDICATION NAME]. Telephone interview on 9/11/14 at 11:30 a.m. with LPN D and the business manager A revealed: *She was aware a medication error had occurred with resident 5's [MEDICATION NAME]. *She stated she had not been feeling well that night, and that was the reason she had administered the incorrect dose of [MEDICATION NAME]. *Resident 5 was swinging and attempted to hit her and another co-worker as they were attending to him. She administered the [MEDICATION NAME] to stop him from hitting at them. Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing 8th Ed., St. Louis, Mo., 2013, p. 582, revealed: *"Administering medications to patients requires knowledge and a set of skills that are unique to a nurse. You first assess that the medication ordered is the correct medication. *A medication error can cause or lead to inappropriate medication use or patient harm. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, and administering extra doses or failing to administer a medication. Preventing medication errors is essential. Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors. Medication errors are related to practice patterns, health care product design, or procedures and systems such as product labeling and distribution."

Based on record review and interview, the provider failed to ensure an anti-anxiety medication was administered to one of one sampled resident (2) for the appropriate indications. Findings include: 1. Review of resident 2's complete medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. -Dementia (memory loss). -Anxiety state. -Right [MEDICAL CONDITION] on 3/8/14 related to a fall. *admitted to Hospice services on 8/28/14 related to his dementia. *On 8/28/14 he had a physician's orders [REDACTED]. Review of resident 2's Antipsychotic Monitoring Tool sheet revealed: *On 8/28/14 at 8:00 p.m. he had been given 1 ml of [MEDICATION NAME] sublingually for displaying "agitation with cares." *On 8/29/14 at 2:00 a.m. he had been given another 1 ml of [MEDICATION NAME] for displaying "agitation with cares." *[MEDICATION NAME] 1 ml was equivalent to 2 mg of [MEDICATION NAME], which would mean the resident had received twice the physician's orders [REDACTED]. Interview on 9/3/14 at 4:00 p.m. with the director of nursing (DON) regarding the above record review revealed: *She had been unaware there was an incorrect dose of [MEDICATION NAME] administered to resident 2. *She agreed the resident had been given twice the physician ordered dose of [MEDICATION NAME]. *The resident could have been severely injured with that incorrect dose of [MEDICATION NAME]. Interview on 9/4/14 at 10:30 a.m. with the DON regarding licensed practical nurse (LPN) L that had been involved in administering the incorrect dose of [MEDICATION NAME] to resident 2 revealed: *She had spoken to LPN L on the phone regarding the medication error. *LPN L had stated she had not been feeling well that night. *That had been LPN L's reason for the medication error. Anonymous interview on 9/10/14 at 3:00 p.m. regarding resident 2 revealed: *The next day after he had received the [MEDICATION NAME] he was hard to arouse. *He had gone all day without eating, because he had been too sleepy. *He had slept most of the next day after he had received the [MEDICATION NAME]. Telephone interview on 9/11/14 at 11:30 a.m. with LPN L and the business manager revealed: *She was aware a medication error had occurred with resident 2's [MEDICATION NAME]. *She stated she had not been feeling well that night, and that was the reason she had administered the incorrect dose of [MEDICATION NAME]. *Resident 2 was swinging and attempted to hit her and another co-worker as they were attending to him. She administered the [MEDICATION NAME] to stop him from hitting at them. Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing 8th Ed., St. Louis, Mo., 2013, p. 582, revealed: *"Administering medications to patients requires knowledge and a set of skills that are unique to a nurse. You first assess that the medication ordered is the correct medication. *A medication error can cause or lead to inappropriate medication use or patient harm. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, and administering extra doses or failing to administer a medication. Preventing medication errors is essential. Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors. Medication errors are related to practice patterns, health care product design, or procedures and systems such as product labeling and distribution."

Based on record review, interview, and policy, the provider failed to assess, monitor, and document pain management and end-of-life care for one of one sampled hospice (terminal) residents (2). Findings include: 1. Review of resident 2's medical record revealed: *A [DATE] admitted from an acute care hospital. *[DIAGNOSES REDACTED]. *He expired (passed away) on [DATE]. Review of resident 2's [DATE] physician's orders [REDACTED]. *[MEDICATION NAME] (narcotic pain medication) ,[DATE] milligrams (mg) one tablet every six hours as needed for pain. (That was discontinued on [DATE] by the physician and resumed on [DATE]). *[MEDICATION NAME] 500 mg, two tablets every four hours as needed for mild pain. Review of resident 2's [DATE] physician's orders [REDACTED]. *"Patient declining, reporting difficulty swallowing, less responsive, and transitioning toward actively dying." *"Okay to discontinue all scheduled medications." *"[MEDICATION NAME] (narcotic pain medication) 0.25 milliliter (ml) to 1.0 ml every one hour as needed (PRN) for shortness of breath (SOB) or pain." *"[MEDICATION NAME] (antianxiety medication) 1.0 mg one tablet crushed and given [MEDICATION NAME] (inside side of mouth) every one hour PRN anxiety/restlessness." Review of resident 2's [DATE] through [DATE] PRN medication record revealed: *Pain monitoring 0 to 10 with 0 being no pain and 10 being worst possible pain. *Non-pharmacological interventions to include: -Food/fluids. -Books on tape. -Toileting. -Massage. -Repositioning. -Soft music. -Quiet environment. -Aromatherapy. -Spiritual counseling. -Deep breathing. -Reassurance. -Exercise. -Relaxation. -Dim lighting. -Warm compress. -Cold compress. *[MEDICATION NAME] had been documented as administered eight times from [DATE] through [DATE]. *Five doses of the [MEDICATION NAME] had no location for the pain. *[MEDICATION NAME] had been documented as administered on [DATE] with no location of pain at a pain rating of 8. Food/fluids, repositioning, relaxation, and dim lighting had been documented as non-pharmacological interventions. There was no follow-up documentation to the effectiveness of the [MEDICATION NAME] or non-pharmacological interventions. *[MEDICATION NAME] had been documented as administered on [DATE] for chest pain at a pain rating of 6 with no non-pharmacological interventions documented. There was no follow-up documentation to the effectiveness of the [MEDICATION NAME]. *[MEDICATION NAME] had been documented as administered on [DATE] for no location of pain, no pain rating, and no non-pharmacological interventions documented. *There was no non-pharmacological interventions documented for the [MEDICATION NAME] administered on [DATE], [DATE], [DATE], and [DATE]. *There was no documentation of any pain medication administration after [DATE]. *The resident never received any [MEDICATION NAME], or [MEDICATION NAME]. Review of resident 2's [DATE] through [DATE] interdisciplinary progress notes revealed: *[DATE] at 11:50 a.m. by hospice registered nurse (RN)- "Denies pain during visit. States he is comfortable." *[DATE] at 5:00 p.m.- "Orders received to discontinue all scheduled medications/PRN medications. New order for [MEDICATION NAME] and [MEDICATION NAME]. Pharmacy made aware by hospice." *[DATE], "Transferred to room [ROOM NUMBER] approximately at 9:00 a.m. Summoned to room at 9:55 a.m. No perceivable pulse or blood pressure. Family at bedside. Hospice nurse here at 10:00 a.m. Orders of doctor at 10:08 a.m." *There was no documentation from [DATE] through [DATE] of his pain control or his condition. Interview on [DATE] at 10:00 a.m. with the director of nursing regarding resident 2 revealed: *She had only been at the facility less than three weeks. *She was not going to state what her expectations of PRN follow-up should have been, as the nurses did not know yet what her expectations were. *He was moved to another room an hour before his death by orders of the administrator. The administrator felt since there was such a large number of visitors a larger room would be more appropriate. *When questioned by the surveyor the lack of documentation regarding his condition from [DATE] through [DATE] her response was "What would you expect?" Review of the provider's [DATE] Hospice Program policy revealed: *"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." *"Provision of drugs and medical supplies as needed for palliation (comfort) and management of the terminal illness and related conditions that will be provided by each entity."

A. Based on observation, interview, record review, and policy review, the provider failed to ensure an appropriate nursing assessment, monitoring, care planning, and medical treatment intervention for one of sampled resident (3) who had significant redness, scaling, and itching of the skin on his scalp, neck, and ears for two months. Findings include: 1. Observation and interview on [DATE] at 9:15 a.m. with resident 3 revealed: *He was unshaven and had dried greenish nasal drainage in his mustache. *He looked as though he had not had a haircut for several months. His hair was quite long and unkept. *His scalp was reddened and had a large amount of dry scaling skin noted. The dry skin was layered and thick on his scalp. *Both ears were very pink, had scabbed areas on the lobes of the ears, and were scaling and dry. *The back of his neck was quite pink and had dry scaly skin. *He was hard of hearing. *He stated his scalp, ears, and neck were "itchy." *He was uncertain as to how long he had that scaling and dryness to those areas. Interview on [DATE] at 10:05 a.m. with certified nursing assistant (CNA) C regarding resident 3 revealed: *She had only been employed one week with the provider. *He would not let her comb his hair, because he stated, "it hurt" when she attempted to comb his hair. *She was unsure how long it had been since he had been shaved or given a bath. *She and CNA D had notified the nurse's about his skin issues on his scalp, ears, and neck. Interview on [DATE] at 10:10 a.m. with CNA D regarding resident 3 revealed: *His shower day was Thursday, and he refused to take a shower at times. *He would complain of pain in his scalp when she attempted to comb it. *She had talked to the nurses about his scalp pain. Interview on [DATE] at 10:20 a.m. with registered nurse (RN) B regarding resident 3's skin issues revealed: *She stated "He is a mess." *He has had the skin issues to the scalp, neck, and ears since [DATE]. *His primary physician had seen him, and there was a dermatology appointment made for [DATE] through the Veteran's Administration. *There had been no treatment ordered after the skin issues had been identified. *She was unsure as to the reason there had been no treatments attempted prior to his dermatology appointment. Telephone interview on [DATE] at 10:30 a.m. with VA community care coordinator G and RN H regarding resident 3 revealed: *He had a dermatology appointment scheduled for [DATE] via telemedicine. *He had been seen on [DATE] at the VA. The provider called the VA on [DATE] and then that was when the dermatology appointment had been scheduled. *They both were unsure as to the reason there had been no medical treatment provided for resident 3's skin condition. Interview on [DATE] at 11:00 a.m. with MDS (Minimum Data Set) coordinator E regarding resident 3 revealed: *There had been no treatment provided for the residents scalp that she was aware of . *She was responsible for his MDS. *She would have gone by what the nurses charted, because she does not perform skin assessments on her residents. She only does pain assessments. Interview on [DATE] at 11:15 p.m. with licensed social worker F regarding resident 3's skin concerns revealed: *He was typically unshaven. That's who he was. *He had refused care at times. *She was unaware that his scalp, neck, and ears were that bad. *She would have expected the nurses to intervene for his skin condition. *She agreed the primary care physician should have been involved with the immediate care of his scalp. Observation on [DATE] at 12:25 p.m. of resident 3 at the Center dining room table revealed as he was eating his noon meal he kept scratching his scalp, ears and face. He only at approximately 10 percent of his noon meal. Then got up from the table and left the dining room. Interview on [DATE] at 3:40 p.m. with RN B regarding resident 3 revealed: *There had been no medical intervention for his skin issues on his scalp, neck, and ears. *The VA had been contacted on [DATE]. Review of resident 3's [DATE] individualized care plan revealed there had been no documentation that he had scalp, ear, and neck skin issues. There was no documentation regarding any scheduled appointments, or that a physician had been notified about his skin issues that had started on [DATE]. Interview and observation on [DATE] at 3:50 p.m. of resident 3's scalp, neck, and ears with the director of nursing (DON) in resident 3's room revealed: *She was unaware of his skin issues. *She agreed the skin issues were severe. *She agreed there should have been some medical treatment intervention from the primary physician or the VA prior to his dermatology appointment on [DATE]. Telephone interview on [DATE] at 4:55 p.m. with primary care physician I regarding resident 3 revealed he: *Had not felt that the residents skin condition was an emergency. *Stated, "I don't know what to do with him." *Had the skin condition for a few months. *Felt the resident was "lucky" to have had an appointment with the VA dermatology. Interview and observation on [DATE] at 9:45 a.m. with the medical director in resident 3's room regarding his skin issue revealed: *He was unaware the skin issue was acute. He thought it looked like a chronic condition. *He agreed the skin condition should have had medical treatment intervention by the primary physician before the scheduled dermatology appointment. Observation on [DATE] at 11:30 a.m. of resident 3 in the Center dining room revealed he had been sitting at the dining room table. Intermittently he was scratching his scalp and ears. Review of resident 3's interdisciplinary progress notes revealed: *On [DATE] at 4:00 p.m. "Writer called Res. (resident) family if it would be okay with Res. going to a provider outside the VA to be seen regarding skin/scalp issues. Fam (family) okay with this, PCP (primary care physician) does not think he needs to be seen ASAP (as soon as possible) and can wait to be seen at the VA ,[DATE] - clinic need the PCP to call and refer him in the clinic in order to be seen tomorrow, PCP doesn't not think this is necessary and will not refer him." *On [DATE] at 10:00 a.m. "Medical Director examined scalp; believes he needs to be seen today at VA ER (emergency room ). Notified PCP and he gave order." *On [DATE] at 1:15 p.m. "Res. went to VA ER via (by) w/c (wheelchair) Express." *On [DATE] at 3:50 p.m. "Res. has new order for [MEDICATION NAME] shampoo twice weekly. Also to keep derm (dermatology) appt (appointment) later this month." Review of resident 3's [DATE] physician's progress notes revealed there had been no documentation of his scalp, ears, and neck skin issues by the primary care physician. Review of resident 3's [DATE] summary after the ER visit revealed: *"Needs to be seen for scalp problem per medical director." *"Seborrheic [MEDICAL CONDITION] (similar to [MEDICAL CONDITION]/dandruff, affects the scalp, may also be known as "cradle cap", itchy and inflamed skin). Rx (prescription) [MEDICATION NAME] 2% (percent) shampoo relieved flaking, scaling, and itching associated with seborrheic [MEDICAL CONDITION] topically twice weekly. Need to keep the dermatology appt scheduled for 16 Sept (September) 2014." Observation on [DATE] at 11:00 a.m. of resident 3 revealed: *He continued to have reddened, scaling, and flaking skin on his scalp. *His ears were dry and had scabbed areas. *His neck continued to be quite pink in color. *He appeared unkept, his hair was long and uncombed. *Facial hair was long and uneven. Interview on [DATE] at 11:15 a.m. with CNA K regarding resident 3 revealed: *She had not given the resident a bath. *She knew of no new treatment for [REDACTED]. *If there was a new order for a special shampoo the nurses would have communicated that to her. *The new treatment would have been placed on her bathing schedule, so she would have known to use the new shampoo when bathing him. Review and interview on [DATE] at 11:30 a.m. of resident 3's September treatment administration record (TAR) with RN A revealed: *He had been seen on [DATE] at the ER. *He had a physician's orders [REDACTED]. *The new medication order had not been placed on his current TAR. *RN A stated she had ordered the medication from the pharmacy on [DATE]. *She had not noted the new physician's orders [REDACTED]. *The new medication was found in the top drawer of the medication cart unopened. *He had not received the medicated shampoo that had been physician ordered four days ago. *She agreed the medicated shampoo ordered on [DATE] should have been started immediately. *She confirmed she had not appropriately transcribed the physician's orders [REDACTED]. Interview on [DATE] at 11:45 a.m. with the DON regarding the above concerns regarding resident 3 revealed: *The physician's orders [REDACTED]. That would have ensured timely treatment for [REDACTED]. *She confirmed the delay in the transcription of the physician's orders [REDACTED]. *The treatment should have been started on [DATE]. Review of resident 3's [DATE] TAR on [DATE] at 3:30 p.m. revealed the order had been transcribed by RN A. The resident had received the physician's orders [REDACTED]. Review of resident 3's [DATE] individualized care plan indicated there had been no revision to his plan of care to include his current medicated shampoo treatment twice weekly that had been ordered on [DATE]. Observation on [DATE] at 10:00 a.m. of resident 3 ambulating in the hallway revealed: *His hair had been trimmed. *He facial hairs had been shaved. *His scalp was less scaly and less reddened. *His ears appeared less scaly. *He was smiling. His appearance was much improved. Review of the provider's [DATE] Guidelines for Nursing Documentation policy revealed: *All observations, medications, and treatments given, services performed, actions taken would have been documented in an accurate, detailed, and readable manner in order to have provided an accurate and detailed description of the condition of the resident. Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing 8th Ed., St. Louis, Mo.,2013, p. 4, pp. 6 and 7, and p. 305 , revealed: *"The Standards of Practice describe a competent level of nursing care. The levels of care are demonstrated by the critical thinking model known as the nursing process, assessment, diagnosis, outcomes identification, and planning, implementation, and evaluation. The nursing process is the foundation of clinical decision making and includes all significant actions by nurses in providing care to patients." *"As a nurse, you are responsible for obtaining and maintaining specific knowledge and skills for a variety of professional roles and responsibilities. Nurses provide care and comfort for patients in all health care settings. Nurse's concerns for meeting the patient's needs remains the same whether care focuses on health promotion and illness prevention, disease and symptom management. Accountability means that you are responsible, professionally and legally, for the type and quality of nursing care provided." *The healthcare provider (physician or the advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care provider's orders unless they believe the orders are in error or harm patients. B. Based on record review, interview, and policy review, the provider failed to assess, monitor, and document pain management and end-of-life care for one of one sampled hospice (terminally ill) resident (17). Findings include: 1. Review of resident 17's medical record revealed: *An [DATE] admitted from an acute care hospital. *[DIAGNOSES REDACTED]. *He expired (passed away) on [DATE]. Review of resident 17's [DATE] physician's orders [REDACTED]. *[MEDICATION NAME] (narcotic pain medication) ,[DATE] milligrams (mg) one tablet every six hours as needed for pain. (That was discontinued on [DATE] by the physician and, then resumed on [DATE]). *[MEDICATION NAME] 500 mg, two tablets every four hours as needed for mild pain. Review of resident 17's [DATE] physician's orders [REDACTED]. *"Patient declining, reporting difficulty swallowing, less responsive, and transitioning toward actively dying." *"Okay to discontinue all scheduled medications." *"[MEDICATION NAME] (narcotic pain medication) 0.25 milliliter (ml) to 1.0 ml every one hour as needed (PRN) for shortness of breath (SOB) or pain." *"[MEDICATION NAME] (antianxiety medication) 1.0 mg one tablet crushed and given [MEDICATION NAME] (inside side of mouth) every one hour PRN anxiety/restlessness." Review of resident 17's [DATE] through [DATE] PRN medication record revealed: *Pain monitoring 0 to 10 with 0 being no pain and 10 being worst possible pain. *Non-pharmacological interventions to include: -Food/fluids. -Books on tape. -Toileting. -Massage. -Repositioning. -Soft music. -Quiet environment. -Aromatherapy. -Spiritual counseling. -Deep breathing. -Reassurance. -Exercise. -Relaxation. -Dim lighting. -Warm compress. -Cold compress. *[MEDICATION NAME] had been documented as administered eight times from [DATE] through [DATE]. *Five doses of the [MEDICATION NAME] had no location for the pain. *[MEDICATION NAME] had been documented as administered on [DATE] with no location of pain at a pain rating of 8. Food/fluids, repositioning, relaxation, and dim lighting had been documented as non-pharmacological interventions. There was no follow-up documentation to the effectiveness of the [MEDICATION NAME] or non-pharmacological interventions. *[MEDICATION NAME] had been documented as administered on [DATE] for chest pain at a pain rating of 6 with no non-pharmacological interventions documented. There was no follow-up documentation to the effectiveness of the [MEDICATION NAME]. *[MEDICATION NAME] had been documented as administered on [DATE] with no location of pain, no pain rating, and no non-pharmacological interventions documented. *There was no non-pharmacological interventions documented for the [MEDICATION NAME] administered on [DATE], [DATE], [DATE], and [DATE]. *There was no documentation of any pain medication administration after [DATE]. *The resident never received any [MEDICATION NAME], or [MEDICATION NAME]. Review of resident 17's [DATE] through [DATE] interdisciplinary progress notes revealed: *[DATE] at 11:50 a.m. by hospice registered nurse (RN)- "Denies pain during visit. States he is comfortable." *[DATE] at 5:00 p.m.- "Orders received to discontinue all scheduled medications/PRN medications. New order for [MEDICATION NAME] and [MEDICATION NAME]. Pharmacy made aware by hospice." *[DATE], "Transferred to room [ROOM NUMBER] approximately at 9:00 a.m. Summoned to room at 9:55 a.m. No perceivable pulse or blood pressure. Family at bedside. Hospice nurse here at 10:00 a.m. Orders of doctor at 10:08 a.m." *There was no documentation from [DATE] through [DATE] of his pain control or his condition. Interview on [DATE] at 10:00 a.m. with the director of nursing regarding resident 17 revealed: *She had only been at the facility less than three weeks. *She was not going to state what her expectations of PRN follow-up should have been, as the nurses did not know yet what her expectations were. *He was moved to another room an hour before his death by orders of the administrator. The administrator felt since there was such a large number of visitors a larger room would be more appropriate. *When questioned by the surveyor the lack of documentation regarding his condition from [DATE] through [DATE] her response was "What would you expect?" Review of the provider's [DATE] Hospice Program policy revealed: *"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." *"Provision of drugs and medical supplies as needed for palliation (comfort) and management of the terminal illness and related conditions that will be provided by each entity."

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Appropriate repositioning, interventions, and care planning for three of four sampled residents (6, 12 and 13) who had current pressure ulcers. *Sufficient fluid intake for two of four sampled residents (12 and 13) who had a current pressure ulcers. Findings include: 1. Observations of resident 13 at various times throughout the day from 9/8/14 through 9/10/14 revealed: *On 9/8/14 from 11:25 a.m. until 12:45 p.m. she sat in her wheelchair. *During that time she was in the dining room being fed by staff. *Staff then took her to her room and transferred her to the commode (portable toilet) for toileting. Upon request by this surveyor, staff measured her pressure ulcer which was located just below her coccyx (tailbone area) on the inside of her left buttock. *She had a Stage II (shallow open area of skin) pressure ulcer measuring 2.5 centimeters (cm) by 2.4 cm at that time, along with two unstageable (depth was unmeasurable) pressure ulcers on both heels. *Her left heel ulcer measured 2.5 cm by 1 cm. *Her right heel ulcer measured 2.5 cm squared. *Staff moved her from her wheelchair to a sitting position in her recliner in her room. *She remained seated in that same position from 12:45 p.m. until 5:00 p.m. *She was then moved back into her wheelchair by staff and taken down for her supper meal. *She had remained in her wheelchair until this surveyor's last observation of her for the day at 6:30 p.m. *She remained seated and was not repositioned for a total of seven hours that day. *On 9/9/14 she was observed seated in her wheelchair in the dining room at 9:45 a.m. where she was fed by staff. *After breakfast, she was moved from the dining room to the nurse's station where she remained seated in her wheelchair. *This surveyor's last observation of her on 9/9/14 was at 4:00 p.m. *She remained upright in a chair without having been repositioned for a total of five hours that day. *On 9/10/14 at 8:05 the resident was observed seated in her wheelchair in the dining room waiting for breakfast. *At 9:45 a.m. and again at 10:30 a.m. that same day her position in the wheelchair was observed to have been unchanged. Review of the medical record for resident 13 revealed: *She had a [DIAGNOSES REDACTED]. *The provider's current care plan dated 5/3/14 revealed: -"I can feed myself after you set up my food. Encourage me to lie and rest if I appear tired." The resident required staff to feed her and position her at the time of the survey. -"I am occasionally incontinent of bladder and am always continent of my bowels." *She was incontinent of both bowel and bladder at the time of this survey. -House supplements were added every meal on 8/1/14 "due to pressure ulcer." -Under the dehydration section it had been documented "I have a history of urinary tract infections. Encourage me to drink fluids when I am sitting up and awake." *She was dependent on staff for hydration (fluid intake) at the time of the survey and she had a recent urinary tract infection [MEDICAL CONDITION]. *Her care plan had not been updated to reflect her needs or current level of care. It had not been combined with the hospice care plan. *The hospice care plan updated on 8/19/14 revealed: -She was incontinent of bowel and bladder as noted by the staff on 5/2/14. -On 6/3/14 she was to have begun wearing heel protectors at all times related to heel pressure ulcers. -On 6/19/14, she needed total assistance by staff with all care. -On 7/23/14 she was moved to the assisted feeding table, as she was unable to feed herself independently. *The hospice care plan had not been updated to meet all of her current needs. *The current undated pocket care plan used by the nursing assistants in providing care to residents revealed: -She was a known "hydration risk" but interventions had not been listed as how to care for her in regards to her hydration needs. -She was to be repositioned every two hours in bed. -There was no documentation to notify staff the resident was dependent on them for her nutrition and hydration. -The pressure ulcer on her coccyx was not listed under the skin care/pressure ulcer area. Staff would not have been able to know how to care for that area. -"Pillow boots in bed." That was not updated to remind staff her heel boots needed to be on at all times or that both of her heels had pressure ulcers. *She required 30 milliliters (ml) of fluid per kilogram of body weight (71 kg) based off her base weight in July (before her weight loss) that totaled 2,154 ml of fluid per day to maintain hydration. Fluid records documented from 8/31/14 through 9/9/14 revealed she had received on average 810 ml of fluid daily. That was less than half of her needed hydration. *The latest Minimum Data Set (MDS) assessment dated [DATE] done monthly by nursing staff revealed: -Her nutritional status documented was "no change" for weight loss. -The skin condition section had no areas of concern or treatments listed. -The bowel and bladder section had been documented as "always incontinent." *The records of weights documented in her chart had been: -158 pounds (lb) in July 2014. -153 lb in August 2014 -145 lb on September 1, 2014 -Her re-weight a few days later had been 143 lb. *Her total weight loss in two months was 15 lb. *On 7/23/14 at the beginning of her weight loss, staff documented the resident had been moved to the assisted feeding table, as she was unable to feed herself independently. *Her Braden Scale (an assessment to predict risk for skin breakdown) had a score of 12. A score of 12 or less indicated she was at high risk for developing a pressure ulcer. . Interview on 9/9/14 at 2:45 p.m. with nursing assistant (NA) JJ regarding residents on the east wing where resident 13 resided revealed: *She was unsure when or if any of the residents of the east wing needed to be repositioned or why. *She stated she had never documented any repositioning. *She had been unaware resident 13 had pressure ulcers. *She had been employed "about a month and a half" and was not a certified nurse aide yet. *She stated they were "short-staffed and residents were lucky to get good care." *She was placed on a weight restriction for muscle strain from lifting residents at the time of the survey from lack of additional staff to help. *She was "lucky to have another aide working on the wing today." *Stated resident 13 was dependent on staff for fluid and nutrition. *She was unsure how she and the other CNA would be able to transfer residents requiring an assist of two safely or at all if she was unable to lift (with her 5 lb. weight restriction). *Average time to answer a call light on the east wing she estimated, had been twenty minutes at best. *Residents were not always given care at the time the call light was answered, but would be routinely be told someone would be there shortly to help and the light was then shut off. *Commonly residents had to push their light "multiple times" before their needs were taken care of. That had occurred regularly since she had been employed at the facility. 2. Observations on 9/9/14 at various times throughout the day of resident 12 revealed: *He had been in the dining room at 11:15 a.m. seated in his wheelchair. *His position in his wheelchair remained unchanged until 4:00 p.m. later that day when staff laid the resident in bed, so his ulcer could be measured. *Staff measured his Stage II pressure ulcer on his left buttock crease at 2 cm by 1 cm. Observation on 9/10/14 at 10:10 a.m. of resident 12's pressure ulcer revealed: *The pressure ulcer had increased in size from 9/9/14 measuring 2 cm squared. *Surrounding it had been a new area of reddened/purplish colored skin measuring an additional 2 cm to equal a 4 cm sized area in total (that was confirmed by RN A). *There was another new area just below the original pressure ulcer, dark purple in color, unstageable, and it had measured 2.5 cm square. Review of the medical record for resident 12 revealed: *He had [DIAGNOSES REDACTED]. *He was taking [MEDICATION NAME] (a medication used to decrease water in the body to lower blood pressure.) *His current care plan dated 7/28/14 revealed he: -Required extensive assistance of one to two staff for all his care. -Frequently was incontinent (loss of control) of bladder and always incontinent of bowel. -Would need encouragement for fluids and was at risk for dehydration. -Was diagnosed with [REDACTED]. -The ulcer was located on his coccyx on 8/12/14. *His Braden Scale had a score of 13 that placed him at moderate risk for a pressure ulcer. *He required 30 milliliters (ml) of fluid per kilogram of body weight (90 kg) based off his weight of 199 lb noted on his 9/1/14 admission to the Veterans Hospital. That weight required 2,713 ml of fluid per day to maintain his hydration. * Fluid records documented from 9/4/14 through 9/9/14 revealed he had received on average 1,183 ml of fluid per day, that was less than half of his needed hydration. *He had a recent UTI. *The latest Minimum Data Set (MDS) assessment dated [DATE] done monthly by nursing staff revealed: -No pressure ulcers had been documented on the skin condition section. -Turning and repositioning was not checked, although he had been check-marked in the "Other" section for positioning every two hours. *The current undated pocket care plan used by the nursing assistants in providing care to residents revealed: -The skin care/pressure ulcer section was blank. -It had not addressed repositioning. -It had not listed him as a hydration risk. 3. Interview on 9/10/14 at 2:00 p.m. with RN A regarding resident 12 revealed she: *Agreed the provider's and the hospice care plans were not updated or specific for staff to know how to care for residents. *Stated staff had not been repositioning residents by schedule or according to their current needs. *Stated she had not performed any new interventions for resident 12 since the new unstageable pressure ulcers had been found that morning. "I just don't have time." *Agreed without specific and measurable interventions, pressure ulcers would form or become worse. *Stated "His (resident 12) (pressure ulcer) will be worse by tomorrow I'm sure. We just don't have the staff or the time." *Stated residents who were dependent on staff for hydration had not been getting fluids between meals as staffing was poor. *Stated bedtime snacks were routinely not given or residents were often sleeping when staff had been offering them. That had been related to the lack of staff available. *Agreed more staff were needed in the facility and had been for a "very long time." *Stated she was doing her best but felt she "had no time." *Stated the monthly MDS assessments had not been getting filled out correctly as nursing staff had little extra time being short staffed. They had been completing them often "without looking at the residents." Review of the provider's undated Prevention of Decubitus (Pressure) Ulcer policy revealed staff should have assisted compromised residents to reposition every two hours and to have encouraged them to drink plenty of fluids. Review of the provider's September 2011 Skin Assessment policy revealed: *The wound team would assess and provide interventions to assist in wound healing. *If the wound was not responding to treatment after two weeks an alternate intervention would have been put in place. Review of the provider's 8/11/09 Hydration Policy and Procedure policy revealed: *All residents would be offered a minimum of 1500 cc (same measurement as a ml) of fluid per day. *Nursing staff would assist residents who needed help. Review of the provider's 4/3/13 Standards of Care for__________(provider's name) policy revealed: *Nurse to notify MD (medical doctor)/Family/Dietician when skin concerns were present. *Turn and reposition residents every one and one-half to two hours and as needed. Review of Patricia A. Potter et al., Fundamentals of Nursing, 8th Ed., St Louis, MO, 2013, Chapter 48-Skin integrity and Wound Care, pages 1176-1229, revealed: *"Nurses constantly observe for skin integrity and identify at-risk patients from developing pressure sores. Nursing interventions focus on prevention." *"Nurses understand factors affecting pressure ulcer formation and wound healing." *"Nurses apply the WOCN (wound, ostomy, and continence nurse) standards for prevention of pressure sores and assessment for skin integrity, prevention and treatment." Review of Madeleine Flanagan's Wound Healing and Skin Integrity- Principles and Practice 1st Ed., Hoboken, NJ, 2013, pages 122-131, revealed: *Risk factors for pressure ulcers are: -Age over 65 -Chronic illness -Immobility -Mental impairment -Poor nutrition and dehydration. -Weight extremes (too little or too much). *"Frequency of repositioning is entirely dependent upon the individual's tissue tolerance. If conditions worsen or fail to improve frequency of repositioning must be more often." *"Continued repositioning is required even in the presence of pressure reducing devices." 4. Observation and interview on 9/3/14 at 9:40 a.m. with resident 6 in his room revealed: *He stated his physician had told him he had needed to lay down in the afternoon. *He was sitting in his room in his wheelchair (w/c). *He stated he slept in his bed, not in his recliner. *His bed was not always made by the afternoon each day, so he had not been consistently laying down. Review of resident 6's medical record revealed: *He was admitted on [DATE]. *He had [DIAGNOSES REDACTED]. *He had needed extensive assistance from two staff members for bed mobility, transfers, dressing, and toileting. *A physician's orders [REDACTED]." Review of resident 6's July 2014 care plan revealed: *"I have a pressure ulcer on my coccyx (tailbone) due to my decreased mobility (movement from one place to another) and incontinence (unable to hold urine)." *"I want my pressure ulcer to be healed by our next meeting." *"Do treatment as ordered." *"Heel boots (new) bilaterally (both sides)." *"Sacral (located at the bottom of the spine) wound open." *"Please reposition me every couple of hours in w/c (wheelchair) or recliner to avoid prolonged pressure to any of my areas." *"I am unsteady and weak, and I need assistance transferring." *"I recently slid out of my recliner." *"I sleep in my recliner." *There was no documentation in his care plan regarding the physician's orders [REDACTED]. -Up in chair for one and one-half hours every a.m. and p.m. -Otherwise bedrest for healing. *There was documentation in two different areas in his care plan that he slept in his recliner. Interview on 9/4/14 at 8:05 a.m. with CNA Y and CNA BB regarding resident 6 revealed: *He had not been sleeping in his recliner. *Both stated they had never observed him in his recliner. Review of resident 6's 7/25/14 Braden Scale (an assessment used for predicting pressure ulcer risk) revealed: *He had scored 13 on the assessment (a score of 12 or less indicated a high risk). *A score of 13 was at moderate risk for pressure ulcers. Review of resident 6's 7/28/14 Interdisciplinary Progress Notes by registered nurse (RN) J revealed he: *Was at moderate risk for pressure ulcers. *Had a stage II (partial thickness loss of skin presenting as a shallow oopen ulcer with a red or pink wound bed) pressure ulcer to his right heel and coccyx. *Had an unstageable (full thickness tissue loss in which the base of the ulcer is cover by dead tissue) pressure ulcer on his left heel. *Had pressure ulcer dressing changes. *Had a pressure reducing mattress on his bed at all times. *Had a seat cushion in his wheelchair (w/c). *Was occasionally incontinent of bladder. *Needed extensive assistance from two staff members for bed mobility, transfering, dressing, and toileting. Review of resident 6's 7/22/14 Minimum Data Set (MDS) assessment revealed: *He required extensive assistance with bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. *He was occasionally incontinent of urine. *He was at risk for developing pressure ulcers. *There was no documentation he had been placed on a turning/repositioning program. Observation on 9/8/14 at 2:30 p.m. of resident 6 in his room revealed he was sitting in his w/c in front of his TV. Interview on 9/9/14 at 9:30 a.m. with resident 6 in his room revealed he: *Was sitting up in his w/c. *Usually did not lay down in the a.m. *Had not thought he had enough time between breakfast and the noon meal to lay down. *Preferred to have laid down in the p.m., as he thought he had more time to do that. *Laid down "quite a bit more in the afternoon." *Complained that "hardly anybody comes down my hall to help me." *Stated he had not always gotten laid down in the p.m. as he had preferred. Interview on 9/9/14 at 9:55 a.m. with CNA VV and CNA WW regarding resident 6 revealed: *They were unaware he needed to be laid down in the a.m. and in the p.m. *That information was not available on their pocket care plan for that hall. *The Pocket Care Plan for east wing was used by the CNAs to guide their care for the residents. Review and interview on 9/9/14 at the same time and location with CNA VV regarding resident 6 and the undated Pocket Care Plan east wing information revealed: *There was no information regarding him needing to have been laid down in the a.m. and the p.m. *The only information under skin care/pressure ulcer was: -"Float Heels/boots." *There was no information listed under the comments/special instructions column of the care plan. Interview on 9/9/14 at 10:00 a.m. with resident 6's physician I and another surveyor regarding resident 6 revealed: *The order for him to have been laid down in the a.m. and the p.m. came from another physician. *He thought that order had come from the wound center. *He would have liked to have seen him laid down to assist with his healing. *He needed to get that area healed. *He stated "he had healed up once, got worse again." Interview on 9/9/14 at 3:22 p.m. with licensed practical nurse (LPN) AA regarding resident 6 revealed: *He had not always laid down as his physician ordered. *That order was to have helped him heal his skin. *He had not always been agreeable to laying down in the a.m. and in the p.m. *It needed to have been "written down in his record" if he had refused to lay down. *She had not been aware of any communication to the physician who ordered the bedrest that he was not always compliant (cooperative and in agreement). *She agreed the physician should have been contacted regarding that. Review on 9/9/14 of resident 6's treatment administration record (TAR) for 9/1/14 through 9/9/14 revealed: *The physician's orders [REDACTED]." *Under AM on the TAR were: -Six days with nursing staff initials that he had been laid down. -One day was left blank. -Two days on 9/8/14 and on 9/9/14 the initials were circled with notes on the back of the TAR he had refused. *There were no other times that it had been written down he had refused. *Under PM on the TAR were: -Eight days with nursing staff initials that he had been laid down. -One day on 9/9/14 the initials were circled with a note on the back of the TAR he had refused. *There were no other times that it had been written down he had refused. Review of resident 6's August 2014 Daily Pressure Ulcer Monitoring Day sheet revealed: *He had three ulcer locations that were being monitored on the following areas: -Coccyx. -Right heel. -Left heel. Review of resident 6's Outpatient Wound Healing Center-Provider Orders Treatment Plans revealed he had gone to the wound center on 6/19/14 and 7/31/14. Interview on 9/9/14 at 4:00 p.m. with NA JJ regarding resident 6 revealed: *He seldom laid down in his bed in the a.m. after breakfast. *If he was going to lay down it was in the p.m. after lunch. *He always refused to lay down in his bed on afternoons when BINGO was being held. *BINGO had been held that day from 2:00 p.m. through 3:00 p.m. Observation on 9/9/14 at 4:00 p.m. of resident 6 in his room revealed he: *Was sitting in his w/c in front of his TV. *His head was down and his eyes were closed. Interviews on 9/9/14 at 12:10 p.m., 1:25 p.m., and at 4:45 p.m. with the director of nursing regarding resident 6 revealed: *He would refuse to lay down depending on the activities going on in the facility. *He would lay down and then want to get up after a few minutes. *She stated he was not always following his physician's bedrest order. *That should have been communicated with the physician that had ordered it. *She confirmed that order was not always being consistently followed by the nursing staff. *She confirmed that order had not been on his care plan. *She confirmed that information was also not on the Pocket Care Plan for East Hall used by the CNAs. Observation on 9/10/14 at 9:17 a.m. of resident 6 in his room revealed he was sitting in his w/c in front of his TV. Random observations of resident 6 in his room by this surveyor during the survey from 9/3/14 through 9/10/14 revealed: *At no time had he been observed in his bed laying down in the a.m. or in the p.m. *When he was in his room he was sitting in his w/c in front of his TV. Review of the provider's revised September 2014 Change in a Resident's Condition or Status policy revealed the purpose was to have had each resident's physician kept informed of changes in the resident's condition or status. Review of the provider's revised August 2011 Skin Assessment policy revealed: *The purpose was to have monitored residents known to have a history of or be at risk of pressure ulcers. *All staff were to have been aware of a need to notify a nurse concerning any resident's skin concerns. Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (3) who had becoming increasingly more incontinent of bowel and bladder had the appropriate interventions in place to prevent skin breakdown. Findings include: 1. Random observations on 10/21/14 from 2:30 p.m through 5:00 p.m. of resident 3 revealed: *He spent much of the time lying on his bed asleep. *There had been no staff in his room assiting him to the bathroom. *He had attended no activities. Review of resident 3's Licensed Nurses Notes revealed: *On 10/10/14 (with no time documented on the notes) "Skin dry and warm and intact. Abdominal wound healing well. Heels and coccyx intact - bottom slightly pink. Heels need lotion, no pain chronic dry scalp. No other issues with skin at this time. Will continue to monitor." *On 10/20/14 (with no time documented on the notes) "New skin concern on R (right) upper coccyx area. 2 cm (centimeter) X (by) 2 cm red open area. Duoderm on for now. Dr. (doctor) orders pending dietary notified notified family notified in a.m." *No other entries had been made from 10/10/14 until 10/20/14. Interview with the director of nursing immediately after the above documentation had been reviewed revealed: *She was unaware resident 3 had skin issues. *She was certain the nurse had done the skin assessment and had forgotten to document her findings. *Her expectation was that each time the skin issues was assessed there would have been documentation completed by the nurse. Interivew on 10/22/14 at 10:00 a.m. with Minimum Data Set (MDS) coordinator

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (3)who had become increasingly more incontinent of bowel and bladder and who had obtained a pressure area had: *A timely nursing assessment completed. *A thorough description sent to the primary care physician. *Appropriate interventions in place to prevent skin breakdown. Findings include: 1. Review of the 10/20/14 Skin Assessment Report for resident 3 revealed: *There was an open reddened area 2 cm X 2 cm on his upper right coccyx. There was no description of the open area. *The contributing factor was increased incontinence (unable to control bowel and bladder). *If pressure related - complete only this forma and forward to the Nurse Manager. Observation on 10/21/14 from 10:00 a.m. to 12:00 noon of resident 3 revealed: *No staff had entered his room to assist him to the bathroom. *He arose off his bed and went to the dining room for lunch at 12:00 noon without going to the bathroom. Observation on 10/21/14 from 1:30 p.m. to 4:00 p.m. of resident 3 revealed: *He spent all the time in his room lying in his bed. *He had not attended any activities. *There had been no staff who had entered his room to prompt him to go to the bathroom or assist him with toileting. Review of resident 3's Licensed Nurses Notes for October 2014 revealed: *On 10/10/14 (no time had been documented) "Skin dry warn (warm?) and intact. Abdominal wound healing well. Heels and coccyx intact-bottom slightly pink. Heels need lotion. No pain. Chronic dry scalp. No other issues with skin at this time. Will continue to monitor." *On 10/20/14 (no time documented) "New skin concern on R (right) upper coccyx (bottom) area 2 cm (centimeters) X (by) 2 cm red open area. DuoDerm (type of dressing) on for now. Dr. orders pending, dietary notified, family notified in the am (morning)." *There had been no narrative documentation between 10/10/14 and 10/20/14. Interview immediately following the above record review on 10/21/14 at 4:00 p.m. with the director of nursing (DON) II revealed: *She was unaware resident 3 had a current skin issue on his coccyx. *She was not sure why there had been no documentation prior to the observation on 10/20/14 of the open area to the right upper coccyx. The nurse must have forgotten to document after her assessment. *The staff should have been assisting resident 3 to the bathroom every two hours. *She would have expected the nurses to document their findings after each skin assessment and with each dressing change. *The care plan should have been updated to ensure appropriate interventions had been put in place to prevent skin breakdown. *She would contact the nurse that was suppose to do the weekly skin assessment in between 10/10/14 and 10/20/14 to make a late entry in resident 3's medical record. Interview on 10/22/14 at 10:00 a.m. with Minimum Data Set (MDS) coordinator E regarding resident 3's open area on his coccyx revealed: *She usually had done wound/skin rounds on Thursday of each week. *She had not seen the coccyx area on resident 3. -She had received a skin assessment report on 10/20/14 but had not investigated the skin issue. -She would not make an assessment of the skin concern until Thursday, which would have been four days after the open area had been observed. *She stated resident 3 had become increasingly more incontinent of bowel and bladder according to the documentation she had received. She had not assessed the resident. Review of the 10/20/14 physician's notification facsimile (fax) for resident 3's skin concern revealed: *The fax had been sent to the physician at 3:00 a.m. *The following had been handwritten: "New skin concerns, open area 2 cm X 2 cm on upper (R) coccyx area. DuoDerm on at this time. Skin sheet included. Any treatment?" *There was no description on the area provided to the physician to ensure an appropriate treatment would have been prescribed. Interview on 10/22/14 at 10:30 a.m. with licensed practical nurse (LPN) AAA regarding resident 3's pressure ulcer revealed: *She was unable to stage pressure ulcers. The registered nurse had to assess and stage pressure ulcers. *She agreed the nurse should have had a description of the open area for the physician to make a determination of the kind of treatment that would have been appropriate for that open area. *Open areas on residents were only measured weekly by the MDS nurses. Interview and observation on 10/22/14 at 12:00 noon with LPN AAA and LPN BBB during the dressing change of resident 3's right upper coccyx area revealed: *There was a reddened area on his upper right coccyx area with an open area. The area was not going to be assessed and measured until Thursday. The LPNs stated the measuring of the pressure areas were only done on Thursdays, but they would document in the Licensed Nurses Notes their findings each time the DuoDerm dressing was changed. Interview on 10/22/14 at 1:25 p.m. with certified nursing assistant C regarding resident 3's bowel and bladder incontinence revealed: *He was increasingly more incontinent of bowel and bladder. *She would attempt to remind him every two hours to go to the bathroom. Review of resident 3's Licensed Nurses Notes on 10/22/14 at 1:30 p.m. revealed: *There had been a late entry documented on 10/22/14 for 10/15/14. *The handwritten entry revealed: "Did wkly (weekly) skin assessment. Res. (resident) has dry scaly skin with scalp a particular problem. Medicated shampoo used and is improving condition. Heels and coccyx intact. No other concerns." *There had been no mention the reddened area noted on 10/10/14 was heeled or improved. Review of resident 3's September 30, 2014 Monthly Summary completed by a registered nurse revealed: *His cognition (memory) was moderately impaired. Required cueing and supervision. *He had little interest or pleasure in doing things. *He was independent with bed mobility and transfers. *He required limited assistance with toileting. *He was on a scheduled toileting program. *He had no skin conditions. Review of resident 3's 10/14/14 MDS assessment revealed he: *Was confused with a Brief Interview for Mental Status (BIMS) score of four. A score of fifteen meant the person was orientated to person, place, and time. *Felt tired and had little or no energy. *Required physical assistance of one staff person with bed mobility and transfers. *Required extensive assistance of two or more staff persons with toileting and personal hygiene. *Was frequently incontinent of bowel and bladder. He was not on a toileting program. *Was at risk for pressure ulcers. *Had a pressure reducing mattress for his bed. *Had not been placed on a turning and repositioning program. Review of resident 3's 2/14/14 comprehensive care plan revealed: *"I am at risk for pressure ulcers due to requiring assist with toileting and being incontinent. I also have decreased mobility. I want my skin to remain intact through our next meeting. Please have the nursing staff keep an eye on my skin when they are doing my personal hygiene cleansing and report to the nurses if they see any reddened areas. Have the Licensed Nurses inspect my skin thoroughly each week and document their findings. If concerns arise, please consult my physician and follow his orders. Make sure my incontinence products are changes as soon as possible after they have become wet. Apply barrier creams to protect my skin. Help me to reposition every couple of hours. Keep my pressure reducing mattress on my bed." Review of the provider's undated Documentation Guidelines for Decubiti (pressure ulcer) revealed: *Location and measurement: Including width, length, and depth in cm of all decubiti upon admission and weekly. *The treatment provided. *Healing process, assessed weekly. *Turning and positioning, how often, daily activity, pressure reduction, and nutritional intake. Review of the provider's June 2004 Skin Assessments policy revealed the purpose of the policy was to monitor residents with a known history or to be at risk of pressure ulcers or have skin breakdown. Review of the provider's October 2010 Pressure Ulcer Risk Assessment revealed: *Pressure ulcers were usually formed when a resident remained in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroyed the tissues. *If pressure ulcers were not treated when discovered, they quickly got larger, become very painful for the resident, and often times would become infected. *Routinely assess and document the condition of the resident's skin per facility wound and skin care programs for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. *Nurses were notified to inspect the skin if skin changes were identified. *Because a resident at risk could develop a pressure ulcer within two to six hours of the onset of pressure, the at-risk resident needed to have been identified and have interventions implemented promptly to attempt to prevent pressure ulcers. *Risk factors for pressure ulcers would include: -Immobility. -Altered mental status. -Incontinence. -Poor nutrition. Review of the provider's October 2010 Prevention of Pressure Ulcers policy revealed: *The purpose of the procedure was to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. *Pressure ulcers were often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (such as perspiration, feces (stool), urine, wound discharge, soap residue, etc (and so on), decline in nutrition and hydration status, acute illness and/or decline in the residents physical and/or mental condition. *The facility should have a system/procedure to ensure assessments were timely and appropriate and changes in condition were recognized, evaluated, reported to the practioner, physician, and family, and addressed. *Address the causes of moisture if possible (bladder training, scheduled toileting). *Check the resident for incontinence at least every two hours and clean skin when soiled. Review of the provider's 11/8/12 Guidelines for Nursing Documentation revealed the following should have been included in the documentation: *Skin surfaces should have been checked regularly. *Changes in the condition of skin. *Specific location of the skin care problem. *Dates of occurrences of skin concerns and dates resolved. *Number, size, degree, and measurement of the pressure ulcer. *Documentation of the cause of the pressure ulcer if known. *Turning and reposition schedules to prevent undue pressure. *Use of specific creams, lotions, medications, or protective devices. *Consultation from other disciplines.

Based on observation, interview, record review, and policy review, the provider failed to ensure routine assessment, monitoring, and documentation of tube feeding process for two of two residents (9 and 14)receiving tube feedings (gastric tube placed in the stomach for feedings and medication administration). Findings include: 1. Observation on 9/3/14 from 5:15 p.m. through 5:30 p.m. of resident 9 revealed: *His feeding tube (tube going directly into ) was not connected and the feeding pump was not infusing at 5:15 p.m. *His feeding tube was connected and the feeding pump was infusing at 5:30 p.m. *No one had entered his room during that time frame. *Resident had history of connecting and disconnecting his own feeding tube to the feeding pump. Review of resident 9's complete medical record revealed: *An interdisciplinary progress note on 6/15/14 at 5:00 p.m. that described the resident adjusting the rate of his feeding on his tube feeding pump. *physician's orders [REDACTED]. -Check feeding tube placement before each feeding was dated 8/13/12. -Give a 200 cc (unit of measure) flush of water through the feeding tube before and after each feeding was dated 8/12/13. -[MEDICATION NAME] (nutritional solution to go through feeding tube in place of meals) 1.0 was to have been infusing at 85 cc per hour for sixteen hours (5:00 p.m. to 9:00 a.m.) was dated 5/27/14. -[MEDICATION NAME] 1.0 was to have been infusing at 200 cc per hour for one and a half hours each noon was dated 6/23/14.-A 200 cc flush of water was to be one through the feeding tube every four hours was dated 7/23/14. Interview on 9/3/14 at 5:37 p.m. with RN B revealed she: *Was aware resident 9 had been starting and stopping his tube feeding himself. *Agreed there was no date or time documented on the [MEDICATION NAME] solution container. *Agreed he might not have been getting the correct amount of [MEDICATION NAME] or fluids ordered by the physician. *Agreed the assessments and water flushes might not have been done as ordered by physician. *Was not sure the date or time the current container of feeding solution had been hung. Observation on 9/8/14 from 12:00 p.m. (noon) to 1:07 p.m. of resident 9 revealed: *At 12:00 p.m. (noon), 12:21 p.m., and 12:40 p.m., his feeding tube was not connected or infusing. *At 12:44 p.m. his visitor left. The feeding tube was not connected or infusing at that time. *At 12:53 p.m. the feeding tube was connected to the solution and infusing at 250 cc per hour instead of the physician's orders [REDACTED]. *No one had entered the room since the visitor left. Interview on 9/8/14 at 1:08 p.m. with RN A regarding resident 9's feeding tube orders revealed she: *Believed his next feeding was at 5:00 p.m. *Stated he needed his every four hour 200 cc water flush done and proceeded to the resident's room. *Identified the feeding tube was infusing at that time. *She stopped the feeding pump and disconnected the feeding tube to administer the water flush. *She reconnected the feeding tube. *She restarted the feeding pump. *She asked the resident if he had connected his feeding tube and started his feeding. The resident stated he had. When asked why he stated no one came at noon to start it. *She was aware that resident 9 had been starting and stopping his feeding himself. *She agreed the resident had connected and started his own noon feeding without an assessment of the feeding tube placement or a water flush before starting it. *She agreed he might not have been getting the correct amount of water or [MEDICATION NAME] solution ordered by the physician. Review of resident 9's intake and output record from 6/12/14 to the present date revealed: *Inconsistent charting of feeding tube water flushes as ordered by the physician. *Occasional documentation of 300 cc 12:00 p.m. (noon) feeding tube fluid, but rare documentation of sixteen hour overnight feeding (from 5:00 p.m. to 9:00 a.m.) fluid which would have been 1,360 cc with the present physician orders. *No documentation of output had been kept. Review of resident 9's Medication Administration Record [REDACTED] *The feeding tube fluid was to be infused twice a day from 5:00 p.m. to 9:00 a.m., and 12:00 p.m. (noon), to 1:30 p.m. *The water flushes before and after feedings were set for 4:00 a.m., 12:00 p.m.(noon), and 5:00 p.m. -The times should have been 12:00 p.m. (noon), 1:30 p.m., 5:00 p.m., and 9:00 a.m. *The every four hour water flush was set for 1:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m. (noon), and 5:00 p.m. -There should have been six times not five. -At these scheduled times the tube feeding was infusing or there was another order for the tube to be flushed. -There was no documentation on clarification of these doubled flush orders with the physician. Interview on 9/10/14 at 1:40 p.m. with the director of nursing (DON) revealed she: *Was unaware resident 9 had been connecting, starting, adjusting the rate of flow, and stopping his feeding tube and nutritional fluid that had been administered through a feeding pump. *Agreed the ordered feeding tube placement assessments and water flushes were not being completed when the resident self-administered (did himself) his feeding solution. *Agreed there was no way to accurately account for the amount of feeding solution resident 9 received since he was stopping and starting the feeding pump at will. *Agreed times for water flushes on the Medication Administration Record [REDACTED]. *Agreed the care plan had not addressed the need to measure intake and output and was not updated regarding the resident's own adjustment of his feeding tube administration. The provider's 10/5/12 Enteral Nutrition/hydration policy and procedure revealed: *Prior to administering nutrition or hydration through a feeding tube there should have been an assessment and a check of the feeding tube placement. *Tubing should have been flushed with water before and after the feedings as ordered by the physician. *Intake and output were to have been recorded every shift while on the feeding tube. 2. Review of resident 14's medical record revealed: *A 7/3/14 admitted . *He had a stomach tube for nutrition and medication. *He did not eat or drink anything by mouth. Review of resident 14's 7/3/14 physician's orders [REDACTED]. Observation on 9/3/14 at 11:00 a.m. of resident 14 revealed: *He was sitting in his room in his wheelchair. *A pump that was infusing his [MEDICATION NAME] was beeping, and the [MEDICATION NAME] had stopped infusing. *RN B adjusted the pump to stop the beeping, and the [MEDICATION NAME] started to infuse again. *There was a 1000 cc container of [MEDICATION NAME] hanging on the pump infusing that was marked with tape it had been started on 9/3/14 at 5:00 a.m. There was 750 cc of [MEDICATION NAME] left in the container. Interview at that time with RN B regarding resident 14 revealed: *The pump used to infuse his [MEDICATION NAME] had been stopping multiple times over the last few days. *She had changed pumps sometime last week, because the previous pump had also been stopping. *She had told administration three to four days ago of the problem with the pumps. *She confirmed when the pumps stopped he was not getting the complete 80 cc an hour. *It was undetermined how long the pump was off before someone heard them beeping and a nurse restarted the [MEDICATION NAME]. *She agreed at this time if he had received the ordered [MEDICATION NAME] 1.2 at 80 cc/hour since 5:00 a.m. there should have been 520 cc in the [MEDICATION NAME] container instead of the 750 cc. Observation on 9/3/14 at 12:00 noon of resident 14 revealed: *He was sitting in his wheelchair in his room. *The pump was not beeping, and the [MEDICATION NAME] was infusing at 80 cc/hour. *There was 700 cc of [MEDICATION NAME] in the container. There should have been 440 cc [MEDICATION NAME] left in the container according to the start time and infusion rate. Interview on 9/3/14 at 12:30 p.m. with the director of nursing regarding resident 14 revealed: *She confirmed the nursing staff had informed her a few days ago of the problem they were having with the feeding pumps. *They planned on ordering some new feeding pumps but had not done that yet. *She confirmed if the feeding pumps kept stopping he was not receiving the full amount of [MEDICATION NAME] 80 cc/hour as ordered by the physician. Interview on 9/3/14 at 12:40 p.m. with the administrator regarding resident 14 revealed: *He was not aware of the problem with the feeding pumps until now. *He would call and get more feeding pumps sent. *There were five feeding pumps in the storage room, and he was unsure if they were working correctly. One had a note taped to the outside of the pump that stated "broken" and one pump had a large amount of dried feeding solution on the outside of the pump. *He was not aware if the provider owned or rented the feeding pumps.

Based on observation, record review, interview, and policy review, the provider failed to maintain adequate nutritional status for one of two sampled residents (1) on a tube feeding resulting in weight loss. Findings include: 1. Observation on 9/3/14 at 5:05 p.m. of resident 1 in his room revealed: *A 1000 cc (cubic centimeter) ready-to-hang prefilled tube feeding container of [MEDICATION NAME] 1.2 (a tube feeding nutrition supplement). *The [MEDICATION NAME] 1.2 was infusing on the feeding pump at a flow rate of 80 cc per hour. *The pump digital reading read "183 ml (milliliters) fed." -That amount of tube feeding would have equaled 183 cc or 6 ounces (oz). *The resident was verbalizing he was "hungry" and "thirsty." Interview on 9/3/14 at 5:07 p.m. with licensed practical nurse F regarding resident 1 revealed: *There had been "issues" with the feeding pump which had been currently beeping. *The physician had ordered his feeding to go until 6:00 p.m. that evening due to problems with the pump. *He complained about being hungry "a lot of the time." *With him "a common thing was thirst." Observation on 9/3/14 at 6:30 p.m. of resident 1 in his room revealed: *That same above container of the tube feeding. *The flow rate on the feeding pump was set at 80 cc per hour. *The feeding pump digital read "295 ml fed." -That amount of tube feeding would have equaled 295 cc or approximately 10 oz. Interview on 9/3/14 at 6:31 p.m. with registered nurse E regarding resident 1's tube feeding revealed: *There had been ongoing problems with the feeding pump not working properly. *The physician had ordered a feeding until 6:00 p.m. that night because of the pump problems. Record review on 9/3/14 of resident 1's medical record revealed he: *Had an admission date of [DATE]. *Had physician's orders [REDACTED]. *Had been on a tube feeding since admission. *Had a [DIAGNOSES REDACTED]. *Had needed extensive assistance with his care. *Had lost a total of 4.7 pounds or 3.7 percent (%) of his weight within the first month of admission. *Had lost a total of 4.6 lb or 3.6% the first month after his admission. *Had lost a total of 3.8 lb or 3.0% the first two months after his admission. *He had a physician's orders [REDACTED]." Review of resident 1's 7/7/14 Nutrition History & Data Collection Form by the consultant registered dietitian (RD) revealed: *No nutritional assessment regarding nutritional adequacy of calories, protein, or fluids. *He had a low [MEDICATION NAME] (a measurement of protein in the blood) level of 3.4 grams(g)/deciliter (dl). -A normal reference range for [MEDICATION NAME] would have been 3.5 through 5.0 g/dl. Review of resident 1's 7/11/14 Interdisciplinary Progress Notes by the consultant RD revealed: *His tube feeding was his primary means of nutrition. *No nutritional assessment had been done regarding nutritional adequacy of calories, protein, or fluids. *His feeding was to have provided 100% of his total nutrient needs as well as his water needs. *"His weight is stable." Review of resident 1's 8/24/14 Interdisciplinary Progress Notes by the consultant RD revealed: *"Overall stable for nutrition." *No nutritional assessment had been done regarding nutritional adequacy of calories, protein, or fluids. Review of resident 1's I/0 (Intake/Output) Chart Detail Report from 8/28/14 through 9/4/14 revealed: *He had an average daily intake of 662 cc. *There was no output on the report form. *That intake was less than half of what he should have received according to his physician's orders [REDACTED]. Interview on 9/4/14 at 8:15 a.m. with the director of nursing regarding resident 1 revealed: *There had been problems with his feeding pump not working properly and "beeping." *A new feeding pump had been obtained on 9/3/14. *She agreed there had not been accurate tracking on how much formula he had received since admission because of the problems with the pump. *There had been poor documentation of the resident's intake of his tube feeding and water. Review of resident 1's 7/22/14 care plan revealed: *"I want to maintain my weight." *"Monitor my weights." *There was no documentation in his care plan regarding the weight loss. Review of resident 1's weight sheet from the first week in July 2014 through the first week in September 2014 revealed *The weekly weights were not completed for: -July, weeks two and four. -August, weeks three and four. Interview on 9/9/14 at 10:35 a.m. and at 2:30 p.m. with the consultant RD regarding resident 1 revealed: *She stated she had been aware of his weight loss. *Weekly weights had not been consistently obtained. *Expected his care plan to have been updated with the weight loss. *His [MEDICATION NAME] level had been low. *His protein level needed to have been increased in his tube feeding. *Had not included nutritional adequacy of calories, protein, and fluids in her assessments. *His tube feeding pump had not been working properly. *His weight loss reflected an estimated 275 calories less per day than his needs. *Those calories would have maintained his weight and prevented weight loss. *She stated he had not received all the tube feeding as ordered that contributed to the weight loss. Review of the provider's 2/16/14 Clinical Nutrition Services policy revealed the consultant RD was to have been responsible for completing a monthly tube feeding assessment that included nutritional adequacy of calories, protein, and fluids. Review of the provider's 10/5/12 Enteral Nutrition/Hydration policy revealed: *Documentation guidelines included: -Type and amount of feeding and water administered. -Intake every shift. -Output recorded every shift. -If feeding was held. -Physician notification as necessary. Review of the provider's undated Documentation Guidelines policy regarding tube feedings revealed there was to have been: *Nutrient used. *Amount and rate. *Number of cc and calories in twenty-four hours. *Weight. Review of the provider's revised 7/16/14 Serving of Food policy revealed nursing was responsible for the feeding of tube-fed residents.

A. Based on observation, record review, interview, and policy review, the provider failed to maintain adequate nutritional status for two of two sampled residents (9 and 14) on a tube feeding resulting in weight loss. Findings include: 1. Observation on 9/3/14 at 5:05 p.m. of resident 14 in his room revealed: *A 1000 cc (cubic centimeter) ready-to-hang prefilled tube feeding container of [MEDICATION NAME] 1.2 (a tube feeding nutrition supplement). *The [MEDICATION NAME] 1.2 was infusing on the feeding pump at a flow rate of 80 cc per hour. *The pump digital reading read "183 ml (milliliters) fed." -That amount of tube feeding would have equaled 183 cc or 6 ounces (oz). *The resident was verbalizing he was "hungry" and "thirsty." Interview on 9/3/14 at 5:07 p.m. with licensed practical nurse UU regarding resident 14 revealed: *There had been "issues" with the feeding pump which had been currently beeping. *The physician had ordered his feeding to go until 6:00 p.m. that evening due to problems with the pump. *He complained about being hungry "a lot of the time." *With him "a common thing was thirst." Observation on 9/3/14 at 6:30 p.m. of resident 14 in his room revealed: *That same above container of the tube feeding. *The flow rate on the feeding pump was set at 80 cc per hour. *The feeding pump digital read "295 ml fed." -That amount of tube feeding would have equaled 295 cc or approximately 10 oz. Interview on 9/3/14 at 6:31 p.m. with registered nurse (RN) B regarding resident 14's tube feeding revealed: *There had been ongoing problems with the feeding pump not working properly. *The physician had ordered a feeding until 6:00 p.m. that night because of the pump problems. Record review on 9/3/14 of resident 14's medical record revealed he: *Had an admission date of [DATE]. *Had physician's orders [REDACTED]. *Had been on a tube feeding since admission. *Had a [DIAGNOSES REDACTED]. *Had needed extensive assistance with his care. *Had lost a total of 4.7 pounds or 3.7 percent (%) of his weight within the first month of admission. *Had lost a total of 4.6 lb or 3.6% the first month after his admission. *Had lost a total of 3.8 lb or 3.0% the first two months after his admission. *He had a physician's orders [REDACTED]." Review of resident 14's 7/7/14 Nutrition History & Data Collection Form by the consultant registered dietitian (RD) revealed: *No nutritional assessment regarding nutritional adequacy of calories, protein, or fluids. *He had a low [MEDICATION NAME] (a measurement of protein in the blood) level of 3.4 grams(g)/deciliter (dl). -A normal reference range for [MEDICATION NAME] would have been 3.5 through 5.0 g/dl. Review of resident 14's 7/11/14 Interdisciplinary Progress Notes by the consultant RD revealed: *His tube feeding was his primary means of nutrition. *No nutritional assessment had been done regarding nutritional adequacy of calories, protein, or fluids. *His feeding was to have provided 100% of his total nutrient needs as well as his water needs. *"His weight is stable." Review of resident 14's 8/24/14 Interdisciplinary Progress Notes by the consultant RD revealed: *"Overall stable for nutrition." *No nutritional assessment had been done regarding nutritional adequacy of calories, protein, or fluids. Review of resident 14's I/0 (Intake/Output) Chart Detail Report from 8/28/14 through 9/4/14 revealed: *He had an average daily intake of 662 cc. *There was no output on the report form. *That intake was less than half of what he should have received according to his physician's orders [REDACTED]. Interview on 9/4/14 at 8:15 a.m. with the director of nursing (DON) regarding resident 14 revealed: *There had been problems with his feeding pump not working properly and "beeping." *A new feeding pump had been obtained on 9/3/14. *She agreed there had not been accurate tracking on how much formula he had received since admission because of the problems with the pump. *There had been poor documentation of the resident's intake of his tube feeding and water. Review of resident 14's 7/22/14 care plan revealed: *"I want to maintain my weight." *"Monitor my weights." *There was no documentation in his care plan regarding the weight loss. Review of resident 14's weight sheet from the first week in July 2014 through the first week in September 2014 revealed *The weekly weights were not completed for: -July, weeks two and four. -August, weeks three and four. Interview on 9/9/14 at 10:35 a.m. and at 2:30 p.m. with the consultant RD regarding resident 14 revealed: *She stated she had been aware of his weight loss. *Weekly weights had not been consistently obtained. *Expected his care plan to have been updated with the weight loss. *His [MEDICATION NAME] level had been low. *His protein level needed to have been increased in his tube feeding. *Had not included nutritional adequacy of calories, protein, and fluids in her assessments. *His tube feeding pump had not been working properly. *His weight loss reflected an estimated 275 calories less per day than his needs. *Those calories would have maintained his weight and prevented weight loss. *She stated he had not received all the tube feeding as ordered that contributed to the weight loss. Review of the provider's 2/16/14 Clinical Nutrition Services policy revealed the consultant RD was to have been responsible for completing a monthly tube feeding assessment that included nutritional adequacy of calories, protein, and fluids. Review of the provider's 10/5/12 Enteral Nutrition/Hydration policy revealed: *Documentation guidelines included: -Type and amount of feeding and water administered. -Intake every shift. -Output recorded every shift. -If feeding was held. -Physician notification as necessary. Review of the provider's undated Documentation Guidelines policy regarding tube feedings revealed there was to have been: *Nutrient used. *Amount and rate. *Number of cc and calories in twenty-four hours. *Weight. Review of the provider's revised 7/16/14 Serving of Food policy revealed nursing was responsible for the feeding of tube-fed residents. Refer to F322, finding 2. 2. Observation on 9/3/14 from 5:15 p.m. through 5:30 p.m. of resident 9 revealed: *His feeding tube (tube going directly into ) was not connected and the feeding pump was not infusing at 5:15 p.m. *His feeding tube was connected and the feeding pump was infusing at 5:30 p.m. *No one had entered his room during that time frame. *Resident had history of connecting and disconnecting his own feeding tube to the feeding pump. Review of resident 9's complete medical record revealed: *An interdisciplinary progress note on 6/15/14 at 5:00 p.m. that described the resident adjusting the rate of his feeding on his tube feeding pump. -Rate had been at 186 cubic centimeters (cc) per hour instead of the 85 cc per hour ordered. *physician's orders [REDACTED]. -Check feeding tube placement before each feeding was dated 8/13/12. -Give a 200 cc flush of water through the feeding tube before and after each feeding was dated 8/12/13. -[MEDICATION NAME] (nutritional solution to go through feeding tube in place of meals) 1.0 was to have been infusing at 85 cc per hour for sixteen hours (5:00 p.m. to 9:00 a.m.) was dated 5/27/14. -[MEDICATION NAME] 1.0 was to have been infusing at 200 cc per hour for one and a half hours each noon was dated 6/23/14.-A 200 cc flush of water was to be one through the feeding tube every four hours was dated 7/23/14. Interview on 9/3/14 at 5:37 p.m. with RN B revealed she: *Was aware resident 9 had been starting and stopping his tube feeding himself. *Agreed there was no date or time documented on the [MEDICATION NAME] solution container. *Agreed he might not have been getting the correct amount of [MEDICATION NAME] or fluids ordered by the physician. *Agreed the assessments and water flushes might not have been done as ordered by physician. *Was not sure the date or time the current container of feeding solution had been hung. Observation on 9/8/14 from 12:00 p.m. (noon) to 1:07 p.m. of resident 9 revealed: *At 12:00 p.m. (noon), 12:21 p.m., and 12:40 p.m., his feeding tube was not connected or infusing. *At 12:44 p.m. his visitor left. The feeding tube was not connected or infusing at that time. *At 12:53 p.m. the feeding tube was connected to the solution and infusing at 250 cc per hour instead of the physician's orders [REDACTED]. *No one had entered the room since the visitor left. Interview on 9/8/14 at 1:08 p.m. with RN A regarding resident 9's feeding tube orders revealed she: *Believed his next feeding was at 5:00 p.m. *Stated he needed his every four hour 200 cc water flush done and proceeded to the resident's room. *Identified the feeding tube was infusing at that time. *She stopped the feeding pump and disconnected the feeding tube to administer the water flush. *She reconnected the feeding tube. *She restarted the feeding pump. *She asked the resident if he had connected his feeding tube and started his feeding. The resident stated he had. When asked why he stated no one came at noon to start it. *She was aware that resident 9 had been starting and stopping his feeding himself. *She agreed the resident had connected and started his own noon feeding without an assessment of the feeding tube placement or a water flush before starting it. *She agreed he might not have been getting the correct amount of water or [MEDICATION NAME] solution ordered by the physician. Review of resident 9's intake and output record from 6/12/14 to the present date revealed: *Inconsistent charting of feeding tube water flushes as ordered by the physician. *Occasional documentation of 300 cc 12:00 p.m. (noon) feeding tube fluid, but rare documentation of sixteen hour overnight feeding (from 5:00 p.m. to 9:00 a.m.) fluid which would have been 1,360 cc with the present physician orders. *No documentation of output had been kept. Review of resident 9's Medication Administration Record [REDACTED] *The feeding tube fluid was to be infused twice a day from 5:00 p.m. to 9:00 a.m., and 12:00 p.m. (noon), to 1:30 p.m. *The water flushes before and after feedings were set for 4:00 a.m., 12:00 p.m.(noon), and 5:00 p.m. -The times should have been 12:00 p.m. (noon), 1:30 p.m., 5:00 p.m., and 9:00 a.m. *The every four hour water flush was set for 1:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m. (noon), and 5:00 p.m. -There should have been six times not five. -At these scheduled times the tube feeding was infusing or there was another order for the tube to be flushed. -There was no documentation on clarification of these doubled flush orders with the physician. Review of resident 9's nutritional assessments by the consultant registered dietician (RD) revealed: *No monthly assessment was documented for July 2014. *An assessment on 8/24/14 titled quarterly assessment revealed the RD consultant: -Calculated the feeding formula measurement for each day using 85 cc per hour for fourteen hours instead of the sixteen hours that was ordered (5:00 p.m. to 9:00 a.m.). The missing two hours of formula would change the figures for the amount of calories and protein received.-Calculated the resident would need one 1500 cc container of the feeding formula ([MEDICATION NAME]) every twenty-four hours. The missing two hours would have required part of a second container being used each twenty four hour period. -Calculated the free water by including the 200 cc every four hours, but did not include the 200 cc before and after each feeding time (two times per day), which would add another 800 cc to the free water calculation. -She was aware the resident was adjusting the rate on his feeding tube pump. B. Based on observation, record review, interview, and policy review, the provider failed to ensure a therapeutic diet of fortified foods (have added vitamins and minerals) had been followed for one of one sampled resident (5) in the memory care unit who had lost weight. Findings include: 1. Review of resident 5's weight records revealed she had weighed 145.0 pounds (lb) in February 2013. In March 2014 her weight had dropped to 139.4 lb. That was a 3.9% weight loss. Review of resident 5's interdisciplinary notes revealed a note dated 3/6/14 from the RD that stated "eats well, although with her recent weight drop, we did add fortified foods, to avoid any further slide." Observation and interview on 9/3/14 at 5:15 p.m. with CNA Q regarding the supper meal in the memory support unit revealed: *The food trays were not identified with residents' names. *There were no diet cards on the food trays. *She delivered the textured diet trays to the three residents that had those diets. *The rest of the trays she delivered in no particular order. Review of resident 5's CNA hand-written weight records revealed she had gone from 135.8 lb in May 2014 to 128.4 lb in June 2014. The weight loss had been a significant weight loss of 5.4%. Review of resident 5's medical record revealed there was no documentation from the CNAs, RNs or RD regarding the significant weight loss or additional interventions attempted. In September 2014 her weight was 127.2 lb. Review of resident 5's 6/2/14 and 8/25/14 MDS assessments revealed she had not been identified as having weight loss. Review of resident 5's undated care plan revealed there were no goals or interventions regarding her weight loss. There were no goals or interventions that identified she was at risk for weight loss. Interview and record review on 9/9/14 at 9:05 a.m. with the RD regarding resident 5 revealed: *By using the CNA hand-written weight records she calculated the weight loss to be 5.4%. *When she was in the facility reviewing weight losses she would run a report called a "Significant Weight Change Report." *On that report the resident's weight loss had recorded as 4.9% instead of 5.4% *The report rounded the weight information up or down. *She was unsure why the report had done that. *She documented on weight loss of 5% or greater. *She should have documented on the 4.9% weight loss, because it was so close to 5%. *She had been unaware of the diet cards not being sent on the food trays to the memory care unit. Observation and interview on 9/10/14 at 7:50 a.m. in the memory care unit revealed CNA S was delivering the food trays. There were no diet cards or names on the trays. She agreed they had not known if resident 5 had been getting the fortified foods. Interview on 9/10/14 at 8:45 a.m. with the DM revealed staff were to have sent the diet cards on the food trays to the memory care unit. She was unaware they had not been sending them. Review of the provider's 12/11/12 Weight and Height policy revealed: *"If any resident has a 5 pound weight variance from their previous weight, the CNA will immediately re-weigh the resident. *If the 5 pound weight variance continues, the following will be completed: -The CNA will inform the nurse of the 5 pound weight variance. -The charge nurse will assess/evaluate probable causes for the weight variances. -The charge nurse will notify the dietician of all 5 pound weight variances, along with probable causes identified. -The dietician will notify the appropriate parties (physician and family) regarding the weight variance." Review of the provider's 5/29/03 Clinical Nutrition Services policy revealed: *"The consulting RD was responsible for completing a nutrition assessment for each resident admitted to the facility and upon a significant change. *Nutrition assessments must be completed prior to developing the resident assessment and care plan. *Progress notes are maintained for each resident in the facility and reflect progress and response to his/her care plan. *Progress notes are recorded whenever changes occur in the resident's condition and at least quarterly."

Based on observation, interview, and record review, the provider failed to ensure a primary care physician (I) had appropriately assessed, documented, and intervened for one of one sampled resident (3) who had an ongoing serious skin issue. Findings include: 1. Observation and interview on 9/3/14 at 9:15 a.m. with resident 3 revealed: *He was unshaven and had dried greenish nasal drainage in his mustache. *He looked as though he had not had a haircut for several months. His hair was quite long and unkept. *His scalp was reddened and had a large amount of dry scaling skin noted. The dry skin was layered and thick on his scalp. *Both ears were very pink, had scabbed areas on the lobes of the ears, and were scaling and dry. *The back of his neck was quite pink and had dry scaly skin. *He was hard of hearing. *He stated his scalp, ears, and neck were "itchy." *He was uncertain as to how long he had that scaling and dryness to those areas. Interview on 9/3/14 at 10:20 a.m. with registered nurse (RN) B regarding resident 3's skin issues revealed: *She stated "He is a mess." *He had the skin issues to the scalp, neck, and ears since 7/10/14. *His primary physician had seen him on 8/26/14 but had not addressed his skin issues. *There was a dermatology appointment made for September 16 through the Veteran's Administration (VA). *There had been no treatment ordered after the skin issues had been identified. *She was unsure as to the reason there had been no treatments attempted prior to his dermatology appointment. Review of resident 3's physician's progress notes and physician's orders [REDACTED]. Telephone interview on 9/3/14 at 10:30 a.m. with VA community care coordinator G and RN H regarding resident 3 revealed: *He had a dermatology appointment scheduled for September 16 by telemedicine. *He had been seen on 7/3/13 at the VA. The provider called the VA on 7/11/14, and that was when the dermatology appointment had been scheduled. *They both were unsure as to the reason there had been no medical treatment provided for resident 3's skin condition. Interview on 9/3/14 at 11:15 a.m. with licensed social worker F regarding resident 3's skin concerns revealed: *He was typically unshaven. That's who he was. *He had refused care at times. *She was unaware his scalp, neck, and ears were that bad. *She would have expected the nurses to intervene for his skin condition. *She agreed the primary care physician should have been involved with the immediate care of his scalp. Observation on 9/3/14 at 12:25 p.m. of resident 3 at the Center dining room table revealed as he was eating his noon meal he kept scratching his scalp, ears, and face. He only ate approximately 10 percent of his noon meal. Then got up from the table and left the dining room. Interview on 9/3/14 at 3:40 p.m. with RN B regarding resident 3 revealed: *There had been no medical intervention for his scalp, neck, and ears skin issues. *The VA had been contacted on 7/10/14. Interview and observation on 9/3/14 at 3:50 p.m. with the director of nursing (DON) in resident 3's room revealed: *She was unaware of his skin issues. *She agreed the skin issues were severe. *She agreed there should have been some medical treatment intervention from the primary physician or the VA prior to his dermatology appointment on September 16, 2014. Telephone interview on 9/3/14 at 4:55 p.m. with primary care physician I regarding resident 3 revealed he: *Had not felt the resident's skin condition was an emergency. *Stated, "I don't know what to do with him." *Had the skin condition for a few months. *Felt the resident was "lucky" to have had an appointment with the VA dermatology. Interview and observation on 9/4/14 at 9:45 a.m. with the medical director in resident 3's room regarding his skin issue revealed: *He was unaware the skin issue was acute. He thought it looked like a chronic condition. *He agreed the skin condition should have had medical treatment intervention by the primary physician before the scheduled dermatology appointment. There was no policy provided from the director of nursing addressing the responsibility of the primary care physician. Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., 2013, p. 278, revealed: *"Nurse/physician collaborative practice. Collaboration is a process between individuals. There is a sharing of different perspectives that are then synthesized to better understand complex problems. An outcome of collaboration is a shared solution that could not have been accomplished by a single person or organization. Nurse-physician collaboration improves patient safety and outcomes and reduces errors."

Based on interview, and policy review, the provider failed to ensure a functional infection control program was in place. Findings include: 1. Interview on 9/4/14 at 10:30 a.m. with the staff member identified as the infection control nurse revealed: *She had been hired as a Minimum Data Set (MDS) coordinator. *She was functioning as an MDS coordinator. *The infection control nurse position was delegated to her a few weeks ago when the former infection control nurse had left. *She had no training in infection control beyond basic training in nursing school. *She had no knowledge of any training that had been scheduled for her. *She was not sure she would be keeping the delegated infection control nurse role. *She expressed a need for training if she was to keep the delegated infection control role. *She was to handle the infection control segment for the residents only and not the employees. *She was not sure who had been assigned the infection control duties regarding employees. *She had not provided any instruction on infection control practices for general orientation to new employees. *She had no idea who would be teaching the scheduled September 2014 all staff inservice on infection control for the provider. *She had not completed any monitoring of the employees concerning infection control practices. Interview on 9/10/14 at 1:40 p.m. with the director of nursing revealed she believed the identified infection control nurse was responsible for infection control practices of both the residents and the employees. Review of the provider's April 2013 monitoring compliance with infection control policy revealed: *The infection preventionist or designee shall monitor the effectiveness of the infection control work practices and protective equipment. That included, but was not limited to: - Surveillance of the workplace to ensure established infection control practices were observed and protective protective clothing and equipment were provided and properly used. -Investigation of known or suspected exposures to blood or body fluids. -Investigation of known or suspected transmission of healthcare-associated infections. -Improvement in training, work practices, or protective equipment to prevent infection recurrence. -Effective implementation of hand hygiene practices by all departments. -Effective implementation of disposable gloves to present the spread of infections. Review of the provider's 2/13/13 employee infection and vaccination status policy revealed: *The medical director and the infection control coordinator would collaborate to determine the significance of any employee health condition in relation to the job responsibilities and the employees' restrictions regarding resident contact. *Staff were to have reported any exposure to a resident's blood or body fluids to the infection control coordinator or designee as soon as practical after the exposure. Review of the provider's 2/13/13 employee training on infection control policy revealed the infection control coordinator and administrator would identify those disciplines or individuals who needed task or job-specific infection control training beyond that provided by initial orientation or policies and procedures. Review of the provider's 2/13/13 employees of other employers, infection control policy revealed the infection control coordinator was responsible for informing employees of other employers of any infection control hazards they might encounter while in the work area or while on the premises.

Based on observation, interview, and policy review, the provider failed to ensure appropriate handwashing had been completed during one of one observed dressing change by one of one nurse registered nurse (RN) EEE . Findings include: 1. Observation on 10/21/14 at 9:30 a.m. revealed RN EEE performing a wound dressing change on an unidentified resident During that time she did not perform any handwashing or hand hygiene. After the dressing change task was completed, she exited the room and went down the hall with soiled hands to the public restroom and completed handwashing there. Interview at that time with RN EEE revealed that resident had tested positive for Methicillin Resistant Staphylococcus Aureus (MRSA) a highly contagious infection in both the wound and blood. Review of the provider's revised October 2010 Dressings, Dry/Clean policy revealed numerous times handwashing or hand hygiene should have been done: * Prior to putting on clean gloves. * After removal of the soiled dressing and soiled gloves. * Prior to re-packing the wound. * Removal of the soiled gloves.

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (5) with a pressure ulcer had been accurately assessed upon readmission. Findings include: 1. Review resident 5's entire medical record revealed: He had an admission date of [DATE]. *He had fell and had been sent to the hospital for surgery on 7/7/13 at 4:00 p.m. *He had returned to the facility on [DATE] at 2:50 p.m. *The last skin assessment had been completed May 2013. *Nurses notes indicated on 7/18/13 at 8:00 p.m. "Blister noted on Lt. (left) heel please note pink skin assessment form." *On 7/19/13 at 3:30 p.m. nurses notes revealed "Orders received from PCP (primary care provider) to refer res. (resident) to wound clinic for left heel." *Nurses note entry on 7/21/13 at 7:00 a.m. revealed "Left heel black area. Tender to touch." *Next entry on 7/22/13 at 4:00 p.m. "Blister to left heel cleansed and dressing changed." *7/23/13 at 6:10 p.m. nurses note revealed "Left heel ulcer, msg (message) left for WHC (wound clinic) to call me back 7/24/13 for appt (appointment) to be scheduled." *7/24/13 at 3:00 p.m. nurses note revealed "New orders for left heel wound, paint with [MEDICATION NAME] once daily, continue with blue boot to left foot. PT (physical therapy) to evaluate for pressure redistribution cushion for w/c (wheelchair). No F/U (follow-up) appt scheduled. Nurse needs to call and make appt with wound care services at ______ (phone number)." *Pink skin assessment form titled Daily Pressure Ulcer Monitoring revealed thefirst documentation had been on 7/25/13. -Daily pressure ulcer monitoring had not been completed 16 out of 31(52%) of the time from July 25, 2013 through August 30, 2013. *Weekly Pressure Ulcer Record indicated the first documentation of onset had been on 7/25/13. - Six out of ten (60%) documentations on the weekly pressure ulcer records indicated the wound bed had eschar (scab) and had been staged at level two (skin breaking open that looked like a scrape or a shallow crater). Wounds that had eschar in the bed were consider unstageable as directed by the descriptions of stages on the form. *The 7/29/13 5-day Nutrition Readmission Assessment note revealed "Skin free of pressure ulcers." *An updated 8/25/13 care plan revealed he had a pressure ulcer on his left heel. Interview on 10/2/13 at 9:00 a.m. with the director of nursing (DON) confirmed: *Resident 5 continued to have eschar on his left heel. *She would have expected the skin assessment to have been completed upon readmission to the facilty. *She would have expected the daily pressure ulcer documentation to have been completed daily. Review of the provider's undated Admit of Resident policy revealed "If a resident is discharged and readmitted , new data needs to be collected at that time." Review of the provider's undated Documentation policy revealed "Data will routinely be added to the resident's medical record, by various members of the health care team, in order to give an accurate and detailed description of the condition of the resident, the cares received and actions taken." Review of the provider's undated Skin Assessments policy revealed "Nursing department staff routinely assess each resident's skin condition during all interactions and report any concerns to a staff nurse for follow-up. All nursing personnel will continually assess residents for impaired skin intregrity."

Based on record review, interview, and policy review, the provider failed to appropriately notify the physician, and to assess, intervene, and document for one of two sampled residents (1) who had fallen and sustained an injury. Findings include: 1. Review of resident 1's interdisciplinary progress notes related to his [DATE] fall revealed: *He had been found by licensed practical nurse (LPN) A after he had fallen on [DATE] at 2:45 a.m. in the hallway outside his room. *LPN A had documented at the above time the resident had a large hematoma (bump) on the right side of his head with a moderate amount of blood coming from it. LPN A further documented she had cleansed the area with water, had applied ice to it, and had administered pain medications. No documentation of physician notification of the resident's change of condition had been noted at that time. *LPN A had noted at 3:00 a.m. that he had an old bruise to his right hand. *His family member had not been informed about the fall until 4:45 a.m. on the morning of [DATE]. *At 10:20 a.m. registered nurse (RN) B had written a late entry that involved multiple events without clear timelines. Those included: -The resident complained of being dizzy. -Physician had been called related to the fall report, and the physician had wanted ice applied to the area of injury. -Family arrived and had wanted to take the resident to the emergency room . -Addendum to the vitals included the statement the resident grunted with respirations. *At 2:00 p.m. the resident's family had reported to nursing he had sustained a neck fracture. Review of the physician's orders [REDACTED]. Review of resident 1's post fall risk assessment dated [DATE] revealed: *He had been alert and confused, his pupils had responded to light, he had strong right and left hand grasps, and he had responded to direction. That had been on all the documentation from 2:45 a.m. through 8:45 a.m. *His vitals had been stable throughout the night until 8:45 a.m. when his blood pressure had been ,[DATE]. *At 4:45 p.m. it had been documented he was hospitalized . Review of resident 1's non-pressure skin condition report dated [DATE] with no time on it revealed: *The hematoma to the right side of his forehead had been seven centimeters (no description was noted to indicate if that measurement was the width or length of the hematoma). *The depth of the hematoma was documented as 0.1 centimeters. *A moderate amount of blood was noted coming from the hematoma. *No documentation the bleeding had stopped or if a bandage had been applied. Review of resident 1's hospital records starting on [DATE] revealed: *His family had brought him to the emergency room . *At the time he had been admitted it had been noted he had swelling and bruising to the right side of his face, forehead, and both eyes. *He had been seen in the emergency room the morning of [DATE] and had been found to have a cervical (neck) fracture, and he had received treatment for [REDACTED]. Interview on [DATE] at 5:00 p.m. with LPN A per telephone call with the director of nursing (DON) and the interim administrator present revealed: *She confirmed she had been the nurse on duty at the time of resident 1's fall on [DATE]. *When she had found resident 1 on the floor outside his room he had a large hematoma on his head, and it was bleeding. After assessing him she had stood him up, brought him back to his room, and had given the treatment documented in the interdisciplinary progress notes. *When asked to describe the injury she was uncertain how to describe it as she could not remember it that well. *She had not notified the physician at all during her shift of work. *Her shift had ended at 6:00 a.m. on [DATE]. *She had not notified resident 1's physician of the fall resulting in a seven centimeter hematoma as she "...thought he was okay." *She did not remember any changes to the injury over the remainder of her shift of work. Interview and policy review on [DATE] at 5:20 p.m. with the DON and the interim administrator regarding resident 1 revealed: *Nursing documentation from LPN A had not been complete and had not described the extent of injury fully to the resident. *The physician should have been notified immediately of the significant injury that had resulted from the unwitnessed fall. *According to the provider's revised [DATE] policy on resident falls the following was to have been done: "If there is a head injury, severe pain, weight bearing pain, or if the resident is not able to move extremities after the fall (change in condition) the resident's physician will be notified before the resident is further moved." *LPN A had not followed the above policy. Interview on [DATE] at 10:15 a.m. with RN B, the DON, the interim administrator, and the administrator in training revealed: *RN B had taken over the care of resident 1 on [DATE] at 6:00 a.m. *RN B had first assessed resident 1 on [DATE] at 6:45 a.m. At that time resident 1's right side of his face, forehead, and eye had been swollen and bruised. His right eye had been so swollen it was closed shut. His left eye and nose had begun swelling and had started to bruise. At the time of that assessment no documentation indicating that change from LPN A's assessment had been documented. The physician had not been notified of the condition of the resident. *RN B stated she should have immediately notified the physician upon her first assessment and could not explain why she had not. *Resident 1 was allowed to have been out of bed the morning following the above fall in a wheelchair and had been transferred back and forth from the wheelchair to the bed. *RN B was unable to determine from her documentation all of the events of that morning and the extent of resident 1's injuries. She agreed her documentation was confusing and incomplete. *RN B was unable to explain how resident 1's pupils were assessed in the [DATE] post fall assessment record if his right eye had been swollen shut. No explanation was given. *RN B stated she had not thought much of the grunting respirations during her assessments, because the resident stopped grunting if asked to. It was not until after the resident had been found to have a neck injury at the hospital that RN B knew what grunting respirations could have meant during her assessment of resident 1. *RN B had not contacted the physician until the family had arrived around 10:00 a.m. after the family had stated they were taking the resident to the emergency room . *Resident 1 had been transported to the family's vehicle per wheelchair by the family and staff. He had the been taken to the emergency room per the family with no nurse in attendance for the care of the resident. *That transfer had not been documented in any portion of resident 1's medical record. Interview on [DATE] at 10:35 a.m. with the DON, interim administrator, and the administrator in training revealed: *They agreed proper nursing assessment, documentation, and physician notification had not occurred after resident 1's [DATE] fall with significant injury. *They were unable to inform this surveyor of the outcome of that fall as resident 1 had not returned to the facility. Interview on [DATE] at 10:15 a.m. with the family member who had come to check resident 1 the morning of [DATE] revealed: *She was met prior to entering the resident's room by RN B and told not to be scared as her father, resident 1 looked like "the elephant man." RN B had told her she might need to contact the doctor for some laboratory samples for resident 1. *Upon entering resident 1's room she had found him half on the bed and half on the floor with his face bruised, swollen, and he had complained of dizziness to her. She took a picture of him with her cell phone and had sent it to her sister at which time her sister had called back and said he needed to go to the emergency room . She informed RN B she was taking her father to the emergency room . Staff had assisted her in transferring him to a wheelchair and into her car. *Upon arrival at the emergency department the physician immediately ordered a cervical collar to be applied to his neck. Later it was found with x-ray that resident 1 had sustained a neck fracture. *Resident 1 died as a result of complications from his injuries. Review of Medline Plus Encyclopedia, "Head Injury and Neck Injury", Service of the National Institute of Health, http://www.nlm.nih.gov/medlineplus/ency/article/ 8.htm, ([DATE]) revealed: *In the case of a serious head or neck injury 911 should be contacted immediately. *Signs of head and neck trauma can include: agitation; confusion; restlessness; fluid draining from the nose, mouth and ears; changes in the size of the pupils; behavioral changes; and lack of coordination. *Persons with suspected significant head and neck injuries should not be moved. All attempts should be made to immobilize the injured persons neck and back to prevent further injury. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO, pp. 279 through 298 and 477, revealed: *A complete and accurate nursing assessment was a critical part of the nursing process. *Complete and appropriate documentation was a vital aspect of nursing practice. *"Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice." Review of the South Dakota Board of Nursing's Administrative Rules, Chapter 20:48, revealed: *"A licensee is personally responsible for the actions that the licensee performs relating to the nursing care furnished to clients and cannot avoid this responsibility by accepting the orders or directions of another person." *"The registered nurse is responsible for the nature and quality of nursing care that a client receives under the nurse's direction." *"The licensed practical nurse may practice in two general settings: with at least minimal supervision when providing nursing care in a stable nursing situation; and with direct supervision when providing nursing care in a complex nursing situation." *"The licensed practical nurse shall consult with a registered nurse or other health team members and seek guidance as necessary and shall obtain instruction and supervision as necessary."

Preceptor: Based on observation, interview, record review, and policy review, the provider failed to prevent pressure ulcers from developing in one of five sampled residents (1) with pressure ulcers. Findings include: 1. Review of resident 1's 9/8/11 MDS (Minimum Data Set) Care Area Assessment Documentation Notes revealed: *Resident made no attempt to move any parts of her body. *She was totally dependent with all aspects of her care. *She had two pressure ulcers that were being treated by a wound clinic. *She was totally dependent in all aspects of her daily living. *She needed to be dressed, transferred, fed and was incontinent of bowel and bladder. *She had a Foley catheter in place to aid in the healing of the pressure ulcer on her buttocks. *She had daily treatments to those areas. *The nurses were to inspect her skin and record their findings. *She had diabetes. *She has had pressure areas before in other areas that have healed. Review of resident 1's licensed nurse notes revealed: *On 6/6/11 an entry had been made in the licensed nurse notes: "[MEDICATION NAME] to rash on lower left buttock, dry chafed spot from brief rubbing continually. No other concerns." *On 6/20/11 "Res (resident) has warm dry skin. Heels dry, lotion applied. [MEDICATION NAME] applied to coccyx et (and) back gluteal (buttock) folds." *6/26/11 at 10:30 a.m. "Skin Assessment - Two open areas noted. Area to coccyx (tailbone region) measures 1.0 cm (centimeters) x 1/2 cm. PCP (primary care physician) notified. Facility dietary notified-Will continue to monitor." *7/4/11 "areas on coccyx; buttock same center sl. (slight) yellow of larger one - no other concerns." *On 7/11/11 at 1:15 p.m. "No new areas of skin concern noted." *7/18/11 at 10:00 p.m. "[MEDICATION NAME] to coccyx. No other new areas of concerns noted." *7/25/11 at 2:35 p.m. "No new areas of skin concerns noted." *8/1/11 "Open area on R (right) buttock remains the same with dark eschar, no s/s (signs or symptoms) of infection in peri (perineal) wound area. [MEDICATION NAME] not applied as CNA's (certified nursing assistants) had covered area with [MEDICATION NAME] ointment et.(and) [MEDICATION NAME] will not stick. No other concerns." *8/8/11 at 10:00 p.m. "Open area on R buttock remains dark eschar, open slit area on coccyx, [MEDICATION NAME] applied to R buttock an coccyx. No other areas of concern noted." *8/15/11 "Open area rt (right) buttock continues dark eschar-area on coccyx now 2 cm round open - message left for skin team about area." *8/22/11 6:45 p.m. "No new area of skin concerns noted. Urine is running on open area. Fax out to Dr. (doctor) to cath (catheterize) till (til) area healed." 8/29/11 1:15 p.m. "No new areas of skin concerns noted." *9/12/11 "Area on buttock remains open, black et. (and) red wound bed. santyl tx (treatment). *9/19/11 at 10:45 a.m. "No new areas of skin concerns noted." Review of resident 1's interdisciplinary notes revealed: *6/26/11 at 10:10 a.m. "Two open areas noted to resident's skin coccyx measures 0.8 cm x 1.2 cm. area to R buttocks measures 1.0 cm x 1.2 cm. PCP (primary care physician) notified. Attempted to notify family. All numbers listed have been disconnected. Will continue to monitor." *6/27/11 at 4:20 p.m."Orders rec'd (received) noted re (regarding): above note, have skin team evaluate, copy to RN (registered nurse) F. *7/26/11 at 11:50 a.m. RTF (returned to facility) via w/c (wheelchair) express after 60 day renewals with PCP." *8/22/11 at 8:00 p.m. "Orders rec'd (received) for Foley cath (catheter) Placed 14 fr (french) cath without diff. (difficulty). Res tol (tolerated) well. Clear yellow urine returned. Orders faxed to pharm (pharmacy) et placed on MAR's (medication administration records)." *8/31/11 at 3:45 p.m. "RTF at this time. Had F/U (follow-up) at wound clinic, wound nurse does call with report, orders are pending via fax from PCP. She does report that we need to send supplies with next appt. (appointment), wound is deeper/bigger (to be expected when using a debridement agent) must lay down immediately after meals, et to never leave lift jacket/sling underneath her when she is laying down." "Addendum: Wound clinic does also report she had done some mechanical debridement, et wound does measure 4 x 3.5 x 1.0 R buttock, et gluteal crease does measure 2 x 1.5 cm." Review of resident 1's Pressure Ulcer Healing Chart revealed: *Ulcer location is the R buttock. -On 6/26/11 measurement was 1 cm. x 1.2 cm. -On 7/12/11 2 cm. x 2 cm. -On 8/11/11 4.7 cm. x ? (question mark in lieu of measurement documented). -On 8/31/11 4 cm. x 3.5 cm. -On 9/15/11 5.2 cm. x 3.5 cm. *There was no consistent documentation found regarding measurements of the pressure ulcer. Observation on 9/20/11 at 1:40 p.m. of resident 1's dressing change revealed: *Resident was lying on her left side *The resident was in a fetal position. *LPN A removed the dressing that revealed: -A large and deep area on R buttock. -Fire engine red in appearance. *There was another open area on the coccyx area. Interview on 9/20/11 at 1:50 p.m. with LPN A revealed: *She did not believe resident 1 had a special pressure relieving mattress. *She believed the pressure area had started from pressure or urine due to the resident's incontinence. *She stated the foley catheter had been placed after the wound opened because of the resident 1's incontinence. *She had never measured the wound because resident 1 had gone to the wound clinic on Monday, Wednesdays, and Fridays and she had thought the wound clinic would measure the wound. Interview on 9/20/11 at 3:30 p.m. with the director of nursing (DON) regarding resident 1 revealed: *She had a pressure relieving mattress. *The DON had not observed resident 1's open areas. Interview on 9/20/11 at 3:45 p.m. with nurse manager B revealed: *She had seen resident 1's open areas. *She did not feel the areas were pressure related. *She thought the area was more of a shear injury caused by repositioning. Review of resident 1's August 2011 routine medication sheet revealed: *They were to reposition her every 2 hours while in bed. *Repositioning from 8/18/11 through 8/30/11 revealed it had not been documented as done seven times. Review of resident 1's September 2011 treatment sheet revealed: *Reposition every 2 hours while in bed. *Repositioning from 9/1/11 through 9/19/11 revealed seven unsigned entries. Review of resident 1's care plan dated 3/25/11 regarding pressure ulcers revealed: "I have Diabetes and I have been told that I am at risk for pressure ulcers. I need staff to keep a close watch on my bony areas. I need the CNAs to monitor my skin closely each shift and also the licensed nurses to inspect my skin weekly and record their findings and report to the Skin Team if they see any areas of concern. I need to be repositioned every 1-1/2 to 2 hours to avoid prolonged pressure to any bony areas. I also need to be laid down between meals and make certain that my heels are off the bed, so use pillows for adequate positioning." Review of resident 1's care plan dated 9/12/11 regarding pressure ulcers revealed: "I need the CNAs (certified nursing assistants) to monitor my skin closely each shift and also the licensed nurses to inspect my skin weekly and record their findings and report to the Skin Team if they see any areas of concern.' Review of the provider's March 2005 Skin Assessment policy revealed: *The purpose of the policy is to monitor residents known to have history of or be at risk for pressure ulcers or have skin breakdown. *Staff nurse/skin team will perform skin assessments weekly. *Pressure related skin integrity issues that are identified are followed by the skin team who will document on the weekly pressure ulcer record. *Skin team will meet weekly and do skin assessments on all residents with pressure related skin integrity issues. *The team will assess the wounds, measure and provide interventions to assist in the wound healing; all assessments will be documented in skin assessment notebook by a skin team member. *Every wound is seen weekly by the skin team/ staff nurse until the wound is closed/healed.