Every finding on record at Avantara Pierre

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interview, the provider failed to protect the resident's right to be free from neglect for two of two sampled residents (1 and 2) who were refused incontinence care and repositioning assistance by one of one contracted travel certified nurse aide (CNA) (E) and three of three sampled residents (3, 4, and 5) who were refused incontinence care and repositioning assistance by one of one contracted travel CNA (G). 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 7/16/26 SD DOH FRI revealed that CNA/RMA D reported that when she got resident 1 up on 7/16/26, she observed that the resident was double-briefed (wearing two incontinence absorbent briefs at the same time. This practice traps heat and moisture, increasing the risk of skin breakdown, pressure ulcers, and urinary tract infections). There was dried bowel movement (feces) in and around the resident's peri-area and inside the resident's incontinence brief. Minimum Data Set (MDS) nurse C assessed the resident's skin and confirmed CNA/RMA D's findings. Director of nursing (DON) B determined that contracted travel CNA E was responsible for resident 1's care during the 7/15/26 overnight shift. Contracted travel CNA E was suspended from working pending the provider's investigation of the incident. Review of resident 1's electronic medical record (EMR) revealed her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities), obesity, and bowel and bladder dysfunction. Her 6/28/26 Brief Interview for Mental Status (BIMS) assessment score was 8. That indicated her cognition was moderately impaired. Section GG of her 6/28/26 MDS assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) indicated she was dependent on the staff for her toileting needs. Interview on 8/6/26 at 9:15 a.m. with CNA/RMA D revealed that she confirmed the above information. She stated there were no further incidents with the overnight shift staff or other staff related to providing incontinence to the residents since that incident that she knew of. Interview on 8/6/26 at 10:30 a.m. with resident 1 revealed that she very vaguely recalled the above incident, but she could not recall any details related to it. She voiced no current concerns regarding the care that the staff provided for her. Continued review of the 7/16/26 SD DOH FRI revealed that contracted travel CNA F reported on 7/16/26 that during the 7/15/26 overnight shift, contracted travel CNA E failed to change resident 2's incontinence brief. The resident told contracted travel CNA F that while he was in his bathroom, he asked contracted travel CNA E for assistance to put on a clean incontinence brief. Contracted travel CNA E threw a clean brief towards him, and indicated he could put it on himself. When resident 2 told contracted travel CNA E that he needed help to do that, she declined to assist him and walked out of his room. Review of resident 2's EMR revealed that his diagnoses included Parkinson's disease (a progressive medical condition that affects movement), dementia, and bladder dysfunction. His 6/14/26 BIMS assessment score was 15. That indicated his cognition was intact. Section GG of his 6/14/26 MDS assessment indicated that he required substantial/maximum assistance from the staff to meet his toileting needs. Interview on 8/6/26 at 10:45 a.m. with resident 2 revealed that he recalled the above incident. He knew contracted travel CNA E no longer worked at the facility. He had no problems with the staff assisting him with his care in a timely and appropriate manner since that incident. Contracted travel CNA F was not available to interview during the survey. Review of contracted travel CNA E's personnel file and her July 2026 time card revealed she was hired on 5/25/26. She completed the Abuse/Neglect and Restraint-Free Environment trainings on 5/1/26. A pre-employment background check was completed with no adverse findings. Contracted travel CNA E did not work at the facility since clocking out on 7/16/26 at 6:00 a.m. She was placed on a permanent do-not-return to work list by the provider, and her employment agency was notified of the above incident. The provider substantiated the allegation of resident neglect. The provider's implemented actions to mitigate the likelihood of the deficient practice from reoccurring were verified on 8/6/26 after record review, and interview with administrator A revealed that the facility had followed its Quality Assurance and Performance Improvement (QAPI) process regarding resident neglect by assessing resident 1 and 2's skin immediately after the above incidents were reported and reassessing their skin weekly thereafter. Skin assessments were completed for all of the other residents residing on the west hall that contracted travel CNA E was assigned to during the 7/15/26 overnight shift. Nineteen residents were interviewed beginning on 7/17/26. Interview questions included: if the resident felt safe in the facility, if they were checked/changed and/or assisted with their toileting needs when they requested staff assistance, if they were double-briefed by the staff, and if they were verbally or mentally abused by the staff. In addition, weekly audits of five random residents were implemented to monitor the status of residents' safety, toileting needs, incontinence brief usage, and any signs of neglect or abuse. Resident 1 and 2's family representatives, their medical providers, local law enforcement, the SD DOH, the long-term care ombudsperson, and the SD Board of Nursing were notified of the above incidents. The incident was brought to the facility's QAPI meeting for further review by that interdisciplinary team. Based on the above information, non-compliance at F600 occurred during the 7/15/26 overnight shift, and based on the provider's corrective action plans that were initiated on 7/16/26 and implemented for the deficient practice confirmed on 8/6/26, the non-compliance is considered past non-compliance. 2. Review of the provider's 7/28/26 SD DOH FRI revealed that on 7/28/26 resident 3 reported to contracted travel CNA H that she was upset by the care that contracted travel CNA G had provided her during the 7/27/26 overnight shift. Resident 3 asked contracted travel CNA G to assist her to the bathroom before going to bed for the night. Her incontinence brief was soiled. Contracted travel CNA G refused to assist resident 3 to the bathroom stating, You're already wet. Additionally, when resident 3 asked contracted travel CNA G for a pillow to be placed by her feet, CNA G didn't listen when the resident told contracted travel CNA G she had used the wrong one [pillow]. When resident 3 pressed her call light later that shift, contracted travel CNA H responded and addressed the resident's needs. Review of resident 3's EMR revealed her diagnoses included macular degeneration (an eye disease that causes blurriness or loss of the central vision) and osteoarthritis (a joint disease). Her 4/29/26 BIMS assessment score was 15. That indicated her cognition was intact. Section GG of her MDS assessment indicated that she was dependent on the staff for her toileting needs. Interview on 8/6/26 at 12:01 p.m. with resident 3 revealed she recalled the above incident. She stated it was an isolated incident with contracted travel CNA G. She knew that contracted travel CNA G was no longer working at the facility. The resident stated that since the incident, she has had no concerns with the staff responding to and assisting her with her toileting needs. She felt that the staff were respectful towards her. Contracted travel CNA H was not available to interview during the survey. Continued review of the 7/28/26 SD DOH FRI revealed that during the 7/27/26 overnight shift, contracted travel CNA H entered resident 4's room and found the resident's call light was not within the resident's reach. The resident told contracted travel CNA H that when contracted travel CNA G was in her room earlier that shift, she asked contracted travel CNA G to reposition her on her side. Contracted travel CNA G refused to help her. Review of resident 4's EMR revealed her diagnoses included dementia and muscle wasting. Her 7/6/26 BIMS assessment score was 11. That indicated her cognition was moderately impaired. Section GG of her MDS assessment indicated that she was dependent on the staff to be rolled side to side in bed. Continued review of the 7/28/27 SD DOH FRI revealed that during the 7/27/26 overnight shift, CNA I asked contracted travel CNA G to assist resident 5 to use the bathroom before helping the resident to bed. Resident 5 slept in her recliner. Contracted travel CNA G acted like she did [assist the resident to use the bathroom, then helped the resident into her recliner], but when CNA I went into resident 5's room later that shift, the resident reported she was not taken to the bathroom by contracted travel CNA G. Resident 5 was also not in her recliner. Review of resident 5's EMR revealed her diagnoses included progressive multiple sclerosis (a chronic autoimmune disease that causes fatigue, vision problems, and muscle weakness), heart failure, and kidney disease. Her 5/20/26 BIMS assessment score was 15. That indicated her cognition was intact. Section GG of her MDS assessment indicated that she was dependent on the staff for her toileting and transfer needs. Interview on 8/6/26 at 12:05 p.m. with resident 5 revealed that she did not remember the above incident. She had no concerns regarding the toileting or repositioning assistance that the staff provided her. She felt that the staff treated her with respect. Review of contracted travel CNA G's personnel file and July 2026 time card revealed she was hired on 5/25/26. Her CNA certification expiration date was 12/22/27. She completed the Abuse, Neglect, and Exploitation educational training on 7/11/26. A pre-employment background check was completed and had no adverse findings. Contracted travel CNA G's July 2026 time card indicated she did not work at the facility since clocking out on 7/27/26 at 6:06 a.m. She was placed on a permanent do-not-return to work list by the provider, and her hiring agency was notified of the above incident. The provider substantiated the allegation of resident neglect. The provider's implemented actions to mitigate the likelihood of the deficient practice from reoccurring were verified on 8/6/26 after record review, and interview with administrator A revealed that the facility had followed its QAPI process regarding resident neglect by assessing resident's 3, 4, and 5's skin immediately after the above incidents were reported and reassessing their skin condition weekly thereafter. The provider interviewed 22 residents on both the east and west resident living units regarding whether they felt safe in the facility, whether the staff met their toileting needs in a timely manner, whether their call light was left within their reach, and whether the staff met their care needs appropriately when their assistance was requested. In addition, staff education was initiated on 7/28/26 regarding the provider's abuse and neglect policies, abuse and neglect reporting requirements, resident rights, and caring for residents with dementia. A weekly audit process was started that included interviewing the residents regarding whether they felt safe in the facility, whether the staff met their toileting needs, whether the staff ensured their call light was within their reach, whether the staff assisted them to bed when they requested their assistance, and whether the staff appropriately assisted them with their care needs when their assistance was requested. Residents 3, 4, and 5's family representatives, their medical providers, local law enforcement, the SD DOH, the long-term care ombudsperson, and the SD Board of Nursing were notified of the above incidents. The incident was brought to the facility's QAPI meeting for further review by that interdisciplinary team. Based on the above information, non-compliance at F600 occurred during the 7/27/26 overnight shift, and based on the provider's corrective action plans that were initiated on 7/28/26 and implemented for the deficient practice confirmed on 8/6/26, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure the staff provided accident prevention interventions and device use according to the resident's care plans (personalized plan that addresses a resident's care needs, goals, and interventions) for one of one sampled resident (29) who needed to be transferred with the use of a full body mechanical lift (a mechanical lift and sling used to lift a person's full body) and sustained a laceration (cut or torn skin) on his right lower leg when certified nursing assistant (CNA) R and contracted travel CNA S assisted the resident to pivot-transfer (when assisted to a standing position, the resident then turns their body to move to another surface) as directed by one of one licensed practical nurse (LPN) K. The resident subsequently was transferred to the emergency room for evaluation and laceration repair with staples and stitches. Findings include:1. Review of the provider's 6/9/26 SD DOH FRI revealed that on 6/9/26 at approximately 11:00 a.m., contracted travel CNA T transferred resident 29 into a shower chair with the use of a full body mechanical lift. After resident 29's shower, CNA T attempted to transfer the resident with a sit-to-stand mechanical lift (a mechanical lift used to assist a person from a seated to a standing position). Resident 29 became upset and refused to transfer with the use of the sit-to-stand lift, stating that he could stand. Contracted travel CNA T moved the shower chair in front of a grab bar and assisted resident 29 to stand using the grab bar and a gait belt (a waist strap gripped as support for safe mobility and transfers), positioned his wheelchair behind resident 29, and he sat down in the wheelchair.At approximately 11:20 a.m. CNA R and contracted travel CNA S were going to transfer resident 29 from his wheelchair to his bed. There was not a full body mechanical lift sling under resident 29 in his wheelchair. CNA R asked licensed practical nurse (LPN) K how they should transfer resident 29 since he did not have a full body mechanical lift sling under him, and LPN K advised them to transfer resident 29 with a two-person assisted pivot transfer.CNA R and contracted travel CNA S pivot transferred resident 29 from his wheelchair to his bed without the use of a gait belt. During that pivot transfer, resident 29 told CNA R and contracted travel CNA S that his legs were tangled. When resident 29 was in his bed, CNA R and contracted travel CNA S noticed resident 29 was bleeding from his leg that which caused by an area on the bed frame that was missing a cover plug.LPN K was notified of the bleeding and assessed resident 29's leg. LPN K found a large skin tear and a puncture on the outside of resident 29's right lower leg. Resident 29 was transported by ambulance to the emergency room for evaluation of his right lower leg laceration. While in the emergency room, resident 29's laceration was repaired with staples and stitches. He returned to the facility with physician's orders for wound care every shift and cephalexin (an antibiotic) to be administered four times per day until 6/16/26. 2. Review of resident 29's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 5/18/26 Brief Interview of Mental Status (BIMS) assessment score was 9, which indicated his cognition was moderately impaired. His diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with agitation. Resident 29's 6/29/26 care plan indicated he used a two-person full body mechanical lift for all transfers since 11/8/24. The care plan did not indicate the full body lift sling was supposed to be left under resident 29 after a transfer was completed, according to the provider's policy.A 6/9/26 Skin Alteration Evaluation indicated resident 29's laceration on the outside of his right lower leg was one centimeter (cm) in length by six cm in width with an unknown depth. There was a large amount of bloody drainage from the laceration and Yes was answered to the question, Is the resident experiencing any pain?A progress note on 6/9/26 at 4:50 p.m. written by LPN K stated, Resident [29] returned from [name redacted] ER [emergency room] accompanied by [the] staff. RT [right] leg is wrapped with [an] ACE bandage and elevated on [a] foot rest. Dressing is dry/intact. Denies any pain. New orders received: Cephalexin 500 mg [milligrams] po [by mouth] qid [four times per day] x [for] 7 days, F/U [follow up] with [redacted name] wound care on 6/11/26 and F/U with [redacted physician name] prn [as needed]. [The] Resident was also given a Tetanus boost [booster] in the ER. 3. Observation and interview on 6/29/26 at 12:45 p.m. with resident 29 in his room revealed he had a full body mechanical light sling draped over his wheelchair. He was resting in bed. There were bed plugs (plugs placed in the open holes in the bed frame to cover the sharp edges of the holes) in the frame of the bed. Resident 29 did not know if he had ever been transferred in any other way than with a full body mechanical lift. He did not know if he had a cut on his leg. 4. Interview on 7/1/26 at 7:49 a.m. with administrator A revealed that the maintenance department staff did not check the residents' beds routinely to be sure the beds were working and that they did not require maintenance. The staff were educated to put a work order into the computer system for the maintenance staff to review if there were any issues identified with the residents' beds that required intervention. After resident 29 cut his leg on his bed frame there was a full facility sweep (check) of the residents' beds which identified the beds that were missing cover plugs on the bed frames. Coban (a cohesive elastic wrap) was placed on the bed frames with missing bed plugs until the bed plugs that were ordered arrived for installation. 5. Review of the 6/9/26 Full House Sweep on Bed Plugs documentation revealed there were 38 beds identified as missing bed plugs. The bed plugs were ordered for those beds missing bed plugs, and the bed plugs were installed on those beds, once they arrived at the facility. 6. Interview on 6/30/26 at 5:45 p.m. with contracted travel CNA S revealed that on 6/9/26 CNA R had asked her to help pivot transfer resident 29 from his wheelchair to his bed. Contracted travel CNA S told CNA R that resident 29 was to use a full body mechanical lift to transfer from his wheelchair to his bed. CNA R told contracted travel CNA S that she got permission from LPN K to transfer resident 29 by pivot transfer because there was no full body mechanical lift sling under him in his wheelchair. Contracted travel CNA S and CNA R completed a pivot transfer with resident 29 from his wheelchair to his bed without the use of a gait belt. When the pivot transfer was completed, they noticed resident 29's leg was bleeding, and notified LPN K. Contracted travel CNA S thought resident 29's leg got caught on the bed frame, which caused the laceration on his right leg. 7. A scheduled phone interview was attempted on 7/1/26 at 9:00 a.m. with contracted travel CNA T. Contracted travel CNA T did not answer the phone call and did not return the phone call by the completion of the survey. 8. Phone interview on 7/1/26 at 11:01 p.m. with LPN K revealed she was the nurse on duty when resident 29's leg was cut by the bed frame during a transfer. CNA R told her that resident 29 did not have a full body lift sling under him in his wheelchair and CNA R needed to transfer him into bed. LPN K knew that resident 29's care plan indicated he was supposed to transfer with the full body mechanical lift, but she did not think the CNAs would be able to put the full body lift sling under him while he was in the wheelchair. LPN K advised CNA R to pivot transfer resident 29 from his wheelchair to his bed. LPN K thought the CNAs would be able to pivot transfer resident 29 safely but stated that was a bad call.CNA R had alerted LPN K that resident 29's leg was bleeding after the pivot transfer from his wheelchair into his bed was completed. LPN K assessed resident 29's legs, which were swollen and he had thin skin. When his legs were against the bed frame he sustained a laceration on his right leg. She described the laceration as a big gash that bled a lot. LPN K felt that resident 29 needed to go to the emergency department to have the laceration evaluated. She covered the laceration with gauze dressing and an ace wrap and sent resident 29 to the emergency room by ambulance. 9. Phone interview on 7/1/26 at 11:30 a.m. with CNA R revealed she and contracted travel CNA S were going to transfer resident 29 from his wheelchair into his bed after his shower on 6/9/26. He did not have a full body mechanical lift sling under him in his wheelchair. CNA R asked LPN K how to transfer him because the full body mechanical lift sling was not under him, and LPN K told her to pivot transfer him. CNA R and contracted travel CNA S pivot transferred resident 29. CNA R did not know resident 29's leg was against the metal bed frame, and the metal bed frame punctured his leg. CNA R stated that she knew that resident 29 was supposed to be transferred with a full body mechanical lift, but she did not think they could get the sling under him when he was already in the wheelchair. 10. Interview and review of the staff education documentation on 7/1/26 at 3:35 p.m. with director of nursing (DON) B revealed she expected the staff to follow each resident's care plan when they provided care for that resident. She acknowledged resident 29's care plan was not followed by LPN K, CNA R or contracted CNAs S and T. She expected all staff to review the education that was provided to them related to the provider's care plan policy, the abuse and neglect policy, the policy related to transferring a resident with the use of a gait belt, and the mechanical lift policy. She acknowledged that all of the contracted travel staff failed to sign the education documentation to indicate they had received the education after 6/9/26 incident. 11. Review of the provider's 5/14/25 Care Plans policy revealed, Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. Each staff member working with the individual resident is responsible to read, utilize and offer input to improve the care plan content ongoing. 12. Review of the provider's 11/18/25 Transfer or Gait Belt Use policy revealed, A transfer belt or gait belt must be used with each assisted transfer and assisted ambulation, unless [the] care plan indicates otherwise. 13. Review of the provider's 5/14/25 Mechanical Lifts policy revealed, Staff will be trained on the use of mechanical lifts upon hire and annually with return demonstrations. The sling may be left under the resident after the transfer if it is resident preference or if removing/placing sling may cause resident pain or skin problems. If sling is left under the resident, the reason for such should be care planned.

Based on record review, interview, and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, the provider failed to ensure 19 of 19 sampled residents (5, 6, 7, 23, 24, 28, 29, 34, 35, 36, 37, 38, 39, 43, 44, 53, 54, 55, and 57) Minimum Data Set (MDS) assessments (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) were signed by a registered nurse (RN), to verify their MDS assessments were completed, within 14 days after the assessment reference date (ARD) (the specific end date of the observation period used to complete the MDS) and a discharge assessment was completed for one of one sampled discharged resident (31) who was transferred to a hospital and did not return to the facility. Findings include:1. Review of resident 36's electronic medical record (EMR) revealed her entry tracking MDS ARD was 6/1/26, and the RN signature completion date was 6/16/26.2. Review of resident 24's EMR revealed his annual MDS ARD of 5/22/26, and the RN signature completion date was 6/12/26.3. Review of resident 54's EMR revealed her annual MDS ARD was 5/29/26, and the RN signature completion date was 6/23/26.4. Review of resident 55's EMR revealed his end of PPS stay MDS ARD was 5/28/26, RN signature completion date was 6/17/26. His significant change MDS assessment ARD was 5/26/26, and the RN signature date was 6/17/26.5. Review of resident 5's EMR revealed her quarterly MDS ARD was 5/27/26, and the RN signature completion date was 6/18/26.6. Review of resident 6's EMR revealed his quarterly MDS ARD date was 5/16/26, and the RN signature completion date was 6/5/26.7. Review of resident 7's EMR revealed her quarterly MDS ARD was 5/21/26, and the RN signature completion date was 6/12/26.8. Review of resident 23's EMR revealed her quarterly MDS ARD was 5/6/26, and the RN signature completion date was 5/28/26.9. Review of resident 28's EMR revealed her quarterly MDS ARD was 5/31/26, and the RN signature completion date was 6/26/26.10. Review of resident 29's quarterly MDS ARD was 5/18/26, and the RN signature completion date was 6/9/26.11. Review of resident 34's EMR revealed her quarterly MDS ARD date was 5/27/26, and the RN signature completion date was 6/17/26. 12. Review of resident 35's EMR revealed her quarterly MDS ARD was 5/11/26, and the RN signature completion date was 6/3/26.13. Review of resident 37's EMR revealed his quarterly MDS ARD was 2/25/26, and the RN signature completion date was 4/10/26.14. Review of resident 38's EMR revealed her quarterly MDS ARD was 5/20/26, and the RN signature completion date was 6/9/26.15. Review of resident 39's EMR revealed her quarterly MDS ARD was 5/12/26, and the RN signature completion date was 6/3/26.16. Review of resident 43's EMR revealed his quarterly MDS ARD was 5/25/26, and the RN signature completion date was 6/12/26.17. Review of resident 44's EMR revealed her quarterly MDS ARD was 5/25/26, and the RN signature completion date was 6/15/26.18. Review of resident 53's EMR revealed his quarterly MDS ARD was 5/20/26, and the RN signature completion date was 6/12/26.19. Review of resident 57's EMR revealed her quarterly MDS ARD was 5/10/26, and the RN signature completion date was 5/30/26.20. Review of resident 31's EMR revealed she was transferred to the hospital on 3/11/26, did not return, and was discharged from the facility on 3/16/26. There was no discharge return anticipated or return not anticipated MDS assessment completed.21. Interview on 7/1/26 at 8:05 a.m. with RN/MDS coordinator D regarding the process for MDS assessment completion revealed she used the RAI manual that was located within the provider's electronic medical record system for reference. She was not certain which version of the RAI manual it was.RN/ MDS coordinator D confirmed she was responsible for reviewing each resident's MDS assessment for completion and for signing the Z0500 section of the MDS. She knew the requirement was for an RN to review and sign that the MDS was completed within 14 days of the MDS ARD. She was aware the MDS's were not always signed within those 14 days.Regarding resident 31's discharge MDS assessment, RN/MDS coordinator D confirmed there was no discharge MDS completed. She stated, I must have missed that.

Based on observation, interview, and policy review, the provider failed to ensure insulin pens with shortened expiration dates (medications that, after opening, expire before the manufacturer's expiration date) were labeled for two of two sampled residents (10 and 27) insulin pens stored in one of one observed medication cart.Findings include:1. Observation and interview on [DATE] at 4:46 p.m. with licensed practical nurse (LPN) L while she was administering insulin revealed resident 10's NovoLog insulin pen had a blank yellow expiration label on it. The nurse who first used the insulin pen was to determine when the insulin's shortened expiration date was and to write that date on the yellow expiration label.2. Interview and review of the provider's guidelines for determining the expiration date of insulin pens after opening on [DATE] at 8:28 a.m. with director of nursing (DON) B revealed that the insulin pen had a pre-placed yellow label on them that had a blank space to document the date when the pen was first opened for use, and a blank space to document when the insulin pen would expire. She expected the nurse who opened the pen and used it for the first time to document the date the insulin pen would expire. She indicated that each insulin type may have a different number of days it could safely be used after opening based on the provider's guidelines. 3. Observation and interview on [DATE] at 2:35 p.m. with LPN L regarding insulin pens stored in the medication cart revealed there were two insulin pens for resident 10, one was NovoLOG FLexPen Subcutaneous Solution Pen-injector 100 unit/milliliters (mL) (Insulin Aspart), and the other was Lantus SoloStar Subcutaneous Solution-Pen Injector 100 unit/mL (Insulin Glargine). There was one insulin pen of Lantus SoloStar Subcutaneous Solution-Pen Injector 100 unit/mL (Insulin Glargine) for resident 27. LPN L confirmed none of those three insulin pens had an expiration date recorded on the yellow expiration date labels. She stated she was not the licensed nurse who first opened those pens, and there was no way to determine which nurse did.4. Review of the provider's [DATE] guidelines for determining expiration of open insulin pens revealed that NovoLog FLexPen Subcutaneous Solution Pen-injector 100 unit/mL (Insulin Aspart) and Lantus SoloStar Subcutaneous Solution-Pen Injector 100 unit/mL (Insulin Glargine) both expired after 28 days of opening.5. Review of the provider's [DATE] Preparation and General Guidelines for Vials and Ampules of Injectable Medications revealed: Expiration Dates: Unopened vials expire on the manufacturer's expiration date. Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both important to be recorded on the multidose vials (on the vial label or an accessory label affixed for that purpose). At a minimum, the date opened must be recorded. These labels are not required on single-use vials or ampules. Triggered expiration dates may be found in the manufacturer's package insert, on the package, provided, or on a reference chart by the pharmacy, or by contacting the pharmacist.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices regarding:The cleaning of a pulse oximeter (a device that clips onto a finger to measure blood oxygen saturation and pulse rate) by one of one licensed practical nurse (LPN) (L) after it was used by one of one sampled resident (44).Hand hygiene (handwashing with soap and water or a hand sanitizer) and glove use by one of one registered nurse (RN) (G) and one of one LPN (L) during medication administration for two of two sampled residents (65 and 44).One of one dietary aide (O) who touched ready to eat foods without the use of gloves.One of one LPN (L) who did not remove personal protective equipment (PPE) after she performed resident cares and before she exited the resident's room.One of one RN (P) and one of one LPN (L) who did not perform hand hygiene before and after the use of gloves while performing resident cares.One of one LPN (L) who did not bag a potentially contaminated wash cloth before she exited the resident's room. Findings include:1. Observation on 6/29/26 at 3:50 p.m. in resident 44's room revealed that LPN L reached into her smock pocket and removed a pulse oximeter. Without first cleaning the device, she placed it on the resident's index finger. LPN L returned the oximeter to her smock pocket after the resident's oxygen saturation level and pulse rate were obtained. 2. Interview on 6/30/26 at 10:00 a.m. with LPN L regarding the above observation revealed that she acknowledged the pulse oximeter should have been cleaned before it was placed on resident 44's finger to mitigate the possibility of cross-contamination. 3. Observation on 7/1/26 at 8:15 a.m. of RN G preparing to administer resident 65's eye drops revealed she removed a pair of gloves from her smock pocket, and without performing hand hygiene, put on the pair of gloves. She then administered resident 65's eye drops, removed her gloves, discarded them, and performed hand hygiene. 4. Interview on 7/1/26 at 9:10 a.m. with RN G regarding the above observation revealed that she acknowledged that gloves should not be placed inside a potentially unclean smock pocket. She agreed that she should have completed hand hygiene before she put on a pair of gloves. 5. Interview on 7/1/26 at 11:20 a.m. with director of nursing (DON) B regarding the above observations revealed that after the oximeter was removed from a potentially unclean smock pocket, it should have been cleaned before it was placed on resident 44's finger and gloves should not be kept inside a smock pocket either. Hand hygiene was expected to be performed before putting on gloves. 6. Review of the provider's revised December 2019 Medication Administration Preparation and General Guidelines revealed, 9. Hands are washed before putting on examination gloves . 7. Review of the provider's revised 2/20/24 Cleaning and Disinfection of Equipment policy revealed, A. Supplies and equipment will be cleaned immediately after use. 8. Observation on 6/29/26 at 11:57 a.m. in the dining room revealed dietary aide O brought resident 52 her noon meal. Dietary aide O removed the paper wrapper from a straw. A piece of that paper wrapper fell into resident 52's mashed potatoes and gravy. Dietary aide O touched resident 52's mashed potatoes and gravy with her ungloved hand as she removed the piece of paper from the mashed potatoes and gravy. Dietary O placed the piece of paper on the table beside resident 52's plate, returned to the kitchen service window, performed hand hygiene with alcohol-based hand sanitizer (ABHS), and continued to deliver meal trays to other residents. 9. Observation and interview on 6/30/26 at 2:28 p.m. of resident 73's medication administration and a nutritional supplement through his percutaneous endoscopic gastrostomy (PEG) tube (a tube surgically placed through the abdomen into the stomach to administer liquid nutrition, fluids and medications) revealed LPN L was standing at the medication cart positioned outside resident 73's room and removed resident 73's cyclobenzaprine 10 milligram (mg) tablet (a muscle relaxer) from the packaging, placed the tablet in a clear packet, and crushed the tablet. She placed that crushed tablet into a plastic cup of water, picked up that cup and took it into resident 73's room, and set it on his bedside table. There was a sign on resident 73's room door that indicated he was on enhanced barrier precautions (EBP; glove and gown use when providing contact care). In resident 73's room, LPN L washed her hands, put on a gown, and put on a pair of gloves. LPN L requested assistance from RN P to boost resident 73 up towards the head of the bed. Without performing hand hygiene, RN P put on a pair of gloves and did not put on a gown. After RN P repositioned resident 73, RN P with those same gloved hands, walked over to the other side of the room, and placed resident 26's fall mat (a padded mat on the floor beside the bed for residents who fall out of bed) on the floor beside his bed. With those same gloved hands, she picked a wet washcloth up from resident 73's bedside table, placed the washcloth in a plastic bag, removed her gloves and discarded them in the trash can, and did not perform hand hygiene. RN P then exited the room, opened the medication cart, removed a container of pH strips (strips to test for acidity) from the medication cart, brought the pH strips into resident 73's room, gave them to LPN L, and exited the room without performing hand hygiene. LPN L raised the head of resident 73's bed, positioned resident 73's shirt to expose his PEG tube, and placed a washcloth below his PEG tube. She used a syringe to withdraw a liquid from his stomach through his PEG tube and into the syringe. She put a pH test strip into the liquid she withdrew to confirm that the contents removed were acidic to verify that the PEG tube was in resident 73's stomach. LPN L reinserted the remaining liquid in the syringe back into resident 73's PEG tube. LPN L turned to resident 73's bedside table and stated the medication she had brought into the room was not on the bedside table where she had placed it. She looked around the room for the medication and could not locate it. She removed her gloves and discarded them in the trash can, did not perform hand hygiene, did not remove her gown, exited resident 73's room, and opened the medication cart. RN P was in the hallway, and when LPN L stated she could not find the cup with resident 73's medication in it. RN P stated she threw the cup that was on the bedside table away because she thought it was left in the room from earlier that day. LPN L did not perform hand hygiene, prepared another cyclobenzaprine tablet for administration, and went back into resident 73's room. Without preforming hand hygiene, LPN L put on a pair of gloves, attached the syringe to resident 73's PEG tube, put water into the PEG tube, and then put the water with the cyclobenzaprine into the PEG tube. LPN L then flushed the PEG tube with more water, administered 250 milliliters of Nutren 1.5 (liquid nutrition), and flushed the PEG tube again with water. LPN L removed the syringe from resident 73's PEG tube, closed the PEG tube, and pulled his shirt down over his stomach. LPN L removed her gown and gloves, disposed of them in the trash can, and washed her hands. With her bare hands, LPN L removed the washcloth from below resident 73's PEG tube on his stomach, folded the washcloth, carried the washcloth into the hallway and set it on the medication cart. Without performing hand hygiene, gave a hug to a visitor, and then documented in resident 73's electronic medical record (EMR) on the computer that she had administered the cyclobenzaprine and Nutren 1.5. LPN L stated resident 73 was on EBP because he had a PEG tube. LPN L acknowledged she had worn the gown into the hallway and did not perform hand hygiene before putting on a pair of gloves and after taking off the gloves. 10. Interview on 7/1/26 at 3:35 p.m. with DON B revealed she expected the staff to complete hand hygiene when the staff entered and exited the residents' rooms, before putting on and after removing gloves. She expected gloves to be worn any time a staff member touched a resident's ready to eat food. She expected the staff to wear a gown when providing direct care for a resident on EBP, including administering medications and nutritional supplements in PEG tubes. She expected gowns to be removed and disposed of in the resident's room and not to be worn into the hallway. She expected dirty laundry for a resident on EBP to be bagged prior to exiting the resident's room and not placed on the medication cart. 11. Review of the provider's 9/26/25 Enhanced Barrier Precautions policy revealed Enhanced Barrier Precautions (EBP): refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and glove use during high contact resident care activities. Enhanced Barrier Precautions (EBP) should be used for all residents with wounds or indwelling devices. Gowns and Gloves should be used during high contact resident care activities that provide opportunities for transfer of MDROs [multi-drug resistant organisms] to staff hands and clothing. 12. Review of the provider's 5/11/26 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] containing 60-95% [percent] ethanol or isopropanol or 65% alcohol if hand wipes utilized, for all of the following situations: Before and after direct contact with residents, When entering and leaving a Resident care area/room, Before donning [putting on] and after removing gloves and other personal protective equipment (PPE).Before preparing or handling medications.After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. Hand hygiene must be completed prior to and after removal of gloves. 13. Review of the provider's 1/14/26 Linen and Laundry Handling policy revealed, All laundry is considered potentially contaminated. Laundry and Nursing Healthcare Personnel (HCPs) will use Standard Precautions and use personal protective equipment (PPE), (e.g, gloves etc.) as appropriate while handling all these soiled items. All soiled laundry will be placed directly into a bagged receptacle or bagged and transported to the bagged laundry receptacle. 14. Review of the provider's 1/14/26 Standard Precautions policy revealed, PPE should be appropriately discarded prior to leaving the room after resident care and hand hygiene completed. Gowns should be removed after resident care and disposed of in the resident [resident's] room. 15. Review of the provider's 4/15/20 Handwashing and Glove Use policy revealed, Gloves may be used when working with food to avoid contact with hands. Gloves must be worn when touching any ready-to-eat food.

Based on observation, interview, and policy review, the provider failed to protect the resident's right for dignity for one of one sampled resident (17) who was dressed in clothing that had his first name written in black marker on the top of his left pant leg and on the left side of his shirt. Findings include:1. Observation and interview on 6/30/26 at 9:45 a.m. with resident 17 in his room revealed that he sat in his wheelchair watching television. His first name was written in black marker vertically, along the top of his left pant leg. His first name was also written vertically in black marker on the left side of his shirt. Resident 17 said he wrote his name on the clothes he was wearing with a black marker because sometimes his clothes were not returned from the laundry after they were washed. He indicated that his roommate's clothes had personalized labels affixed to the inside of them. Resident 17's clothes were not labeled like that. Resident 17 had other clothes that were not labeled with a black marker, but he did not wear them because he was concerned they would not be returned to him after they were washed. Resident 17 relied on donated clothes from the facility to wear. He had no local family support. Before he admitted to the facility, he had lived locally in his own apartment. He did not know what happened to his personal belongings he had in his apartment. 2. Interview on 6/30/26 at 10:45 a.m. with laundry aide M revealed she used a heat-activated device to affix name individualized labels to the residents' clothing. She was aware that not all of resident 17's clothing were labeled in that manner. Laundry aide M previously told the resident she would label his clothes, but she did not do that yet. 3. Interview on 6/30/26 at 1:30 p.m. with social services designee (SSD) E revealed that resident 17 admitted to the facility in October 2025. She confirmed that he lived in a local apartment before he admitted to the facility, and he had no local family support. SSD E did not contact the resident's former landlord to retrieve any of his personal belongings from the apartment after he admitted to the facility. SSD E confirmed that most of resident 17's clothing was donated to him by the facility. That clothing should have been labeled with the resident's name before they were provided to him to wear. She knew he had some clothing that was not returned to him after it was laundered because the facility had not labeled them. She agreed that having resident 17's first name printed with a black marker on his clothes was a privacy issue and compromised his self-esteem. Staff, other than those who worked in laundry, including herself, should have ensured resident 17's clothes were labeled in a dignified manner to mitigate the resident writing his name on them with a marker. 4. Review of the provider's revised 11/18/25 Resident Dignity and Privacy policy revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as, care for each resident in a manner and in an environment, that maintains resident privacy.

Based on observation, interview, record review, and policy review, the provider failed to ensure residents were assessed for their ability to safely self-administer their medications, had a physician's order to self-administer their medications and store those medications in their room, according to the provider's policies for:*One of one sampled resident (54) observed self-administering a medication through a nebulizer (a device that converts liquid medication into an inhaled mist) in her room, who was not assessed for the ability to safely self-administer medications and did not have a physician's order to self-administer that medication.*One of one sampled resident (7) who self-administered her medications had her Symbicort inhaler (a medication to prevent and control inflammation in the lungs and open the airways) and a fluticasone nasal spray (allergy medication) securely stored when they were not being self-administered. Findings Include: 1.Observation on 6/30/26 at 9:50 a.m. in resident 54's room revealed she was sitting in her recliner, and coughing up phlegm and spitting it in the trash can next to her recliner. Resident 54 stated she did not received her 10:00 a.m. nebulizer treatment yet, did not refuse the nebulizer treatment, and believed registered nurse (RN) G was running late. 2. Review of resident 54's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her diagnoses included pneumonia (an infection that inflames the air sacs in the lungs and can fill with fluid), and chronic obstructive pulmonary disease (COPD a progressive incurable lung disease that restricts airflow causing difficulty to breathe). Her 5/29/26 Brief Interview of Mental Status (BIMS) assessment score was 9, which indicated her cognition was moderately impaired. She had a 12/29/25 physician's order for, DuoNeb Solution 0.5-2.5 (3) MG [milligram]/3ML [milliliter] (Ipratropium-Albuterol) 3 ml inhale orally via nebulizer three times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Resident 54's did not have a self-administration of medication assessment completed or a physicians order to self-administer. A care conference note on 3/16/26 indicated that resident 54's power of attorney (POA- someone designated on a legal document to act on behalf of a resident) expressed concern that resident 54 was not receiving her full nebulizer treatments. Resident 54's medication administration record (MAR) indicated her nebulizer treatments were to be administered at 10:00 a.m., 4:00 p.m., and 9:00 p.m., and her that she had refused that morning nebulizer treatment. 3. Interview on 6/30/26 at 10:25 a.m. with RN G revealed that at 6:30 a.m. that day resident 54 stated she did not want the 10:00 a.m. nebulizer treatment. When RN G was informed that resident 54 was in her room waiting for her 10:00 a.m. nebulizer, RN G stated that resident 54 was forgetful and probably forgot she refused earlier, but that she could give resident 54 her 10:00 a.m. nebulizer treatment. 4. Observations on 6/30/26 from 10:47 a.m. to 11:22 a.m. in resident 54's room revealed that her nebulizer treatment was running and was alone in her room. She was fidgeting with the nebulizer mouthpiece and repeatedly removed it from her mouth and placed it back in. At 10:54 a.m., resident 54 then fell asleep, and the nebulizer mouthpiece fell out of her mouth and rested at her side away from resident 54's mouth. RN G walked past resident 54's room seven times without checking in on resident 54. At 11:22 a.m., RN G walked away from the medication cart positioned in the hallway, and resident 54's nebulizer treatment was on and still running. 5. Interview on 6/30/26 at 2:22 p.m. with RN G revealed that she was aware that resident 54 did not have a self- administration of medication assessment completed. She was not aware that she should have remained with resident 54 during her nebulizer treatment. 6. Interview and EMR review on 6/30/26 at 3:30 p.m. with director of nursing (DON) B revealed that she acknowledged that resident 54 did not have a self-administration of medication assessment completed or a physician's order to self-administer her nebulizer treatment. 7. Review of the provider's revised January 2018 Medication Administration Preparation and General Guidelines policy revealed staff will, Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. 8. Observation and interview on 6/29/26 at 2:00 p.m. with resident 7 in her room revealed she had a Symbicort inhaler and a fluticasone nasal spray on her bedside table. Resident 7 stated she took those medications when she woke up in the morning. After she took the medications, she would tell the nurse she was done with them. Sometimes she forgot to tell the nurse she had taken them, and the inhaler and the nasal spray would stay on her bedside table for hours, and at times overnight. 9. Review of resident 7's electronic medical record revealed she admitted to the facility on [DATE]. Her 5/21/26 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. Her diagnoses included chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) and allergic rhinitis (inflammation of the nasal passages). She had a 11/14/23 physician's order for fluticasone propionate suspension 50 micrograms per activation (MCG/ACT) two sprays to be administered in each nostril one time per day at 12:00 p.m. and a 3/1/24 physician's order for Symbicort Inhalation Aerosol 80-4.5 MCG/ACT two puffs to be administered orally two times per day at 12:00 p.m. and 8:00 p.m. A 4/23/25 physician's order indicated she, May self administer medications as listed cough drops maybe [may be] kept at bedside. Fluticasone nasal spray and symbacort [Symbicort] inhaler may be self admin [self-administered] and return to [the] medication cart after use daily. Resident 7's 5/28/26 Medication Self-Administration Evaluation indicated that fluticasone nasal spray and the Symbicort inhaler were two of the medications she was evaluated for and found able to self-administer. The 5/28/26 Medication Self-Administration Evaluation form indicated, No to the question Is there an order to keep medications at bedside (medications cannot be kept at bedside without an order)? To the question, Where will the medications be stored? Medication cart was indicated as the locations of medication storage. 10. Interview and review of resident 7's EMR on 7/1/26 at 10:23 a.m. with RN P revealed resident 7 self-administered her inhaler and nasal spray. On 6/29/26 her Symbicort inhaler was documented as administered at 12:18 p.m. and her fluticasone nasal spray was documented as administered at 12:15 p.m. by LPN L. RN P stated resident 7 liked to sleep in in the morning so the nurse would place the Symbicort inhaler and fluticasone nasal spray on her bedside table. After resident 7 woke up she was take her Symbicort inhaler and fluticasone nasal spray and then she would alert a certified nursing assistant (CNA) to bring the medication to the nurse, or she would tell the nurse that she had taken the Symbicort inhaler and the fluticasone nasal so the medications could be returned to the medication cart. RN P was not concerned that another resident could wander into resident 7's room and take her inhaler and nasal spray. She acknowledged there were residents who wander into other residents' rooms. 11. Observation on 7/1/26 at 2:02 p.m. of resident 7's room revealed the Symbicort inhaler and the fluticasone nasal spray were sitting on resident 7's bedside table. 12. Interview on 7/1/26 at 5:01 p.m. with director of nursing (DON) B revealed that residents' medications were stored in the medication carts. Resident 7 administered her own nasal spray and inhaler. Staff would leave at her bedside and when she woke up, she would take the nasal spray and inhaler and alert the staff when she had taken them. She was not aware her inhaler and nasal spray were left in her room for hours and overnight. She acknowledged resident 7 did not have a physician's order to store her medications in her room and her physician's order indicated the medications were to be returned to the medication cart after they were administered. 13. Review of the provider's January 2018 Self-Administration of Medications policy revealed, Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. Then the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the central medication cart or medication room. The resident requests each dose from the medication nurse, who provides the medication to the resident in the unopened package for the resident to self-administer. The nurse then records each self-administration on the MAR by placing a check mark in the appropriate space and noting in the nursing comments the initials of the nurse who obtained the information from the resident.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, and interview, the provider failed to protect the resident's rights to be free from verbal, mental, or physical abuse for one of one sampled resident (28) who was verbally abused by one of one certified nurse aide (CNA) Q who called resident 28 a derogatory name, one of one sampled resident (58) who was emotionally and physically abused by one of one contracted travel CNA (Y) who had put her hand inside the residents brief to check if she was incontinent (involuntary urine or bowel leakage) and one of one sampled resident (58) by one of one contracted travel CNA (BB) who was rough while transferring resident 58 and two of two sampled residents (38 and 65) who were emotionally and physically abused by one of one contracted travel CNA (BB) who did not provide appropriate perineal care and who entered resident 38's room and with a rude tone of voice told her that her room smelled.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 5/11/26-submitted SD DOH FRI regarding resident 28 revealed that at 6:00 p.m. on 5/10/26, CNA Q approached resident 28, who had just returned to the facility with her family member, and said, Midget is back. CNA Q then looked at resident 28's family member and said, You look just like her. This information was reported to the staff by resident 28's family member on 5/11/26 at 1:30 p.m. Administrator A was notified at 1:50 p.m. that same day. CNA Q was suspended pending the outcome of the facility's investigation into the above incident. CNA Q provided a statement in response to the allegation, confirming that she had called resident 28 midget but did not intend to be mean. The facility verified the allegation of verbal abuse and decided to terminate her employment, but CNA Q self-terminated her employment with the facility on 5/14/26 in response to the allegation and investigation. The facility reported CNA Q to the South Dakota Board of Nursing. 2. Review of resident 28's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her diagnoses included recurrent major depressive disorder (a clinical mood disorder where a person experiences two or more distinct major depressive episodes, separated by at least two months of normal mood). Her 5/28/26 Brief Interview of Mental Status (BIMS) assessment score was 8, which indicated her cognition was moderately impaired. 3. Interview on 6/30/26 at 1:40 p.m. with resident 28 revealed that she did not recall the 5/10/26 incident. She denied any psychosocial impact from the incident and stated that she felt things were going well at the facility. 4. Interview on 6/30/26 at 3:07 p.m. with licensed practical nurse (LPN) L revealed that she received training on abuse identification, prevention, and reporting requirements all the time. If she became aware of any allegation of abuse, she would report it immediately. We report allegations even if we're not sure about them. It is not up to us to make that determination. The DON [director of nursing] will investigate. 5. Interview on 6/30/26 at 3:20 p.m. with contracted travel CNA N revealed that she had received training on abuse identification, prevention, and reporting requirements many times because I've [I have] been a CNA for 10 years. There was training and testing when she started working at the facility. If she became aware of any allegations of abuse, she would report them to the nurse immediately. If she could not find the nurse, she would report them to DON B. 6. Review of CNA Q's personnel file revealed that she was hired at the facility on 4/23/25. She had completed training in abuse prevention, care for individuals with cognitive impairments, effective communication, resident rights essentials, and dementia care. CNA Q's CNA certification was current, and there were no known disciplinary actions associated with it. Her background check was completed and had no notable findings. 7. The providers' actions to mitigate the likelihood of the deficient practice recurring were verified on 7/1/26. A record review and an interview with DON B revealed that the facility had followed its Quality Assurance and Performance Improvement (QAPI) process regarding verbal abuse toward residents by interviewing resident 28 on 5/11/26 about the above incident. Resident 28 did not recall the incident and voiced no concerns regarding her care. Her psychosocial well-being was assessed and determined to be at her baseline, according to DON B and social services designee (SSD) E. They monitored and documented resident 28's behavior and psychosocial well-being following the incident. They ensured resident 28's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was reviewed in relation to her impaired cognition. Resident 28's family member participated in care plan meetings and denied any concerns regarding resident 28's care. In addition, 40 residents were interviewed about their sense of safety, whether they were addressed by any term other than their name, and whether they had observed the staff calling other residents inappropriate names. No concerns were identified. The facility interviewed 23 staff members about whether they had witnessed the staff calling residents terms other than their names, whether they had witnessed the staff being mentally or verbally abusive toward residents, and whether they knew whom to report allegations or observations of verbal or mental abuse to. No concerns were identified. All staff were reeducated to ensure they call residents by their name and do not use terms or names that may be perceived as derogatory. The incident was brought to the facility's QAPI meeting for further review and recommendations. Based on the above information, non-compliance at F600 occurred on 5/10/26, and based on the provider's corrective action plans that were initiated on 5/11/26 and implemented for the deficient practice confirmed on 7/1/26, this occurrence of non-compliance is considered past non-compliance. 8.Review of the provider's 3/12/26 submitted SD DOH FRI report regarding resident 58 revealed that at approximately 1:00 p.m. on 3/12/26, SSD E informed administrator A that resident 58 reported to CNA V that contracted travel CNA Y had come into her room and stated that her room stunk and asked resident 58 if her incontinence (involuntary urine or bowel leakage) brief was soiled and when resident 58 replied no, contracted travel CNA Y put her hand inside of resident 58's brief and rubbed her buttocks up and down twice then proceeded to the front and rubbed up and down twice checking to see if her brief was soiled. Resident 58 reported that incident happened on 3/12/26 at approximately 7:00 a.m. Contracted travel CNA Y was suspended on 3/12/26 pending the facility's investigation. During the facilities investigation they interviewed LPN Z and resident 99, who was resident 58's roommate at that time, and both confirmed seeing contracted travel CNA Y in the room with resident 58 that morning. LPN Z completed skin assessments on resident 58 on 3/16/26 and 3/18/26 with no skin concerns found. 9. Review of resident 58's EMR revealed she admitted to the facility on [DATE]. Her diagnoses included cerebral palsy (a disorder that affects a person's ability to move and maintain balance and posture), and the need for assistance with personal care. Her 5/27/26 BIMS assessment score was 15, which indicated her cognition was intact. 10. Resident 58 was out of the facility and was not available for interview during the time of the survey. 11. Review of contracted travel CNA Y's personnel file revealed she had completed education for abuse, and neglect on 12/23/25. Her certification was current, and there were no known disciplinary actions associated with that certification. Her background check was completed on 7/12/25 and had no remarkable findings. 12. Interviews with contracted travel CNA N and CNA AA confirmed they had received education regarding perineal care, and the facility abuse and neglect policy. 13. Record review confirmed that the staff were educated about perineal care, and the facility's abuse and neglect policy. 14. The providers implemented actions to mitigate the likelihood of the deficient practice from reoccurring were verified on 6/29/26 after record review, and interview with DON B revealed that the facility had followed its QAPI process regarding mental and emotional abuse towards a resident. Clinical staff received education on perineal care and the facility's abuse and neglect policy. Resident 58's well-being was monitored and documented by SSD E visits conducted twice weekly for two weeks. Resident 58 was offered counseling services but declined. Both the resident and the medical provider were notified of the investigation's findings. In addition, a sample of residents were interviewed regarding any care concerns they had, how to report allegations of abuse, and whether residents felt safe in the facility. A sample of the staff were interviewed regarding any observations of inappropriate staff behavior toward residents and their understanding of the facility's abuse reporting procedures. Contracted travel CNA Y was permanently removed from eligibility to work in the facility. The incident was brought to the facility's QAPI meeting for further review by the interdisciplinary team. Based on the above information, non-compliance at F600 occurred on 3/12/26, and based on the provider's corrective action plans that were initiated on 3/12/26 and implemented for the deficient practice confirmed on 6/29/26, this occurrence of non-compliance is considered past non-compliance. 15.Review of the provider's 4/17/26 submitted SD DOH FRI report regarding resident 65 revealed that at 2:00 p.m. on 4/17/26, CNA V notified DON B that resident 65 had expressed concerns about contracted travel CNA BB. DON B interviewed resident 65 who reported that contracted travel CNA BB assisted her to the bathroom and contracted travel CNA BB handed resident 65 the wipes to clean herself. When resident 65 stated she needed assistance, contracted travel CNA BB discarded the wipes and pulled up resident 65's pants without providing the necessary perineal care. Contracted travel CNA BB was suspended pending the facility's investigation. During the facility's investigation, DON B interviewed resident 65 as well as additional staff members. Their statements corroborated the resident 65's allegations of abuse from contracted travel CNA BB. The resident's medical provider and her power of attorney (POA someone designated on a legal document to act on behalf of a resident) were notified of the incident and the investigation findings. 16. Review of resident 65's EMR revealed she admitted to the facility on [DATE]. Her diagnosis included the need for assistance with personal care. Her 4/30/26 BIMS assessment score was 15, which indicated her cognition was intact. 17. Interview on 6/29/26 at 2:05 p.m. with resident 65 regarding the abuse incident on 4/17/26 revealed that she and contracted travel CNA BB were in the hallway bathroom when contracted travel CNA BB handed her the wipes. Resident 65 told contracted travel CNA BB that she could not wipe herself. At that point, contracted travel CNA BB threw the wipes away without cleaning her, pulled up resident 65's pants, and took her back to her room without speaking to her during the interaction. 18. Review of the provider's 4/17/26 SD DOH FRI report regarding resident 38 revealed that at 2:00 p.m. on 4/17/26 resident 38 reported to CNA V that on the evening of 4/16/26 contracted travel CNA BB entered her room and stated that her room stinks. Resident 38 reported feeling upset by the tone used by contracted travel CNA BB. CNA V reported the concern to DON B, who then notified administrator A. Contracted travel CNA BB was suspended pending the facility's investigation. During the facility's investigation, administrator A assisted resident 38 in completing a grievance form regarding the incident involving contracted travel CNA BB. Based on witness statements from other staff members, the facility was able to confirm the allegations of abuse from contracted travel CNA BB. Resident 38's medical provider and POA were notified of the incident and the investigation findings. 19. Review of resident 38's EMR revealed she admitted to the facility on [DATE]. Her diagnosis included heart failure, and multiple sclerosis (disabling disease of the central nervous system where the immune system attacks the protective sheath covering the nerve fibers.) Her 5/20/26 BIMS assessment score was 15, which indicated her cognition was intact. 20. Interview on 6/29/26 at 2:50 p.m. with resident 38 revealed she did not remember the 4/17/26 incident above. 21. Review of the provider's 4/17/26 submitted SD DOH FRI report regarding resident 58 revealed that at 2:00 p.m. on 4/17/26 CNA V informed DON B that resident 58 reported contracted travel CNA BB was rough and rushing during her transfer the previous evening o 4/16/26. DON B interviewed resident 58, who stated that contracted travel CNA BB had raised the bed too high, nearly causing her leg to fall out of the bed. LPN Z assessed resident 58 and noted no injuries. Contracted travel CNA BB was suspended pending the facility's investigation. During the facility's investigation DON interviewed additional staff members, and based on their statements, the facility was able to confirm the allegations of physical abuse by contracted travel CNA BB. Resident 58 and her medical provider were notified of the incident and the investigation findings. 22. Review of resident 58's EMR revealed she admitted to the facility on [DATE]. Her diagnoses included cerebral palsy (disorder that affects a person's ability to move and maintain balance and posture), and the need for assistance with person care. Her 5/27/26 BIMS assessment score was 15, which indicated her cognition was intact. 23. Resident 58 was out of the facility and was not available for interview during the time of the survey. 24. Review of contracted travel CNA BB's personnel file revealed her certification was current, and there were no known disciplinary actions associated with that certification. Her background check was completed on 4/4/26 and had no remarkable findings. 25. The providers implemented actions to mitigate the likelihood of the deficient practice from reoccurring were verified on 6/29/26 after record review, and interview with DON B revealed that the facility had followed its QAPI process regarding mental, emotional, and physical abuse towards the residents. Monitored and documented the well-being of all three residents, with SSD E completing two visits per week for two weeks for each resident. Weekly audits were initiated to observe the staff performing residents' transfers. In addition, a sample of residents were interviewed regarding whether they feel safe in the facility, whether the staff listen to and meet their toileting needs, whether any staff members were verbally or mentally abusive, whether any staff members had made inappropriate comments regarding odors in their rooms, and whether any staff member were rough during transfers. A sample of staff members were interviewed regarding whether they had witnessed staff members refusing to meet residents' toileting needs, making inappropriate comments to a resident about their room odors, or being rough during resident transfers. Contracted travel CNA BB was permanently removed from eligibility to work in the facility. The incident was brought to the facility's QAPI meeting for further review by the interdisciplinary team. Based on the above information, non-compliance at F600 occurred on 4/17/26, and based on the provider's corrective action plans that were initiated on 4/17/26 and implemented for the deficient practice confirmed on 6/29/26, the 4/17/26 occurrences of non-compliance are considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to follow professional standards of nursing by one of one licensed practical nurse (LPN) (L) who did not assess and document one of one sampled resident's (44) pain level before she administered that resident a pain medication, and did not document that pain medication administration on the resident's medication administration record (MAR). Findings include: 1. Observation and record review on 6/29/26 at 3:50 p.m. with LPN L revealed she responded to resident 44's request to be seen by a nurse. The resident complained of a cough and a headache. She thought she had a slight stroke because she felt unable to control her mouth secretions. Resident 44 sat calmly in a chair in her room. She was alert, oriented, and able to answer LPN L's questions. The resident's vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were within normal limits (WNL). Resident 44 winced when the blood pressure cuff inflated around her arm, but she demonstrated no other verbal or non-verbal indications of pain. The resident's pulse and oxygen saturation levels (the percentage of hemoglobin in the blood carrying oxygen) were WNL. LPN L completed a stroke assessment that included evaluating the resident's arm strength, her vision, speech, facial symmetry, and orientation. That assessment was negative for any remarkable findings. LPN L failed to assess the resident's headache pain by not asking questions such as the location of the headache pain, the type of headache she had, how long she had the headache, if anything helped to relieve the headache, or how intense her headache pain was. After exiting the resident's room and reviewing resident 44's MAR, LPN L prepared a 5 milligram (mg) oxycodone (controlled pain medication) tablet to administer to resident 44. The oxycodone was scheduled to be administered PRN (as needed) every four hours for pain. LPN L returned to the resident's room and administered the oxycodone to the resident. 2. Review of resident 44's June 2026 MAR revealed that the resident was expected to assign a numerical value between 0 and 10 (0 being no pain and 10 being excruciating pain) to her pain level that the nursing staff were to document on the MAR before administering the resident's PRN oxycodone. There was no pain level or PRN oxycodone administration documented on her MAR for the PRN oxycodone that was administered to the resident by LPN L on 6/29/26. 3. Record review and interview on 6/30/26 at 10:00 a.m. with LPN L revealed that she acknowledged failing to assess, identify, or document resident 44's pain level on 6/29/26, before she administered the resident's PRN oxycodone. She also did not document the PRN oxycodone administration on the resident's MAR after it was given on 6/29/26 at 4:00 p.m. 4. Interview on 6/30/26 at 5:20 p.m. with director of nursing (DON) B revealed that LPN L was expected to complete and document resident 44's pain assessment score on the resident's MAR before she administered the resident her PRN oxycodone. LPN L was also expected to document on resident 44's MAR the PRN oxycodone administration immediately after that administration was completed. 5. Review of the provider's revised 4/28/25 Pain Management policy revealed-5. Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 6. Review of the provider's revised December 2019 Medication Administration Preparation and General Guidelines policy regarding medication administration documentation revealed: The individual who administers the medication dose records the administration on the resident's MAR/eMAR [electronic MAR] directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMar to ensure necessary doses were administered and documented.

Based on record review, interview, and policy review, the provider failed to complete a trauma informed care assessment for two of two sampled residents (5 and 6) with a post-traumatic stress disorder (PTSD-a disorder in which an individual has difficulty recovering after experiencing or witnessing a traumatic event) diagnosis. Finding included:1. Review of resident 5's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her diagnoses included PTSD, major depressive disorder (a mental health condition that causes persistent feelings of sadness, hopelessness, and a total loss of interest in activities), and anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable worry or fear). Her 7/1/26 Brief Interview for Mental Status (BIMS) assessment score was 5, which indicated her cognition was severely impaired. Her revised 4/20/26 care plan did not include goals or interventions identified related to her PTSD. Resident 5 had no documentation indicating that a trauma informed care assessment was completed to identify her related needs or that behavioral health counseling was offered. 2. Observation on 6/29/26 at 2:20 p.m. of resident 5 in her room revealed she was in her bed with the television on and unable to be interviewed as she was nonverbal when questioned. 3. Interview on 6/29/26 at 5:02 p.m. with resident 5's emergency contact revealed that staff updated him with any information or changes in resident 5's care. He attended resident 5's care meetings and visited resident 5 twice a month. Resident 5's emergency contact voiced no concerns regarding her care and services. He stated that resident 5 was in a good place, she was doing well at the facility, and that the facility provided her with good care. 4. Review of resident 6's EMR revealed he admitted to the facility on [DATE]. He had a diagnosis of PTSD. His BIMS assessment score was 15, which indicated his cognition was intact. His 3/18/26 care plan indicated he had altered mood and behaviors related to his PTSD. The interventions identified in the care plan related to his PTSD were to allow him to choose his activities, stop and talk to him as the staff were passing by, and allow positive interactions. Resident 6 had no documentation indicating that a trauma informed care assessment was completed to identify his related needs, or that behavioral health counseling was offered. 5. Interview on 6/29/26 at 1:52 p.m. with resident 6 revealed he had PTSD from combat. He stated the facility did not offer him much support regarding his PTSD, he was not offered any counseling services, and he would like to be referred for counseling services. 6. Interview on 6/30/26 at 4:00 p.m. with social services designee (SSD) E revealed she was the SSD for three years at the facility. She was unaware she was responsible for completing the resident's trauma informed care assessments until approximately three months ago. 7. Interview on 6/30/26 at 4:16 p.m. with director of nursing (DON) B revealed that she acknowledged residents 5 and 6 did not have trauma informed care assessments completed in their EMRs and that they were not offered any counseling services for their PTSD. She expected staff to follow the provider's policy and complete a trauma informed care assessment for residents diagnosed with PTSD to identify the residents' needs and to offer them counseling services. 8. Review of the provider's revised 9/30/24 Mental Health Adjustment Difficulties Related to Trauma, PTSD, or Other Mental Health Issues policy revealed staff, Assess the resident to determine if services are needed

Based on observation, interview, record review, and policy review, the provider failed to ensure continued behavioral health services to treat a diagnosed mental illness were provided and to identify and implement interventions and effective communication processes with other healthcare entities for one of one sampled resident (10) with depression symptoms and suicidal thoughts. Findings include:1. Interview on 6/30/26 at 7:56 a.m. with resident 10 revealed she felt like she wanted to give up. She did not have an interest in participating in activities anymore. She worried about her finances. She received counseling in the past, but she no longer did. She did not know why those counseling sessions stopped. She thought the counseling helped her when she had counseling sessions. 2. Review of resident 10's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 5/22/26 Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated her cognition was moderately impaired. Her diagnoses included major depressive disorder.Resident 10's 3/4/25 PHQ-9 (a tool used to assess for depression) assessment score was 00, which indicated she did not have any depression symptoms. On 11/18/25 her PHQ-9 assessment score was 5, which indicated she had mild depression symptoms. She reported feeling down, depressed, or hopeless for two to six days in the past fourteen days. She had trouble falling asleep or staying asleep for seven to eleven of the past fourteen days. She felt tired or had little energy for seven to eleven of the past fourteen days.Resident 10's 2/18/26 PHQ-9 assessment score was 9, which indicated she had mild depression symptoms. She reported feeling down, depressed, or hopeless for seven to eleven of the past fourteen days. She felt tired or had little energy for two to six of the past fourteen days. She felt bad about herself for two to six of the past fourteen days. She had trouble concentrating on things for two to six of the past fourteen days.Resident 10's 5/22/26 PHQ-9 assessment score was 5, which indicated she had mild depression symptoms. She reported that she had felt down, depressed, or hopeless for seven to eleven of the past fourteen days. She felt tired or had little energy for seven to eleven of the past fourteen days. She felt bad about herself for two to six of the past fourteen days.Her 7/1/26 care plan had a focus area of I receive an antidepressant medication related to Depression. The interventions for that focus area were, Attempt gradual dose reductions (GDR) for me for anti-depressant medications based on my progress and stability, Give antidepressant medications ordered by my attending physician. Observe me for any side effects every shift. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Observe for and report to my physician any ongoing s/sx [signs and symptoms] of depression unaltered by antidepressant meds [medications]: Sadness, irritability, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideation, neg. [negative] mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, doesn't enjoy usual activities, changes in condition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, & [and] concern with body functions. Her 7/1/26 care plan did not indicate any non-pharmacological interventions (treatments and preventative measures that do not rely on medication) that staff could use if resident 10 expressed symptoms of depression. 3. Review of resident 10's 2/24/26 and 3/24/26 paper psychiatry notes revealed she was being seen by a psychiatrist for psychiatric evaluation and medication management. During her 2/24/29 initial visit, it stated that resident 10, whimpers throughout the visit stating she needs a mom and is lonely. Her mood was described as Down, her appetite and energy were Poor, and she had anxiety Daily, related to losing family members and grief. Her suicidal risk assessment indicated she was at moderate risk for suicide due to suicidal thoughts without a plan or intent. Resident 10 indicated she had little interest or pleasure in doing things nearly every day. She felt down, depressed, or hopeless nearly every day. She had trouble falling or staying asleep, or sleeping too much, nearly every day. She had trouble concentrating on things, such as reading a newspaper or watching television more than half the days. She either moved or spoke slowly, or was so fidgety and restless that she was moving around more than usual nearly every day. She indicated there were several days when she had thoughts that she would be better off dead or had thoughts of hurting herself. Her PHQ-9 score was 18, which indicated she had moderately severe depression symptoms.During the 2/24/26 psychiatry visit, anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability) was added to her diagnoses. Her sertraline (an antidepressant medication) was changed to duloxetine (an antidepressant medication) to help her mood and her chronic pain. A plan was made for a follow-up appointment in one month, and a referral was made for mental health therapy.Resident 10's 3/24/26 psychiatry visit notes revealed she had continued depression, grief, and pain. Her sleep was described as poor and her interests were low. She had continued thoughts of suicide without a plan or intent. Her PHQ-9 score was 19, which indicated moderately severe depression symptoms.Resident 10 had been previously referred to therapy and the psychiatrist felt that it would be beneficial due to resident 10's depression. Resident 10's duloxetine was stopped, and she started on Prozac (an antidepressant medication). The plan was made for a follow-up appointment in one month. There were no paper psychiatry visit notes after 3/24/26. 4. Interview on 7/1/26 at 2:04 p.m. with licensed practical nurse (LPN) L revealed resident 10 was a very emotional person. Resident 10 did not express to LPN L that she felt depressed. LPN L stated resident 10 could be down one minute and then be rearranging things in her room the next. 5. Interview and review of resident 10's EMR on 7/1/26 at 2:34 p.m. with social service designee (SSD) E revealed she completed the resident's PHQ-9 assessments. She thought she offered resident 10 counseling services but indicated that there was no documentation in resident 10's EMR to support that counseling services were offered to her, or that she declined counseling.Resident 10 would come into her office when she was feeling down and they would talk. SSD E did not document any of those visits with resident 10 in her EMR. SSD E verified there were no non-pharmacological interventions identified for resident 10's depression in her care plan. 6. Interview on 7/1/26 at 3:18 p.m. with assistant director of nursing (ADON) U revealed she was responsible for setting up and attending the residents' psychiatry appointments with the residents. She would request the visit notes from the psychiatrist because they did not get sent to the provider automatically. Resident 10's psychiatry notes were not in her EMR or reviewed by ADON U before the notes were requested by the surveyor for review on 6/30/26 and were received by the provider from the psychiatrist on 7/1/26.ADON U was not aware that resident 10 had additional diagnoses identified in her psychiatry visit nots. She was not aware that resident 10 had expressed suicidal thoughts, that her PHQ-9 assessments indicated moderately severe depression, or that resident 10 was referred to therapy due to her depression. She acknowledged that not having all the information related to resident 10's current mental health status and needs had the potential for a decline in resident 10's mental health and quality of life. 7. Interview on 7/1/26 at 5:01 p.m. with ADON U revealed resident 10 did not have a follow-up appointment scheduled with psychiatry, and she was not scheduled with the therapist she was referred to on 2/24/26. 8. Review of the provider's 11/18/25 Mental Health Adjustment Difficulties Related to Trauma, PTSD or Other Mental Health Issues policy revealed, To ensure appropriate treatment and services are provided to all residents with adjustment difficulties to achieve the highest practicable mental and psychosocial well-being. 'Appropriate' means based upon assessment and care plan, should be person-centered, and the facility must make attempts to provide the services or assist residents with accessing such services. Assess the resident to determine if services are needed. Services Provided need to address individualized approaches that address the assessed needs of the resident. Care Plan should address the individualized emotional and psychosocial needs of the resident. Staff must consistently implement the care approaches identified in the Care Plan.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure:The staff completed and documented controlled medications (medications at risk for abuse and addiction) supply counts for two of two medication carts (East and West), and one of one sampled resident (24) who had one tablet of oxycodone (a controlled pain medication) unaccounted for.The residents were safe from medication errors for one of one sampled resident (66) who was not administered the prescribed dose of antihistamine medication by one of one RN (G). Findings include:1. Review of the provider's 5/5/26 SD DOH FRI revealed that on 5/5/26 at approximately 5:19 a.m. licensed practical nurse (LPN) J notified director of nursing (DON) B that when LPN J checked her controlled medication at approximately 3:45 a.m. that morning she noticed resident 24 was missing one oxycodone 5 milligram (mg) tablet. LPN J counted the controlled medications on the East medication cart with registered nurse (RN) W, and verified that resident 24 was missing one tablet of oxycodone 5 mg. The evening of 5/4/26, LPN L and LPN J completed the controlled medication count, and that count was accurate.LPN J and RN W checked the locked drawer on the medication cart together and searched the hallway near where LPN J was when she last administered a dose of oxycodone to resident 24. Resident 24's room and surrounding areas were searched for the missing oxycodone tablet. The oxycodone tablet was not found.Resident 24's medication administration record (MAR) indicated he had received all of his scheduled doses of oxycodone, and he did not have a physician's order for an as needed (PRN) oxycodone dose.DON B Interviewed resident 24 on 5/5/26 at 8:20 a.m.and but he did not recall receiving an extra dose of oxycodone after his 4:00 p.m. dose on 5/4/26 or being given two tablets of oxycodone. 2. Observation, interview, and review of the East medication carts controlled substances binder on 6/30/26 at 11:08 a.m. with LPN L revealed the 6/30/26 day to evening Shift Verification of Controlled Substances Count was signed by LPN L as the off-going nurse. There was no signature for the on-coming nurse. LPN L stated the controlled medications were to be counted by the on-coming and the off-going nurse at each shift change. The signatures on the Shift Verification of Controlled Substances Count form indicated the controlled medications were counted and the count was accurate.LPN L verified it was her signature in the off-going nurse count column. She did not count the controlled medications with the on-coming nurse because that would happen at change of shift and the change of shift would not happen until that evening. She acknowledged she documented with her signature that the controlled medications were counted and the count was accurate before having counted the controlled medications. 3. Review of resident 24's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. He had a 5/13/25 physician's order for oxycodone 5 mg one tablet to be administered four times a day at 4:00 a.m., 10:00 a.m., 4:00 p.m., and 10:00 p.m. 4. Interview on 6/30/26 at 2:45 p.m. with LPN L revealed she worked the night before (5/4/26) and the morning after resident 24's oxycodone tablet was found to be missing on 5/5/26. LPN L counted the controlled medications the evening of 5/4/26 with LPN J. During that controlled medication count, LPN L noticed she had forgotten to document that she removed resident 24's 4:00 p.m. oxycodone on his Controlled Drug Receipt/Record/Disposition Form. After she documented that she had removed it from the locked drawer for administration, the controlled medication count was accurate.The next morning, when LPN L returned for her scheduled shift, she was informed that resident 24 was missing one oxycodone tablet. LPN L counted the controlled medications with LPN J and verified that resident 24 was missing one oxycodone tablet. 5. Observation on 7/1/26 at 10:00 a.m. of the East medication cart controlled substance binder revealed there was a signature on 7/1/26 for the off-going nurse on the Shift Verification of Controlled Substances Count sheet, but there was no signature for the on-coming nurse. LPN L was preparing medications on the East medication cart during the observation. 6. Observation and interview on 7/1/26 at 2:04 p.m. of LPN L documenting on a Controlled Drug Receipt/Record/Disposition Form revealed that she administered resident 24's oxycodone at 10:00 a.m. She tried to document on the Controlled Drug/Receipt/Record/Disposition Form at the time she removed the controlled medication from the medication cart, but after the medication pass was completed she went back through the Controlled Drug/Receipt/Record/Disposition Forms to be sure she documented that she had removed the controlled medications that she administered to each resident.She rounded the time she documented the removal of the controlled medication to the hour, not the actual time she removed the controlled medication to be administered. 7. Review of the East medication cart Shift Verification of Controlled Substance Count sheets from January 2026 through June 2026 revealed two nurses did not sign that the controlled medication count was completed and accurate on 2/16/26 for the night to day shift change and the day to evening shift change, on 2/19/26 for the night to day shift change or the day to night shift change, on 2/25/26 for the night to day shift change, on 3/22/26 for the night to day shift change, on 3/23/26 for the day to night and the night to day shift change, on 3/31/26 for the day to night shift change, and on 4/19/26 for the day to night shift change. 8. Review of resident 24's Controlled Drug Receipt/Record/Disposition Form for his oxycodone 5 mg tablets from January 2026 through June 2026 revealed there were three doses of oxycodone not accounted for on 6/24/26. There was no oxycodone 5mg Controlled Drug Receipt/Record/Disposition Form from 6/1/26 through 6/8/26. 9. Review of resident 24's May 2026 and June 2026 MAR and Controlled Drug Receipt/Record/Disposition Form revealed that on 5/1/26 at 10:00 a.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 11:39 a.m. On 5/4/26 at 10:00 a.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 11:16 a.m.On 5/7/26 at 10:00 a.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 11:21 p.m. On 5/10/26 at 4:00 p.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 5:11 p.m. On 5/11/26 at 4:00 p.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 5:44 p.m. On 5/14/26 at 10:00 a.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 11:04 a.m. On 5/15/26 at 10:00 a.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 11:17 a.m. On 5/18/26 at 10:00 a.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 11:56 a.m.On 5/19/26 at 10:00 a.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 11:27 a.m.On 5/19/26 at 4:00 p.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 5:07 p.m. On 5/22/26 at 10:00 a.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 11:04 a.m. On 5/22/26 at 4:00 p.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 6:15 p.m. On 5/23/26 at 10:00 a.m. resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart and documented in his MAR as being administered at 11:37 a.m. On 5/23/26 resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart at 4:00 p.m. and documented in his MAR as being administered at 5:45 p.m. On 5/27/26 resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart at 9:00 a.m. and documented in his MAR as being administered at 11:04 a.m.On 6/15/26 resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart at 4:00 p.m. and documented in his MAR as being administered at 6:30 p.m. On 6/17/26 resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart at 10:00 a.m. and documented in his MAR as being administered at 11:36 a.m. On 6/20/26 resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart at 10:00 a.m. and documented in his MAR as being administered at 11:17 a.m. On 6/22/26 resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart at 10:00 a.m. and documented in his MAR as being administered at 11:34 a.m. On 6/22/26 resident 24's oxycodone tablet was documented on the Controlled Drug form as being removed from the locked drawer on the medication cart at 4:00 p.m. and documented in his MAR as being administered at 6:09 p.m. On 6/25/26 resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart at 4:00 p.m. and documented in his MAR as being administered at 5:06 p.m. On 6/30/26 resident 24's oxycodone tablet was documented on the Controlled Drug form as removed from the locked drawer on the medication cart at 10:00 a.m. and documented in his MAR as being administered at 11:15 a.m. 10. A phone interview on 7/1/26 at 3:05 p.m. with LPN J was attempted and she did not return the call by the end of the survey. 11. Phone interview on 7/1/26 at 3:28 p.m. with RN W revealed she had removed five tablets of oxycodone from the Nexsys (an automated medication dispensing machine used for single doses or emergency medication dispensing) on 6/24/26 to administer resident 24's 4:00 a.m. dose because his bubble packed (presorted medication cards where doses are organized into sealed, clear compartments by day and time) supply from the pharmacy had run out.DON B informed her on 7/1/26 that she was supposed to initiate a Controlled Drug Receipt/Record/Disposition Form to document when each dose oxycodone was removed from the locked drawer on the medication cart for administration and to document the number of pills that remained in the locked drawer when she removed the oxycodone from the Nexsys. RN W did not know she was supposed to do that.RN W did not work the night resident 24's oxycodone tablet was discovered to be missing. 12. Interview and review of resident 24's EMR, resident 24's oxycodone Controlled Drug/Receipt/Record/Disposition forms and the Shift Verification of Controlled Substance Count Sheet on 7/1/26 at 3:35 p.m. with DON B revealed she expected the on-coming nurse and the off-going nurse to count the controlled medications at each change of shift. When the nurse signed the Shift Verification of Controlled Substance Count Sheet it indicated that the controlled medications were counted and the count was accurate. She acknowledged there were missing signatures in May and June on the Shift Verification of Controlled Substances Count sheets for the East and [NAME] medication carts.She expected the nurse to sign out controlled medications on the Controlled Drug Receipt/Record/Disposition Form with the time the medication was administered, not the scheduled time or a rounded time. She acknowledged that the times documented on the Controlled Drug Receipt/Record/Disposition form did not match the times the controlled medications were documented in resident 24's MAR as administered.She expected the nurse to initiate a Controlled Drug Receipt/Record/Disposition form when removing a controlled medication from the Nexsys. She was not aware that the nurses had removed oxycodone from the Nexsys for resident 24 and did not document it on a Controlled Drug Receipt/Record/Disposition Form.Once all the controlled medications were used or destroyed from a medication bubble pack, she expected the Controlled Drug Receipt/Record/Disposition Form to be placed in a basket to be scanned into that resident's EMR. She was not aware that resident 24's Controlled Drug Receipt/Record/Disposition Form was not scanned into his EMR for 6/1/26 through 6/8/26. She verified that the form was unable to be found in the EMR, on the medication cart, or in the basket to be scanned into the EMR.She acknowledged that on 6/24/26 there was no documentation on resident 24's Controlled Drug/Receipt/Record/Disposition Form that his oxycodone was removed from the locked drawer on the medication cart to be administered at 4:00 a.m., 10:00 a.m., and 4:00 p.m., but it was documented on resident 24's EMR that he was administered his oxycodone at those times. She stated the oxycodone was removed from the Nexsys by RN W. RN W administered resident 24's 4:00 a.m. oxycodone from the supply she removed from the Nexsys. His 10:00 a.m. dose was administered by RN/minimum data set (MDS) coordinator D from the supply that was removed from the Nexsys, and LPN K administered his 4:00 p.m. dose of the oxycodone removed from the Nexsys because he had run out of his oxycodone that was dispensed from the pharmacy. 13. Review of the provider's January 2018 Controlled Substances policy revealed, Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): Date and time of administration (MAR , Accountability Record). Amount administered (Accountability Record). Remaining quantity (Accountability Record). Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record). 14. Observation on 7/1/26 at 8:20 a.m. of RN G revealed that after she reviewed resident 66's medication administration record (MAR), she removed a stock bottle (a supply of over-the-counter medications kept on hand by the facility) of 60 milligram (mg) fexofenadine (an antihistamine medication) tablets from her medication cart. She placed one 60 mg fexofenadine tablet, a multivitamin tablet, and an 81 mg tablet of aspirin into a medication cup. The cup was taken into resident 66's room, and those medications were administered to the resident. 15. Interview and review of resident 66's MAR on 7/1/26 at 9:10 a.m. with RN G revealed that the physician's order read- Fexofenadine HCl [hydrochloride] Oral Tablet, 180 MG. Give 1 tablet by mouth one time a day related to seasonal allergic rhinitis [inflammation of the mucous membrane inside the nose]. RN G had read only the medication administration instructions and not the entire fexofenadine medication order when she prepared that medication for administration. Based on the above physician's order, she should have prepared and administered three 60 mg tablets (180 mg) to resident 66. 16. Interview on 7/1/26 at 2:00 p.m. with DON B revealed that RN G should have compared the fexofenadine stock bottle label to the MAR, and the medication administration instructions for accuracy. Any identified discrepancy was expected to be reconciled with the resident's physician before that medication was administered. 17. Review of the provider's revised December 2019 Medication Administration Preparation and General Guidelines policy revealed: 4). Five Rights-Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.

Based on observation, interview, record review, and policy review, the provider failed to ensure an in-room call light (a device activated by a resident to alert staff for assistance) was accessible for one of one sampled resident (2) to use. Findings include:1. Observation and interview on 6/29/26 at 5:00 p.m. with resident 2 in his room revealed that he sat in his wheelchair near the television. The resident's hands had a tremor. The television was on the west wall of his room. There was a red mat on the floor on the exit side of the resident's bed. The head of the resident's bed was on the east wall of the room. The resident stated that the non-skid red mat was used to steady his feet and reduce his risk of falling when he stood up from his bed. He was not supposed to stand up without having staff with him. He had Parkinson's disease (a progressive neurological disorder that primarily affects movement). The resident's call light was wrapped around and secured with medical tape to the top of a positioning pole near the head of his bed. The call light was attached to the call light cord. The part of that cord near where it was attached to the call light device was taped to the center of the positioning pole. The remainder of the call light cord was tucked behind the resident's bedside table against the wall. The resident confirmed he had no access to his call light when he sat in his wheelchair watching television. He would have to turn his wheelchair around and move it towards his bed to activate the call light for staff assistance. 2. Observation on 6/30/26 at 10:15 a.m. of resident 2 in his room revealed that he sat in his wheelchair watching television. He had no access to his call light that was taped to the positioning pole near the head of his bed. 3. Review of resident 2's electronic medical record (EMR) revealed he had a revised 8/11/25 activities of daily living (basic self-care tasks) care plan that indicated the resident had self-care deficits related to unsteadiness on his feet, dementia, and Parkinson's disease diagnoses, and needed the staff's assistance with his personal care. A revised 6/16/25 intervention read, Encourage me to use my call light to call for assistance. A revised 8/11/25 fall risk care plan revealed that resident 2 was at risk for falling related to a history of falling. Interventions included, I have been educated by [the] nurse to call for assistance. Date Initiated: 12/19/2025. Please make sure that my call light is within my reach and encourage me to use it to call for assistance. Date Initiated: 06/16/2025. 4. Interview on 6/30/26 at 4:15 p.m. with certified nursing assistant V revealed that she knew that resident 2's call light was secured to the positioning pole on his bed. She stated that that was where the resident wanted it. She agreed that securing the call light to that pole prevented it from being accessible to the resident when he sat in his wheelchair to watch television. 5. Interview on 6/30/26 at 5:15 p.m. with director of nursing (DON) B revealed that resident 2 was able to access the call light taped to his positioning pole only if he was in his bed or able to move his wheelchair to the bed to activate the call light. She agreed that in the event the resident fell out of his wheelchair and onto the floor in his room while watching television, he would not be able to summon staff assistance without access to a call light. 6. Review of the provider's revised 9/30/24 Call Lights policy revealed, 4. Ensure call lights are placed within reach of residents.

50015 Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interviews, and policy review the provider failed to ensure the on-call physician was notified of complaints of acute pain by one of one sampled resident (1) for determination of treatment. 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 provider's 4/2/25 SD DOH FRI revealed: *Resident 1 was admitted on [DATE]. *On 4/2/25 resident 1 reported to senior regional nurse consultant (SRNC) A that he was having trouble with two-night nurses and he expressed: -They were mean to him. -They would not get him water. -They would not give him pain medication. *Resident 1's pertinent diagnoses are: -Cirrhosis of liver (liver damage and scaring). -Diabetes Mellitus type II. -Cardiomyopathy (a disease that makes it harder to pump blood through the heart) -Unspecified convulsions. -Difficulty with walking. -Glaucoma. *Resident 1 reported he was having stomach pain. *Resident 1 was on an ordered 1200 cc fluid restriction. -Resident 1 was given a cup of ice chips by registered nurse (RN) C after reviewing his recent labs values. *Resident 1 did not have orders for a pain medication. *Resident 1's Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated he was cognitively intact. *Resident 1 was unable to name the staff, but was able to give descriptions to SRNC A. *Director of nursing (DON) B was able to identify RN C and certified nursing assistant (CNA) D as the staff members he was reporting based on his descriptions given. -They were immediately suspended on 4/2/25 pending further investigation by DON B. *A new order for Tylenol 500 mg every eight hours PRN was obtained on 4/2/25 for resident 1. *RN C was reinstated on 4/5/25 following education on resident rights regarding fluid restrictions and the abuse and neglect policy by DON B. *RN C was given a disciplinary write-up regarding allegations that were substantiated by the provider for pain management to ensure notification to the provider to obtain an order for pain medication if indicated. *RN C was educated on pain management policy on 4/14/25. *CNA D was reinstated on 4/4/25 after allegations were unsubstantiated by the provider through staff interviews and interview with resident 1. *Resident 1 was seen by a healthcare provider on 4/3/25 and his fluid restriction was discontinued after education and against medical advice of that healthcare provider. *Standing orders have been initiated for residents with the medical director's input. -Those included a PRN pain medication that would be available immediately for pain management needs of the residents. *Audits of all new admissions are to be completed weekly for two months to ensure a scheduled or PRN pain medication is available. *Licensed nurse education has been initiated on notifying the provider of resident pain complaints and the need for additional pain-relieving medication or evaluation. *Education on standing orders was to be completed with all nurses once approved by the medical director. *All care staff were to be educated on their responsibilities for pain management. 2. Review of resident 1's electronic medical record (EMR) revealed: *He had pain monitoring completed twice daily on his medication administration record (MAR) that started 3/13/25. *Pain assessment completed on 3/13/25 indicated he rarely had pain. *Pain assessment completed on 3/18/25 indicated he frequently had pain, and it affected his sleep and interfered with his day-to-day activities no pain level was given. *Pain assessment completed on 4/21/25 indicated he rarely had pain. *His care plan had a focus area of being at risk for pain related to impaired mobility and oral pain. -Interventions initiated on 3/25/25 included: --Ask for medication. --I would like to receive pain relief upon request. --My nurse to review my pain level every shift. --Report to nurse any complaints of pain or any requests for pain treatment. *Review of his every shift pain check documentation revealed: -On 3/26/25 he complained of pain, was evaluated in the local emergency room (ER) his X-rays were negative, he was given hydrocodone (a pain medication) and returned to the facility. -On 4/1/25 RN C documented a pain check was completed, and his pain level was 0 out of 10. -On 4/5/25 he rated his pain level at a 10 on a 0 to 10 pain scale, attributed to constipation. He was given milk of magnesium, and it resolved. *Standing orders, that included PRN Tylenol were signed on 4/18/25. *Risks vs Benefits for fluid restriction was signed on 4/24/25. *An order was received for palliative care dated 5/5/25. 3. Interview on 5/6/25 at 10:14 a.m. with resident 1 revealed: *When he was admitted he was asked about pain. *He was asked daily by the nurses if he was having pain. *He did not have any pain, if he did have pain he would have asked the staff for pain medication. *He felt the staff treat him good. He had no complaints and was happy with his care. Observation and interview on 5/7/25 at 8:36 a.m. with RN/minimum data set (MDS) E revealed: *The number for the hospital is listed on the phone list at the nurse's station. *They call that number to get the on-call physician. Interview on 5/6/25 at 5:44 p.m. with RN C revealed: *She works the night shift. *She does not admit new patients. *She had not had to implement new or admission interventions for residents. *She had worked for the facility for about three months. *She received one month of orientation with a nurse preceptor. *Her initial training consisted of online training and included pain management, resident rights, abuse, neglect, fall risk and fall prevention. *Resident 1 complained of pain on the night of 4/2/25. *He had labs completed on 3/31/25 which indicated he had elevated liver enzymes and low platelets, so she did not want to give him acetaminophen or ibuprofen. *He had no physician ordered pain medication at that time. *She did not call a provider for pain medication orders. -She now knows she can call the on-call physician for orders and has an e-kit (emergency kit) with medications for residents if needed. *She had offered non-pharmacological interventions such as repositioning, but resident 1 refused. -He then fell back to sleep and was observed snoring. *She reported that information to the oncoming nurse in the morning on 4/2/25 and to get orders for a pain medication that he would have been able to take with his abnormal labs. *Their was no documentation in resident 1 progress notes that he had complained of pain, any interventions that were offered by RN C, and no documentation of refusals by resident 1. Interview on 5/7/25 at 9:10 a.m. with DON B revealed: *New nurses are oriented with another nurse when they are hired for one to two weeks topics included were pain management, after-hours on-call physician notification. -She checks in with nurses during their orientation period to determine if more orientation time is needed and given, if applicable. *Nurses complete online training based on their nursing position. *If a new nurse had questions, they could ask the other nurse working. *She was always on-call and available as well if there were questions. *The contact phone numbers for the hospital, clinics, physicians and other providers were located at the nurse's station. *The on-call instructions were not posted at the nurse's station or included on the nurse's orientation checklist. *She expected that if a resident complained of pain during the night and did not have orders for a pain medication, the nurse would call the on-call physician. *During her investigation into the above incident RN C did not think she needed to make the physician aware of the situation. *She had offered the resident repositioning and ice and had notified the day nurse to call the physician to request pain medication orders. *She was in the process of adding contact information for on-call physicians and instructions by the phone list at the nurse's station. 4. Review of provider's revised 4/28/25 Pain Management policy revealed: *The purpose of this procedure is to help the staff identify pain in a resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Defining goals and appropriate interventions: 4.For those situations where the cause of the resident's pain has not been or cannot be determined, follow current standards of practice for managing pain to help determine appropriate options. Implementing pain management strategies: 4.The physician and staff will establish a treatment regimen based on consideration of the following: -The resident's medical condition. -Current medication regimen. -Nature, severity and cause of the pain. -Course of the illness. -Treatment goals. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 5/7/25 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding pain management policy, and education regarding residents having complaints of pain and needing additional evaluation was provided to applicable staff. Standing pain management orders were developed with their medical director. Postings were at the nurses' station for notification and instructions for contacting the on-call physician. A whole house audit for pain medication orders was completed. Audits were being completed weekly. Observation and staff interviews revealed the staff understood the education provided and the revised process. Based on the above information, non-compliance at F697 occurred on 4/2/25, and based on the provider's implemented corrective actions for the deficient practice confirmed on 5/7/25, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, and policy review, the provider failed to protect the resident's right to be free from neglect for one on one sampled resident (206) who expressed he felt bad that he had been sent to the emergency room (ER) by registered nurse (RN) (N) without being provided personal hygiene after he had been incontinent of loose stool. Findings include: 1. Review of the provider's 3/15/25 SD DOH FRI regarding resident 206 revealed: *He was admitted to facility on 3/13/25. *His Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated he was cognitively intact. *On 3/14/25 he was transported to a local ER for evaluation by ambulance. -A paramedic observed he had loose stool leaking out of the side of his brief, and reported that to RN N. -RN N did not offer to clean or provide personal hygiene to the resident at the time of transport. *The paramedic reported that information to director of nursing (DON) B when he called her about the incident and added: -The ambulance team would transport the resident. -The hospital may not be happy about the condition of resident 206 upon arrival to the ER. *DON B gave immediate verbal education to RN N via phone on resident dignity and neglect. *RN N was suspended pending the provider's investigation of the incident. *Resident 206 returned to provider facility on 3/15/25. *A skin assessment was completed on 3/15/25 on resident 206, with no new skin concerns noted. *All staff education had been initiated on ensuring resident dignity was maintained, as well as abuse and neglect. *The resident's primary care provider (PCP) was notified of the incident. *The local police department was notified of the incident. 2. Interview on 4/2/25 at 9:00 a.m. with RN N revealed: *Resident 206 had been having loose stools on 3/14/25 in the evening and was not taking fluids. *He was on a strict fluid restriction. *His blood sugar was 126. *She had orders to give him insulin. *She had called the on-call provider, who gave an order to send the resident to the ER for evaluation of his loose stools and low fluid intake. *She had called the hospital and gave them a verbal report regarding the resident. *At 9:30 p.m. on 3/14/25 staff had completed a total bed change on the resident following an incontinent episode. *When the paramedic arrived at the facility, the resident had again been incontinent of loose stool. *She had asked the paramedic if he wanted the facility staff to clean up the resident. *The paramedic had said he did not care but the hospital staff would not like it. *They did not clean the resident up and the resident was transferred to the ER. *The resident returned to facility on 3/15/25. *She stated she did not want to make the paramedics wait that evening. *She said she felt terrible that resident 206 went to the ER in that condition and the hospital staff made him feel bad about it. *She agreed that situation could have been prevented by ensuring he was provided with personal hygiene and was clean before he was sent to the ER that evening. 3. Interview on 4/2/25 at 9:30 a.m. with resident 206 revealed: *He stated the hospital staff were upset that he was incontinent of bowel when he went to theER on [DATE]. *He felt bad because the hospital staff was upset. *They cleaned him up. *His bowels had improved since then. *He felt staff had time to change him before he went to the hospital that evening. *He had heard the paramedic tell RN N he was incontinent of bowel. *He did not remember being updated on the facility's investigation of the incident. 4. Interview on 4/2/25 at 10:25 a.m. with administrator A revealed: *He and DON B completed the investigation regarding the above incident involving resident 206 on 3/14/25. *On 3/15/25 a skin assessment was completed on resident 206, with no new areas of concern. *They had interviewed other staff working that evening as part of their investigation. *They had notified the local police of incident with resident 206. *They had notified resident 206 PCP of the above incident. *RN N had received disciplinary action and was allowed to return to duty after completion of that. *Resident 206's care plan was updated with the following intervention: -He has frequent loose stools related to the use of lactulose for treatment of hepatic encephalopathy. He will require assistance with toileting and personal hygiene as needed initiated. on 3/19/25. *Education was provided to all staff regarding the provider's Abuse and Neglect Policy and the Dignity Policy. *No audits or monitoring related to the above incident had been completed following the incident or the completion of the investigation. Review of the provider's 2/20/24 revised Abuse and Neglect Policy revealed: *It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect or mistreatment. 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 (&) federal components of prevention and investigations. -Mental abuse includes, but is not limited to humiliation, harassment, threat of bodily harm, punishment, isolation (involuntary, imposed seclusion) or deprivation to provoke fear of shame. -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 or 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. Review of the provider's 11/19/24 revised Resident Dignity and Privacy Policy revealed: *It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as , care for each resident in a manner and in an environment, that maintains resident privacy. -6. Groom and dress residents according to resident preference. Clothing should be changed when soiled. Document any resident refusals. -10. Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source.

Based on observation, interview, record review, and policy review, the provider failed to identify and implement pressure ulcer prevention interventions to ensure facility-acquired pressure ulcers had not developed for one of two sampled residents (205) identified at high risk for skin breakdown and dependent on the staff assistance with their activities of daily living (ADL). Findings include: 1. Observation and interview on 3/31/25 at 8:38 a.m. with resident 205 revealed: *He was seated in his wheelchair and wore blue padded pressure-reducing boots on both of his feet. *He said he had been at the facility for about two weeks and did not know why he needed to wear those boots. -He stated his feet did not hurt. 2. Observation and interview on 4/1/25 at 7:59 a.m. with resident 205 and certified nursing assistant (CNA) R in resident 205's room revealed: *CNA R stated that resident 205 had been at the facility for about two weeks. *Resident 205 wore a Tubi Grip (compression stocking) on his right leg and blue boots on both feet due to a pressure ulcer on his right heel. *Resident 205 stated that the ulcer on his right heel did not cause him any pain. 3. Observation on 4/2/25 at 7:43 a.m. with resident 205 revealed: *He was lying in bed on his back with blue boots on both feet. *His bed did not have an air mattress on it. 4. Review of resident 205's electronic medical record (EMR) revealed: *He had been admitted on [DATE] from another long-term care facility. *His Braden assessment score was 18 on 3/13/25 which indicated he was as risk for developing pressure ulcers. *His Braden assessment score was 6 on 3/17/25 which indicated he was at high risk for developing pressure ulcers. -That assessment indicated he did not have a history or an existing pressure ulcer at that time. *A 3/13/25 physician's order, Transfer to [provider] on current orders. Send current supply of meds [medications]. -Those orders indicated: --Skin prep to bilateral heels for skin protection one time daily. --Pressure Injury Treatment/Prevention on each shift two times a day. 1. Check that [the] air mattress is on [the] bed and operating correctly. 2. Float heels when in bed. 3. Ensure dressings are in place as ordered. 4. Pressure redistributing cushion in w/c [wheelchair]. 5. Reposition q2-3h [every two to three hours]. 6. Pericare as indicated, were noted as received 3/17/25. ---There was no documentation that indicated that those orders had been initiated upon resident 205's admission to the facility. *His diagnoses included hemiparesis (paralysis) following cerebral infarction (a stroke) affecting the left non-dominant side, Type 2 Diabetes Mellitus, major depressive disorder, pressure ulcer of the right heel, unstageable, and personal history of Staphylococcus Aureus [drug resistant organism] infection. *A 3/24/25 Skin Alteration Evaluation identified a new pressure injury to resident 205's right heel that measured 4.4 centimeters (cm) in length by 5.0 cm in width and was staged as a suspected deep tissue injury. *His care plan indicated: -I have an ADL Self Care Performance Deficit r/t [related to] impaired mobility. 2 [Two] staff and the hoyer lift [a full-body mechanical lift and sling used to move a person's full body] for all transfers, was initiated on 3/18/25. -I am dependent on staff with: roll left and right, chair/bed-to-chair transfers, toilet transfers, tub/shower transfers, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, [and] personal hygiene, was initiated on 3/25/25. -Utilizes an [a] bariatric bed, was initiated on 3/18/25. -Ensure that I am wearing appropriate footwear when mobilizing in w/c [wheelchair], was initiated on 3/25/25. -I have an unstageable pressure ulcer to right lateral heel r/t AFO [ankle-foot orthosis] use. My pressure ulcer will show signs of healing and remain free from infection through the review date, was initiated on 3/25/25. *There was no documentation that indicated: -An air mattress had been utilized, trialed, or refused as ordered by the physician at the time of his admission. -The resident wore blue padded pressure-reducing boots. -That the above pressure injury treatment and prevention interventions ordered by the physician had been care planned or implemented upon admission. 5. Interview on 4/02/25 at 8:04 a.m. and again at 11:10 a.m. with assistant director of nursing (ADON) C regarding resident 205 revealed: *She was the wound care nurse. *She had been on vacation when resident 205 was admitted to the facility. *Resident 205 did not have any pressure ulcers when he was admitted to the facility on [DATE]. *Resident 205 had been assessed as high risk for developing pressure ulcers when he was admitted . *She stated all residents were provided with an air mattress when they were admitted and those mattresses were only removed at the resident's request. -Resident 205 did not have an air mattress on his bed. He had a mattress that would not have saved his heels from a pressure ulcer. -She had been told resident 205 refused the air mattress. *Resident 205 was identified as having a new pressure ulcer to his right heel on 3/24/25. *She felt that resident 205's right heel pressure ulcer had been caused by his AFO brace that his daughter had brought to the facility for him to wear. -That brace was sent home before she had returned to work, and she had not seen that brace. *She expected pressure relieving interventions including the use of an air mattress, pressure reducing boots in bed and while in the wheelchair, and every two-hour repositioning would have been implemented for any resident admitted and assessed as high risk for pressure injury. *She confirmed that there were no interventions, including the pressure-reducing boots, for pressure relief listed in resident 205's care plan before or after the identification of that pressure area. *She stated that those above interventions would not have prevented a pressure injury from his AFO. *Resident 205 had been provided with those pressure reducing boots when the pressure ulcer was identified. -She expected resident 205 to wear those pressure reducing boots when he was in bed and in his wheelchair. 6. Interview on 4/2/24 at 12:16 p.m. with DON B regarding resident 205 revealed: *She expected that all the physician transfer orders and interventions should have been implemented and followed when resident 205 had been admitted including the pressure ulcer prevention orders. -Those interventions for pressure ulcer prevention should have been included in resident 205's care plan before he developed a pressure ulcer and updated with additional interventions if needed after the pressure ulcer had been identified. *Resident 205 had been provided with the pressure reducing boots after the right heel pressure ulcer had been identified. *She confirmed the resident had developed the pressure ulcer after his admission to the facility. 7. Interview on 4/2/25 at 12:30 p.m. with registered nurse (RN) D regarding resident 205's admission orders revealed: *Resident 205 was transferred from another long-term care facility with orders from his physician. *She had reviewed those admitting orders and entered the medication orders and care plan interventions. *The treatment orders and interventions including the pressure ulcer treatment and prevention orders were to have been reviewed by ADON C before they were entered into the EMR. *When ADON C was unavailable to review those orders and interventions she expected DON B to review and enter them. Review of the provider's revised 9/11/24 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 conditions demonstrates that they are unavoidable. *A plan of care (POC) will be put in 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 .d. Educate staff, residents and families, e. Train front-line caregivers, f. Immediate prevention plan instituted when potential areas are identified. *Pressure can come from splints, casts, bandages, and wrinkles in the bed linen.

Based on observation, interview, record review, Voluntary Agreement for Arbitration review, and policy review, the provider failed to ensure 50 of 55 residents (1, 2, 3, 4, 5, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 46, 47, 48, 50, 104, 105, 106, 115, 154, 156, 204, 205, 206, 304, 305) who had entered into an Arbitration Agreement upon admission to the facility were explicitly granted the right to rescind the agreement within 30 calendar days of signing it. Findings include: 1. Observation and interview on 3/31/25 at 1:25 p.m. with resident 34 in her room regarding the Voluntary Agreement for Arbitration addendum she had signed upon admission revealed she: *Knew she signed several papers when she was admitted . *Was not sure what a Voluntary Agreement for Arbitration was for. *Did not recall signing a Voluntary Agreement for Arbitration specifically. Review of resident 34's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) score of 15 which meant she was cognitively intact. *Her 12/30/24 admission agreement was signed by resident 34. *The admission packet included information regarding arbitration. 2. Review of the provider's undated Voluntary Agreement for Arbitration agreement revealed: *The execution of this Arbitration Agreement is voluntary and is not a precondition to receiving medical treatment at or for admission to the Facility. *The Resident and/or Legal Representative understands that this Arbitration Agreement may be rescinded by giving written notice to the Facility within 10 days of its execution. If not rescinded within 10 days of its execution, this Arbitration Agreement shall remain in effect for all claims arising out of the Resident's stay at the Facility. 3. Interview on 4/2/25 10:19 a.m. with administrator A regarding the amount of time a resident had to rescind the arbitration agreement revealed: *All residents were offered arbitration upon admission. *The social services director went over the arbitration agreement during the admission process with the resident and/or their representative. *Arbitration was not a condition for admission to the facility. *No residents had used the arbitration process to settle a dispute. *He was not sure why the corporate agreement allowed 10 days for a resident/responsible party to rescind the agreement. *He agreed it should be 30 days in the arbitration agreement according to the requirements. *All residents would have signed the same agreement. *50 of the 55 current residents (1, 2, 3, 4, 5, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 46, 47, 48, 50, 104, 105, 106, 115, 154, 156, 204, 205, 206, 304, 305) admitted after the 2019 arbitration agreement implementation and had signed arbitration agreements. *The five residents who did not have those signed agreements were admitted prior to the 2019 arbitration agreements being implemented. *The social services director was not available for an interview during the survey. 4. Review of the provider's undated Arbitration Agreement policy revealed: *It is the policy of Avantara [NAME] (Facility) to present the Arbitration Agreement to Resident/Resident's Legally Authorized Representative (Representative) after the admission paperwork is completed. *Not require any resident or his/her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at a facility. *Provide the resident or his/her representative a 30-day rescission period.

Based on observation, interview, record review, testing, and policy review, the provider failed to ensure adequate temperatures for three of three sampled residents (24, 27, and 304) who expressed their rooms were cold and uncomfortable. Findings include: 1. Observation and interview on 3/30/25 at 4:40 p.m. in resident 27's room revealed: *The temperature of the room felt cold in comparison to other areas within the facility. *The resident was in bed and covered with blankets. *The window shade was down with a blanket along the bottom edge of the window. *The resident stated: -She would get into her bed under the blankets to stay warm. -The room was cold and she had no control over the temperature in her room. -The maintenance man would check the boiler when she reported her room was cold, but her room temperature would remain cold and uncomfortable for her. 2. Review of resident 27's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) assessment score of 14, which indicated she was cognitively intact. 3. Observation and interview on 3/30/25 at 5:10 p.m. in resident 24's room revealed: *The temperature of the room felt cold in comparison to other areas within the facility. *The resident was wearing a lined shirt/jacket and was sitting in his recliner chair. *The window shade was down and two pillows were along the bottom edge of the window. *The resident stated the room was cold, and he walked the hall multiple times daily to warm up. *The resident used extra blankets at night to stay warm. 4. Observation and interview on 3/31/25 at 4:00 p.m. with resident 24 in the west hallway revealed: *The resident was walking up and down the hall with his walker. *He stated he needed to be out of his room and moving to warm up because his room was cold, and he was freezing. 5. Review of resident 24's EMR revealed: *He was admitted on [DATE]. *He had a BIMS assessment score of 15, which indicated he was cognitively intact. 6. Observation and interview on 3/31/25 at 9:00 a.m. in resident 304's room revealed: *The temperature of the room felt cold in comparison to other areas within the facility. *The resident returned from therapy and entered her room and stated, The room is a bit chilly. *The window shade was up and a blanket was along the bottom edge of the window. *The resident stated the room would get cold if the door was shut. 7. Review of resident 304's EMR revealed: *She was admitted on [DATE]. *She had a BIMS assessment score of 12, which indicated she had moderate cognitive impairment. 8. Interview on 4/1/25 at 9:57 a.m. with maintenance director H revealed: *The resident room temperatures should range be between 70 and 80 degrees Fahrenheit (F). *The facility used boiler heat, which could only be adjusted for some areas of the building. -He stated it was difficult to maintain temperatures for residents who were hot or cold. *Resident room temperatures were checked and documented five times weekly. -He would check three to four temperatures in resident rooms and then document the average of those temperatures. *The boilers were checked when the resident room temperatures were out of range. *He stated the resident rooms' windows leaked allowing outside air into the room and the windows should be replaced. *Thermostats were located throughout the building and were locked so staff and resident could not adjust them. -No thermostats were located within the resident rooms. *Temperature settings were controlled by the maintenance department staff. -The thermostats were set between 70 and 72 degrees F. *He stated a local vendor would complete a check on the facility boilers as requested. 9. Temperature testing on 4/1/25 at 10:07 a.m. with maintenance director H in resident 24's room revealed: *The north wall temperature next to the resident's bed was 65.3 degrees F. *The west wall next to the resident's recliner chair was 68.4 degrees F. *The south wall next to his roommate's bed was 69.1 degrees F. 10. Interview on 4/1/25 at 1:33 p.m. with the assistant director of nursing (ADON) C revealed: *The maintenance director controlled and adjusted the buildings' thermostats for the temperatures of the rooms. *She did not think anyone else touched the thermostats or adjusted the temperatures. 11. Interview on 4/2/25 at 9:06 a.m. with activity aide O revealed: *She had never touched a thermostat at the facility to adjust a room temperature. *She was unsure if the residents' rooms had thermostats. 12. Interview on 4/2/25 at 9:09 a.m. with CNA P revealed: *She confirmed there were no thermostats in residents' rooms to control and maintain comfortable temperatures according to their preferences. *The maintenance director controlled and adjusted the thermostats for temperature control throughout the building. 13. Interview on 4/2/25 at 9:23 a.m. with administrator A revealed: *The facility areas and residents' room temperatures were monitored weekly and documented by the maintenance director. *A grievance was presented at the 2/18/25 resident council meeting regarding cold resident rooms. *There was a plan to replace the facility's windows. *The expectation was for residents' rooms to be at adequate temperature settings to maintain a comfortable level. *The residents' room temperature should be maintained between 71 and 81 degrees F. *He confirmed that residents' room temperatures below 70 degrees F was not within the required temperature range. Review of the resident council grievance form dated 2/18/25 revealed the residents had complained of being too cold and that the heat needed to be turned up. Review of the investigation and follow-up responses dated 2/19/25 on the above grievance form revealed: *Maintenance was educated on air temperature parameters and steps for notification if the air temperatures were out of range. *The required temperature range should be between 71 and 81 degrees F. *The thermostat was to be adjusted if the temperatures were out of range. *The corporate maintenance consultant and the administrator were to be notified if the appropriate temperatures were not reached. *If necessary, maintenance was to follow up with the vendor as soon as possible. Review of the providers 9/30/24 Homelike Environment policy revealed: *Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. *Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. *The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: -Comfortable temperatures.

Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans reflected the residents' current needs and/or to provide interventions as directed on the care plans for four of twenty sampled residents (3, 34, 205, and 206) as follows: *Interventions were not provided as directed on the care plan for resident 3 who required a fall mat and a call light within her reach. *The care plan did not include interventions to prevent the development of a pressure ulcer for resident 205. *Interventions were not provided as directed on the care plan for resident 206 who required the use of a positioning alarm. *The care plan did not include interventions for lymphedema (condition causing swelling in the arms or legs) wraps for resident 34. Findings include: 1. Observations on 3/30/25 at 3:05 p.m., 4:44 p.m., 5:06 p.m. and 5:13 p.m. of resident 3 revealed: *She was in her bed which was in a low position and against the wall. *The privacy curtain was tucked between the bed and the wall near the foot of her bed. *A blue fall mat was folded in half and propped up against her bedside table. *The call light was on a bedside table behind the fall mat and not within her reach. Observation on 3/30/25 at 5:48 p.m. with resident 3 revealed: *She was in her bed which was in a low position and against the wall. *A blue fall mat was folded in half and on the floor near her bed in a position that appeared as if it had fallen over. *The call light was on the bedside table and not within her reach. Review of resident 3's electronic medical record (EMR) revealed: *She had been admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) assessment score was 5, which indicated she was severely cognitively impaired. *Her diagnoses included a fracture of the right femur (thigh bone) and dementia. *Her 3/26/25 Fall Risk Evaluation indicated she had a low risk for falling. *Her care plan indicated: -She was At risk for falls related to [the] history of falls, right hip fracture with no right hip joint, dementia, anemia and arthritis. -Please make sure that my call light is within my reach and encourage me to use it to call for assistance. -Bed to be in low position and floor mat is placed next to the bed. Interview and record review on 4/02/25 at 8:45 a.m. with director of nursing (DON) B regarding resident 3 revealed: *She confirmed resident 3's 3/26/25 Fall Risk Evaluation indicated Low Risk. *Resident 3 had fallen on 1/2/25 and was at risk for falls. She thought the fall mat intervention on her care plan was still needed and appropriate. *She expected that resident 3's care-planned interventions of the fall mat and ensuring resident 3's call light was within her reach would have been followed. 2. Observation and interview on 3/31/25 at 8:38 a.m. with resident 205 revealed: *He was seated in his wheelchair and wore padded pressure-reducing boots on both of his feet. *He said he had been at the facility for about two weeks and did not know why he needed to wear those boots. Observation and interview on 4/1/25 at 7:59 a.m. with resident 205 and certified nursing assistant (CNA) R in resident 205's room revealed: *CNA R stated that resident 205 had been at the facility for about two weeks. *Resident 205 wore a Tubi Grip (compression stocking) on his right leg and blue pressure-reducing boots on both feet due to a pressure ulcer on his right heel. *CNA R stated that information on how staff were to care for each resident was located in the residents' care plans in the EMR. Observation on 4/2/25 at 7:43 a.m. with resident 205 revealed: *He was lying in bed on his back with blue boots on both feet. *His bed did not have an air mattress on it. Review of resident 205's EMR revealed: *He had been admitted on [DATE] from another long-term care facility. *A 3/13/25 physician's order, Transfer to [provider] on current orders. Send current supply of meds [medications]. -Those orders indicated: --Skin prep to bilateral heels for skin protection one time daily. --Pressure Injury Treatment/Prevention on each shift two times a day. 1. Check that [the] air mattress is on [the] bed and operating correctly. 2. Float heels when in bed. 3. Ensure dressings are in place as ordered. 4. Pressure redistributing cushion in w/c [wheelchair]. 5. Reposition q2-3h [every two to three hours]. 6. Pericare as indicated, were noted as received 3/17/25. *His diagnoses included hemiparesis (paralysis) following cerebral infarction (a stroke) affecting the left non-dominant side, Type 2 Diabetes Mellitus, and an unstageable pressure ulcer of the right heel. *A 3/24/25 Skin Alteration Evaluation identified a new pressure injury to resident 205's right heel that measured 4.4 centimeters (cm) in length by 5.0 cm in width and was staged as a suspected deep tissue injury. *His care plan indicated: -I have an ADL [activities of daily living] Self Care Performance Deficit r/t [related to] impaired mobility. 2 [Two] staff and the hoyer lift [a full-body mechanical lift] for all transfers, was initiated on 3/18/25. -I am dependent on staff with: roll left and right, chair/bed-to-chair transfers, toilet transfers, tub/shower transfers, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, [and] personal hygiene, was initiated on 3/25/25. -Utilizes an [a] bariatric bed, was initiated on 3/18/25. -Ensure that I am wearing appropriate footwear when mobilizing in w/c, was initiated on 3/25/25. -I have an unstageable pressure ulcer to right lateral heel r/t AFO [ankle-foot orthosis] use. My pressure ulcer will show signs of healing and remain free from infection through the review date, was Initiated on 3/25/25. *There was no documentation that indicated an air mattress had been utilized, trialed, or refused. *There was no documentation that indicated that resident 205 wore blue padded pressure-reducing boots. Interview on 4/2/25 at 8:04 a.m. and again at 11:10 a.m. with assistant director of nursing (ADON) C regarding resident 205 revealed: *She was the wound care nurse. *She had been on vacation when resident 205 was admitted to the facility. *Resident 205 did not have any pressure ulcers when he was admitted on [DATE]. *Resident 205 had been assessed as high risk for developing pressure areas when he was admitted . *She stated all residents were to be provided with an air mattress when they were admitted and those were only removed at the resident's request. -Resident 205 did not have an air mattress on his bed. He had a mattress that she felt would not have saved his heels from a pressure ulcer. -She had been told resident 205 refused the air mattress. *Resident 205 was identified as having a pressure ulcer on his right heel on 3/24/25. *She felt that resident 205's right heel pressure ulcer had been caused by his AFO brace (used to control ankle/foot position and movement) that his daughter had brought to the facility for him to wear. -That brace was sent home before she had returned to work, and she had not seen that brace. *She expected interventions including the use of an air mattress, pressure-reducing boots while in bed and while in the wheelchair, and every two-hour repositioning to have been implemented for any resident admitted and assessed as a high-risk for a pressure injury. *She confirmed that there were no interventions, including the pressure-reducing boots, listed in resident 205's care plan before or after the identification of that pressure ulcer. *She stated that those above interventions would not have prevented a pressure ulcer from his AFO. *Resident 205 had been provided with those pressure-reducing boots when the pressure area was identified. -She expected resident 205 to wear those pressure-reducing boots when he was in bed and in his wheelchair. Interview on 4/2/25 at 12:16 p.m. with DON B regarding resident 205 revealed: *She expected resident 205's physician's transfer orders for wound prevention should have been included in resident 205's care plan and implemented before he developed a pressure ulcer. *His care plan should have been updated with additional interventions if needed after his pressure ulcer had been identified. *Resident 205 had been provided with pressure-reducing boots after the right heel pressure ulcer had been identified. Interview on 4/2/25 at 12:30 p.m. with registered nurse (RN) D regarding resident 205's admission orders revealed: *Resident 205 was transferred from another long-term care facility with orders from his physician. *She had reviewed those admitting orders and entered the medication orders and care plan interventions. *The treatment orders and interventions including the pressure injury treatment and prevention orders were to have been reviewed by ADON C before they were entered into the resident's EMR. *When ADON C was unavailable to review those orders and interventions she expected DON B to review and enter them. 3. Observation and interview on 3/30/25 at 2:52 p.m. and again at 6:43 p.m. with resident 206 revealed: *He was lying in his bed. *A tabs alarm (a device that alerts staff with an audible sound when the resident changed position) was draped over the handle of his bedside table and hung down towards the floor. *He stated that he had fallen recently, was getting stronger, and wanted to return home. Observation on 3/30/25 at 6:52 p.m. with resident 206 in the dining room revealed he was seated in his wheelchair with no tabs alarm. Observation on 3/31/25 at 8:06 a.m. with resident 206 in the dining room revealed he was seated in his wheelchair eating breakfast and there was no tabs alarm on his wheelchair. Observation and interview on 4/1/25 at 7:30 a.m. with resident 206 revealed: *He was seated in a recliner chair outside the dining room with his wheelchair parked to the left of a recliner. *He stated that he had transferred himself to that recliner chair and was waiting to go to the dining room for breakfast. *There was no tabs alarm on his wheelchair or the recliner chair. Observation and interview on 4/2/25 at 8:39 a.m. with resident 206 revealed: *He was lying in his bed. *The tabs alarm was attached to the bedside table drawer. -He was not wearing the tabs alarm in bed. *He stated he did not know what the tabs alarm was used for and that he did not wear it while in bed or in his wheelchair. Review of resident 206's EMR revealed: *He was admitted on [DATE]. *His diagnoses included Type 2 Diabetes Mellitus, cirrhosis of the liver, convulsions, and difficulty in walking. *Physician orders on 3/13/25 included, Ensure tabs alarm is on at all times when in bed and his wheelchair, and Tabs alarm on in bed and to wheelchair to notify staff of position changes. *His care plan included: -I am at risk for falls related to history of hepatic encephalopathy, cardiomyopathy and glaucoma, was initiated on 3/25/25. -Tab alarm to alert staff with position changes, was initiated on 3/25/25. -I require substantial/max assist [assistance] by staff with: roll left and right, sit to lying, sit to stand, lying to sitting on [the] side of [the] bed, chair/bed-to-chair transfers, toilet transfers, tub/shower transfers. Interview on 4/1/25 at 9:29 a.m. with CNA K revealed: *CNA K worked at the facility for approximately three months. *CNA K had found resident 206 on the floor near his bed a few weeks ago. She could not recall the date that occurred. -Resident 206 had tried to transfer himself to his bed. *Resident 206 required the assistance of one staff person to transfer him from his bed or wheelchair. *Resident 206 did not wear a tabs alarm before or after that fall. *Resident 206 had a call light that he used to request staff assistance. *CNA K reviewed information on how to care for residents from the residents' paper charts and the EMR when she completed her charting. *CNA K carried an assignment sheet that provided her with information about the residents she cared for. -That sheet was also used to provide a report to the next shift's staff. --It did not indicate that resident 206 required a tabs alarm. Interview on 4/1/25 at 9:53 a.m. with CNA F regarding resident 206 revealed: *Resident 206 did not wear a tabs alarm. *CNA F stated he would ask the nurse or look in the residents' care plan for information on how to care for the residents. -He stated he reviewed those resident care plans every day. Interview on 4/1/25 at 10:03 a.m. with infection preventionist/licensed practical nurse (IP/LPN) G regarding resident 206 revealed: *She was the nurse who was working on the floor that day and was responsible for resident 206's care. *Resident 206 had a tabs monitor. -He would at times refuse to wear that tabs monitor. -IP/LPN G stated that she had ensured resident 206 was wearing that tabs alarm and he had allowed her to clip it to his shirt. *CNAs would find resident care information in the resident's care plan in the EMR. *She completed the CNA daily assignment sheets and would not have included that resident 206 wore a tabs monitor on that sheet. *IP/LPN G confirmed that resident 206's care plan included that he wore a tabs monitor. Interview on 4/1/25 at 10:34 a.m. with DON B revealed: *She expected the CNAs to look at the Kardex (a report of residents' care needs and interventions) or EMR care plans regularly for information on how to care for the residents. *She stated that a resident's need for a tabs alarm would be care planned. *She confirmed that resident 206's care plan indicated his need for a tabs alarm. *She stated a resident's use of a tabs alarm would not be on the CNA's assignment sheet. 45683 4. Observation and interview on 3/31/25 at 9:19 a.m. with resident 34 in her room revealed: *She was sitting in her wheelchair. *Her legs were wrapped with Ace bandages. *She stated the physical therapist wraps her legs daily and it had helped reduce the swelling. Interview on 4/1/25 at 10:39 a.m. with physical therapist M revealed: *She wrapped resident 34's legs with Ace elastic bandages daily because it was a physician-ordered treatment for her lymphedema (fluid build-up that causes swelling). *She had worked with the Minimum Data Set (MDS) coordinator to get the physician's orders for resident 34's Ace wrap treatments. Review of resident 34's electronic medical record (EMR) revealed: *She had been admitted on [DATE]. *She had a brief interview for mental status (BIMS) score of 15 which indicated she was cognitively intact. *Her diagnoses included: -Lymphedema, not elsewhere classified. -Edema, unspecified. -Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity. *Resident 34's current care plan did not include her use of the Ace wraps. -PT/OT/ST as ordered by MD. -Tx and medications as ordered by MD. Interview on 4/1/25 at 1:55 p.m. with assistant director of nursing (ADON) C regarding resident 34's lymphedema revealed: *She knew the physical therapist was providing the Ace wrapping treatment for resident 34's lymphedema. *She expected that treatment to be addressed in the resident's care plan. *Staff needed to be aware of the care being provided. Interview on 4/2/25 at 12:05 p.m. with RN/MDS coordinator D regarding resident 34's lymphedema revealed: *The nursing staff were not trained regarding the elastic bandage wraps resident 34 needed on her legs. *She had obtained orders from resident 34's physician for the wrap treatments that therapy provided. *She did not think resident 34's use of elastic wraps needed to be part of the resident's care plan because the treatments did not involve the nursing staff. Interview on 4/2/25 at 1:30 p.m. with DON B regarding resident 34's lymphedema revealed: *She knew about the treatments for resident 34's lymphedema. *She confirmed the information regarding the lymphedema treatments was not on her care plan. *It was her expectation that information would be a part of the resident's care plan. Review of the provider's revised 9/30/24 Care Plans policy revealed: *Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. *Interventions act as the means to meet the individual's needs. The recipe for care requires active problem solving and creative thinking to attain, and clearly delineates who, what, where, when, and how the individual resident goals are being addressed and met. *Care plans are accessible to all direct-care staff, including the resident's physician/provider. It is the responsibility of all direct care members to familiarize themselves with the care plan and review the routinely for changes.

Based on observation, interview, record review, and manufacturer's manual review, the provider failed to ensure appropriate infection control practices were followed for: *Enhanced barrier precautions (EBP) (gloves and gown use when providing direct contact care) by two of two certified nursing assistants (CNAs) ( J and S) for one of one sampled resident (205) with a catheter, multidrug-resistant organism (MDRO), and a pressure injury. *Appropriate whirlpool (WP) tub cleaning by two of two CNAs (F and I) in one of two WP tub rooms used for bathing residents. *Maintaining the cleanliness of the laundry room. Findings include: 1. Observation on 3/30/25 at 5:26 p.m. with resident 205 revealed: *There was a sign on his door that indicated Stop Enhanced Barrier Precautions Everyone must: Clean their hands, including before entering and leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities dressing bathing/showering, transferring, changing linen changing briefs, or assisting with toileting . *Resident 205 was in bed and had been rolled on his side facing the window. *CNA J and CNA S were providing resident 205 assistance with personal hygiene and changing his undergarments. *CNA J and CNA S had gloves on but did not have gowns on while they assisted resident 205. Interview on 3/30/25 at 5:37 p.m. with CNA S regarding the above observation revealed: *She stated that the EBP sign on resident 205's door meant that she needed to wear gloves and a gown when she emptied his catheter. *She confirmed that she and CNA J had been wearing gloves but no gowns when they changed resident 205's undergarments. *She did not think they needed to wear a gown when they provided the above care, because they did not empty his catheter. Review of resident 205's electronic medical record (EMR) revealed: *He had been admitted on [DATE]. *His diagnoses included, a pressure ulcer of the right heel, unstageable, and personal history of Staphylococcus Aureus (a bacterial) infection. *His care plan indicated: -I am on Enhanced Barrier Precaution r/t [related to] catheter and wound care. -Ensure that gown and gloves are used during high-contact resident care activities of catheter cares, draining of Foley catheter and wound care that provide opportunities for transfer of MDROs to staff hands and clothing. Interview on 4/1/25 at 10:08 a.m. with infection preventionist/licensed practical nurse (IP/LPN) G regarding EBP revealed she expected staff to wear both a gown and gloves while providing direct care, such as personal hygiene and changing undergarments to residents with catheters and wounds. 2. Observation and interview on 4/1/25 at 10:49 a.m. with CNA I and CNA F in the west WP tub room of the cleaning and sanitizing process of the resident WP tub revealed: *Both CNA I and CNA F used the WP to bathe residents that day. *CNA I took a spray bottle of Micro-Kill Q10 disinfectant cleaner from the cabinet and sprayed the surfaces of the WP tub. *CNA F indicated that the Micro-Kill Q10 was not the correct cleaner for the WP tub and took a spray bottle of BruTab 6S cleaner/disinfectant from that same cabinet. -That spray bottle of BruTab 6S was not dated, the bottle's label was worn, and there was no indication of the time the surface needed to remain wet with that product to achieve sanitization. *There were instructions for cleaning the WP tub posted and taped to the front of that cabinet. *CNA F sprayed the surfaces of the tub and tub seat with the BruTab 6S spray, stated he would wait 10 minutes, and then used the shower sprayer to rinse down the surfaces. *CNA F stated that was the process used to clean and sanitize the WP tub between each resident's bath. *CNA I and CNA F confirmed there was no brush used to clean the tub. Observation and interview on 4/1/25 at 2:08 p.m. with director of nursing DON B in the west WP tub room revealed: *She expected the CNAs to clean the WP tub with the BruTab 6S cleaner and that the surface needed to remain wet for 10 minutes. -That spray bottle's contents had been made with an effervescent tablet of that cleaner. -That was the last bottle of that cleaner. -Staff were to use that bottle until it was gone. -She confirmed that the spray bottle was not dated to indicate when it had been mixed with the tablet. --She confirmed that it did not indicate the time the surface needed to remain wet to achieve sanitization. *Staff could also have used the Micro-Kill Q10 cleaner to clean the whirlpool. -That bottle was refilled from a larger bottle of Micro-Kill Q10. -It was not dated when it had been filled. -She confirmed that it did not indicate the time the WP tub surface needed to remain wet to achieve sanitization. *She expected the staff to follow the posted manufacturer's guidelines when using and cleaning the whirlpool. -Those guidelines stated to .spray all surfaces of the tub with Dispatch Cleaner and Disinfectant. -She confirmed that the CNAs had not followed the manufacturer's guide for cleaning the WP tub. *They did not have the Dispatch Cleaner and Disinfectant listed in the WP tub's manufacturer's manual. Review of the BruTab 6S safety data sheet indicated it was: *Stable: 1 [One] week shelf life when diluted into a closed container. Review of the WP cleaning instruction sheet that was observed taped to the cabinet in the west WP tub revealed it was a copy of page 23 of the WP manufacturer's manual. Review of the provider's eSide Entry Whirlpool Tubs manufacturer's manual review revealed: *The tub MUST be cleaned and disinfected after each use. *Clean and disinfect the tub after EACH use to avoid resident infection and contamination of the tub. * Read and understand ALL information on disinfecting BEFORE use. ALWAYS wear rubber gloves, an apron and a face shield when using disinfectant. *Use of unapproved cleaners will dry out the rubber seals and gaskets and the tub will not function properly. *Page 23 of the manual indicated, Perform these procedures in the following order: 1. Use the drain plug to close the drain. 2. Remove and disassemble all jet assemblies. Lay all pieces in the bottom of the tub . 4. Clean the pieces and spray all surfaces of the tub with Dispatch Cleaner and Disinfectant. Take a long handled brush and thoroughly clean surfaces of the tub and the jet casings. 5. Allow the Dispatch Cleaner and Disinfectant to sit on the surfaces for one minute. 6. Rinse all surfaces and pieces in the footwell of the tub with water. 7. Use a clean towel to dry all tub surfaces . 3. Observation and interview on 4/2/25 at 9:18 a.m. with laundry aide L in the facility laundry room revealed: *Laundry aide L had worked at the facility for approximately 3 years. *She stated that the laundry staff were responsible for cleaning the laundry room. *There was an oscillating fan mounted to the wall adjacent to the entrance door. -That fan blew air from the side of the laundry room where the soiled linens were brought in and loaded into the washing machines towards the area where the laundry aide folded the clean linens. *There was an area under the wall-mounted chemical system approximately two feet by two feet where the paint was peeled and had exposed concrete. *The area of the floor near that chemical system had more than three areas two inches by five inches where the tiles were cracked or peeling and were uncleanable surfaces. *Laundry aide L stated those areas were from when the chemicals leaked. The leak had been fixed but the floor and wall had not been repaired. -She could not recall when that leak had occurred and stated it had been a while, and that maintenance was aware of those areas. *In the clean linen room there were hooks on the wall that held the mechanical lift slings. -More than six of those lift slings touched the floor and had thick gray dust on them. *The area below the slings had an area of approximately three inches by two feet of cracked or missing tiles and peeling paint on the wall. -Laundry aide L was not sure if maintenance was aware of those areas. Observation and interview on 4/2/25 at 9:41 a.m. with maintenance director H in the laundry room revealed he: *Was aware of the areas near the wall-mounted chemicals that needed repair. -Had not ordered tiles to replace the cracked ones. *Was not aware of the areas on the wall or the cracked flooring in the clean linen room. *Agreed that the missing tiles and the peeling paint made the floor and walls uncleanable surfaces. *Confirmed the wall-mounted fan was placed in a spot where it would blow air from the dirty side to the clean side of the laundry room and indicated he would move that fan. Observation and interview on 4/2/25 at 12:08 p.m. with IP/LPN G in the laundry room revealed: *She confirmed that the above areas were not cleanable surfaces. *She expected that the laundry room areas would have been maintained and cleaned regularly. *The fan had been removed from the wall. *The mechanical lift slings had been hung in a position where they no longer touched the floor. *Maintenance director H was responsible for the laundry department, and she had been unaware of the above-observed infection control concerns. *She confirmed that there had been no April cleaning log. Review of the provider's revised 6/21/24, Enhanced Barrier Precautions policy revealed: *Enhanced Barrier Precautions (EBP): refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. *Enhanced Barrier Precautions (EBP) should be used for all residents with wounds or indwelling devices. *Gowns and Gloves should be used during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .Dressing .Changing briefs or assisting with toileting . Review of the provider's Laundry Room Daily Sweep/Mop/Dust logs revealed: *There was no log for April 2025 *The March 2025 log indicated: -Sweeping and mopping had not been completed on 3/24/25, 3/25/25, 3/27/25, 3/28/25, 3/29/25 , or 3/30/25. -Dusting washers and dryer shelves had not been completed on 3/1/25, 3/2/25, 3/5/25, 3/8/25, 3/9/25, 3/12/25, 3/15/25, 3/16/25, 3/19/25, 3/23/25, 2/24/25, 3/25/35, 3/27/25, 3/28/25, 3/30/25 or 3/30/25. Review of the provider's revised 2/28/25 Infection Prevention Program Policy revealed: *The facility-wide comprehensive infection prevention and control program addresses detection, prevention, and control of infections among residents and personnel. It is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (52) had been: *Provided with appropriate activities to meet his sensory needs. *Free from isolation. *Cared for by staff that had been educated to meet his unique needs. Findings include: Resident 52 was admitted from a local group home on 8/18/22 and had multiple diagnoses that included Down syndrome, unspecified; autistic disorder; dysphagia, oral phase; and developmental disorder of scholastic skills, unspecified. Observation on 1/10/23 at 8:00 a.m. in the day room revealed: *There was a radio, two tables, two chairs, and some colorful fidget toys in the southeast corner of the room. *There were several recliners up against the west wall. *Resident 52, the only one in the room, was seated in his wheelchair in between two recliners. *He had two noticeable patches of hair that were shorter than the rest of the hair on his head. Observation on 1/10/23 at 11:23 a.m. in the day room revealed: *Resident 52 was sitting by himself near the radio, with the radio playing music. *With his body positioned facing the corner and his back to the room, he was moaning and grunting every few seconds, and using his balled-up fists to rub his head. Observation on 1/10/23 from 12:10 p.m. to 1:04 p.m. in the dining room revealed: *Resident 52 was sitting in his wheelchair just outside the dining room doors. *At least five staff members walked past him without acknowledging him. *Resident 52's vocalizations became louder and more frequent. *At 12:59 p.m., a staff member wheeled resident 52 into the dining room, parked him at the assisted dining table and fed him his lunch. Observation on 1/10/23 at 3:19 .m. of resident 52 in his room revealed: *His call light was blinking. *The door was halfway open, the lights were dim, and his roommate was not in the room. *He was seated cross-legged on his bed facing the window, with his back to the door. *He was rocking back and forth, moaning and grunting every few seconds, using his balled-up fists to rub his head. *There was a cushioned mat on the floor next to his bed. Continued observation at 3:24 p.m. revealed certified nurse aide (CNA) D knocked on the door and entered the room. *She greeted him and asked if he was doing alright. *Offering no response, he continued rocking back and forth. *She turned off the call light and left the room stating, He's a hard one because we can't tell what he needs. Observation on 1/11/23 at 9:57 a.m. in the hallway outside the dining room and near the day room revealed: *Resident 52 was sitting in his wheelchair in the middle of the hallway. *He was moaning and grunting every few seconds. *At times, he would ball up his fists and rub his head in the same two spots where his hair was shorter than the rest of the hair on his head. *At least two staff members walked past him without acknowledging him. Observation on 1/11/23 at 11:10 a.m. in the 200 hallway revealed: *Resident 52 was sitting in his wheelchair in the middle of the hallway. *He was sitting just outside the whirlpool room. -That section of hallway was particularly busy as it was near the nurse's station, the director of nursing office, and the business office. *Several staff members had walked past him without acknowledging him. *He continued to moan and grunt every few seconds. *He did not have any activities or items to occupy his time. Observation on 1/11/23 from 12:34 p.m. to 1:07 p.m. in the dining room revealed: *Residents had already been seated in the dining room. *Resident 52 was sitting in his wheelchair just outside the dining room doors. *No one assisted resident 52 to the dining room until administrator A wheeled him to his assigned spot at 12:54 p.m. *His meal was served at 1:07 p.m. and activity director Q assisted with feeding him. Observation on 1/11/23 at 3:39 p.m. in resident 52's room revealed: *The door was mostly shut. *The lights were dim. *He was alone in his room. *Christian music was playing on the television. *Resident 52 was sitting cross-legged on his bed. -He was rocking back and forth. -He was continually moaning and grunting every so often. *There was a stuffed teddy bear sitting on his bedside table, out of reach. Confidential interview on 1/11/23 at 3:50 p.m. with a staff person revealed: *Staff did not bring resident 52 to any group activities. *One-to-one interactions with the resident were limited due to tight staffing schedules. *The staff were instructed to have resident 52 wait outside the dining room instead of sitting in the dining room with the other residents due to his moaning and grunting. -They usually had him wait in the hallway until his tray was set up and there was a staff member ready to assist him with his meal. *They had a few sensory toys in the day room, but no one had made the effort to find out what type of sensory items he enjoyed. -He did not have the cognition or sight abilities to reach out and grab an item. *Staff had a difficult time communicating with him and knowing what his needs were, such as: -When he was hungry or thirsty. -If he needed to go to the bathroom. -If he was sad, upset, tired, happy, etc. *He was not on a check and change schedule for incontinence cares. *There was no education provided to them on how to: -Interact and communicate with resident 52. -Provide him with meaningful activities and enrichment. -Meet his social and mental wellbeing needs. Interview on 1/12/23 at 9:44 a.m. with certified nurse assistant (CNA) R about resident 52 and staff education related to the unique needs revealed: *He had been working at the facility for [AGE] years. *He usually did not work on the hallway that resident 52 lived on, but on occasion he would cover over there. *Since resident 52 was admitted in August 2022, there had been no education provided to staff on the unique needs the resident required. Observation on 1/12/23 at 2:51 p.m. of resident 52 in his room revealed: *He was sitting cross-legged on his bed. *Music was playing on the television. *He was alone. *He was moving his arms up and around his head, and at times would ball his fists up and rub his head. *He was moaning and grunting every so often. *The teddy bear was still sitting on his bedside table. *CNA D knocked on his door and entered. -She attempted to hand the teddy bear to him. -He was startled slightly at the introduction of the teddy bear as he shuddered suddenly and grunted. -He held the teddy bear for a few seconds, then threw it across the room. *The CNA picked up the teddy bear and placed it back on the bedside table. Interview on 1/12/23 at 2:58 p.m. with CNA S about resident 52 revealed: *She and her coworkers had a hard time figuring out what resident 52 needed. *They based his needs on how agitated he became. -Such as, if he was squirming around or vocalizing more, they tried to determine what he needed. *She would usually turn on the music for him. *His attention span was not that long. *There were fidget toys in the day room, but he did not reach out for them. -He could not see very well, because his vision was highly impaired. *They would try to hand him things, but he tended to throw it away. *She had not been educated on the unique needs the resident required. *They went over that he was a two assist for care, but no other specific education was provided. Interview on 1/12/23 at 4:09 p.m. with activity director Q about resident 52 revealed: *He needed more appropriate placement where his needs could have been better met. *She believed he required more one-on-one care, which they were unable to provide. *She was unable to spend as much time as she would have liked with him and the other residents due to staffing issues. -She was also covering shifts in housekeeping, laundry, and as a CNA working on the floor. *Resident 52 tended to do a self-soothing motion, that was why he rubbed his head often. *When she did get the chance, she would provide physical touch enrichment through rubbing his back, putting lotion on his hands and arms, and letting him feel different fabrics. *She could tell what kind of music he enjoyed because of his reactions. -He would become more agitated if he heard country music, but he seemed to enjoy classical and Christian music. *He did not like it when staff performed oral cares and would become increasingly agitated. -Oral cares included helping him brush his teeth, performing oral swabs, and helping him put lip balm on his dry/cracked lips. *She had previous education and experience on caring and interacting with people who had developmental disabilities. *The provider had not educated staff on resident 52's unique needs, such as how to communicate with him and how to provide meaningful activities that fulfilled his sensory needs. *She felt that some staff might have been timid of resident 52 because they were unsure how to interact with him. Interview on 1/12/23 at 5:13 p.m. with administrator A revealed: *Resident 52 deserved to be in a facility that had the capacity to meet his needs. *He was admitted from a group home in town for physical therapy rehabilitation in August 2022. *When he had completed rehab, the group home refused to readmit him. *They had a hard time trying to find placement for him due to requiring total assistance with care and activities of daily living. *Resident 52 was discharging to a different group home the following week. *Her staff did not have the background knowledge to care for a person with resident 52's diagnoses. -They should have provided an in-service to their staff about resident 52, how to communicate with him, how to care for him, and how to meet all his needs. Interview on 1/12/23 at 5:59 p.m. with director of nursing (DON) B about resident 52 revealed: *She confirmed resident 52 was discharging the following week to a group home that could better meet his needs. *Her staff did not have the background knowledge to meet all the needs of a person with resident 52's diagnoses. *She indicated it would have been a good idea to educate the staff about resident 52, how to communicate with him, how to care for him, and how to meet all his needs Review of resident 52's care plan revealed: *He was to receive one-on-one sessions at least five times per week. *On 8/30/22, an intervention was added under the nutrition portion of his care plan which read, Staff to not bring [resident 52] into the dining room until his food is at the table. *There was no information about: -Providing soothing touch enrichment. -The types of sensory items he had enjoyed. -The type of music he liked to listen to. -How staff could anticipate his needs. -That he disliked oral cares. -What staff should do if he refused care or became agitated. Review of resident 52's 11/16/22 quarterly Minimum Data Set assessment revealed: *His hearing was adequate. *He was rarely or never understood in terms of verbal and non-verbal communication. *He was rarely or never able to understand verbal communication. *His vision was highly impaired. *He required extensive assistance of two or more people for toilet use, transferring, and bed mobility. *He required extensive assistance of one person for locomotion on and off the unit, dressing, eating, bathing, and personal hygiene. *He was always incontinent of bladder, and frequently incontinent of bowel. Review of social services progress note from 10/18/22 revealed: [DON B] expressed to [registered nurse from resident 52's previous group home] that this is not the appropriate setting for resident as he would benefit from more of a small group environment that would be able to provide more 1:1 attention. Review of activity note from 11/16/22 at 10:26 a.m. by activity director Q revealed: *Activities such as movies, bingo, trivia, hangman have not been appropriate for him to participate due to him continually making loud noises. *[Resident 52] does some self-soothing activities, tapping his leg, rubbing his head etc . *I have encouraged staff to interact with [resident 52] as frequently as possible. These interactions are not necessarily being charted as I am not necessarily informed when they occur. Review of resident 52's one-to-one activity log for the past 30 days (from 1/11/23) revealed there were only 12 days out of the past 30 days when he received one-to-one activities. Review of resident 52's independent activity log for the past 30 days (from 1/11/23) revealed: *There was a total of 10 days charted. *7 of the 10 days was recorded as people/bird watching. *That activity would not be appropriate for resident 52 due to his highly impaired vision. Review of the provider's 10/12/22 Facility Assessment indicated they were able to admit residents with medical conditions such as Down syndrome, autism, and loss of vision. Review of the provider's September 2019 Resident Dignity and Privacy policy revealed: *Policy: -It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as, care for each resident in a manner and in an environment that maintains resident privacy. -15. During meals, each table should be served at the same time. Review of the provider's resident rights packet revealed: *Residents have the right to be treated with respect. -You have the right to be treated with dignity and respect . *Residents have the right to participate in activities. -You have the right to participate in an activities program designed to meet your needs . *Residents have the right to be free from abuse and neglect. -You have the right to be free from verbal, sexual, physical, and mental abuse. Nursing homes can't keep you apart from everyone else against your will.

Based on observation, interview, and record review, the provider failed to ensure restorative nursing therapy was available to maintain activities of daily living (ADL) for one of one sampled resident (53). Findings include: 1. Review of resident 53's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Parkinsonism, unspecified. -Low back pain. -Muscle weakness (generalized). Review of resident 53's 4/4/19 Minimum Data Set (MDS) assessment revealed: *He required the limited assistance of one staff person for: -Transfers. -Dressing. -Toilet use. *He required the supervision of one staff person for personal hygiene. Review of resident 53's 6/26/19 MDS assessment revealed: *He required the extensive assistance of one staff person for: -Transfers. -Dressing. -Toilet use. -Personal hygiene. Random observations of resident 53 on 7/9/19 from 8:00 a.m. through 6:00 p.m. and on 7/10/19 from 7:30 a.m. through 5:30 p.m. revealed: *He was sitting in the day room watching TV or sleeping. *He was at meals in the dining room. *He was at activities in the dining room. Interview on 7/10/19 at 12:56 p.m with licensed practical nurse F revealed: *They did not have a restorative nursing program. *They did not have enough nurses to run a restorative nursing program. *They were using traveling nurses. *Certified nursing assistants were responsible for walking residents to meals. Interview on 7/10/19 at 2:51 p.m. with the director of nursing regarding resident 53 and their restorative nursing program revealed: *There was no restorative nursing program at the current time. *The previous assistant director of nursing had over seen the program, and she resigned. *They had identified not having the program as a problem. *They were working with a nurse to restart that program. *They did offer physical therapy (PT) and occupational therapy (OT). *Resident 53 had been referred to PT and OT sometime between (MONTH) 25 and (MONTH) 2, 2019. Interview on 7/10/19 at 2:59 p.m. with physical therapy assistant R regarding resident 53 revealed: *He had been referred to PT and OT services. *She was not sure why he was referred. -She believed it had to do with his walking, as he had [MEDICAL CONDITION]. *She was not aware of the decline in his ADLs. She stated, it would be nice if we had restorative to relay those things and keep track of them for us regarding his decline in ADLs. Review of resident 53's 6/27/19 PT care plan revealed: *He was referred to PT for an acute exacerbation of Parkinsonism symptoms and exacerbation of low back pain that began approximately 1 week ago. *There was no mention of decreased function in ADLs. Review of resident 53's 7/1/19 OT care plan revealed: *He was referred to OT for decline in ADLs, functional transfers, and functional mobility over the past few weeks do to increased weakness, low endurance, tremors, and decreased ROM (range of motion). Review of resident 53's undated care plan revealed: *He had an ADL performance deficit. *His interventions for that included an evaluation by PT and OT on 7/24/18. *ADLs were listed and stated the level of assistance he required for each. *There were no nursing interventions for maintaining his level of functioning.

Based on observation, interview, record review, the provider failed to ensure interventions were implemented and documented to prevent pressure ulcers and skin concerns for two of two sampled residents (3 and 16). Finding include: 1. Review of resident 3's 10/31/18 Minimum Data Set (MDS) assessment revealed: *He was admitted on [DATE]. *His Brief Interview for Mental Status (BIMS) assessment score was twelve indicating that his cognition was moderately impaired. *He required the extensive assistance of two staff persons for bed mobility and transfers. *He was at risk for developing pressure ulcers. *He had no pressure ulcers. *He had no rejection of care in the look back period. Review of resident 3's 1/31/19 MDS revealed: *His BIMS assessment score was fifteen indicating his cognition was intact. *He required the extensive assistance of two staff persons for bed mobility. *He was totally dependent on two staff persons for transfers. *He was at risk for developing pressure ulcers. *He had one stage four and one unstageable pressure ulcer. *He had no rejection of care in the look back period. Review of resident 3's following Braden Scale for Predicting Pressure Score Risk assessments revealed: *11/1/19 was the first assessment completed. -The assessment scored him at sixteen indicating he was at low risk for development of pressure ulcers. *11/8/19 another assessment was completed. -The assessment scored him at seventeen indicating a lower risk for developing pressure ulcers. *Quarterly assessments were completed on 1/31/19 and 7/3/19. -Those assessments scored him at thirteen indicating he was at moderate risk for developing pressure ulcers. Review of resident 3's 10/24/18 Admission Nursing Assessment revealed: *He had a pink healed pressure injury with flap repair. *His left heel was dry with a dark pigmented area. *Heel boots, side rails, a trapeze, and an air mattress were to be used in bed. Review of resident 3's following skin assessments revealed on: *11/2/18 he had a healed skin flap repair. *11/30/18 Healed skin flap repair; pink on left side from sitting up in wheelchair too long. *12/7/18 a stage two facility acquired pressure ulcer was identified on his coccyx. -The wound measured 9 centimeters (cm) by 8 cm by 0.1 cm. *12/28/19 the wound was now unstaggable, and the resident was being treated with a wound vac. -The wound measured 4.2 cm by 8.3 cm by 3.6 cm. *4/2/19 wound was then being treated with Dakin's packing and covered. -The wound measured 4.2 cm by 9.2 cm by 3.2 cm. *5/7/19 the wound measured 4.5 cm by 6.0 cm by 2.0 cm *6/4/19 the wound measured 3.1 cm by 6.4 cm by 3 cm. *7/2/19 the wound measured 2.7 cm by 4.5 cm by 1.8 cm. Interview on 07/09/19 at 9:01 a.m. with licensed practical nurse (LPN) F regarding resident 3 revealed: *He had two facility acquired pressure ulcers. *The one on his coccyx was from him refusing to be repositioned when he had first been admitted to the facility. Observation and interview on 7/9/19 at 9:50 a.m. with resident 3 revealed: *He was sitting in his wheelchair in his room and agreed to meet for a full interview at 10:15 a.m. *An unidentified certified nursing assistant (CNA) asked him if he wanted to lay down. *He stated he could not due to meeting with the surveyor at 10:15 a.m. *CNA stated okay and turned to walk out of the room. *I told him it would be okay for him to be in bed while we talked at 10:15 a.m. *He agreed to be laid down. Review of resident 3's nursing progress notes from 10/24/18 through 1/15/19 revealed: *On 10/25/18 he had refused to lay down for the CNA on duty. -After he was educated by registered nurse (RN) P of the risks and benefits of repositioning be agreed to lay down. *On 11/1/18 he sat up all morning and part of the afternoon, per his request. -No documentation about education or encouragement to have been laid down. *On 11/20/18 he was noted as pleasant and cooperative. *On 11/26/18 he has been up all evening shift he requested to remain up to watch TV. -No documentation about education or encouragement to have been laid down. *On 11/28/18 refuses to lay down when he has reached his max time. -No documentation about education or encouragement to have been laid down. *On 12/4/18 refused to lay down after being up for 2 hours. -No documentation about education or encouragement to have been laid down. *Five out of eighty-four oppertunities were doucmented he had refused to be repositioned. *One out of five oppertunites was documented about education and encouragment for repositioning. *Seventy-nine of eighty-four oppertunites were missed for documentation regarding his repositioning. Interview and record review on 7/10/19 at 1:15 p.m. with the director of nursing (DON) regarding resident 3 revealed: *When he was first admitted he was staying up in his wheelchair too long. *He had been encouraged to lay down and protect his bottom. *They had tried different schedules for repositioning. *His care plan had been deleted in (MONTH) 2019, and there were no focus areas, goals or interventions, prior to 3/30/19 that could be provided. Review of resident 3's undated care plan revealed, no mention of him refusing to be repositioned. 2. Review of resident 16's 5/9/19 MDS assessment revealed: *He was admitted on [DATE]. *His BIMS assessment score was nine indicating his cognition was moderately impaired. *He required the limited assistance of two staff persons for bed mobility. *He required the extensive assistance of one staff person for: -Transfers. -Dressing. -Locomotion on and off the unit. *He required the limited assistance of one staff person for walking in his room. *He required the limited assistance of one staff person for toilet use and personal hygiene. Interview on 7/9/19 at 2:25 p.m. with resident 16 revealed he had heel pain. Interview and observation on 7/9/19 at 2:30 p.m. with LPN F regarding resident 16 revealed: *He should probably have been on a repositioning schedule. *He had a round red area on his right heel approximately 2 inches in diameter. *It was squishy and blanchable. *He had a red area on his outer left ankle bone. *It was on a bony prominence but blanchable. *They were both areas of concern. *She was going to initiate heel protectors. Random observations of resident 16 on 7/10/19 from 7:40 a.m. through 11:20 a.m. revealed: *He was on his back in his bed with his eyes closed. *The blankets were tucked under his mattress at the end of his bed. *His feet were being pushed into his mattress. *Unable to tell if heel protectors were in place. Interview and record review on 7/10/19 at 1:46 p.m. with the DON regarding resident 16 revealed: *He was independent in positioning. *If there was a change in his status the CNAs would be expected to notify a nurse, so it could be assessed. *Heel protectors had been initiated, family and the physician had been notified the day prior about the areas of concern. *He did not have any pressure ulcers at that time. Observation on 7/10/19 at 2:42 p.m. of resident 16 revealed: *He was on his back, in his bed with the blankets over his face. *His heel protectors were on incorrectly at that time. -His right heel was protruding from the heel protector and lying on the mattress. -His left heel protector had slid off to the side and wa not protecting his ankle area. Review of resident 16's undated care plan revealed: *He was at risk for skin breakdown on 5/2/19. -He was to have heel protectors on at all times starting 7/10/19. -Dietician as needed starting 5/2/19. -Well balanced diet starting 5/2/19.

Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being for all fifty-four residents in the facility. Findings include: 1. Observations, interviews, record reviews, and policy reviews conducted throughout the course of the survey from 7/8/19 through 7/10/19 revealed the administrator and the director of nursing had not been an effective leadership team to ensure the safe management and overall well-being of the residents. Interview and record review on 7/10/19 at 2:30 p.m. with the administrator, the director of nursing (DON), and nurse consultants regarding baths getting done revealed: *The administrator stated the problem was only a documentation issue. *They had not asked the residents if they were or were not getting their baths. *She stated the audits were done by an evening staff member. -She looked through the electronic medical record to see when residents were getting baths. -The administrator would then look at the bath sheets and compare when the resident last got a bath. *They were still residents that had not had baths in thirty days that had not been addressed. *They had not implemented any course of action when the audits identified baths were not getting done. Refer to 561. 2. Review of resident 53's medical record revealed the provider failed to ensure restorative nursing therapy was available to maintain activities of daily living (ADL) to prevent a major decline in his condition. Refer to F676. 3. Review of residents 3 and 16's medical record revealed interventions were not implemented and documented to prevent pressure ulcers and skin concerns. Refer to F686. 4. Review of the provider's 10/1/16 Social Services Specialist job description revealed: *To assist the Social Services Director/Coordinator in identifying and providing for each resident's social, emotional, and psychosocial needs, and the continuing development of the full potential during his/her stay at the facility and to assist in the planning for his/her discharge. *This position reported to the social services director/coordinator. Review of the provider's 10/29/17 Director of Nursing (DON) job description revealed: *The DON is responsible for effective overall management of the Nursing Department and coordination with other disciplines to provide quality care to all patients/residents. *She monitors the outcomes of all nursing service activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agency standards, policies and procedures. *She reported to the administrator. *Only three of five pages were provided of the job description by the end of the survey on 7/10/19. Review of the provider's 10/1/16 CEO job description revealed: *Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. *Leads the facility facility management staff and consultants in developing and working from a business plan that focuses on all aspects of facility operations, including priorities and job assignments. Monitors each department's activities, communicates policies, evaluates performance, provides feedback, and assists, observes, coaches and disciplines as needed. *Maintain a working knowledge of and ensure compliance with all governmental regulations.

Based on observation, record review, interview, and policy review, the provider failed to ensure residents' care plans for 3 of 13 sampled residents (3, 8, and 17) were developed, reviewed, and revised for appropriate problems, goals, and approaches. Findings include: 1. Review of resident 8's medical record revealed he had been admitted on [DATE]. The record revealed he had been admitted with stage 1 pressure ulcers on both heels. Upon admission the pressure ulcers had not been care planned and the physician had not been notified of the stage 1 pressure ulcers. They had not been addressed as pressure ulcers until they had reached a stage 4 in severity. Refer to F314, finding 1. 2. Review of the following investigation reports sent to the Department of Health for resident-to-resident abuse revealed: *On 9/20/12 resident 17 had attempted but it had not been substantiated that resident 17 had slapped another resident. *Staff had been educated to monitor the two residents in question to ensure no inappropriate behaviors had occurred between them. *On 12/16/12 at 6:00 p.m. resident 17 had slapped another resident across the face. Review of resident 17's care plan last updated on 1/7/13 revealed no additions to the care plan in response to the above incidents of resident-to-resident abuse. Review of the provider's May 2001 abuse reporting policy revealed steps were to be taken to prevent recurrence to include care planning and documentation. Interview on 1/10/13 at 9:40 a.m. with the Minimum Data Set (MDS) coordinator confirmed the care plan should have but had not been updated to address resident 17's resident-to-resident abuse. Preceptor: 2. Two of twenty-two sampled resident's (10 and 18) had orders to self-administer medications per the director of nursing. Self-administration of medications had not been care planned for residents 10 and 18. Refer to F176. Preceptor: 3. Review of resident 3's medical record revealed he had been admitted on [DATE]. Review of resident 3's treatment assessment record (TAR) for month of January 2013 revealed: *"Complete skin assessment weekly and document impaired skin integrity on TAR or wound evaluation flow sheet. Order date: 8/19/2012." *His skin was scheduled to be checked weekly at 8:00 p.m. *His TAR reflected that initials had been placed by that scheduled nurse on 1/6/13 that his skin assessment had been done. *No documentation had been found on the condition of his skin. Review of resident 3's comprehensive care plan dated 10/29/12 revealed: *Focus: resident was at risk for pressure ulcers. Date initiated 11/9/10. *Goal: resident would maintain skin integrity through 1/23/13. *Preventions included: -Monitor extremities and report changes. -Promptly clean and dry skin after each incontinent episode. -Weekly skin assessment per nursing, refer to TAR. *It did not address current skin changes to his right heel. *It did not address any repositioning to be done when recently ill with influenza A. *It did not address the heel lift boot on his right foot. Refer to F314 finding 3.

Based on observation, record review, policy review, and interview, the provider failed to ensure the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care were developed and carried out for two of four sampled residents (3 and 8) with pressure ulcers. Findings include: 1. Review of resident 8's medical record revealed he had been admitted with stage 1 pressure ulcers on both heels. Upon admission the pressure ulcers had not been care planned and the physician had not been notified of the stage 1 pressure ulcers. They had not been addressed as pressure ulcers until they had reached a stage 4 in severity. Refer to F314, finding 1. Preceptor: 2. Review of resident 3's medical record revealed: *He had recently been ill with influenza A. *He had recently experienced a decline in his condition. *Therapy had been ordered to help him improve his strength. *He was at risk of pressure ulcers and had developed a stage II pressure ulcer on his right (R) heel. *There were conflicting interviews and a lack of documentation to support when the stage II pressure ulcer had been found. *There was no documentation in the interdisciplinary notes until 1/8/13 to support the presence of a stage II pressure ulcer and medical doctor (MD) involvement. *His comprehensive care plan and treatment assessment record (TAR) had not been updated until 1/8/13 to support the presence of the stage II pressure ulcer to his (R) heel. *No repositioning, pressure relieving measures, daily documentation, therapy and MD involvement had been found until 1/8/13.

Based on observation, interview, record review, and policy review, the provider failed to render necessary care and treatment to prevent a pressure ulcer or the worsening of a pressure ulcer for two of four sampled residents (3 and 8) with a pressure ulcer. Findings include: 1. Review of resident 8's medical record revealed he had been admitted on [DATE]. Review of resident 8's 10/12/12 clinical health status assessment form revealed: *The resident's Braden score had been a 12. *The resident was at high risk for a pressure ulcer. *Section B for skin conditions had been completed. *The resident had a 0.5 centimeter (cm) slightly red area on the side of the left foot by the heel. *The resident had a 1.0 cm slightly red area on the side of the right foot. *Both were on the outer aspects of the foot. *The resident had been wearing foam foot/heel boots from the hospital. Review of the resident's 10/22/12 care plan revealed: *A focus that stated the resident had been at risk for pressure ulcers related to: -Activities of daily living functional status. -Non-weight bearing status to the left leg. -Bowel incontinence. *The goal was the resident would maintain skin integrity through 1/18/13. *Preventions included: -Refer to the treatment administration record (TAR) for current treatment to surgical wounds to the left leg. -Reposition the resident every two hours. -Gel foam wheelchair cushion and alternating air mattress were to be in-use. -Monitor extremities and report changes. -Promptly clean and dry skin after each incontinent episode. -Complete a weekly skin assessment by nursing/refer to the TAR. *It had not addressed the reddened areas on the resident's feet as stage one pressure ulcers. Review of the Minimum Data Set 3.0, section M, skin conditions, revealed a stage one pressure ulcer was a non-blanchable localized red area usually over a bony prominence. Review of the resident's October 2012 handwritten TAR revealed: *No pillow was to have been placed under the left leg. *Heel protectors were to be checked every shift. *A skin assessment was to have been completed every Monday. *It had documentation entered for 10/12/12 and 10/13/12 only. *A new TAR was computer generated and documentation had been started on 10/13/12. Review of the resident's computer printed TAR from 10/12/12 through 10/31/12 revealed: *Heel protectors to both feet were to be checked every shift starting on 10/13/12. *Both feet were to have been monitored for breakdown twice every day. *That had not been initiated until 10/19/12, seven days after the resident had been admitted . *Complete a weekly skin assessment and document impaired skin integrity on the TAR or a wound evaluation sheet. *No pillow was to have been placed under the resident's left leg. Review of resident 8's TAR from 11/1/13 through 11/30/12 revealed: *No pillow was to have been placed under the resident's left leg *No change in the above treatments from 10/31/12 until 11/14/12. *On 11/14/12 heel protectors had been discontinued for both feet. *Measurements for pressure ulcers on both heels every Tuesday had been added on 11/14/12. *Those measurements were to have been entered on a wound flow sheet. *The pressure ulcers were to have been monitored every day. *On 11/14/12 Rook boots were added to have been applied to both feet when the resident had been up in the wheelchair. *On 11/27/12 monitoring and measuring of the left heel pressure ulcer had been discontinued. *Monitoring of the site of the old pressure ulcer on the left heel twice every day had been added on 11/27/12. Review of resident 8's 12/1/12 through 12/31/12 TAR revealed: *On 12/19/12 it had been documented the skin of the left heel was non-tender, intact, and healed. *The pressure ulcers were to have been monitored everyday. *Rook boots were to have been applied to both feet when the resident had been up in the wheelchair. *Monitoring of the site of the old pressure ulcer on the left heel twice everyday had been continued. *No pillow was to be placed under the resident's left leg. *Weekly measurements for the right heel ulcer continued on the wound flow sheet. Review of resident 8's 1/1/13 through 1/31/13 TAR revealed: *Rook boots were to be applied to both feet when the resident had been up in the wheelchair. *Monitoring of the site of the old pressure ulcer on the left heel twice everyday had been continued. *No pillow was to be placed under the resident's left leg. *Weekly measurements for the right heel ulcer continued on the wound flow sheet. Review of resident 8's interdisciplinary progress notes (IPN) revealed: *From 10/12/12 through 10/24/12 no documentation had been entered in regards to the status of the resident's heels. *On 10/25/12 at 9:30 p.m. RN N documented the resident's left foot had a reddened area on the outer side of the heel 0.5 cm and circular in shape. *An area surrounding the reddened area was 1.0 cm by 0.5 cm that was also red. *The left ankle joint had a 1.0 cm dark pink area. *None of those areas had been open. *The resident had complained of pain when it was touched. *The nurse had communicated to the director of nursing (DON) and the day nurse the need to evaluate the resident for Rook boots in place of the sponge boots. *On 11/14/12 at 10:00 p.m. RN N documented Rook boots had been on when the resident had been up and had been off when in bed. *On 11/15/12 at 11:33 a.m. the dietician entered documentation of a stage 4 pressure ulcer on both heels. *The dietician added supplements and recommended a multiple vitamin to address the pressure ulcers. *On 11/15/12 at 2:56 p.m. it had been documented by nurse D new orders had been received from the resident's physician to start the pressure ulcer protocol. On 11/14/12 a wound evaluation chart had been started for resident 8 and revealed: *Stage 4 pressure ulcers to the right and left heels. *The resident had been admitted with stage 1 reddened areas to both heels. *Both heels now had black scabbed areas. *The right heel ulcer measured 1.0 cm by 0.8 cm. *The left heel ulcer measured 0.4 cm by 0.4 cm. The resident's care plan updated on 11/14/12 revealed: *As a focus unstageable pressure ulcers had been declared to both heels. *The goals were to have the ulcers healed by 1/18/13, and no other ulcers were to have occurred. *Interventions had been added that included: -Check TAR for treatments as ordered. -Measure pressure ulcers weekly and document on the wound evaluation flow sheet. -Referral to physical therapy for wound evaluation. -Rooke boots to be worn when up in wheelchair. *No Rooke boots or socks to be worn in bed. The provider's undated pressure ulcer checklist had revealed: *The nurse who discovered the pressure ulcer was to have started the necessary paperwork. *The physician was to have been notified and orders received for medications and treatments to address the pressure ulcer. *The problem was to have been added to the care plan within 24 hours. *Notify dietary about the skin problem. Review of the provider's 2006 prevention of pressure ulcer policy revealed: *The purpose had been to prevent skin breakdown and the development of pressure ulcers. *Documentation was to have included notification of the physician of a new pressure ulcer when it was identified. *Care planning was to have identified the problem, treated the underlying problem, and listed possible risks and complications. *Necessary monitoring and observation was to have been included. Interview on 1/9/13 at 2:20 p.m. with the DON confirmed: *She would have expected the pressure areas on resident 8's heel to have been added to the care plan when the resident had been admitted . *All of the nurses were responsible to update the care plans as needed. *Resident 8 was at high risk for a pressure ulcer to have developed. *She had believed the correct interventions had been in place on admission for prevention of pressure ulcers. *The care plan had not reflected what had been documented in the clinical assessment in regards to the resident's heels. Interview on 1/9/13 at 3:40 p.m. with the DON further confirmed documentation for the pressure ulcere would have been found on weekly skin evaluation sheets, on the TAR, or in the IPN notes. No other documentation existed in regards to skin/pressure ulcers. Preceptor: 2. Review of resident 3's medical record revealed: *He had been admitted on [DATE] *He had [DIAGNOSES REDACTED]. *He had cognitive impairment, usually understood, but did not verbalize (talk). *He had been diagnosed with [REDACTED]. *On 1/8/13 it had been reported to the medical doctor (MD) he had a stage II pressure ulcer to his right (R) heel. Observation on 1/7/13 at 3:30 p.m. of resident 3 revealed: *He was ambulating down the hallway with an unidentified certified nursing assistant (CNA). *He was wearing a heel lift boot on his right foot. Random observation from 1/7/13 at 3:20 p.m. through 1/8/13 at 9:05 a.m. revealed: *He had a regular mattress on his bed. *There was no pressure relieving mattress or air overlay on his bed. *There was no pressure relieving cushion placed in his recliner. Interview on 1/7/13 at 3:45 p.m. with certified nursing assistant (CNA) F revealed: *He had a pressure ulcer to his right heel and that was why he had the heel lift boot. *He had recently been ill with influenza A. *"He does not position well and it is hard to keep pressure off his heels as he pulls his legs up in bed." *Physical therapy (PT) had put the heel boot on that day. Observation of resident 3 on 1/8/13 at 9:00 a.m. revealed: *He was sitting in a recliner in the Alzheimers care unit (ACU) day room with his feet elevated. *The heel lift boot was on his (R) foot. *Minimum data set (MDS) coordinator registered nurse (RN) removed his boot, viewed the area, and measured a circular area on his (R) foot. That circular area was a wound to his (R) heel was reddened, and was fluid filled. *No vocalization nor signs and symptoms (s/s) of pain had been observed from resident 3. Interview on 1/8/13 at that same time with the MDS coordinator regarding the above observation with resident 3 revealed: *She stated the pressure ulcer had been found last night. *She was unsure who had put the heel lift boot on. "But it was a good idea as it keeps pressure off it." Review of resident 3's physical therapy assistant (PTA) progress note dated 1/7/13 at 2:07 p.m. revealed: *"Pt has a closed blister on (R) heel which a pressure relief boot has been placed to decrease any further break down." *"PT and PTA have discussed plan of care (POC) and goals with a direct supervisory visit. Plan to continue." Interview on 1/8/13 at 2:45 p.m. and again on 1/10/13 at 7:50 a.m. with the PTA revealed: *On 1/7/13 they had been informed by the CNA at the time of his therapy treatment he had a pressure ulcer to his (R) heel. *The wound had been found over the weekend. *Therapy had checked the wound on Monday and had recommended an air bed or protective boot to relieve pressure. *They had called maintenance and had been informed the facility did not have anymore air mattresses. The heel lift boot has then been placed on his (R) foot to relieve pressure. *As of today his heel boot was to be removed with ambulation (walking). *All of the above had been reported to the charge nurse and the ACU coordinator on 1/7/13 and today. *"All changes are reported to the charge nurse." Review of resident 3's treatment assessment record (TAR) on 1/8/13 at 8:00 a.m. revealed: *His skin was to have been checked weekly on Sundays at 8:00 p.m. *His TAR reflected that initials had been placed by that scheduled nurse on 1/6/13 that his skin assessment had been done. *No documentation had been found on the condition of his skin. Review of the ACU bath schedule had revealed: *He was to have a bath on Sundays during the daytime. Interview on 1/9/13 at 2:30 p.m. with CNAs I and J revealed charge nurses did not check any residents skin during their baths unless a problem was reported to them by the CNA. Interview on 1/9/13 at 5:05 p.m. with RNs C and K revealed: *Weekly skin assessments were done on the evening shift from 5:00 p.m. to 10:00 p.m. *New wounds were to have been documented on the back of the resident's TAR. *The nurses had a checklist that was to be initiated and when completed was to have been given to the director of nurses (DON). *Items on the checklist included: notification of the medical doctor (MD), dietary, CNA, and family. *All of those items were to have been documented in the interdisciplinary progress notes by the charge nurse. Review of resident 3's interdisciplinary progress notes from 1/3/13 through 1/8/13 revealed: *1/3/13 He had been diagnosed with [REDACTED]. -[MEDICATION NAME] had been started. -He had eaten in his room. *1/4/13 He had been resting soundly all shift. -Tylenol had been given for fever. *1/8/13 Was the first note written by ACU director that addressed his stage II pressure ulcer to his (R) heel. -Orders had been received from his MD to start pressure ulcer protocol. *No documentation had addressed: -Stage II pressure ulcer to his (R) heel prior to 1/8/13. -Therapy's involvement with the pressure ulcer and placement of the heel lift boot. Review of resident 3's wound evaluation flow sheet dated 1/8/13 revealed: *Stage II pressure ulcer on his (R) heel. *Appearance of wound: -measured 4.0 width and 3.8 diameter, fluid filled, and margins were intact. Review of resident 3's comprehensive care plan dated 10/29/12 revealed: *Resident 3 was at risk for pressure ulcers. Date initiated had been 11/9/10. *It had not addressed any repositioning when recently ill with influenza A nor the heel lift boot on his (R) foot. *There was no recommendations from therapy for when his heel lift boot was to be on and off. *There were no documentation dietary had been notified or involved of his (R) heel pressure ulcer. Review of resident 3's updated comprehensive care plan dated 1/7/13 and 1/8/13 revealed: *No changes had been made to the "at risk for pressure ulcer" focus area. *A new focus area had been added to his comprehensive care plan dated 1/8/13. -Focus: "Stage 2 pressure ulcer declared to right heel. At risk for further pressure ulcers." Date initiated had been 1/8/13. *Goals: -"Ulcer will be healed by Target date: 4/2/13." -"No further pressure ulcers will develop." *Preventions had addressed: -A repositioning schedule at least every two hours. Date initiated: 1/8/13. -PT involvement. *Preventions had not addressed: -The heel lift boot to his (R) foot. -Any pressure relieving devices for his bed or recliner. Review of resident 3's TAR revealed: *The pressure ulcer to his (R) heel: -Was to be measured weekly and documented. -Was to be checked daily. *"Heel lift boot to right foot at all times until pressure ulcer healed." *"Therapeutic air mattress." *All of the above had been initiated on 1/8/13. Interview on 1/9/13 at 9:45 a.m. with the DON revealed: *She clarified resident 3 had been recently experiencing a decline in condition. No reason for the decline had been found. *Therapies had been ordered to help the resident "get better." *Resident 3 had spent most of his time in his room during his recent illness with influenza A. *She was unsure if he had been repositioned every two hours while he had been ill. *Repositioning was not required to be put on the care plan. Every two hours was their standard repositioning schedule. *The pressure ulcer to his (R) heel had been reported to her on Monday, 1/7/13. She had visited with nursing staff to initiate the process at that time. No documentation to support that process had been found. *She confirmed PT had put the heel lift boot on his (R) foot on Monday, 1/7/13. *She confirmed that therapy had been notified by nursing staff of his (R) foot pressure ulcer, but no documentation had been found. *She had the MDS coordinator check the wound yesterday (Tuesday). *She agreed there had been no documentation found in regards to the pressure on his (R) heel. *The pressure ulcer checklist was only for their own personal use. *She stated they had no policy on nursing documentation. The nurses were to chart by exception, change of condition, or as required by Medicare. Policy (undated) review on nursing documentation revealed: *No policy on MD notification. *They were to follow the nursing standard. Review of the DONs undated pressure ulcer checklist revealed: *"Number 1: Professional nurse discovering the pressure ulcer is responsible to start the necessary paperwork and orders." *Number 2: "Notify the MD that resident had pressure ulcer."

Based on record review and interview, the provider failed to ensure care plans for 3 of 13 sampled residents (8,10, and 13) were completed to show information essential to care for the resident. Findings include: 1. Review of resident 8's record revealed she was admitted to the facility on [DATE]. Review of a hospital discharge summary dated 7/14/10 revealed the resident had a dual chamber pacemaker placed on 6/8/10 while in the hospital. Review of resident 8's current care plan revealed there: *Was no focus of resident 8 having a pacemaker. *Were no goals or interventions about the care the resident should have been provided in relation to the pacemaker. Interview on 10/18/11 at 4:20 p.m. with the director of nursing (DON) revealed the placement of a pacemaker and the cares related to it were items of information that should have been included on the resident's care plan. 2. Review of resident 13's care plan with a target date of 10/20/11 revealed no focus, goals or interventions regarding bowel elimination events/problems were noted. Refer to F309. 3. Review of resident 10's care plan with a target date of 12/27/11 revealed no focus, goals or interventions regarding [MEDICAL TREATMENT] events/problems had been noted. Refer to F514, finding 2.

Based on record review, nursing standard of practice review, and interview, the provider failed to assess, monitor, and intervene in the individualized care and service to maintain the highest practical physical and psychosocial well being for one of one resident (13) with a fecal impaction. Findings include: 1. Review of resident 13's nurses' notes revealed: *On 7/15/11 at 5:57 p.m.: "Had a rectal impaction so after lunch meal manually removed a large amount of hard bm (bowel movement) from rectum. Much more comfortable after procedure." *No further documentation regarding that until 7/17/11 at 12:08 p.m.: "c/o (complains of) pain and discomfort this am (morning) et (and) noted res (resident) rectal vault again full of hard stool. manually removed a large amt (amount) of hard bm. . . is incontinent of bowel et bladder." *No further documentation regarding that until 7/29/11 at 2:51 p.m.: "Fall follow up: . . . Called _____ PA (physician assistant) about residents refusal to take medications and her needed mare (more) for her bowel. New order received to discontinue [MEDICATION NAME] 17 gm (grams) Q (every) day, and [MEDICATION NAME] Suppository 10 mg RC (rectally) q 3 days. Orders noted and faxed to pharmacy." Only [MEDICATION NAME] was discontinued. The other medications were started. *No further documentation regarding that until 8/16/11 at 11:33 a.m.: "Was reported by therapy that res rectum was full of hard bm. a rectal exam done et vault was full of hard formed bm. a large amt was manually removed with a small amt of bleeding noted." *On 8/16/11 at 5:58 p.m.: "Called dr _____ with update on being dug out et rectal bleeding et order for additional stool softner. his nurse ___ said dr ____ said to be sure to use prn's if needed et order for senna 1 po (by mouth) qd (every day)." There was no documentation on the MAR indicated [REDACTED]. *No further documentation was noted in the resident's medical record regarding the above events. Review of resident 13's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She was on hospice from 6/22/11 through 7/12/11. *Her physical therapy and occupational therapy began on 7/13/11. Review of resident 13's medication administration records (MAR) and physician orders [REDACTED]. *[MEDICATION NAME] 15 milligrams (mg) twice daily for pain since admission. *[MEDICATION NAME] 15 mg every one hour PRN for pain since admission. Eight doses had been given in July 2011 and August 2011. *[MEDICATION NAME] 10/325 1-2 tablets every four hours as needed (PRN) for pain since admission. *Iron 150 mg twice daily since admission. That was changed to 17 milliliters iron solution on 8/15/11. *[MEDICATION NAME] 0.5 mg twice daily for anxiety. [MEDICATION NAME] had been given three times daily PRN since admission. During July 2011 it had been given almost daily and sometimes twice a day. It had been changed to scheduled twice daily and one tablet daily PRN on 8/9/11. Review of resident 13's MARs and physician orders [REDACTED]. *[MEDICATION NAME] 10 mg PRN rectally since admission. None had been given in 2011 for July, August, September, and through October 18. *Milk of magnesia 30 cubic centimeters (cc) PRN since admission. None had been given in 2011 for July, August, September, and through October 18. *[MEDICATION NAME] 100 mg twice daily since admission and discontinued on 7/29/11. *[MEDICATION NAME] 17 gm every day was started on 7/29/11. *[MEDICATION NAME] 10 mg rectally at bedtime every third day since 7/29/11. *Senna S 8.6-50 mg daily since 8/17/11. *A standing order signed by the physician on 6/18/11 included a Fleets enema or soapsuds enema PRN for constipation. Review of resident 13's physician's progress note dated 8/5/11 revealed "She has a past history of rectal impaction." Review of the dietary quarterly progress notes dated 7/21/11, 7/28/11 and 8/5/11 revealed no documentation regarding bowel elimination. Review of the resident's care plan with a target date of 10/20/11 revealed: *Interventions listed were to "Administer pain medication as ordered, evaluate what makes the patient's pain worse, and observe for potential medication side effects." *"Frequently incontinent of bladder and bowel, and briefs were worn for incontinence management. A goal was noted to remain free of complications related to incontinence. Interventions included provide prompt incontinence care, brief checked/changed at least every two hours and as indicated, and was not appropriate for scheduled toileting program related to severe cognitive impairment." *No focus, goals or interventions regarding bowel elimination events/problems was noted. Review of the printed care tracker report for bowel and bladder revealed: *A small BM on 7/6/11. *No BM on 7/7/11. *A small BM on 7/8/11. *No BM on 7/9/11. *A small BM on 7/10/11. *No BM on 7/11/11, 7/12/11, and 7/13/11. No PRN laxative was noted on the MAR indicated [REDACTED] *Two small BMs at 3:19 a.m. and 10:04 p.m. and one large BM at 1:48 p.m. on 7/15/11 when the nurses' notes at 5:57 p.m. stated "Had a rectal impaction after lunch." *No BM on 7/16/11. *One medium BM at 1:49 p.m. and one small BM at 3:50 p.m. on 7/17/11 when the nurses' notes stated at 12:08 p.m. "Manually removed a large amount of hard BM." *No BM on 8/15/11. *A large BM during shift 2 (6:30 a.m. to 2:30 p.m.) on 8/16/11 when the nurses' notes stated at 11:33 a.m. "A large amt was manually removed with a small amt of bleeding noted." Interview on 10/18/11 at 4:50 p.m. with registered nurse (RN) E and F revealed the bowel procedure was to give a laxative on the third day with no BM. What was given depended on the resident, but usually it was milk of magnesia. On the fourth day a suppository was usually given. Interview on 10/19/11 at 8:35 a.m. with RN E revealed she had done digital checks but had never done a manual removal of stool. If she would have had to do that, she would have documented it in the nurses' notes and called the physician for any further medications needed. Interview on 10/19/11 at 8:50 a.m. with RN G revealed resident 13 would not have been able to verbalize if she was constipated, and she was incontinent most of the time. RN G had not done a manual removal of stool for that resident, but remembered a past report of it done by another nurse. She agreed she would have called the physician if a manual removal of stool was done. Interview on 10/19/11 at 9:45 a.m. with the director of nursing (DON) revealed: *She agreed on the third day of no BM some type of laxative should have been given or a non-medication intervention should have been done and documented. *She would not have expected the nurse to call the physician after one manual removal of stool. If it happened again, she would have expected the physician would have been notified to review of medications. *No policy existed for the standard of care for physician notification and documentation regarding manual removal of stool. *She was not aware of the PA's note regarding a "history of fecal impaction." *She would have to look through the chart to see why there had been no documentation on the care plan, why the PRN laxatives had not been used since admission, and why the physician had not been notified after the second manual removal of stool on 7/17/11. *The resident was immobile for awhile after admission and had not been able to sit on the toilet due to a [MEDICAL CONDITION]. That might have caused a need for manual removal of stool. *The resident frequently refused oral medications. *The resident was taken off of hospice due to the family's request for therapy. Physical and occupational therapy was started on 7/13/11 per the medical chart. Interview on 10/19/11 at 2:30 p.m. revealed the DON had not had time to review the chart but will facsimile any further documentation regarding the incidents by 10/21/11. Review of the provider's undated Guidelines for Bowel Care revealed: *"Standard of Care: Assessment, Diagnosis, Education, Treatment by non-pharmacological and pharmacological." *"The desired outcomes of a treatment strategy is a comfortable bowel movement at least every several days with the minimum required use of laxatives as well as satisfaction of the resident and/or family. "Normal" bowel movements vary from person to person." *"Three days without a bowel movement requires intervention of treatment of [REDACTED]." *"Watch for anything unusual and any problems related to elimination. Report and/or document any concerns immediately."