Every finding on record at Avantara Redfield

Based on observation, interview, record review, and policy review the provider failed to monitor and document the temperatures for one of one commercial dishwashing machine according to the provider's policy to ensure it reached the minimum rinse cycle temperature of 180 degrees for sanitization of dishes and equipment used to prepare and serve residents' meals after every meal service.Findings include:1.Observation and interview on 1/25/26 at 11:41 a.m. in the main kitchen with dietary aide R revealed:*A clipboard hanging on the wall at the end of the dish machine tray line with dishwasher temperatures on it.*The January 2026 dishwashing machine temperature log did not have temperatures documented for:-Breakfast on 1/12/26, 1/14/26, 1/21/26, and 1/24/26.-Lunch on 1/12/26, 1/14/26, 1/21/26, and 1/24/26.-Dinner on 1/10/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, and 1/20/26.*The manufacturer's sign attached to the dish machine stated:-NSF Machine Operation Requirements as Manufactured by CMA Dish machines.Wash Temperature-Minimum 155 degrees F cycle.Wash cycle Time 49 seconds.Rinse temperature minimum 180 degrees F cycle.Rinse Cycle time 12 seconds.*Dietary aide R stated the temperatures should have been recorded after each meal.*Dietary aide R confirmed the dish machine used a high temperature rinse and should be a minimum of 180 degrees.*Further review of the January 2026 dish machine temperature log revealed there were nine documented temperatures below 180 degrees.*Dietary aide R agreed the rinse temperature log was not always documented at or above the 180 degree minimum for a high temperature rinse dish machine. 2. Interview and record review on 1/25/26 at 12:42 p.m. with maintenance director N revealed:*She knew the temperature had to be at least 180 degrees.*She did not receive any notices from the kitchen staff that it was not meeting rinse temperature. *She would notify the vendor if there were issues with the dish machine. *Her expectation was the dietary manager would notify her if the dish machine was not getting to 180 degrees during the rinse cycle. *She stated the dish machine has a heat booster that should notify staff if it was not up to temperature and sometimes the staff needed to run an extra rinse cycle to help reach the correct temperature.*She agreed there were 14 documented temperatures in January that did not reach 180 degrees. 3. Review of the dish machine temperature logs from October 2025 through December 20205 revealed: *The October logs were missing 25 rinse temperature logs out of 93 opportunities. *The November logs were missing 14 rinse temperature logs out of 90 opportunities, and three temperatures were documented below 180 degrees. *The December logs were missing 8 rinse temperature logs out of 93 opportunities, and nine temperatures were documented below 180 degrees. 4. Interview on 1/27/26 at 9:13 a.m. with dietary aide M regarding the dish machine revealed: *She knew some of the documentation for the rinse temperature logs were not indicating 180 degrees. *She was not sure who had done that documentation. *She stated if she had issues with the dishwasher she would notify her boss, who would then notify maintenance. 5. Interview on 1/27/2026 2:40 p.m. with dietary manager L regarding dish machine temperatures revealed:*She would notify maintenance if there was an issue with the dish machine.*She expected staff to document the wash and rinse temperatures for the dish machine after all meals.*She agreed that did not happen for some meals. 6. Interview on 1/28/26 at 11:51 a.m. with administrator A regarding dish machine temperatures revealed:*Her expectation was that staff would document dish machine temperatures.*She thought dietary staff were not waiting for the rinse cycle to document the accurate temperature.*She agreed the documentation was not supporting the rinse cycle meeting the 180 degree minimum temperature. 7. Review of the manufacturer's instructions for the dish machine revealed:*The wash temperature must be 155 F (Fahrenheit) minimum. The rinse temperature must be 180 F.*If necessary, adjust the temperature by removing the panel in front of the respective heater and turning the adjustment stem clockwise to increase. 8. Review of the provider's 6/6/19 revised Recording of Dish Machine Temperature policy revealed:*3. Record temperatures every shift on Dish Machine Temperature Log (FORM 408) or other designated form or on Food Temperature and Sanitation Record (FORM 401B).*High Temperature Dish Machines Rinse temperature >180 (degrees) F (Fahrenheit).*Or follow manufacturer's directions, if different.*4. Any inaccurate temperatures must be brought to the attention of the Director of Food and Nutrition Services or other clinically qualified nutrition professional immediately.

Based on observation, interview, record review, and policy review, the provider failed to ensure staff members followed quality of care practices and professional standards that ensured:*A Roho cushion's (air filled cushion designed for high-level pressure ulcer prevention and treatment) were used and maintained according to manufacturer's instructions for one of one sampled resident (5) with a pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) to her buttocks and upper thighs.*Specialized compression garments had complete physician's orders for use and were applied according to the manufacturer's instructions for one of one sampled resident (5) with lymphedema (tissue swelling caused by blocked lymph node fluid drainage) who used Circaids (adjustable compression garments designed to treat lymphedema, venous insufficiency, and edema).*A urine sample was collected according to the facility's identified professional standard reference by registered nurse (RN) E for one of one sampled resident (33) who was on an antibiotic for a urinary tract infection (UTI). Findings include:1. Observation and interview on 1/25/26 at 2:54 p.m. with resident 5 in her room revealed:*She was sitting in her recliner with her feet elevated.*She stated she had an open sore on her right foot, her buttocks and her upper legs.*There was a Roho cushion in her wheelchair that was covered with a pillow and a protective absorbent pad.*Resident 5 stated she put the pillow on top of the Roho cushion when she used it because she did not like sitting on plastic.*The Roho cushion did not have a protective cover on it and the air pockets were flattened.*Resident 5 stated she also had a Roho cushion in her recliner.*That Roho cushion had an absorbent protective pad over it and did not have a protective cover on it.2. Review of resident 5's electronic medical record (EMR) revealed:*She was admitted on [DATE].*Her 11/21/25 Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated her cognition was moderately impaired.*She had a stage III (3; open wound with full-thickness skin loss. Fatty tissue may be visible) pressure ulcer on her left and right buttocks.*Her 1/25/26 care plan stated ROHO cushion placed in recliner and in w/c [wheelchair]. I prefer a pillow be placed on top of cushion when using it.3. Observation and interview on 1/26/26 at 9:32 a.m. of licensed practical nurse (LPN) G and certified medication aide (CMA) H when providing care for resident 5's pressure ulcer in her room revealed:*LPN G stated resident 5 had a pressure ulcer on her buttocks and her upper thighs.*She had a Roho cushion in her wheelchair and her recliner.*LPN G verified there were no protective covers on resident 5's Roho cushions.*LPN G stated the staff placed the pillow on top of resident 5's Roho cushion in her wheelchair because she requested it.*She stated that staff have been educated that the pillow on top of the Roho cushion made the Roho cushion ineffective.*LPN G picked up the Roho cushion in resident 5's wheelchair and stated it was flat and needed more air put into it to provide support.*She stated she checked resident 5's Roho cushions for proper inflation on Mondays when she completed resident 5's skin assessments.*She rolled the Roho cushion up and placed it into a plastic bag and stated she would take it to the therapy department to fill it with air.*LPN G stated the therapy department was responsible for maintaining the residents' Roho cushions.*When asked if resident 5 used her wheelchair that morning CMA H verified resident 5 was in her wheelchair in the dining room for breakfast.4. Observation and interview on 1/26/26 at 10:28 a.m. of CMA H and LPN G in resident 5's room revealed:*LPN H placed the inflated Roho cushion into resident 5's wheelchair.*There was no protective cover on that Roho cushion.*She did not check that the Roho cushion was sufficiently inflated to provide pressure relief.*She did not check the Roho that was on resident 5's recliner to determine if that was sufficiently inflated to provide pressure relief.*CMA H and LPN G did not remove the absorbent protective pads that covered the Roho cushions in resident 5's recliner or wheelchair.*Resident 5 denied that a staff member told her the pillow and pads make the Roho cushions less effective.*CMA H stated she could not recall ever seeing protective covers on resident 5's Roho cushions.*CMA H stated she did not received any training about Roho cushion use.5. Interview on 1/27/26 at 8:50 a.m. with administrator A revealed:*The provider did not have a policy related to the use of Roho cushions.*The staff did not receive training related to the maintenance and use of Roho cushions.6. Interview on 1/28/26 at 9:31 a.m. with physical therapy assistant (PTA) T revealed:*The therapy department would give a resident a Roho cushion to use and monitor it if the resident was receiving therapy services.*Resident 5 was recently referred to therapy, but she had her Roho cushion prior to that.*If a resident was not receiving therapy services and has a Roho cushion the nurses were responsible for monitoring and maintaining it.*PTA T stated Roho cushions should have a protective cover that was designed for use with the Roho cushion.*If the protective cover was not on the Roho cushion it would potentially cause increased moisture exposure to a resident's skin which could cause skin breakdown.*She was aware resident 5 did not have a protective cover on her Roho cushion.*PTA T stated the Roho should not have anything over it other than the protective cover, such as a pillow or an absorbent protective pad, because that would interfere with the functionality of the Roho cushion.7. Interview on 1/28/26 at 10:28 a.m. with CNA K revealed:*She stated she did not do anything with the Roho cushions.*LPN G was responsible for monitoring and maintaining the Roho cushions.*If she noticed a Roho cushion was flat she would notify LPN G or the nurse on duty.8. Interview on 1/28/26 at 11:29 a.m. with LPN G revealed:*She verified the Roho cushions were to have protective covers on them.*She should have had resident 5 sit on the Roho cushion, put her fingers under resident 5 and assess if her fingers were able to move without moving her entire hand to ensure theRoho cushion was inflated to an effective level.*She stated the Roho cushions should be checked to determine if they will be effective each time she added or removed air from them.*She stated a pillow, or a pad should not be placed on top of a Roho cushion because it made the Roho cushion less effective.*LPN G stated she was told to add the pillow on top of resident 5's Roho cushion to her care plan because resident 5 requested it.*LPN G stated told resident 5 that the pillow on top of her Roho cushion made it less effective but she did not document that conservation.9. Interview on 1/28/26 at 12:52 p.m. with director of nursing (DON) B revealed:*LPN G was responsible for checking the residents' Roho cushions when she completed the residents' weekly skin assessments.*She expected the protective covers to be on the Roho cushions.*She stated without the protective covers the plastic of the Roho cushions could cause increased moisture on the skin, which could cause skin breakdown.*She verified a pillow on top of a Roho cushion would make the Roho cushion ineffective.10. Review of the providers 2022 Roho cushion manufacturer's instructions revealed:* DO NOT place obstructions between the individual and the cushion. The cushion and the cover MUST be compatible sizes and MUST be used as directed in this manual. Except for the compatible covers listed in 'Product Specifications' in this manual, placement of any items between the individual and the cushion; 1) may reduce or eliminate the benefits of the cushion, increase the risk of skin or other soft tissue, and 2) may cause the individual to become unstable and vulnerable to falling.* DO NOT use a product that is underinflated or over inflated, because 1) the product benefit will be reduced or eliminated, resulting in and increased risk to skin and other soft tissue, and 2) the individual may be unstable and vulnerable to falling. Carefully follow the instructions for inflations, placement and hand check.10.Observation and interview on 1/26/26 at 9:32 a.m. with resident 5 in her room revealed:*Resident 5 had a tubi grip (tubular sock that applies pressure to an area to help treat excess fluid or swelling (edema)) on her right lower leg that was rolled on the top and bottom of the tubi grip.*Resident 5 had swelling that overlapped below and above the edges of the tubi grip.*Resident 5 stated she wore the tubi grip at night for the swelling in her legs.11. Observation and interview on 1/26/26 at 10:28 a.m. with CMA H and LPN G in resident 5's room revealed:*CMA H and LPN G removed the tubi grips from resident 5's legs.*They wrapped the Circaids around resident 5's legs and secured it with the Circaids' Velcro straps.*CMA H and LPN G wrapped the Circaids around resident 5's feet and secured them with the Circaids' Velcro straps.*The heel portion of the Circaids was wrapped under resident 5's arch instead of her heel and did meet or overlap the leg Circaids to provide continuous compression to decrease the edema.*LPN G did not use a measuring tool to measure the amount of pressure the Circaids were applying to resident 5's legs after they were applied.*CMA H stated she assisted LPN G to put on resident 5's Circaids but the nurses were responsible for putting on and removing the Circaids.*CMA H stated she did not know when resident 5 wore tubi grips because they were applied and removed by the nurses.12. Further review of resident 5's EMR revealed:*Her diagnoses included diabetes (a condition involving disruptions in how the body regulates blood sugar), heart failure (a condition where the heart cannot pump enough blood for the body's needs), peripheral vascular disease (a circulation disorder that involves the narrowing or blocking of blood vessels), and lymphedema.*There was a 1/21/26 physician's order that stated Foot Circaids.*Resident 5's medication administration record (MAR) stated, Circaids to feet every shift for diabetic foot ulcer.*There was no physician's order for the use of Tubi grips.13. Interview on 1/28/26 at 9:40 a.m. with physical therapist (PT) U revealed:*She had received additional training related to resident wounds and Circaids use.*Cicaids were typically used for swelling or lymphedema.*PT U did not know who ordered resident 5's Circaids use originally, but stated resident 5 wore the Circaids since November 2025 when she began working at the facility.*PT U stated Circiads typically were to be on while the resident was up and could be removed at night.*She stated there should be a sleeve applied to the resident's leg before the Circaid, and then the Circaid on top of that. If an ankle or foot Circaid is used with a leg Circaid the Circaids should be close together or overlap.*Once a Circaid was put on, a measuring tool should be used to determine the amount of pressure being applied to the resident's extremity.*The pressure of the Circaid should have been ordered by a physician or physical therapist.*The pressure should be measured each time the Circaid was put on the resident.*She stated that if there was not enough pressure applied to the resident's extremity, the resident's swelling would not be treated, and the resident would have increased edema. If the Circaid was too tight it could cause circulation issues.*She thought a physician's order for Circaids should include when the Circaids were to be on and off the resident, and the pressure the Circaids were to apply.14. Interview and review of resident 5's EMR on 1/28/26 at 11:29 a.m. with LPN G revealed:*LPN G acknowledged resident 5 had tubi grips on her legs on 1/26/26 at 9:32 a.m.*She stated she did not know where the tubi grip had come from. She had found the box for the tubi grips in resident 5's room that same day (1/26/26) and removed it because resident 5 did not have a physician's order to wear tubi grips.*She thought physical therapy in a neighboring town ordered the Circaids for resident 5 quite a while ago but resident 5 refused to wear them.*LPN G stated the nurses were responsible for applying and removing resident 5's Circaides.*When resident 5's feet began to swell more her primary care provider ordered for her Circaids to be worn on her feet.*LPN G stated resident 5 was to wear the Circaids at all times, and they were only to be removed for providing her personal care.*LPN G stated she received some training on the Circaids when they were first ordered.*She was not aware that there was a measuring device that was to be used to determine the amount of pressure the Circaids applied to the area they covered.*LPN G verified the Circaids were only ordered for resident 5's feet, not her legs, and the staff were applying the Circaids to her feet and legs.*She verified the 1/21/26 physician's order for the Circaids was for every shift, but it did not indicate what was supposed to be done every shift.*LPN G acknowledged that the 1/21/26 physician's order did not prompt the nurses to remove the Circaids and assess resident 5's skin for areas of pressure or skin breakdown.15. Interview on 1/28/26 at 12:52 p.m. with DON B revealed she:*Expected the staff to review the directions for the Cicaids before putting them on a resident.*Was not aware there was a measuring device for the Circaids to determine the amount of pressure the Circaids applied and that pressure would have been part of the order for use.*Reviewed the physician's order in resident 5's EMR and agreed the physician's order included the Circaids on resident 5's feet but did not indicate what the pressures of the Circaids were supposed to be.16. Review of the provider's undated Circaid manufacturer's instructions manual revealed:* This compression system is designed to provide upper leg compression to patients with venous and lymphatic disorders.* Using the Built-In-Pressure System (BPS)Step 1: Locate the BPS card in your packaging.Step 2: Identify the appropriate side of the BPS card based on your ankle circumference.Step 3: Identify your prescribed pressure scale using the color-coded system.Step 4: Starting with the bottom band, line up the arrow on the BPS card with one of the BPS lines on the bottom band of the component.Step 5: Note where the second BPS line lines up with the card's compression angles.Step 6: If the BPS lines on the component either falls short or goes beyond the correct compression range, readjust the band as necessary so that the second BPS line on the component is aligned with the prescribed compression range.* Wearing recommendations-Always ensure that the correct pressure range is being applied.Slightly loosen the bands of the component for night-time wear.* Application instructionsStep 1: Slide the circaid undersleeve onto the leg so that it covers the entire leg up to the groin.17.Observation and interview on 1/26/26 at 8:42 a.m. with resident 33 in his room revealed:*There were two undated disposable urinals on his bedside table.*One of those urinals had a brown ring near the opening on the top if it where resident 33 would urinate into.*Resident 33 stated he was recently given an antibiotic and told he had a UTI.*He stated he was not ill and did not know why he was started on an antibiotic for a UTI because he did not given a urine sample by urinating into a specimen cup.*He was concerned that the staff took the urine sample from the urinals on his bedside table.*Resident 33 pointed at the urinals and stated those urinals were dirty.18. Review of resident 33's EMR revealed:*He was admitted on [DATE].*His 12/3/25 BIMS assessment score was 15, which indicated his cognition was intact.*A 1/21/26 progress note written by LPN G stated, Resident seen on rounds by Dr [redacted name] for recert [recertification]. Noted crack to right foot beneath toes healed. Resident complaints of right back pain specific to kidney region, new orders for Tylenol 10000 [1,000] mg [milligrams] tid [three times] daily scheduled x [times] 5 days. Cyclobenzaprine [a medication used to relax muscles] 10 mg tid prn [as needed], UA [urinalysis] with micro [microbiology] dx [diagnosis] N.*The urine sample was documented as having been collected by registered nurse (RN) E on 1/22/26 at 4:30 a.m.*There was a 1/24/26 physician's order for Nitrofurantoin (an antibiotic) 100 mg capsule Give 1 cap by mouth every 12 hours for five days for a UTI.19. Interview on 1/27/26 at 12:05 p.m. with administrator A revealed:*The provider did not have a policy for UA collection.*The staff used the [NAME]/[NAME] Fundamentals of nursing 10th edition as their professional standards reference.20. Interview on 1/27/26 at 6:33 p.m. with RN E revealed:*She collected the urine sample from resident 33 on 1/22/26.*RN E stated resident 33 did not urinate that night until between 3:00 a.m. and 4:00 a.m.*When she saw that resident 33 had urinated in his urinal she got a urine specimen cup, poured the urine from his urinal into the specimen cup, labeled the urine cup with resident 33's name, put the urine specimen cup in a bag, and placed the bag into the refrigerator.*RN E verified she did not replace resident 33's urinal with a clean urinal before he urinated in it.*She stated she used the urinal that was already beside his bed when she came to work.*She did not know when that urinal was given to resident 33.21. Interview on 1/28/26 at 10:28 a.m. with CNA K revealed:*The urinals in residents' rooms were replaced by the hospitality aids but there was no established schedule for when the urinals were to be replaced.*There was no documentation when the urinals were replaced, and the urinals were not dated when they were replaced.22. Interview on 1/28/26 at 11:18 a.m. with LPN G revealed a resident's urine sample that was to be tested for a potential infection should not be collected from a previously used urinal due to the risk of it being contaminated.23. Interview on 1/28/26 at 12:52 p.m. with DON B revealed:*She expected the nurses to follow the [NAME]/[NAME] nursing standards of practice when they collected a urine sample.*She stated the resident's genitals were to be cleaned, the resident should urinate into the toilet or urinal and then the sample should be collected in a urine specimen cup.*The urinals were to be replaced every month and as needed if they became soiled.*DON B verified RN E did not follow the standards of practice when she collected the urine sample from resident 33, which could have resulted in a contaminated urine sample that resident 33 was being treated with antibiotics for.24. Review of the provider's professional standards reference [NAME]/[NAME] Fundamentals of nursing 10th edition revealed:* COLLECTING MIDSTREAM (CLEAN-VOIDED) URINE SPECIMEN.2. Collect clean-voided urine specimen.a. Perform hand hygiene and apply clean gloves. Give patient cleaning towelette or towel, washcloth, and soap to clean perineum [the area between the anus and genitals] to help with cleaning perineum.-Cleaning prevents contamination of specimen from skin and surface bacteria after urine passes from the urethra.e. Open specimen container, maintaining sterility of inside specimen container, and place cap with sterile inside up. Do not touch inside the cap or container.-Contaminated specimen is most frequent reason for inaccurate reporting of urine C&S [culture and sensitivity]f. Use aseptic technique to help patient or allow patient to independently clean perineum and collect specimen.(1) Male:(a) Hold penis with one hand using a circular motion and antiseptic towelette, clean meatus, moving from center to outside 3 times with 3 different towelettes.-Reduces number of microorganisms at urethral meatus and moves from areas least to most contamination.(c) After patient initiates urine stream into toilet, urinal, or bedpan, have him pass urine specimen container into stream and collect 90 to 120 ml [milliliters] of urine.-Initial urine flushes out microorganisms that normally accumulate at urinary meatus and prevents transfer into specimen.

Based on record review, interview, and policy review, the provider failed to develop a person-centered baseline care plan that included the minimum healthcare information necessary to provide care for four of five newly admitted residents (8, 18, 32, and 33) and failed to ensure the resident's baseline care plan was reviewed with the resident or resident representative within 48 hours of admission for three of five newly admitted residents (18, 32, and 33). Findings include:1. Review of resident 32's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Resident 32's representative and licensed practical nurse (LPN) G signed her baseline care plan on 8/13/25, nine days after she was admitted to the facility. *Resident 32's 8/4/25 baseline care plan did not indicate the level of assistance he required from staff to complete bathing tasks or what diet he should receive at meal times. -Resident requires assistance with ADL's [activities of daily living]: bed mobility, transfers, dressing, personal hygiene, eating and toileting. The goal was Resident will be assisted with ADLs as needed. The intervention was Assist resident with showering/bathing per schedule. --The baseline care plan did not indicate the level of assistance that resident 32 required to complete bathing tasks. 2. Review of resident 33's EMR revealed: *He was admitted on [DATE]. *Resident 33 did not have an individualized baseline care plan completed or reviewed with him or his representative within 48 hours of his admission to the facility. 3. Review of resident 8's EMR revealed: *He was admitted on [DATE]. *His 10/28/25 admission nursing assessment indicated that he was dependent on staff members for bathing, dressing, using the toilet, and eating. *His 10/28/25 baseline- care plan indicated: - Resident requires assistance with ADL's: bed mobility, transfers, dressing, personal hygiene, eating and toileting. The goal was Resident will be assisted with ADLs as needed. The interventions were to provide assistance for meals if indicated and to assist resident 8 with showering/bathing per schedule. --The baseline care plan did not indicate that resident 8 was dependent on staff for assistance with eating. --The baseline care plan did not indicate the level of assistance that resident 8 required to complete bathing tasks. -Assist with application of appliances if needed (hearing aids, eyeglasses, dentures). -Make sure that the resident wears eyeglasses and/or hearing aids, if applicable. -Provide DME [durable medical equipment] if needed (wheelchair, cane, walker, etc). --The baseline care plan did not indicate which of these that resident 8 used or the level of assistance he required for transferring and mobility. 4. Review of resident 18's EMR revealed: *He was admitted on [DATE]. *Resident 18 signed his baseline care plan on 12/22/25, six days after he was admitted to the facility. Review of resident 18's baseline care plan revealed: *Resident 18's 12/16/25 baseline care plan did not indicate: -The level of assistance he required to complete bathing tasks. -If he needed hearing aids, glasses, dentures, a wheelchair, a cane, or a walker. -The level of assistance he required to complete bed mobility, transfers, dressing, personal hygiene, eating and toileting. 5. Interview on 1/26/26 at 10:13 a.m. with administrator A revealed resident 33 did not have a baseline care plan that was completed or reviewed with him or his representative. 6. Interview on 1/28/26 at 10:28 a.m. with certified nursing assistant (CNA) K revealed she referred to the resident's Kardex (a report of the resident's care needs and interventions) to determine how to care for a newly admitted resident. -The resident care needs in the Kardex was based off the information in that resident's care plan. 7. Interview on 1/28/26 at 11:18 a.m. with LPN G revealed: *She stated a resident's baseline care plan was to be completed within the first 24 hours of admission and reviewed with the resident or the resident's representative within the first 48 hours after their admission to the facility. *The resident's baseline care plan was documented in a check box format within the admission assessment in the EMR. *After the admission assessment was completed, the nurse would document that information in the resident's care plan to make the baseline care plan. *She stated each resident's baseline care plan should reflect the assistance needs of that resident. 8. Interview on 1/28/26 at 1:13 p.m. with director of nursing (DON) B revealed: *Baseline care plans were to be completed and reviewed with the resident or resident representative within 48 hours of that resident being admitted to the facility. *She expected the baseline care plans to be individualized to include the basic needs to care for that resident, such as how a resident can transfer. 9. Review of the provider's 5/14/25 Care Plan 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. *The DON will be responsible for holding the team accountable to initiating and completing the admission [baseline] care plan within 48 hours and the long-term care plan by day 21 and updated as necessary thereafter. *Interventions act as the means to meet the individual's needs. *A Baseline Care plan is started by nursing staff on the first day of admission to provide guidance to direct care givers as soon as possible after admission and completed no later than 48 hours after admission. Nursing, Dietary, Activities and Social Service staff complete formal assessments, interviews, and observations and begin formulating the full care plan as soon after admission as possible. (These departments do have areas that need to be completed by the 48- hour deadline). *The areas that must be addressed in the base line care plan include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a) Initial goals based on admission orders. b) Physician orders. c) Dietary orders. d) Therapy services. e) Social services.

Based on interview, resident council meeting, resident council meeting minutes review, grievance forms review, and policy review, the provider failed to ensure that grievances regarding the food quality of residents' meals were addressed, and documentation reflecting the staff's efforts to resolve those grievances was communicated to the residents and approved as effective resolutions for:*Nine of nine residents (13, 18, 19, 22, 24, 36, 40, 50, and 51) who individually reported concerns in grievance records reviewed from July 2025 through January 2026.*Five of five residents (12, 19, 25, 32, and 44) who attended the resident council meeting on 1/26/26. Findings include:1. Interview on 1/25/26 at 12:19 p.m. with resident 4 revealed: *He preferred to eat meals in his room. *When his meal trays were delivered to his room, the food was not always as hot as he thought it should be. 2. Interview on 1/26/26 at 8:45 a.m. with resident 41 revealed: *He preferred to eat meals in his room. *When his meal trays were delivered to his room, the food was not always as hot as he thought it should be. *He stated he was served burnt French Toast for a morning meal. 3. A resident council meeting held on 1/26/26 at 1:01 p.m. revealed: *The resident council had a president, and they met monthly to discuss their concerns. *Residents 12, 19, 25, 32, and 44 voiced complaints that their concerns regarding their meals and the food quality, which were communicated during previous resident council meetings, were not resolved. *They felt their complaints were heard and documented, but there were no solutions or follow-up provided to them. *They felt that they complained and complained and that no one cares. *Resident 19 stated he heard there was a new cook, but the quality of the food had not improved. 4. Review of the provider's August 2025 through January 2026 resident council meeting minutes revealed: *On 8/4/25, Mashed potatoes still very watery. Was the issue resolved to your satisfaction was marked no, and How are they doing? Dietary was marked Lots of carbs [carbohydrates]. *On 11/4/25, Evening food isn't [is not] good- Bean Soup was to [too] spicy to even eat [on] 11/3/25, and Desserts are not very good. How are they doing? Dietary was marked Days are good, Evenings [are] not good. *On 12/5/25, Evening meals are not good. Was the issue resolved to your satisfaction was marked no, and How are they doing? Dietary was marked Weekend & [and] evenings are not good. *On 1/8/26, Evening meals are not good. Was the issue resolved to your satisfaction was marked no, and Evening meals [are] not good. [They] Just throw food together & [we] don't always know what it is. How are they doing? Dietary was marked Evening meals are still not good. 5. Review of the provider's July 2025 through January 2026 grievances revealed: *On 7/8/25, the resident council filed three grievances regarding the dietary meal service and the quality of the food, which indicated that four out of six unnamed residents who attended the resident council meeting shared the concerns. -The provider's Resident Council Department Response Form indicated a response was due to the resident council representative within 5 days after they filed a grievance. There was no documentation to indicate The Department Response: (Includes dates of proposed or completed actions. Describe actions taken and results expected), or when that Departmental Response was Presented to [the] Resident Council. *On 7/9/25, resident 50's representative filed a grievance indicating, food not done, tray was a mess. The provider indicated the resolution was a staff inservice. *On 10/3/25, residents 13 and 40 filed grievances regarding the dietary department not following their diet orders. -The Resolution on the Grievance and Satisfaction Form indicated that the dietary manager was re-educated to follow [the] resident's diet on 10/3/25. *On 12/20/25, residents 18, 19, 22, 24, and 51 filed grievances regarding the dietary department. Their concerns included the timing of the meal delivery, the quality of the food, not enough food on the plate, no meat, and the food not having been cooked as it should be. -The Resolution on the Grievance and Satisfaction Form indicated cook working on 12/20 will be re-educated and trained on proper preparation and serving of food. *On 1/4/26, resident 36 filed a grievance indicating that the food [was] not done. *On 1/8/26, the resident council filed a grievance regarding the quality and presentation of the food served at their evening meals, which indicated that three out of four unnamed residents who attended the resident council meeting shared those concerns. -The Resident Council Department Response Form indicated working on plating presentation and seasoning to meals to add a little color. There was no indication that information was shared with the resident council representative. 6. Interview on 1/28/26 at 8:49 a.m. with activities director (AD) O revealed: *She facilitated the monthly resident council meeting and felt that the residents shared concerns about the quality of the food, the temperature of the food, the taste of the food, and not receiving the planned meals for about eight months. *She completed a Resident Council Department Response Form to document the residents' concerns and gave that form to dietary manager (DM) L and social services coordinator (SSC) Q. -She expected that DM L would complete the Department Response section of that form, and AD O would share that information with the residents at the next resident council meeting, but she did not receive the forms back. *The residents seemed frustrated during the resident council meetings because they did not see an improvement in the quality of the food they were served at their meals. Their complaints were mostly about food served to them in the evenings and on the weekends. *She assisted residents in filling out a Grievance and Satisfaction Form if they reported a concern outside of the resident council meeting. *DM L, SSC Q, and administrator A did not attend the resident council meetings. 7. Interview on 1/28/26 at 9:09 a.m. with SSC Q regarding resident grievances revealed: *When she received a grievance from the resident council or a resident, she would provide a copy to the department manager to complete the form, which included the resolution and the notifications. -Those completed forms were to be signed by administrator A, then SSC Q was to log the grievance for tracking purposes. *SSC Q did not communicate the resolution to the resident council or individual residents. -She expected that DM L would discuss concerns regarding the dietary department with the residents and follow up with the residents with resolutions to those concerns. 8. Interview on 1/28/26 at 9:19 a.m. with DM L regarding resident grievances concerning their meals revealed: *She began working at the facility about a month ago. She was aware that the residents shared concerns about the quality of their meals, the temperature of the food served to them, and the dietary department's not following menus or residents' physician-ordered diets or preferences. *She was working on completing the 1/8/26 Resident Council Department Response Form regarding resident council concerns about the quality and presentation of the evening meals. *She spoke with other residents to see if they shared the same concerns, but did not meet with the resident council about their food-related grievances. 9. Interview on 1/28/26 at 9:37 a.m. with administrator A revealed: *She was aware of the residents' concerns about the quality, temperature, and presentation of their meals. *The previous DM's employment with the facility ended approximately three months ago, and she felt that they were working on resident concerns about the food for quite a while before he left. *Resident concerns about the food were addressed by providing additional education to the dietary staff members. *She did not attend the resident council meetings, but would if they invited her. *She expected DM L to follow up with residents about their concerns with the food. *She was unsure if SSC Q followed up with residents when she received the completed grievance forms or if she just tracked those forms. *She expected AD O to share the resolution to the resident council grievances with the residents at the next resident council meeting. *She was unaware that the residents did not receive information about the provider's actions being taken to address their food-related grievances. 10. Review of the providers' 5/15/25 Grievances policy revealed: *It is the policy of this facility to investigate all grievances. *The Administrator or designee shall confer with persons involved. and within three (3) days of receiving the grievance shall provide a written explanation, upon request, of findings and proposed remedies to the complainant and the aggrieved party. *During the investigation, the facility will put in place immediate action to prevent potential violation of resident's rights. *All written grievance decisions will include. the steps taken to investigate the grievance, a summary of the pertinent findings. any corrective action to be taken by the facility as a result of the grievance. *Communicate to[the] customer [the] actions taken and discuss [the] outcomes of this action to determine effectiveness. Ensure Customer satisfaction with outcomes. Follow-up to ensure concern is resolved. 11. Review of the providers' undated Resident Rights -Food and Nutrition Services Department policy revealed, All dietary requests and concerns should be addressed in a courteous manner. Any request given to a dietary staff member should be promptly addressed. Those concerns that cannot be addressed by the [NAME] or Dietary Aide should be communicated to the Director of Food and Nutrition Services or other clinically qualified nutrition professional.

Based on observation, interview, and policy review, the provider failed to ensure the staff followed standard infection control practices regarding:*Hand hygiene (handwashing or hand sanitizer use) and gloves used by one of one certified medication aide (CMA) (H), and one of one licensed practical nurse (LPN) (G) while providing personal cares for resident 5.*Hand hygiene and use of personal protective equipment (PPE) (such as a gown, gloves, and mask) by one of one certified nursing assistant (CNA) (S) observed while delivering meal trays to four of four sampled residents (10, 14, 20, and 22) with COVID-19 (a contagious disease that can spread quickly) and on enhanced droplet precautions (which need and a N95 mask (a mask that filters 95 percent of airborne particles), gown, gloves, and eye protection to be worn when entering those rooms) according to the provider's policy. Findings include:1. Observation on 1/25/26 at 11:58 a.m. of CNA S passing lunch trays to residents in their rooms revealed:*On the door of resident 10's room was a sign for enhanced droplet precautions (EDP).*The alcohol-based hand sanitizer (ABHS) dispenser outside resident 10's room did not have hand sanitizer in it.*Without performing hand hygiene, CNA S put on a gown, removed her surgical mask and placed it in the pocket of her pants, put on a N95 mask, put on a pair of gloves, tied the gown around her back, and took resident 10's food into his room.-CNA S did not put on eye protection before entering resident 10's room.*CNA S exited resident 10's room with an uncovered garbage can, set the garbage can down outside the resident's door, and with the same gown, gloves, and N95 mask on.*CNA S removed her gown, gloves and N95 mask in the hallway and discarded them in the uncovered garbage can.*She took her used surgical mask out of the pocket of her pants and put it on.*She attempted to use the ABHS from the hallway dispenser outside of resident 10's room, but the dispenser did not dispense hand sanitizer.*CNA S then pushed the cart with other residents' meal trays on it down the hallway.*Outside of resident 20's room, without performing hand hygiene CNA S put on a gown, put the surgical mask she was wearing in the pocket of her pants, then put on an N95 mask, a pair of gloves, and a face shield.*She entered resident 20's room with the resident's meal tray.*On resident 20's door was a sign that indicated she was on EDP.*CNA S exited resident 20's room with an uncovered garbage can with the same gown, gloves, and N95 mask on.*CNA S removed her gown, gloves and N95 mask in the hallway and discarded them in the uncovered garbage can.*She then put on the used surgical mask from her pants pocket and sanitized her hands with ABHS.*CNA S went to resident 14's room, which had a sign on the door that stated he was on EDP.*Outside of resident 14's room, without performing hand hygiene, CNA S put on a gown, put the used surgical mask she was wearing in the pocket of her pants, and put on an N95 mask, a pair of gloves, and a face shield.*She entered resident 14's room with his meal tray.*CNA S exited resident 14's room with an uncovered garbage can and with the same gown, gloves, and N95 mask on.*CNA S removed her gown, gloves and N95 mask in the hallway and discarded them in the uncovered garbage can in the hallway.*She put on the used surgical mask from her pocket and sanitized her hands with ABHS.*CNA S pushed the cart with the residents' meals on it to resident 22's room, which had a sign on the door that stated he was on EDP.*Outside of resident 22's room, without performing hand hygiene, CNA S put on a N95 mask over her surgical mask, put on a gown, a pair of gloves, and a face shield.*She entered resident 22's room with his meal tray.*CNA S exited resident 22's room with an uncovered garbage can and with the same gown, gloves, and N95 mask on.*CNA S removed her gown, gloves and N95 mask in the hallway, discarded them in the uncovered garbage can in the hallway, and sanitized her hands with ABHS.2. Interview on 1/25/26 at 12:08 p.m. with CNA S revealed residents 10, 14, 20, and 22 were on EDP because they had COVID (COVID-19).3. Observation on 1/26/26 at 10:28 a.m. of CMA H and LPN G changing resident 5's wound dressings revealed:*On the outside of resident 5's door was a sign that stated she was on enhanced barrier precautions (EBP) (glove and gown use when providing contact care).*CMA H and LPN G each put on a gown and a pair of gloves without performing hand hygiene.*LPN G washed the wound on resident 5's right foot, removed her gloves, discarded them in the garbage can, and without performing hand hygiene, put on a clean pair of gloves.*LPN G placed a clean dressing over resident 5's foot wound, put a compression wrap on resident 5's leg, removed her gloves and discarded them in the garbage can, did not perform hand hygiene, and put on a clean pair of gloves.*CMA H assisted LPN G with putting the compression wrap on the resident, then removed her gloves, discarded them in the garbage can, did not perform hand hygiene, and put on a clean pair of gloves.*CMA H took the garbage bag out of the garbage can and set it on the floor, put a new garbage bag in the garbage can, removed her gloves discarded them in the garbage can, did not perform hand hygiene, and put on a clean pair of gloves.*CMA H and LPN G assisted resident 5 to a standing position, removed her incontinence brief, and washed resident 5's buttocks.*LPN G removed her pair of gloves, discarded them in the garbage can, did not perform hand hygiene, put on a clean pair of gloves, and measured resident 5's wounds on her buttocks and thighs.*LPN G took the garbage out of the garbage can, put a new garbage bag in the garbage can, removed her gloves, discarded them in the garbage can, and performed hand hygiene.*CMA H assisted resident 5 into a wheelchair, CMA H removed her gloves, discarded them in the garbage, did not perform hand hygiene, put on a clean pair of gloves, and handed resident 5 a glass of water.*CMA H then cleansed resident 5's finger with an alcohol swab, poked resident 5's finger with a lancet and collected a drop of resident 5's blood to check her blood sugar.*CMA H removed her gloves, discarded them in the garbage, and performed hand hygiene before she left resident 5's room.4. Interview on 1/28/26 at 10:28 a.m. with CNA K revealed:*Hand hygiene should be completed before and after providing any resident's care needs, before putting on gloves, and after removing gloves.*A resident on EDP required staff to put on a gown, a pair of gloves, an N95 mask, and eye protection before entering the resident's room.*When she exited a resident's room who was on enhanced droplet precautions, she sometimes took her gown and gloves off in the room and sometimes she took them off in the hallway. It depended on where the garbage can was located.*She acknowledged that the garbage cans in the hallway where the gowns, gloves, and masks were disposed of were not covered, which could expose others in the hallway to COVID-19.5. Interview on 1/28/26 at 11:08 a.m. with LPN G revealed:*Hand hygiene should be performed before and after providing any resident's care needs, before entering a resident's room, after leaving a resident's room, before putting on gloves and after removing gloves.*She verified she did not wash her hands during resident 5's dressing change.*When a resident was on EDP staff were to put on PPE before entering the resident's room and remove the gown and gloves before they exited that resident's room.*The used gown and gloves should be put in the garbage can inside the resident's room, the N95 mask was to be placed in a garbage can outside of the resident's room, and a new surgical mask was to be put on.6. Interview on 1/28/26 at 12:52 p.m. with director of nursing (DON) B revealed:*Hand hygiene was to be completed before a staff member entered a resident's room, after leaving a resident's room, before putting on gloves and after removing a pair of gloves, and before and after providing any resident's care needs.*She expected staff to put PPE on before entering the room of a resident who was on EDP, remove and dispose of their gown and gloves in the resident's room, exit the room, remove their N95 mask, wash their hands, and put on a clean surgical mask.7. Review of the provider's October 2019 Hand Hygiene policy revealed:* This facility considers hand hygiene the primary means to prevent the spread of infections.* In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations:a. Before and after direct contact with residentsb. When entering and leaving a Resident care area/roomc. Before donning [putting on] and after removing gloves;d. Before performing any non-surgical invasive procedures;e. Before preparing or handling medications;f. Before handling clean or soiled dressings, gauze pads, etc.;g. Before moving from a contaminated body site to a clean body site during resident care;h. After contact with a resident's intact skin;i. After handling dressings, contaminated equipment, etc.;j. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; andk. After contact with body fluids, mucous membranes and non-intact skin or dressing.* Hand hygiene is always the final step after removing and disposing of personal protective equipment.Review of the provider's 1/26/25 Transmission Based Precautions policy revealed:* For diseases that have multiple routes of transmission, more than one transmission based precaution category may be required (e.g., Droplet and Contact for COVID-19 etc.)* Precautions signage will be placed on the door or door jamb. [NAME] (put on) appropriate PPE BEFORE entry to room or cubicle.* Soiled laundry and trash containers will be placed inside the room. PPE will be placed in these containers after doffing (removing) PPE and/or soiled linen items are used. Hand hygiene will be performed.* CONTACT PRECAUTIONS.-Hand hygiene should be completed prior to donning and after removal of gloves.-Gloves should be worn when entering the room and while providing care for the resident.-Gloves should be changed when contaminated (e.g., handling fecal material and wound drainage).-Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately.- A gown should be donned prior to entering the room or resident's cubicle.- The gown should be removed before leaving the resident's room.* DROPLET PRECAUTIONS.-Hand hygiene should be completed prior to donning and after removal of gloves.-Gloves should be worn when entering the room and while providing care for the resident.-Gloves should be changed when contaminated (e.g., handling fecal material and wound drainage).-Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately.* Enhanced Droplet Precautions (Use of Contact and Droplet Precautions together)1. Under certain circumstances, such as a novel respiratory infection (e.g., COVID-19) the CDC [Center for Disease Control] recommends the use of both Contact and Droplet Precautions together. All residents with contact and droplet precautions will be identified with an Enhanced Droplet Precautions/Contact and Droplet Precautions sign on the resident's door or door jamb.2. Follow above requirements for Standard, Contact Precautions and Droplet Precautions, including use of full PPE:a. N95 respirator must be used along with gown, gloves, and eye protection.

Based on record review, interview, and policy review, the provider failed to ensure two of two sampled resident's (25 and 43) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment was accurately coded for the Pre-admission Screening and Resident Review (PASRR). Findings include: 1. Review of resident 25's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included major depressive disorder, obsessive compulsive disorder (reoccurring thoughts and repetitive behaviors), anxiety disorder (anticipation of future danger or misfortune with symptoms such as restlessness or irritability), and paranoid schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a distorted sense of reality). *Her 5/9/23 level II [2] PASRR which stated, This PASRR approval is not time limit [does not have a time limit] there is no need to re-submit unless there is a significant change that may impact PASRR status. *Item A1500 of her 12/20/23, 12/4/24, and 3/31/25 comprehensive MDS assessments were coded No to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? *Her 1/27/26 care plan had a focus area initiated on 4/11/24 that stated, PASRR/MH [mental health] LEVEL II NOTICE OF DETERMINATION The resident has been screened by the contracted Pre-admission Screening (PASRR) agency and found to be in need of long-term care placement/services. The resident has a diagnosis of severe persistent mental illness. 2. Review of resident 43's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included delusional disorders (false beliefs and distorted views that are classified as a serious mental health condition). *Her 10/15/25 notice of PASRR Outcome Explanation, indicated The facility should mark yes for question A1500 on the Minimum Data Set, 'Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition?' *Item A1500 of her 10/27/25 comprehensive MDS assessment was coded as No to the question: Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition? *Her 1/28/26 care plan did not indicate she was considered to have a PASRR Level II. 3. Interview and record review on 1/27/26 at 11:59 a.m. with social service coordinator (SSC) Q regarding completing MDS assessment item A1500 revealed: *She was provided with training on how to complete the MDS by a consultant. *She completed A1500 for all residents' comprehensive MDS assessments. *After reviewing resident 25's comprehensive MDS assessments for 12/20/23, 12/4/24, and 3/31/25, she confirmed all of those assessments should have been coded as a Yes for item A1500. *After review of resident 43's PASRR Outcome Explanation and her comprehensive MDS from 10/27/25 she confirmed item A1500 for resident 43 should have been coded as yes. 4. Interview on 1/28/26 at 10:48 a.m. with administrator A regarding MDS item A1500 coding for residents 25 and 43 revealed that she expected those MDS assessments to be coded accurately. 5. Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed section A, item A1500, revealed Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition.

Based on observation, interview, record review, and policy review, the provider failed to follow food safety standard pratices to ensure resident food temperatures were monitored and recorded according to the provider's policy for all meals prepared and served in one of one kitchen. Findings include: 1. Observation and interview on 4/14/25 at 4:45 p.m. with cook C in the kitchen revealed: *He was checking the temperature of the food for the evening meal. *He took the temperature of each food item five to fifteen minutes before it was served. *Staff were to document food temperatures on the food temperature chart for all meals. 2. Interview and record review on 4/15/25 at 9:50 a.m. with dietary manager B regarding food temperatures revealed: *Staff were instructed to take food temperatures for all meals. *The food temperatures were to be documented in the food temperature chart. *He stated it had been a struggle to get some staff to document the food temperatures. *He had implemented a new food temperature system on 4/1/25 to try to improve charting by the dietary staff. *In March 2025, there were no food temperatures documented for 23 of 31 days. -One day in March, only the breakfast food temperatures were documented. -Five days in March, only the breakfast and lunch food temperatures were documented. *In April 2025, there were no food temperatures documented for two of the first fourteen days. -Three days in April, only the breakfast and lunch food temperatures were documented. *It was his expectation that dietary staff would document the food temperatures for all meals. *He agreed there was missing food temperature documentation for several meals in March and April 2025. 3. Interview on 4/15/25 at 11:25 a.m. with administrator A regarding food temperatures revealed: *She knew there were issues with the dietary staff not documenting food temperatures for meals. *It was her expectation the dietary staff would document food temperatures on the food temperature chart for all meals. *She agreed the temperatures were not being taken or documented as they should be. 4. Review of the provider's revised 3/19/2020 Food Temperature policy revealed:*Food should be served at proper temperature to insure [ensure] food safety and palatability. *Record reading on Food Temperature Chart (FORM 401) or Food Temperature/Sanitation Combined Record (FORM 401B) and/or Always available Food Temperature Chart (FORM 401A) or other designated form at [the] beginning of [the] trayline and end of [the] trayline. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) record review, interview, and policy review, the provider failed to ensure the safety for one of one sampled resident (1) who was served a food item she had a documented food allergy to. The failure of serving the resident a food item that was identified as a food allergy resulted in the resident's allergic reaction symptoms and need for evaluation and treatment at the emergency department. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's 3/10/25 SD DOH FRI regarding resident 1 revealed: *On 3/8/25 at 5:22 p.m. she was served cake that contained strawberries for dessert. *Licensed practical nurse (LPN) C recognized the issue and immediately did an assessment and contacted the physician. *An order for 50 milligrams (mg) of Benadryl (an antihistamine to treat allergy symptoms) was received and administered. *Staff were to monitor for signs and symptoms of an allergic reaction. *Resident 1's family was notified. *At 8:12 p.m. further assessment showed slight swelling of resident 1's tongue. *She was transferred to the local emergency department for further evaluation. *She received 40 mg of Prednisone (a steroid) and returned to the provider. *Resident evaluations throughout the night revealed no new symptoms. *Administrator A reviewed video footage in the dining room on the evening of 3/8/25. *Cook D was not using the meal tray tickets when serving supper. *Cook D was suspended on 3/10/25 for failure to follow facility policy regarding meal tray tickets. *Cook D was re-instated on 3/12/25 after education for meal tray tickets and resident allergies had been reviewed. Review of resident 1's electronic medical record (EMR) revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was 3 which indicated she had severe cognitive impairment. *Her care plan indicated she was allergic to strawberries. Interview on 3/17/25 at 3:33 p.m. with guest services aide F regarding resident food allergies revealed: *Staff had received education on resident food allergies and signs and symptoms of allergic reactions. *She indicated the resident's face could turn red, and the resident may be holding their throat if they were having trouble breathing or swallowing. *She stated when serving residents their trays at mealtimes there was a sheet with their allergies listed on it. *Staff needed to make sure that there were no items on the tray that were listed as an allergy. Interview on 3/17/25 at 4:00 p.m. in the kitchen with cook E regarding resident food allergies and meal tray tickets revealed: *A list of residents and their food allergies was posted on a cupboard door in the kitchen. *The meal tray tickets also had resident food allergies listed on them. *The dietary staff were to always review the resident meal tray tickets to ensure they were not serving any food to a resident that they were allergic to. *If there was something on the menu that a resident was allergic to, the cook was to provide an alternative item that contained the same nutritive value. Interview on 3/17/25 at 4:30 p.m. with administrator A and director of nursing (DON) B regarding resident food allergies revealed: *The kitchen had a list of residents with food allergies. *The resident's meal tray cards also listed any food allergies. *They reviewed video footage in the dining room of the day of the incident and the cook that day was not using the meal tray tickets. *Staff were educated on accommodation of resident food allergies and signs and symptoms of allergic reactions. *Audits were to be completed by the dietary manager or designee of randomly selected meals. -Weekly for four weeks. -Monthly for three months. -Audit results were to be reviewed at the monthly quality assurance meeting for compliance and further recommendations. *It was their expectation that the policy for resident allergies and meal tray tickets be followed to ensure the safety of the residents. Review of the provider's 5/20/20 Food Allergy/Intolerance Awareness policy regarding resident food allergies revealed: *Food that accommodates resident allergies, intolerances, and preferences should be prepared and served. *Written instructions for food to be avoided should be documented during the initial dietary interview/pre-screen (Form 101) and detailed tray or resident card identification honored. *A food substitute for the food allergy, intolerance, or preference should be consistent with the usual or ordinary food item provided by the community. The provider implemented the above actions to ensure the deficient practice does not recur was confirmed after record review revealed the facility had followed their quality assurance process, education was provided to all staff regarding resident safety related to their process for accommodations of food allergies, and signs and symptoms of allergic reactions. Observation and interviews revealed staff understood the education provided. Based on the above information non-compliance at F806 occurred on 3/8/25, and based on the provider's implemented corrective actions for the deficient practice confirmed on 3/17/25, the non-compliance is considered past non-compliance.

51471 Based on observation, interview, and document review, the provider failed to ensure food items were appropriately labeled, stored, handled, prepared, and served to residents in a safe and sanitary manner in one of one kitchen and one of one dining rooms for the following: *One of one kitchen was not maintained in a safe and sanitary manner. *One of one commercial refrigerator contained beverage items that were not labeled, dated, or discarded by the use-by date. *Unsafe meat thawing practices. *Inappropriate glove use and hand hygiene by four of four observed dietary staff (dietary manager C, cook D, cook E, and dietary aide (DA) I) while preparing and serving residents' food. *Inappropriate glove use and hand hygiene by four of four observed staff (certified nursing assistant (CNA) K, CNA L, CNA N, and restorative aide (RA) J) while assisting residents in the dining room. Findings include: 1. Observation on [DATE] at 7:47 a.m. of CNA K and CNA N in the main dining room revealed: *CNA K and CNA N were seated at a table with four residents who had not yet been identified. *CNA K and CNA N were both wearing gloves and assisted the resident to their right and the resident to their left to eat breakfast. *CNA K and CNA N wore the same gloves throughout the observation and touched items on the table while they assisted residents with those same gloved hands. 2. Observation on [DATE] at 7:50 a.m. during the initial tour of the kitchen revealed: *An unidentified black substance between the caulking and the area above the sink next to the dishwasher. *An unidentified white and orange flaking substance along the edges of the dishwasher that appeared to be limescale. *An unidentified thick, black substance on the floor drain under the dishwasher and along the wall under the dishwasher. A visibly dirty plastic cup was between the dishwasher and the wall. *Cracked and missing floor tiles from the entrance of the food storeroom door that continued into the storage room and were uncleanable surfaces. *The frame of that door was rusted and uncleanable. *The floor under the commercial gas stove had a thick, brown, oily substance that extended behind the stove. *A metal container on the floor to the left of the stove caught grease as it dripped from the bottom of the stove. *A metal pan contained two sandwiches that had not been labeled or dated in refrigerator three *An unidentified black stringy substance hung from the front edge of the steam table. *An unidentified black and brown substance in the cut marks of the cutting board that was attached to the steam table. *Cook D, DA I, and DM C ate leftover breakfast food while standing in the kitchen where the food was pre-pared. *Cook D, DA I and DM C left the kitchen unattended with: -The serving utensils in the uncovered pans on the steam table. -Plastic containers of dry rice cereal and brown sugar were not labeled or dated and left uncovered at the steam table. -An unmarked container on the counter with a scoop in a yellow unidentified food that was partially covered. *The cabinet handles near the serving table that contained dishes used to serve the residents were dirty with a black, oily, and sticky substance. *A clear plastic hose from the overhead ventilations system was attached to the faucet of the handwashing sink. -The handwashing sink was also the eye wash sink. -There was an unidentified black and orange substance in the hose. -A clear liquid dripped into the sink. -There was a metal strainer in that sink that contained unidentified white flaky particles. *The Hydrion chemical sanitizer test strips used to test the sanitizer level in the sanitizer buckets and the dishwashing sink had an expiration date of [DATE]. 3. Interview on [DATE] at 8:15 a.m. with DM C and cook D revealed: *DM C confirmed that the expiration date on the sanitizer test strips was [DATE] and stated, We just opened them a month ago. -He was unaware that they had expired, and then stated, I will order more. *Cook D confirmed that the sanitizer buckets were filled that morning. -She then refilled the sanitizer bucket and used those test strips to test the sanitizer level -She stated the level of sanitizer was 200. 4. Observation on [DATE] at 8:20 a.m. of the residential style fridge with a top freezer revealed: *The bottom row of the refrigerator door contained: -An open jug of thickened cranberry juice labeled ,d+[DATE] with a black marker. -An open jug of thickened apple juice with a manufacturer use by date of [DATE] labeled ,d+[DATE] in black marker. -An open jug of thickened orange juice with a manufacturer use by date of [DATE] labeled ,d+[DATE] in black marker. -An open jug of thickened water labeled with two dates ,d+[DATE] and ,d+[DATE] in black marker. -An open jug of thickened apple juice labeled ,d+[DATE] in black marker. *The second to bottom row of the refrigerator door contained: -An open carton of thickened lemon water labeled ,d+[DATE] in black marker. -An open carton of thickened orange juice labeled ,d+[DATE] in black marker. *On the top shelf inside the refrigerator there were five pitchers of juice that were not labeled or dated. 5. Observation and interview on [DATE] at 8:30 a.m. with cook D revealed she: *Had been employed as a cook at the facility for eight years. *Confirmed the all in one sheet was where the daily food temperatures, the sanitizer levels, and the refrigerator and freezer temps were logged. -The log sheet for [DATE] was blank. There was no documentation to indicate that the food temperatures, the sanitizer levels, and the refrigerator and freezer temps had been checked. The log sheets are to be completed daily. *Had cooked breakfast that morning, *Stated she had checked the temperature of the food when the food came out of the oven and again when she had served the food. *When was asked where the food temperature checks for that day had been logged, she pointed to her head. 6. Observations on [DATE] at 11:27 a.m.to 11:54 a.m. in the dining room revealed: *The ice machine had an unidentified white flaky substance at the base of it along the edges of the metal stand of that machine. -There were two orange, circular, fuzzy areas on the grill of the overflow tray. -There was a significant buildup of an unidentified white flaking substance inside of the ice shoot *DA I lifted the drinking cups out of the ice tray and held those cups by the area where the resident placed their lips to drink from those cups. *DM C served a resident plate while wearing gloves, then with those gloved hands he: -Took a straw from the container and gave it to the resident. -Removed those gloves, and without performing hand hygiene (HH) he touched the cupboard door with his right hand and then left the room. -He returned to the dining room and touched the door with his right hand. His left hand was in his pants pocket. Without washing his hands, he put on a pair of gloves and delivered another plate to a resident. *RA J delivered a plate of food to a resident, then touched her pants, crossed her arms, and without performing HH delivered another meal. -Her apron was visibly soiled. *CNA L delivered a plate of food, crossed her arms, touched a chair, without performing HH she put on a pair of gloves and assisted resident 4 drinking from a cup. With those gloved hands she then assisted resident 19 by placing a sandwich into her hand. With those same gloved hands, she touched resident 19's wheelchair then removed the sandwich from resident 19's hand and placed it on her plate. 7. Observation and interview on [DATE] at 8:53 a.m. with DM C in the kitchen revealed: *The unidentified orange and white substance remained on the dishwasher. -DM C stated he cleaned the dishwasher a week ago. *A hole in the wall under the dishwasher sink exposed drywall and had unidentified brown dried substance on it. -DM C stated that he had been aware of that area and had notified the maintenance department. *The storage room floor was dirty, and a pile of trash and empty boxes sat on the floor. -DM C confirmed he was aware of the missing tiles on the floor near the exit door. *The wall and door frame in that storage room had paint peeling and were uncleanable surfaces. 8. Observation on [DATE] at 9:02 a.m. to 9:09 a.m. in the food storage room revealed: *Three plastic zip bags labeled Pretzels ,d+[DATE], Pretzels ,d+[DATE], and Vanilla Wafers ,d+[DATE]. *A plastic zip bag that was not labeled had pretzels in it and was dated ,d+[DATE]. *A plastic zip bag that appeared to have corn chips in it was dated ,d+[DATE]. *Two unidentified black splatter marks on the wall. *A plastic container with a red lid that appeared to have graham cracker crumbs in it that was not labeled or dated. 9. Observations on [DATE] between 10:53 a.m. and 11:25 a.m. in the kitchen revealed: *DA I filled two cups with thickened lemon water and apple juice from containers dated ,d+[DATE] with black marker. *Cook D moved the mashed potatoes, carrots, and meat directly from the oven to the steam table. -She cleaned the thermometer with an alcohol wipe between each food as she checked each food's temperature. *She stated the following food temperatures: -Mechanical meat 166 degrees Fahrenheit. -Puree meat 203 degrees Fahrenheit. -Puree carrots 186 degrees Fahrenheit. -Mashed potatoes 182 degrees Fahrenheit. -Fried potatoes 187 degrees Fahrenheit. -Sausage 205 degrees Fahrenheit. *Cook D wet her hands at the three-compartment dishwashing sink without using soap, then dried her hands on her apron, and then used the thermometer to check the temperature of the dessert. -Without performing HH, she placed the lids on the food items on the warm serving table, wiped her hands on her apron, scooped the dessert into small serving bowls, touched the inside of the bowls, and wiped her hands on her apron in between each serving. *At 11:06 a.m. cook D stated she had forgotten to log the food temperatures and filled out the temperature log. *Cook D placed a bag of rolls on the food prep counter, wet her hands at the three-compartment sink, wiped those hands on her apron, then placed the fruit into the puree mixer adjusting that fruit with her bare hand. *Cook D moved the refrigerated food items to the ice packs at the serving area. -The temperature of the refrigerated items was not checked prior to serving them. *Cook D placed a clean, wet dishcloth against her apron, folded it, and then set it on the edge of the cutting board on the warm serving table. *Cook D opened a bag of rolls for the sausages and without performing HH she put on a pair of gloves. With those gloved hands she: -Opened the cabinet and took out serving bowls, -Touched a resident's menu. -Took a plate from the warmer and with those gloved hands placed the roll on that plate. -Touched the utensil handles and placed a sausage in that roll. -Scooped potatoes on to that plate and with those gloved hands touched the potatoes and moved them away from the edge of the plate. -Took the next paper menu and continued to prepare several more plates with those gloved hands. *Cook D then removed those gloves, threw them in the trash can, stated My hands are sweaty, and without performing HH put on a new pair of gloves and continued to serve the remaining plates of food. 10. Interview on [DATE] at 5:08 p.m. with director of nursing (DON) B and registered nurse in-service director (RNID) M revealed: *DON B and RNID M provided education to the nursing staff on hand washing and glove use but did not provide that education to the kitchen staff. -The dietary manager or dietician would have provided education to the dietary staff. *DON B expected staff to wear gloves only when touching ready-to-eat foods such as a sandwich, but stated, They could cut the sandwich and feed it with a fork. *DON B and RNID M confirmed they expected staff to use hand sanitizer between assisting residents. *DON B stated They are allowed to feed 2 residents at once as long as they use the residents' utensils and don't touch their food. They should be using hand sanitizer if they touch other surfaces in the dining room. *RNID M confirmed that hand sanitizer and a hand-washing sink are available in the dining room. *DON B stated about the staff assisting residents in the dining room, They never usually wear gloves, and I don't know why they did while you were here. 11. Observation and interview on [DATE] at 9:16 a.m. with DM C in the kitchen revealed: *Thickened beverage containers should be labeled when they are opened with OP and a date and the date for three days later when to discard that container. *The container stated use in 7 days but it was his expectation that it be discarded in three days. *The thick black marker date was the date the item was received. *He confirmed that the following containers were expired and threw them in the trash. -An open jug of thickened apple juice with a manufacturer's use by date of [DATE] labeled ,d+[DATE]. -An open jug of thickened cranberry Juice labeled ,d+[DATE]. -An open jug of thickened orange juice with a manufacturer's use by date of [DATE] labeled ,d+[DATE]. -An open jug of thickened water labeled ,d+[DATE] and ,d+[DATE]. -An open jug of thickened apple juice labeled ,d+[DATE]. -An open carton of thickened orange juice labeled ,d+[DATE]. 12. Interview on [DATE] at 2:04 p.m. with DM C revealed: *He completed training with the dietary staff and re-educated them as needed. *He expected dietary staff to wash their hands and to wear gloves to cover cuts when preparing or serving food. *He expected dietary staff to use hand sanitizer in between serving resident meals. *He expected the food temperatures to be taken and recorded when it came out of the oven and again before it was served if it was over 45 minutes. *He expected tongs to be used when serving buns or ready-to-eat foods. -If gloves were used instead of tongs, then he expected no other food items or objects would be touched with those gloved hands. *He stated the main cleaning was scheduled to be done on the evening shifts. -He had trouble getting the staff to complete those tasks. -The dishwasher was delimed once a week. 13. Observation and interview on [DATE] at 2:58 p.m. with DM C and cook E during a return tour of the kitchen revealed: *Several small pieces of raw chicken in the wash compartment of the three-compartment dishwashing sink. -Cook E confirmed that she had thawed the chicken in a bin with running water because it was needed for dinner. *Cook E stated that she had thawed the chicken in the three-compartment sink because the two-compartment food preparation sink leaked. *The cabinet under the two-compartment sink contained wet towels, a plastic bin that contained individually wrapped filters, and an orange and brown unidentified substance coated all the items. *The floor under the commercial gas stove had not been cleaned. -There was grease dripping from the grease drawer and the left edge of the griddle. -The grease drawer was full of a partially congealed black substance. *DM C confirmed that the three burners with pilot lights lit on the right side of the stove, were the only ones that worked. *DM C confirmed that the clear hose attached to the sink faucet was from the air conditioning unit. -That was the only hand-washing sink in the kitchen. 14. Review of the provider's Kitchen Cleaning Schedule revealed: *Dispose of Out-of-Date products Daily. *Remember Your 'Opened-On Dates! *For the week of [DATE] all daily tasks were marked completed on Sunday through Thursday. -Daily tasks were not marked completed on Friday or Saturday. -Twice weekly tasks were all marked completed on Sunday and Thursday. *The cleaning schedules for [DATE] through [DATE] both had several tasks not marked as completed. Review of the provider's undated Handwashing and Glove Use Policy revealed: *Hands must be washed prior to beginning work .and following contact with any unsanitary surfaces i.e. touching hair, sneezing, opening doors, etc. *Washing procedure .Wet hands. Apply soap. Lather, vigorously rubbing hands together for 20 seconds. Rince hands to remove soap and debris. Dry hands with a disposable paper towel. Discard paper towel(s) into a waste container without touching the container, *Gloves must be worn when touching any ready-to-eat food. *When gloves are used, handwashing must occur per above procedure prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed, see above. Gloves may be used for one task only. *It is important to remember that gloves can often give a false sense of security and can carry germs the same as our hands. Review of the provider's undated Food Storage Policy revealed: *Food items should be stored, thawed, and prepared in accordance with good sanitary practice. *Any expired or outdated food products should be discarded. *Frozen Meat/Poultry and Foods: Thaw foods at 41 [degrees Fahrenheit] or less or in refrigerator. Thawing foods under cold running water is no longer recommended due to strict guidelines set forth by the 2013 Food Code. Review of the provider's undated Dish machine policy revealed: *After each meal, clean machine according to cleaning procedure. *Frequency: After each meal Wipe exterior of machine and soap dispenser. Dry and Polish with cloth. *Frequency: Weekly .Clean dish machine exterior with deliming solution. Review of the provider's undated Cleaning Schedules Policy revealed: *The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professionals. -2. A cleaning schedule shall be posted with tasks designated to specific positions in the department. -6. On the Position cleaning schedules the Director of Food and Nutrition Services or other clinically qualified nutrition professional fills in the Position, the item to be cleaned, Frequency I.e. daily, day of the week, or week 1,2,3,4. Review of the Dining Services Guideline revealed: *Person serving the food follows meal ticket, noting the diet order, allergies, likes/dislikes, religious or cultural notes. -Assisted, Cued, Restorative Resident's list is in the kitchen. This is for each meal. a. when assisting residents, you are not getting up to get other residents items. b. Sit at eye level to assist. c. You can assist and cue at the same time. d. Alternate food and fluids. e. Ensure the resident is sitting upright in chair. Please review Signs and Symptoms of Dysphagia starting on page two.

Based on observation, interview, and policy review, the provider failed to maintain a clean and homelike environment for 5 of 49 sampled residents (6, 7, 13, 16, and 19) and for the residents who ate their meals in the main dining room. Findings include: 1. Observation on 12/3/24 at 9:00 a.m. in the bathroom shared by residents 16 and 19 revealed: *The floor at the base of the toilet was wet. -There were areas of an unidentified black substance. -The caulking at the base of the toilet was peeling and missing in several areas. 2. Observation on 12/3/24 at 9:29 a.m. in resident 17's room revealed: *The faucet on the sink in that room had a white and green, thick, unidentified build-up, and areas of the faucet were missing. -This was not a cleanable surface. -The handle spun around in a circle and the surveyor was unable to get hot water at that sink. 3. Observation on 12/3/24 at 9:25 a.m. revealed a wall-mounted hand sanitizer outside of residents 16 and 19's room that did not dispense hand sanitizer and flopped forward when the lever was depressed. 4. Observation on 12/4/24 at 8:30 a.m. in residents 6 and 13's room revealed: *The wood cabinet below the sink was scratched, scuffed, and lacked varnish. It was not a cleanable surface. *The area behind the toilet had flaking paint and an area where the drywall was exposed. *The bathroom door had a plastic protector with pieces missing that exposed rough edges and bare wood. *The cover to the heater in the bathroom was leaning against the door frame and the heating element was exposed. 5. Observation on 12/4/24 at 8:12 a.m. in the dining room revealed: *A 10 to 12-inch long gouge to the back wall located to the right of the door, next to the heater that had exposed drywall. *The heater under the windows was visibly dirty and had rusted areas on the front and along the top vents. *The area behind the hand wash sink had exposed drywall, unidentified food substances, and bubbling paint. *The door to the kitchen located in the dining room labeled Authorized Personnel Only was worn and delaminated in several areas exposing the wood. 6. Observation on 12/4/24 at 8:15 a.m. revealed the North Nurses station door near the entrance of the building was worn and delaminated around the handle and was not a cleanable surface. 7. Interview on 12/5/24 at 3:29 p.m. with maintenance director G revealed: *The facility used an online work order system for maintenance issues to be reported. *Many small issues were reported to him in person. *He expected staff to report any issues that needed to be repaired urgently directly to him and to log issues that could wait to be repaired in the online system. -He did not log the repairs he made that had been reported directly to him. *He confirmed that the handle of the faucet in room [ROOM NUMBER] spun all the way around. -He became aware that the faucet needed to be replaced and ordered a new one when the life safety surveyor had pointed it out to him. -He stated he had found a position on that faucet where it provided hot water. *He was aware that several of the doors throughout the facility had areas where the wood was exposed. Review of the Maintenance Work Orders Log revealed: *The log contained closed work orders from 1/1/24 through 12/4/24. *The log did not contain any open or unaddressed work orders. *There were no work orders for the above observations. Review of the provider's revised 8/16/24 Maintenance policy revealed: *It is the facility's policy to maintain equipment and the building environment. *Any staff who is made aware of malfunctioning equipment or any part of the building that is in disrepair will report the issue to the maintenance department. *The maintenance department will address the issue as soon as possible. *Any equipment that can not be fixed will be replaced accordingly. Review of the provider's reviewed 9/30/24 Homelike Environment policy revealed: *Residents are provided with a safe, clean, comfortable and homelike environment . *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: cleanliness and order; Walls and door scuffs/chips repaired with paint/stain when needed. *The facility will have a mechanism for reporting disrepair to Maintenance personnel and staff will be educated on the process.

Based on observation, interview, and policy review, the provider failed to ensure that essential dietary department kitchen equipment was in safe working condition including: *Five of the eight stove-top burners on the commercial gas stove that did not ignite. *Two of the two ovens in the commercial gas stove that were not in working condition. *One of one flattop grill that leaked oil down the side of the equipment and onto the floor beneath. *The two-compartment food preparation sink leaked and was not used to prepare food. *The air conditioning unit in the kitchen ceiling had condensation tubing attached to the faucet and drained into the handwashing sink. Findings include: 1. Observation on 12/3/24 at 7:50 a.m. during the initial tour of the kitchen revealed: *The floor under the commercial gas stove and flattop grill had a thick brown oily substance on the left side that extended behind the stove. A large can containing grease was on the floor to the left of the stove and appeared to be catching grease as it dripped from the flattop grill and the bottom of the stove. *A clear plastic hose was attached to the faucet of the hand washing and eye wash sink. -It dripped liquid that appeared to be water into that sink. -It was attached to the overhead ventilation system. -The hose contained an unidentified orange and black substance. -A metal strainer in that sink contained unidentified white flaky particles. -The base of the faucet of that sink contained an unidentified black substance. 2. Observation and interview on 12/5/24 at 2:58 p.m. with dietary manager (DM) C and cook E during a return tour of the kitchen revealed: *Several small pieces of raw chicken in the wash compartment of the three-compartment dishwashing sink. *Cook E stated that she had thawed the chicken in the three-compartment sink because the two-compartment food preparation sink leaked. *The cabinet under the two-compartment sink contained wet towels, a plastic bin that contained individually wrapped filters, and an orange and brown unidentified substance coated all the items. *The floor under the commercial gas stove had not been cleaned. -There was grease dripping from the grease drawer. -DM C suspected that grease was dripping from the flattop grill due to potentially faulty [NAME] along the edges. *DM C confirmed that the three burners with pilot lights lit, on the right side of the stove, were the only ones that worked. *DM C stated that the lower two ovens in that commercial gas stove were not operational. *DM C confirmed that the clear hose attached to the sink faucet was from the air conditioning unit. -That was the only hand-washing sink in the kitchen. 3. Interview on 12/5/24 at 3:29 p.m. with maintenance director G revealed: *He was not aware that the burners or the oven of the commercial gas stove did not work. *He was not aware that the food preparation sink was leaking. *He expected that staff would have entered a work order if something was broken. 4. Review of the Maintenance Work Orders Log revealed: *The log contained closed work orders from 1/1/24 through 12/4/24. *Work order number 2216 sink at prep table is leaking, was assigned a medium priority in the kitchen. -There was no date associated with that work order. *Work order number 2222 leak, was assigned a medium priority in the kitchen. -There was no date associated with that work order. Review of the provider's revised 8/16/24 Maintenance policy revealed: *It is the facility's policy to maintain equipment and the building environment. *Any staff who is made aware of [a] malfunctioning equipment or any part of the building that is in disrepair will report the issue to the maintenance department. *The maintenance department will address the issue as soon as possible. *Any equipment that can not be fixed will be replaced accordingly.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *The foam filter was replaced on one of one sampled resident's (34) oxygen concentrator machine. *One of one sampled resident (34) had current physician's orders to receive oxygen therapy. *Facility policy had been followed regarding documenting oxygen tubing and foam filter replacement in one of one sampled resident's (34) electronic medical record (EMR). Findings include: 1. Observation and interview on 12/3/24 at 3:11 p.m. with resident 34 in her room revealed: *She was receiving oxygen through a nasal cannula (flexible tubing with prongs to deliver oxygen through the nose). *There was no foam filter on the back of the oxygen concentrator machine. *She said the staff gave her new oxygen tubing that morning. *The oxygen concentrator machine was delivering oxygen at a rate of 3L (liters per minute). 2. Review of resident 34's EMR revealed: *There was no current physician's order for supplemental oxygen. *Three of her recent Minimum Data Set (MDS) assessments indicated she was receiving oxygen therapy. -Quarterly MDS dated [DATE]. -Significant change MDS dated [DATE]. -Quarterly MDS dated [DATE]. *Her physician had assessed her on 11/27/24 and noted in the vitals section of the assessment that the resident was receiving oxygen through a nasal cannula at 2.5L. -She was observed receiving oxygen through a nasal cannula at 3L on 12/3/24 at 3:11 p.m. *There was no documentation indicating when the oxygen tubing was last changed, or when the foam filter was last cleaned and replaced. *She had a physician's order for supplemental oxygen at 2L from April 2024 to at least May 2024. *There was a physician's note from 7/29/24 that mentioned, questioning if O2 [oxygen] is new . 3. Interview on 12/5/24 at 9:25 a.m. with registered nurse (RN) O about resident oxygen use revealed: *She was not aware that there was no foam filter on resident 34's oxygen concentrator machine. *The facility's normal practice was to change the oxygen tubing and clean the concentrator's foam filter weekly. *The staff in charge of changing the tubing were to mark that task as completed in the resident's treatment administration record (TAR). *Regarding resident 34, she confirmed: -There were no physician's orders for oxygen use. -The resident's care plan did not include oxygen use. *She indicated that the orders might have fallen off with the resident's recent trips to the emergency department. 4. Interview on 12/5/24 at 4:25 p.m. with director of nursing B and MDS coordinator P revealed: *Resident 34 had been receiving supplemental oxygen for a while. *They confirmed there was no current physician's order for oxygen therapy in the resident's orders list. *They were not aware that the foam filter was missing and indicated it should have been replaced at the same time the oxygen tubing was replaced. *They both indicated that resident 34's oxygen therapy orders may have fallen off one of the times she went to the emergency department and back. *DON B indicated the oxygen therapy should have been included on the resident's physician orders list. 5. Review of the provider's 11/19/24 Oxygen Administration policy revealed: *Procedures: -1. Verify that there is a physician's order for oxygen that includes route (via mask or nasal cannula), liter flow, and duration (i.e., continuous, prn, at night, etc.) -2. Review the resident's care plan to assess for any special needs of the resident. *General Guidelines -1. Oxygen therapy is administered by way of an oxygen mask or nasal cannula. -- .b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. The nasal cannula and tubing will be changed weekly and as needed. Change of tubing and cannula would be documented in the medical record. - .2. Oxygen concentrators will have exterior wiped down when soiled and at least weekly. If equipped with a filter, filter will be cleaned at least weekly by rinsing with water and allowing to dry. If filter becomes torn, filter should be replaced. Weekly cleaning of the concentrator and filter should be documented in the medical record.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, and interview the provider failed to ensure the safety for one of one sampled resident (1) who staff let out of the building in the early morning hours. Resident left the grounds and his wheelchair got stuck on the railroad tracks, and was unable to get himself free. The county sheriff found him and called the provider to let them know that he was gone. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include: 1.Review of provider's 8/23/24 SD DOH FRI for resident 1 revealed: *His Brief Interview for Mental Status (BIMS) score was 9 (meaning moderate cognitive impairment). *On 8/23/24 at 3:37 a.m. the resident was assisted out the front door by registered nurse (RN) H. *RN H had not told other staff that he was outside. *RN H got busy and forgot the resident was outside. *RN H received a call from the county sheriff at 5:11 a.m. asking if resident 1 was a resident of the facility. *The resident was observed by the sheriff on the railroad tracks which was approximately three blocks from the building. *His diagnoses include: -Cerebral infarction (stroke). -Arthritis. -Hemiplegia (paralysis) right side. -Aphasia (affects communication). *He was upset and wanted to go outside when he was awakened by staff when they assisted his roommate. *Administrator A was notified and drove the facility van to collect him. -They returned to the facility at 5:44 a.m. -He had been outside alone for over two hours and stuck on the railroad tracks when discovered. *Full skin assessment and vitals signs were obtained upon return. *No marks, bruises, or injuries had been noted. *The primary care provider was notified. -An order for Wanderguard (wearable alerting device) was given and placed on resident's wheelchair. *The sister was notified of the incident and the interventions that had been put in place for his safety. *Interventions included: -Resident 1 added to elopement binder. -A Wanderguard was placed on his wheelchair. -He was moved to a private room. -He was to be supervised at all times while outside by the care staff. -His care plan was updated with new interventions. -Provider reviewed all the residents with BIMS scores less than 11 for appropriate interventions. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 8/28/24 after record review revealed: *The facility had followed their quality assurance process, and education was provided to all nursing care staff. -The nursing staff had been educated on their abuse and neglect policy. -No resident should have been outside after dark. *New interventions for resident 1 included: -He must be supervised at all times while outside. -A Wanderguard was placed on his wheelchair. *Corrective actions for the nurse had included: -Education on their abuse and neglect policy. -Preventing and responding to abuse. -Preventing, recognizing, and reporting abuse. -Understanding of wandering and elopement. -Review of the RN job description. *Observations and staff interviews revealed the staff understood the education that had been provided and the revised processes. Based on the above information, non-compliance at F600 occurred on 8/23/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 8/28/24, 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 safety for one of one sampled resident (2) identified at risk for elopement, had eloped (left the facility without staff knowledge) and was outside the building approximately 2 hours and 4 minutes when an activity door was left unalarmed. Failure of staff to ensure the door alarm was rearmed resulted in the resident's elopement and put him at risk for physical injury or serious harm. Specifically, the provider failed to monitor/revise interventions after elopement to ensure resident safety. Findings include: 1. Review of the SD DOH FRI revealed: *On 7/23/24 at 4:41 a.m. resident 2 walked out of facility and the doors alarmed. *Staff assisted resident back inside and put him to bed. *At 4:44 a.m. registered nurse (RN) C deactivated the door alarm and never reactivated it. *Resident C left facility again at 4:59 a.m. *Licensed practical nurse (LPN) E saw resident sitting on the lawn at 6:55 a.m. and staff assisted him inside. 2. Record review of resident 2's orders, care plan, and progress notes revealed: *His physician orders for a Wanderguard included: -On 11/6/23 an order for a Wanderguard to be placed on his right wrist and ankle. -On 6/18/24 a discontinued order for the Wanderguard to his right wrist and ankle. -On 7/23/24 an order for a Wanderguard to be placed on his right wrist. Check for placement and to see if working correctly every shift. Machine to check working condition is in North med cart. *The resident's care plan included: -I am elopement risk/wanderer as evidenced by leaving facility unattended, impaired safety awareness. Date Initiated: 03/04/2024. *A progress note on 7/16/24 at 5:45 p.m. stated resident was seen walking out of the facility and staff had assisted him back inside. *A progress note on 8/12/24 at 9:40 p.m. was written by medication aide G about residents Wandergaurd stated, resident removed???? 3. Observation and interview on 8/27/24 at 11:44 a.m. of resident 2 in his room revealed: *He was laying in bed with only a brief on. *He was not wearing a Wanderguard. *He was pleasant, smiling, and stated he did not remember anything about his elopement and did not have feelings of wanting to leave. 4. Observation and interview on 8/27/24 at 12:00 p.m. with administrator A about wanderguard placement on resident 2 revealed: *She stated resident 2 should have a Wanderguard on his wrist or ankle. *When asked to verify if a Wanderguard was on, she went to residents' room and confirmed there was no Wandergaurd on the resident. 5. Interview and review of resident 2's electronic medicat record (EMR) on 8/27/24 at 12:05 p.m. with administrator A and director of nursing (DON) B revealed: *They confirmed resident 2's EMR should have a Wanderguard on his right wrist and it should have been checked every shift per physician order. *They were unable to verify when the resident last had a Wanderguard on due to the lack of documentation by the staff. 6. Interview on 8/28/24 at 8:15 a.m. with DON B revealed: *She was not aware that the resident had taken off the Wanderguard before. *The previous Wanderguard was discontinued because they didn't think he needed it anymore based on resident not exit seeking and elopement risk assessements were categorized as low risk. *The Wanderguards only work on the central door. *The other 11 doors at the facility do not have the Wanderguard alarm system attached to them. *She does not believe having a Wanderguard in place would have prevented the incident because the activity door the resident went out of did not have the Wanderguard alarm system. *She stated if the staff had reactivated the central alarms, then the elopement could have been prevented. 7. Interview on 8/28/24 at 8:50 a.m. with administrator A revealed: *She confirmed only the central door has the Wanderguard alarm system. *She had spoken to corporate about getting the Wandergaurd alarm system for all the doors. *She would have expected the staff to inform her when a resident was able to take the Wanderguard off because it was an important safety mechanism for residents who elope. 8. Review of providers 11/7/2023 Wanderguards/Door Signaling Devices policy revealed: *A Wanderguard or other door signaling systems uses a bracelet token that will secure the door should a resident who wears such a device come near a door or tries to egress the door. *Procedure: -6. Placement verification and testing of each Wanderguard or signaling device will be completed daily and recorded on the Mar or TAR. -7. Maintenance of the door alarm system throughout the facility will be conducted by the Maintenance Department per user manual instructions. Door function will be checked daily.

Based on observation, interview, record review, and policy review, the provider failed to ensure wound care treatments were completed per physician orders and documented for one of one resident (2). Findings include: 1. Observation and interview on 7/16/24 at 1:58 p.m. with resident 2 and licensed practical nurse (LPN) D revealed: *He was seated in his recliner with the footrest in the up position. *There was a wound dressing on his left foot. *LPN D removed the wound dressing and stated it was a vascular wound. *Resident 2 stated he had a scheduled appointment the next day with a vascular surgeon for possible amputation of his left foot. *Resident 2 stated that a nurse who worked the night shift had not completed his dressings a couple of times. Review of resident 2's medical record revealed: *He was admitted on [DATE]. *His diagnoses included: peripheral vascular disease, vitamin D deficiency (Vitamin D deficiency can lead to delayed or chronic wounds), major depressive disorder, low back pain, varicose veins bilateral lower extremities with other complications, morbid obesity, edema, heart disease, toes of left foot surgically removed, and bacterial infection. Review of resident 2's Treatment Administration Record (TAR) revealed: *A 6/18/24 physician ordered treatment for a wound on his left foot was to be completed two times each day. -On 6/24/24 there was no documentation to support that treatment had been completed on the second shift. -On 6/25/24 that treatment had been discontinued. *On 6/27/24 a physician ordered treatment indicated that a wound dressing was to be completed twice each day. every day and night shift for wound care. -On 7/13/24 there was no documentation to support that treatment had been completed on the first shift. Interview on 7/16/24 at 3:30 p.m. with director of nursing (DON) B regarding resident 2's treatment dressing changes not being documented as completed revealed: *She stated the lack of documentation meant either it was done and not signed, or not done and not signed. Interview on 7/17/24 at 8:19 a.m. with DON B regarding resident 2 revealed: *The provider had determined, through reviewing of their hallway camera-taped recordings that resident 2 had his wound treatment completed on 6/24/24. *On 7/6/24 he had refused to have his wound dressing changed. *On 7/7/24 he had wanted to wait until a later time to have the dressing changed and he refused RN F's care of his foot. *On 7/13/24 on the first (day) shift the nurse did not have time to complete the dressing change. -That nurse had notified the oncoming nurse that she had not had time to complete the dressing change. --There was no documentation to support that notification had occurred. *When a wound dressing change was not able to be completed, the physician should have been notified. -There was no documentation to support that his physician had been notified. Interview on 7/17/24 at 11:34 a.m. with certified nursing assistant (CNA) E regarding resident 2 revealed: *He did not refuse care. *He only called for assistance when he was in the bathroom. *When a resident refused care, CNA E would have notified the nurse. Interview on 7/17/24 at 11:04 with CNA C at 11:04 a.m. regarding resident care revealed: *When a resident refused care she would document that in their medical record and report it to the nurse on duty. *She was not familiar with the care resident 2 required. Interview on 7/17/24 at 11:15 a.m. with LPN D regarding resident 2 revealed: *He had not refused care provided by her. -She was aware that he had refused a nurse's care during the night shift. -He preferred to request cares when he needed or wanted them. *The process for when a nurse was unable to complete a treatment during their shift was to: -Communicate that to the next shift so they would attempt to complete the treatment. -Document that the treatment was not completed and notify the resident's physician of the missed treatment. *The medication administration record (MAR) and the treatment administration record (TAR) had an area to document when a resident refused the medication or treatment, which included why that resident had refused. Review of the provider's 12/1/19 RN Floor Nurse Job Description revealed: *Administer or supervise all treatments prescribed by physicians including but not limited to pressure ulcer care, Foley catheter care, hot and cold compounds and intravenous therapy. *Provide wound care when needed. *Completes medical records documenting care provided and other information in accordance with nursing policies while maintaining strict confidentiality. *Ensure each Guest receives person centered care. Review of the provider's 12/1/19 LPN Floor Nurse Job Description revealed: *Administer or supervise all treatments prescribed by physicians including but not limited to pressure ulcer care, Foley catheter care, and hot and cold compounds. *Provide wound care when needed. *Completes medical records documenting care provided and other information in accordance with nursing policies while maintaining strict confidentiality. *Ensure each Guest receives person centered care.

Based on observation, interview, record review, email communication review, and policy review, the provider failed to ensure: *A functional whirlpool tub was available to all residents who preferred a tub bath. *Scheduled showers were offered and given to 16 of 40 sampled residents (3, 5, 6, 10, 12, 15, 17, 20, 23, 24, 25, 30, 32, 33, 38, and 40). Findings include: 1. Observation on 8/29/23 at 9:35 a.m. of the resident's shower room revealed: *A wheeled high-back chair was sitting against a wall and a handheld shower-head with a long hose was connected to the wall. -Bottles of shampoo, conditioner, and body wash were on top of the half-wall located next to the chair. *A whirlpool tub was in the corner covered with plastic. *There were no other whirlpool tub visible in the shower room. 2. Interview on 8/29/23 at 2:32 p.m. with maintenance director C regarding the non-functional whirlpool tub revealed: *They had a whirlpool tub, but it leaked, had draining and electrical issues. -He was not aware the last time it had been used. -They removed it from service two to three months ago. *The plastic-covered whirlpool tub was from another facility that they had received in July 2022. *He had not been able to get the whirlpool tub working for the residents due to having to have a new electrical outlet put in. *He had been calling the local electrician since October 2022 to have them come to the facility to work on the whirlpool tub. -The last time he talked to the local electrician was two months ago when they were at the facility fixing another electrical issue. --The local electrician stated he would have to set a time but has not gotten back to him. 3. Observations and interviews on 8/29/23 between 9:37 a.m. and 3:29 p.m. revealed: *At 9:37 a.m. resident 6 was observed resting in bed with her eyes closed; her hair appeared greasy and unkempt. *At 9:51 a.m. during interview with resident 33 she shared, at times it has been three weeks between her showers. She would have preferred a shower once a week. *At 10:10 a.m. resident 30 was observed laying in bed watching TV; his hair appeared greasy and unkempt and there was an odor of urine present. -When asked, he was unable to recall his last shower. The staff were unable to offer a bath because the whirlpool tub was not working. *At 10:22 a.m. during interview with resident 25 he shared, he had been admitted [DATE], and it was over two weeks before he had received a shower after admission to the facility. He had never been offered a bath because the whirlpool tub was broken. There was a bathing schedule but had felt it was not followed. *At 10:57 a.m. during interview with resident 12 he shared; he was to have been given a shower every Friday. While sometimes he does refuse, he was not always asked if he would like a shower every Friday. *At 11:12 a.m. during interview with resident 40 he shared, it had been over a week since he had his last shower and had never refused a shower. *At 11:13 a.m. resident 3's husband was present when she was observed. She was sleeping in her recliner; her hair appeared greasy and unkempt. -When asked, he stated her last shower was a week ago. There was no functioning whirlpool tub to offer a resident a bath. *At 1:23 p.m. resident 23 was observed her hair appeared greasy and unkempt and there was body odor present. -When asked she reported the staff were behind a few weeks giving resident showers. While there was documentation that she had been given a shower she stated she had not received a shower. *At 1:30 p.m. resident 10 was observed resting in bed with his eyes closed; his hair appeared greasy and unkempt. *At 2:18 p.m. resident 32 was observed; his hair appeared greasy and unkempt. *At 2:23 p.m. resident 15 was observed with greasy and unkempt hair. -When asked he reported it had been over a week since his last shower and he had never refused a shower. *At 2:45 p.m. resident 17 was observed with greasy and unkempt hair. *At 2:50 p.m. resident 24 was observed sitting on his bed; his hair appeared greasy and unkempt with body odor present. -He stated he was ton have a shower every two weeks and had never refused a shower. *At 2:56 p.m. resident 20 was observed his hair appeared greasy and unkempt; he was unshaven and there was body odor present. His eyeglasses were not clean. -When asked, he could not recall the last shower he had. *At 3:21 p.m. resident 5 was observed resting in bed; his hair appeared greasy and unkempt. -When asked, he had only been offered a shower and not a whirlpool tub bath due to no operational whirlpool tub for months. *At 3:29 p.m. resident 38 was observed with greasy and unkempt hair. -When asked, he stated it had been a week and a half since his last shower and he had never refused a shower. 4. Interview on 8/30/23 at 2:28 p.m. with regional director D regarding whirlpool tub revealed he: *Had known that the maintenance director C had been attempting to get the local electrician to the facility. *Had been calling electricians outside the local area to have them come to the facility to work on the whirlpool tub but they have all declined. -Had last called an electrician two and a half months ago. Interview on 8/31/23 at 10:54 a.m. with administrator A and director of nursing (DON) B regarding the non-functional whirlpool tub revealed they: *Stated there has not been a working whirlpool tub since they had received the whirlpool tub from the other facility in July 2022. -Stated the whirlpool tub they had was leaking and had electrical issues. *Had known it was an issue getting an electrician into the facility to work on the whirlpool tub. -Had known regional director D was assisting maintenance director C with trying to find an electrician. *Were not aware that some of the residents would have preferred a whirlpool tub bath. Interview on 8/31/23 at 10:58 a.m. with DON B revealed she: *Stated the not offering of the shower could have been that the staff had not documented that the showers were done or if the residents had been out of the facility on the scheduled day of their shower. *Stated staff were to offer a bed bath if the resident refused a shower or offer a different day to take a shower when a resident refused. *Had a bath aide but that the bath aide gets pulled to the floor often and the floor staff were then responsible for getting the resident's showers done for that day. -Had been attempting to get the floor staff to work together to complete the resident's showers for that day. *Stated it could have been the approach of the staff to the residents that caused the refusals but that had not been addressed with the staff. 5. Review of email communications from infection control nurse E to DON B and administrator A during period from 6/12/23 through 8/22/23 revealed the content reflected approximate one week of data in each email of resident shower refusals and those residents that had not been offered a shower . *On 6/12/23 at 10:15 p.m. email reflected 5 refusals and 5 not offered. *On 6/20/23 at 4:17 p.m. email reflected 6 refusals and 3 not offered. *On 6/26/23 at 10:22 a.m. email reflected 11 refusals and 4 not offered. *On 7/3/23 at 9:42 a.m. email reflected 3 refusals and 1 not offered. *On 7/10/23 at 10:36 a.m. email reflected 8 refusals and 1 not offered. *On 7/17/23 at 2:10 p.m. email reflected 4 refusals. *On 7/24/23 at 11:16 a.m. email reflected 5 refusals and 1 not offered. *On 8/2/23 at 9:56 p.m. email reflected 1 refusal and 1 not offered. *On 8/8/23 at 2:19 p.m. email reflected 2 refusals and 10 not offered. *On 8/14/23 at 3:06 p.m. email reflected 4 refusals and 10 not offered. *On 8/22/23 at 2:04 p.m. email reflected 13 refusals and 4 not offered. 6. Review of the provider's September 2019 bathing policy revealed: *Policy -The resident has the right to choose timing and frequency of bathing activity. Bathing preferences are asked upon admission and during quarterly care conference.

Based on observation, interview and a cleaning checklist for housekeepers the provided failed to ensure a clean and homelike environment that included the following: *A handwashing sink in the dining room that had noticeable water damage and one of the doors were hanging off the hinge. *A cracked half-wall located in the resident's shower room. *A resident's door opening only halfway and leaving grooves in the floor. *Paint on a heating unit in a resident's room is peeling away. *A wall heating unit in the dining room was that pulling away from the wall. *Spider webs around a non-exit door. *Multiple non-used screws in the wall. *Wallpaper in multiple places throughout the facility was bubbling and peeling away from the wall. 1. Observation on 8/29/23 8:32 a.m. in the main dining room revealed: *A handwashing sink was located next to the entrance to the kitchen. -It had noticeable water damage located at the bottom front and side. -The right-side door had fallen off the hinge and was hanging down. Observation on 8/29/23 at 9:00 a.m. in the resident's shower room revealed: *A wheeled high-back chair was sitting against the wall that had a handheld shower-head and a long hose connected to the wall. *A cracked half-wall that contained bottles of shampoo, conditioner, and body lotion were sitting on top of it. -The crack started at the top of the half wall and went down the outside approximately three feet and inside less than a foot. Observation and interview on 8/29/23 at 9:48 a.m. in resident 35's room revealed: *The door was opened halfway. *She was sitting in her chair and waved at me to come in. -When attempting to open the door, the door was stuck and there were visible grooves in the floor. *She could not remember how long the door has been difficult to open. Observation on 8/29/23 at 1:58 p.m. in resident 2's room revealed: *The light-colored bathroom heater unit had multiple spots with the paint peeling away, leaving dark brown spots in those areas. Interview on 8/31/23 at 10:03 a.m. with maintenance director C revealed he: *Stated the sink in the dining room had a water leak and they have a different one on order that will match the rest of the countertops in the dining room *Agreed the half-wall in the resident's shower room was a safety and sanitary issue for the residents. *Stated he has had to file down two other doors that were getting stuck and leaving grooves in the resident's floors. *Agreed the residents heater unit needed to have been repaired or replaced. *Stated the staff were to use the electronic TELS system to put in work orders for identified issues. Interview on 8/31/23 at 10:54 a.m. with administrator A and DON B revealed they: *Stated the sink in the dining room was brand new, a pipe leaked and ruined the bottom part of it and they were getting a new one to match the rest of the countertops and cabinets. *Stated the humidity has been the issue with the resident's doors getting stuck and hard to open. -Stated maintenance director C could have sanded down the door for more ease to open and close it. *Stated they have had contractors come and complete a walk through of all the resident's rooms. -Have been talking to a local painter to come in and paint the resident's rooms. *Agreed the crack in the half-wall in the resident's shower room needed to have been fixed. 45901 2. Observation from 8/28/23 to 8/30/23 of non-exit door number 8 revealed: *There were thick spider webs around the door, around the frame and the doorway. Interview on 8/30/23 at 3:30 with housekeeper G, and administrator A revealed: *The door-way was not used but should have been cleaned daily. *Agreed that it had not been cleaned for some time. Review of the undated Next Level Hospitality Services Detailed Cleaning Check Off List revealed: *6 Sanitized all doors and door frames. 3. Observation on 8/31/23 at 8:30 of the north, south and west hallways revealed: *Fourteen areas where unused screws were left in the walls. *Fourteen areas where wallpaper was separating, bubbling and peeling from the wall. 4. Observation on 8/31/23 at 10:30 a.m. in dining room revealed: *On the north wall of the dining room, the heating register was separated from the wall and exposing a crack where the sheet rock ends and the register hangs down. 5. Interview on 8/31/23 with maintenance director C revealed he: *Never noticed all the screws in the hallways and agreed they should have been removed. *Agreed that the wallpaper needed to have been removed and the walls needed to have been painted. *Agreed the register in the dining room could have been a hazard to the resident's and should have been fixed. Interview on 8/31/23 at 11:00 with administrator A and DON B revealed: *Maintenance director C showed them the wallpaper and screws before the interview. *They are waiting on a bid from a construction company to have the wallpaper removed and then paint the walls. *Agreed the heating register in dining room needed to have been fixed on the north wall of the dining room.

Based on observation, interview, record review, and policy review, the provider failed to ensure all areas of the building were maintained in a clean, clutter-free, fresh smelling, and homelike manner for: *Seven of 17 sampled residents (6, 11, 14, 26, 33, 34, and 39) rooms had urine odors and were cluttered. *Five of five hallways (100, 200, 300, and 400) including residents' room doors, hand rails, and public areas had areas which had a strong urine odor and the finish was missing making them uncleanable. Findings include: 1. Observation on 9/7/22 at 7:45 a.m. when entering the facility revealed: *A strong odor of urine. *The armchair in the corner of the entrance sitting room had visible stains on the backrest where a person's head would rest and on each armrest where a person's arms and hands would rest. -The odor of urine grew stronger when standing closer to the furniture. 2. Observation on 9/7/22 from 8:00 a.m. through 11:30 a.m. revealed: *The hallway floors were very sticky and dull looking. *The surfaces of the hall room doors and bathroom doors on the 100, 200, 300, and 400 halls had different sized areas where the finish had worn off. This revealed the bare wood and made those areas uncleanable. *The hand rails throughout the building had areas where the finish had worn off. This revealed the bare wood and made those areas uncleanable. 3. Observation on 9/7/22 at 8:37 a.m. of resident 33 revealed the guard that covered the heating coils was broken. Those coils were sharp and could have caused injury to a resident. 4. Observation and use of senses on 9/7/22 at 11:24 a.m. in resident 34's room revealed: *There was a strong odor of urine. *A used plastic urinal was on the floor. *The floors were sticky. 5. Observation on 9/7/22 at 11:45 a.m. in resident 26's room revealed: *There was a strong smell of urine. *The floors were sticky. 6. Interview and observation on 9/7/22 at 1:06 p.m. with resident 39 revealed: *He wanted to share an issue he had about a hole he had in his bathroom wall. *After being invited into his room this surveyor observed a soccer ball sized hole in the wall of his bathroom. *He had shared the problem with maintenance director C a month ago. *Maintenance director C informed resident 39 he was trying to gather supplies but the price of lumber was too high to repair it at this time. Interview on 9/8/22 at 3:00 p.m. with maintenance director C revealed he: *Had just transferred to the maintenance department from dietary a couple of weeks earlier. *Was aware of the hole in resident 39's bathroom wall. *Did not have experience with sheet rock repair. *Was gathering supplies to fix the hole. *Was waiting on a piece of wood to start the project. 7. Observation and interview on 9/7/22 at 2:30 p.m. with resident 11 revealed: *Her room had a moderate smell of urine. *The tile floors appeared to have stains in front of the sink and along the wall by the door. *There were four 12 packs of pop on the floor. *There was an overbed table that had clean linens on it. *She stated there was no place to put all her things. 8. Observation and touch on 9/7/22 at 3:10 p.m. revealed: *Forty-six wood doors had areas of missing finish making them uncleanable. -There were also gouges in the wood. *The handrails throughout the building also had areas of bare wood that could cause splinters. 9. Observation and interview on 9/7/22 at 4:30 p.m. with resident 14 revealed: *Her room was very cluttered. *She had an oxygen concentrator that was against her bedside dresser. -The top drawer of the dresser was extended and was over full with her belongings. It was not able to be closed. -She stated if she moved the oxygen concentrator the dresser would fall over. -She stated she had reported it to the maintenance person but it had not been fixed yet. *The chair between her bedside dresser and her roommates were full of pillows and blankets. -She stated those all belonged to her roommate. *There was a wheelchair by her bed also. *A narrow path led from her bed to the bathroom. *She used the wheelchair as she was not able to put any weight on her left foot. 10. Observation and use of senses on 9/8/22 at 7:45 a.m. upon entering the building revealed the same strong urine odor as the day prior. 11. Observation and use of senses on 9/8/22 at 10:30 a.m. of the nurses station desk revealed: *A strong odor of urine next to the nurses station. *The laminate trim on the edge of the counter where the nurses did there charting was missing in places. *The laminate counter top had visible finger and hand prints on it. 12. Observation and interview on 9/08/22 at 2:10 p.m. with housekeeping/laundry supervisor N revealed: *She was not aware of the strong urine smell in the front entrance. -The furniture in the front entrance was shampooed several times a month with an upholstery cleaner. -She stated the urine must have gotten trapped in the foam under the fabric. *Residents 6 and 11's rooms were cleaned twice a day due to the increased traffic and strong odors in their rooms. *They use Micro Kill on the doors and the hand rails. That product had taken the finish off of the wood. *Housekeeping did not have access to the online reporting of concerns to the maintenance department. She would leave a note or ask other staff to enter in the online reporting system. Interview on 9/08/22 at 9:00 a.m. with administrator A and 9/9/22 at 10:30 a.m. with administrator A and director of nursing B revealed: *They had not realized the smell in the front lobby area was so bad. *Agreed the doors and handrails had the finish worn off and bare wood was present. *The maintenance director had just started approximately one month prior. *Had just started an audit of the building after the ombudsman had notified her of some of the above findings. *Those areas had not been included in the prior quality assurance improvement plans. *They were in the process of making housekeeping checklists for cleaning. On 9/7/22 at 2:00 p.m. a copy's of the cleaning and housekeeping policy and procedures and a copy of the provider's preventative maintenance program had been requested from administrator A. Those copies had not been received by the time of the exit on 9/9/22 at 1:00 p.m.

Based on observation, interview, record review, and policy review, the provider failed to ensure transmission based precautions had been followed: *For one of one sampled resident (35), by two of two certified nursing assistants (CNA) (D and E) when helping resident 35. *For appropriate signage and supplies for two of two (6 and 14) sampled residents with contact precautions. Findings included: 1. Observation on 9/7/22 at 8:24 a.m. in the former Alzheimers care unit (ACU) hallway revealed: *CNA D was carrying a room tray in the hall to deliver breakfast to resident 35. She: -Did not put on personal protective equipment (PPE). -Knocked on the door for room [ROOM NUMBER]. -Entered the room with the room tray. -Left the tray in the room for resident 35. -Exited the room. -Used hand sanitizer. Observation on 9/7/22 at 9:00 a.m. of the signs on resident 35's door revealed: *Enhanced droplet precautions. *Visitors were not to enter the room they were to see a nurse. *Hand hygiene: wash hands or perform alcohol hand gel according to standard precautions. *Masks: surgical masks when entering room or N95 respirator, if available, and healthcare personnel have been fit tested . *Eye protection: eye protection when entering room. *Gowns: gowns when entering room. *Gloves: gloves when entering room. *Keep door closed at all times. Observation on 9/7/22 at 12:16 p.m. revealed the door to room [ROOM NUMBER] was open and resident 35 was eating lunch. Observation on 9/7/22 at 12:57 p.m. revealed the door to room [ROOM NUMBER] was open and resident 35 was napping. Obseration on 9/8/22 at 9:01 a.m. revealed the door to room [ROOM NUMBER] resident 33's room was ajar. Interview on 9/8/22 at 10:57 a.m. with director of nursing (DON) B revealed she: *Knew resident 35 was quarantined due to a rehospitalization and his COVID vaccination status. *Expected CNA D to follow the PPE policy. *Shared resident 35 gets claustrophobic at times so, the door may be open. *Agreed there should be a see-through barrier covering the door if it was going to be open. Observation and interview on 9/8/22 at 11:55 a.m. in the ACU hallway revealed: *CNA E removed a room tray from the lunch tray rack. She: -Did not put on PPE or perform any hand hygiene. -Knocked on resident 35's door. -Entered the room. -Exited the room. -Performed hand hygiene. *When asked why she had not used PPE before entering resident 35's room she stated, I did put it on and threw it in the garbage can inside the room before I left the room. Review of the provider's revised February 2021 infection prevention program plan revealed: *Purpose: To determine what resources are necessary to care for our residents competently and to assist with the review and updating of the Infection Prevention and Control Program. *The goals of the infection prevention and control program are to: A. Decrease the risk of infection to residents/patients and personnel. B. Prevent, to the extent possible, the onset and spread of infection. C. Monitor for occurences of infection and control outbreaks and cross-contamination. D. Monitor for occurrence of infection and implement appropriate control measures. E. Identify and correct problems relating to infection prevention practices. F. Maintain compliance with state and federal regulations and standards of practice relating to infection prevention and control. *Prevention of spread of infections is accomplished by use of hand hygiene, standard and transmission precautions and other barriers (PPE-Personal Protective Equipment), appropriate treatment and follow-up, and employee health. *Staff and resident education focuses on risk of infection and practices to decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures, in cleaning/disinfection of equipment, and cleaning and handling linens. Immunizations are offered as appropriate to residents and personnel to decrease the incidence of preventable infectious diseases. 2. Interview on 9/7/22 at 8:15 a.m. with administrator A revealed there was one resident (35) who was on quarantine to rule out COVID-19. She had not indicated any other residents on transmission based precautions. Observation on 9/7/22 at 10:00 a.m. outside of resident 6's room revealed a cart that contained disposable gowns and gloves. There were no signs to indicate if precautions were to have been taken. Interview on 9/7/22 at 10:30 a.m. with director of nursing (DON) B revealed resident 6 was on contact precautions for extended spectrum beta-lactamase (an enzyme made by some bacteria that prevents certain antibiotics from being able to kill the bacteria. The bacteria then become resistant to the antibiotics.) in her urine. She agreed there was no sign to indicate what precautions were to have been used. Resident 6 had moved rooms and the signs had not transferred with her. 3. Review of resident 14's electronic medical record revealed she had been diagnosed with [CONDITION(S)] in a wound on 9/7/22. No signs or preventative equipment had been placed by her room. The wound was on her left foot. It was covered by a dressing. That dressing was changed by the nurses. Interview on 9/9/22 at 9:00 a.m. with DON B confirmed the above findings.

Based on observation, interview, record review, and policy review, the provider failed to provide a activity program that involved three of three sampled (11, 14, and 16) residents individual interests and needs. Findings include: Review of the provider's July 2022, August 2022, and September 2022 activity calendars revealed: *The calendars all said the same thing: -Weekends consisted of family visits, Find a friend and play a game, and church services. -One-to-one activities were scheduled two times a week. -Group activities that included: Puzzles and music, bingo, trivia, nail care, resident choice, shopping, arts and crafts, resident council, Yahtzee, happy hour, ladder golf, veteran men's group, and fishing to be determined. -There was only one group activity scheduled each weekday. 1. Observation and interview on 9/7/22 at 12:25 p.m. with resident 11 revealed: *No activity calendar in her room. *No one had asked her about what activities she would like to do. *She mostly watched television and had her laptop computer. *She had not been out of her room, other than one hospital visit, since her 4/5/22 admission. Review of resident 11's activity participation documentation revealed: *June 2022 she had three one-to-one visits. *July 2022 she had two one-to-one visits. *August 2022 she had two one-to-one visits. *September 1st through the 8th she had two one-to-one visits. 2. Interview on 9/8/22 at 2:45 p.m. with resident 16 revealed he: *Would like to have more activities to go to. *He used to have an activity calendar in his room and would know what was done. *Many times, what is listed on the information board for an activity was not held. *It was better in June but had declined since then. Review of resident 16's activity participation document revealed: *June 5th through June 30th revealed he had three one-to one visits, one group outing, and had refused one group activity. *July 2022 revealed he had three one-to-one visits and had refused one group activity, *August 2022 revealed he had two one-to-one visits and had refused on group activity. *September 1st through the 8th revealed he had one one-to-one visit. 3. Interview on 9/8/22 at 5:00 p.m. with resident 14 revealed she: *Stayed in her room most of the time. *Had been invited to some of the group activities. *Did not like any of the activities that were available. Review of resident 14's activity participation documentation revealed: *June 22nd through June 30th revealed she had refused one group activity and had not been available for another. *July 2022 revealed she had refused activities that had included: puzzles and music, bingo, church services, trivia, and the resident council meeting, she had a one-to-one visit. *August 2022 revealed she had two one-to-one visits. *September 1st through the 8th revealed she not participated in any activities. Interview on 9/9/22 at 9:30 a.m. with administrator A revealed: *The activity coordinator had been out on leave in April and was back for one day in May and decided to not return. *She had hired three staff to assist with activities until a new coordinator was hired. *She agreed the documentation of what the residents had participated in was minimal compared to what the residents had participated in. Review of the provider's January 2020 Activities policy revealed: *It is the goal to provide meaningful activities for our residents. Individual programming ensures all residents who are unable to participate in group programs have consistent, person centered goal-oriented and individualized recreation opportunities. The activity department will be directed by a qualified professional. *Regularly scheduled programming will be provided to all residents who are unable or unwilling to attend group activities and will be developed based on each resident's assessed needs and choices. *Document the resident's participation in activities provided and whether the resident was engaged in the activity. Refer to F656 findings 1, 2, and 3.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure effective pain management for: *One of one sampled resident (9) who voiced and exhibited signs and symptoms of pain during a dressing change by one of one licensed practical nurse (LPN) (A). *One of one sampled resident (1) who was cognitively (memory) impaired with communication deficits (problems) during personal care. Findings include: 1. Observation on 10/20/15 from 3:10 p.m. through 3:30 p.m. with LPN A during a dressing change for resident 9 revealed: *The resident had been laying in bed on her back. *She had a dressing that covered her left ankle. *She was hard of hearing but able to understand the LPN's conversation and direction. *She became very anxious prior to and during any movement of her left foot and leg. *During the entire process of removing, cleansing, and re-dressing the wound the LPN had to move the resident's foot and leg. *During that entire time she grimaced and cried out oh, oh, ow that hurts, what you doing now? *The LPN had informed her of every movement and step she had to perform for her to complete the dressing change. Each time the resident would respond with the statements above. *The LPN had not asked the resident if she was having pain or offered to stop during the entire process of performing the dressing change. Interview on 10/20/15 at the time of the above observation with LPN A revealed: *The resident had received pain medication earlier that day. She stated She receives [MEDICATION NAME] (pain medication) every morning. *She had just given the resident a [MEDICATION NAME] (nerve pain medication). She stated She receives this three times a day. *She had not considered the resident's reaction to the dressing change as abnormal. Review of resident 9's complete medical record revealed: *A 7/1/15 re-admitted . *[DIAGNOSES REDACTED]. *She was hard of hearing but was able to make her needs known. *She was dependent upon staff to assist her with all of her activities of daily living that included grooming, bathing, dressing, toileting, and moving from place-to-place. *She had been under hospice care (end-of-life) since May 2015. Review of resident 9's 10/20/15 physician's orders [REDACTED]. *[MEDICATION NAME] 100 milligrams (mg) three times a day for shingles pain. *[MEDICATION NAME] 50 mg once a day for pain. *[MEDICATION NAME] 50 mg one tablet every six hours as needed (PRN) for pain. Review of resident 9's 10/1/15 through 10/20/15 medication administration records (MAR) revealed: *She had received the [MEDICATION NAME] at 7:30 a.m. every day. *She had received the [MEDICATION NAME] three times a day at 7:30 a.m., 1:30 p.m., and 8:00 p.m. *No other pain medications had been provided during that time frame. Review of resident 9's 9/7/15 Quality Care Meeting Summary revealed she had pain with the above pain medications ordered. No further changes had been required for her care plan. Review of resident 9's updated 10/12/15 care plan revealed: *There had been no problem area for pain. *Under the behavioral problem area there had been one intervention that stated Make sure I am not in pain or uncomfortable. *Under the Hospice care problem area there had been one intervention that stated Evaluate effectiveness of medications/interventions to address comfort. Review of resident 9's nurses' notes revealed: *On 8/21/15, Hospice cares continue. Resident does say ou (ow) when anyone touches ankle and is to get scheduled [MEDICATION NAME] to help alleviate the pain and soreness. *On 8/22/15, Area to left outer ankle treated per TAR (treatment administration record), drainage and redness noted to area. Resident does experience pain during treatment. Resolves after cares. *There was no documentation to support any PRN pain medications had been given or offered to the resident. *On 8/30/15, Surrounding tissue is reddened with resident complaining of pain to the area. Area cleansed and treatment completed. *There was no documentation to support the resident had been given or offered pain medication prior to the dressing change. *On 9/3/15, Resident had complaints of pain to ankle with dressing change. *There was no documentation to support the resident had been given or offered pain medication prior to the dressing change. *On 9/11/15, Resident does wince when dressing change to ankle are done and pain medications given with relief obtained. *There was no documentation to support if the pain medication had been given prior to the dressing change. *On 9/14/15, Resident noted to have pain with dressing changes to left ankle. PRN pain medication has been given and noted to be effective. *There was no documentation to support the pain medication had been given prior to the dressing change. *On 9/28/15, Resident does wince when touching ankle and is on scheduled pain med and [MEDICATION NAME] as ordered. *There was no documentation to support PRN pain medication had been given or offered for the resident's ankle pain. *On 9/30/15, (physician's name) here to assess resident's plan of care/condition/medication for recertification with no new orders noted at this time. *On 10/20/15, there was no daily charting note available for review and to support the observation at 3:10 p.m. of the resident during the dressing change to her left ankle by LPN A. Interview on 10/21/15 at 3:15 p.m. with the Minimum Data Set (MDS) coordinator revealed: *The nurses had a pain management assessment form to have been used as a tool for them to determine a resident's pain level. They had completed that pain assessment with the residents' MDS assessments. *The nurses had been responsible for the follow-up with the physicians regarding pain management for the residents. *She would have only performed her required pain interview from the MDS section J. She would not have completed a pain assessment form to support her interview. She would have completed a nursing order for the charge nurses to review and follow-up on with any resident that had complaints of pain. *She had not been aware resident 9 had been experiencing pain during the dressing change. She had not visualized the wound or observed the dressing change. That had not been a part of her duties when completing an MDS assessment. She would have only interviewed the staff. Interview on 10/22/15 at 8:30 a.m. with the director of nursing regarding resident 9 revealed: *She supported the above interview with the MDS coordinator. *They had talked to the physician yesterday to increase her pain medications. *She agreed they had not visited with the physician regarding her pain and pain medications until after the surveyor brought it to their attention. *She would have reviewed the nurses' documentation on all of the resident's everyday. *She had not been aware of the resident's signs and symptoms of pain during the dressing change to her left ankle. *She would have expected the staff to give the resident pain medication prior to the dressing change. *She had been aware the [MEDICATION NAME] was scheduled once a day in the morning. If the nursing staff had not been able to do the dressing change until later that day she would have expected another pain pill to have been given. *She would have expected: -The nursing staff to stop the dressing change with complaints or signs and symptoms of pain. -The resident to have been provided a pain pill before resuming the dressing change. 2. Review of resident 1's medical record revealed: *A 2/21/14 admitted . *Diagnoses: [REDACTED]. Observation on 10/20/15 at 6:00 p.m. of resident 1 revealed she was hollering help me and trying to push her wheelchair backwards from the dining room table. Interview on 10/20/15 at that time with unlicensed assistive personnel (UAP) I regarding resident 1 revealed: *She often hollered out repetitively. *She had been hollering earlier in the day, and she had given her an as needed (PRN) [MEDICATION NAME] (narcotic pain medication). *The [MEDICATION NAME] appeared to help the hollering for a little while until the effectiveness of the medication wore off. Observation on 10/21/15 from 9:00 a.m. to 9:30 a.m. of resident 1 revealed: *Certified nursing assistant (CNA) G was pushing her back to her room in her wheelchair after breakfast. *She was going to change her soiled sweater and provide incontinence care. *The resident was hollering gotch ya and come on. *CNA G assisted her to stand in the mechanical stand-aide (equipment to move the resident that requires the resident to have the ability to bear weight on their legs). *When CNA G was positioning the resident's legs in the stand-aide she was hollering loudly and repetitively ouch, ouch, ouch, hurts. *She was unable to tell CNA G where she was hurting. *She had facial grimacing when CNA G stood her from a sitting position in her wheelchair to a standing position in the stand-aide. *CNA G transferred her from that standing position to a sitting position on the toilet. She hollered bad, bad, bad in a loud tone of voice repetitively. *She rubbed her forehead and stated head hurts after CNA G assisted her back from the toilet to her wheelchair. *CNA G transferred her from her wheelchair to the easy chair in the day room with the use of the stand-aide. *The resident hollered ouch, ouch, ouch again in a loud tone of voice repetitively during that transfer. Interview on 10/21/15 at 9:40 a.m. with CNA G regarding resident 1 revealed: *The resident usually hollered frequently throughout the day. Some days the hollering was worse than others. It was hard to determine if she was having pain or if she was being repetitive. *She thought they had changed the resident's medications back in May 2015, and since then her hollering had increased. Prior to May the resident used to be able to carry on a conversation without yelling repetitively. *She thought the nurse had given her a pain pill at breakfast. *She was unsure what the medication was she used to be on, but she did not really holler at that time. *She often hollered ouch when they were providing personal care to her or transferring her with the use of the stand-aide. Interview on 10/21/15 at 10:00 a.m. with licensed practical nurse (LPN) F regarding resident 1 revealed she: *Had received her scheduled dose of Tylenol at breakfast. *Received scheduled Tylenol three times a day that had been ordered on [DATE]. The use of the Tylenol had really made no difference in her hollering. *Had been on scheduled [MEDICATION NAME] that seemed to make her memory worse and had made no change in her hollering. The [MEDICATION NAME] had been changed to PRN on 7/8/15 when she was put on the scheduled Tylenol. *Had been put on a [MEDICATION NAME] (narcotic pain) patch on 9/9/15. The patch had been stopped after two weeks, but she was unsure why. *Started hollering worse when her [MEDICATION NAME] (mood and behavior altering medication) had been discontinued on 9/9/15. *Often hollered out, but it was difficult to determine if that had been caused by pain. *Had not been hollering out about pain at breakfast. Review of resident 1's 5/8/15 through 10/20/15 nursing progress notes revealed: *5/8/15, Brief interview for mental status (BIMS, testing of thought processes) and pain interview completed. Resident with nonsensical (does not make sense) answers. Long term memory/short term memory impaired, no memory recall, and daily decision making skills severely impaired. Noted to have inattention, disorganized thinking, and altered level of consciousness (alertness) which fluctuate. *5/11/15, Pain scale for [MEDICATION NAME]/Tylenol at noon based on when resident is being transferred. No pain/discomfort noted when at rest. Resident was started on [MEDICATION NAME] one week ago. *5/12/15, Resident has been having shakes off and on since Sunday afternoon. She was started on [MEDICATION NAME] 50 milligrams (mg) on 5/6/15 and also had a reduction in [MEDICATION NAME] from 0.5 mg to 0.25 mg on 5/4/15. She has not received the [MEDICATION NAME] for the last four to five days reported by the night nurse. Pharmacy has not sent a card but card is to be coming today. *5/13/15, Seen by physician with orders to discontinue [MEDICATION NAME], hold [MEDICATION NAME], and discontinue [MEDICATION NAME] (memory medication). Continue to monitor pain/mental issues. *5/14/15, Staff attempt to toilet resident and resident yelled ouch before staff got lift securely in place. Resident became agitated (angry) and pinched and attempted to scratch staff. Denies pain but yells ouch during transfer. Calmed down after finished in bathroom. *5/26/15, Resident heard calling out and found laying on the floor beside her bed. Has history of multiple falls with and without injury. *6/4/15, Monthly weight review indicates a loss of 9 pounds (lb). Weight has been increasing from six months ago through May 2015 from 149 lb to 160 lb, and then she lost weight down to 151 lb. It is noted that during her weight loss period her [MEDICATION NAME] was discontinued for approximately two weeks. During this time, the staff noticed a decrease in her ability to feed herself and overall intake. It was restarted on 6/2/15. Her [MEDICATION NAME] was also discontinued. *6/10/15, Seen by physician and order received for [MEDICATION NAME] 2.5/325 mg three times a day for arthritis pain. *7/2/15, Weight is stable at 152 lb. [MEDICATION NAME] was restarted and this is helpful for her to maintain her ability to feed herself. *7/8/15, Seen by physician's assistant and order to discontinue [MEDICATION NAME] scheduled and PRN and start Tylenol 650 mg every a.m. and p.m. *7/12/15, Resident has been calling out come on, come on for most of the shift. Nothing has made a difference in her calling out. Medications were changed last week. *7/15/15, Was found sitting/lying in corner of the dayroom at approximately 6:40 a.m. Had been up since 4:30 a.m. and was placed in wheelchair since then. Was self propelling wheelchair around the unit/anxious/yelling. *7/20/15, Has been having much more calling out since [MEDICATION NAME] was discontinued on Resident is either calling come on over or ow, ow over and over. Received order from physician for [MEDICATION NAME] 2.5/325 mg four times a day for twenty doses. *7/22/15, Combative during clinical assessment. Had been sleeping in bed and found resident on mattress on floor next to bed. *7/31/15, Has been calling out come on or help or ouch all shift. Does quiet down only for one-to-one visits. *8/13/15, Has been yelling all day almost constantly ouch or come on and when questioned about pain points to different areas of the body every time. *8/14/15, Seen by physician. [MEDICATION NAME] ([MEDICATION NAME]) patch 12 micrograms (mcg) on every three days for thirty days. *8/20/15, Orders for [MEDICATION NAME] (chronic pain medication). Physician' assistant telephoned and ordered [MEDICATION NAME] 0.5 mg at approximately 4:00 p.m. Targeted behaviors are increased disruptive sounds/excessive yelling out numerous times per day, wandering other residents' rooms and hallway, and very upset when calling out. Note resident received order on 7/8/15 to decrease alprazalam (antianxiety medication) from 0.25 mg in the a.m. and noon and 0.5 mg at bedtime to 0.5 mg at 4:00 p.m. From 5/22/15 to 7/7/15 resident had a total of twelve behaviors. From 7/8/15 to 7/27/15 after [MEDICATION NAME] was decreased resident had a total of twenty-five behaviors. Note behaviors continue to increase. *8/21/15, Orders received to change [MEDICATION NAME] to 0.25 mg in the a.m. and 0.5 mg in the p.m. and to discontinue the [MEDICATION NAME]. *9/13/15, Resident was very loud and calling out all shift yesterday. Unable to get to stop calling out. *10/1/15, Has been loud and anxious today. Wandering around the unit in her wheelchair running into anything and anyone that is in her way. Just before lunch she had wandered into the day room and was being loud and pulling her hair. Attempted to redirect with food and one-to-one attention which was not effective. *10/2/15, Bruise to top of left shoulder reported by staff. Has dementia and is frequently loud, aggressive, and wandering in her wheelchair. It is possible that another resident had struck her on the shoulder. *10/5/15, Had been sitting in wheelchair at table, but was then found lying on floor in front of wheelchair. Patient (resident) has behavior of yelling ouch frequently even when sitting still. *10/6/15, Resident is having increased pain to left ankle, ankle [MEDICAL CONDITION] (swollen), and is starting to bruise. X-rays negative for fracture. *10/8/15, Has been non-stop yelling/calling out this morning. Only time she stops is if someone is talking with her. Will mock (copy) what staff say to her and then just continue yelling out. Shows no signs/symptoms of pain when this yelling is going on and she will stop calling out the minute someone starts to talk with her. *10/9/15, Prior to, during, and after breakfast resident was yelling ouch, ouch, ouch. She was unable to tell me where she was hurting. She would also yell out come on. PRN [MEDICATION NAME] was administered and was effective. *10/10/15, Monthly weight review indicates a 4 lb weight loss in thirty days and 16 lb weight loss in six months. Her weight has been trending down. *10/12/15, Upon review of resident's chart and behavior log noted to have an increase in yelling out, disruptive sounds, and agitation. Resident is toileted, provided activities, one-to-ones, and snack. However is not able to be redirected at times. *10/13/15, Per pharmacy recommendation, doctor agreed to discontinue [MEDICATION NAME] (antidepressant) and start [MEDICATION NAME] (antidepressant) 30 mg to see if this will help with pain/anxiety. *10/14/15, Seen on rounds by physician. Physician noted that resident has shown increased restlessness, ongoing and continuous yelling out, pulling of own hair, and scratching at own skin. New order is for [MEDICATION NAME] 0.5 mg for increased behaviors. *10/19/15, Continually yells out help, or owee or whatever she hears over and over again which is very upsetting to the other residents and causes the other residents to have behaviors also. *10/20/15, While attempting to redirect resident away from crowded area resident's right arm was caught between the wall and wheelchair. Review of resident 1's 5/3/15 through 10/1/15 weight summary revealed: *5/3/15, Weight (wt) 160 lb. *10/1/15, Wt. 143 lb. Review of resident 1's 10/1/15 through 10/20/15 PRN medication record revealed: *[MEDICATION NAME] was documented as administered ten times on seven different days. There was no PRN [MEDICATION NAME] administered on thirteen days. *Her FACES pain rating scale (0 no hurt, 2 hurts a little bit, 4 hurts a little more, 6 hurts even more, 8 hurts a whole lot, and 10 hurts worse) was rated from a 4 to a 9. *All the documented doses of [MEDICATION NAME] administered were effective. Review of resident 1's 5/6/15 through 10/20/15 physician's progress notes revealed: *5/6/15, Apparently with the scheduled [MEDICATION NAME] ([MEDICATION NAME]), pain behavior has been better. *6/10/15, She has a PRN [MEDICATION NAME]. Previous attempt with [MEDICATION NAME] had side effect. Previously scheduled [MEDICATION NAME] led to significant cognitive (thinking, reasoning,and memory) change. We will try [MEDICATION NAME] 2.5/325 mg one three times a day and keep the PRN. Complaints of knee pain, but no falls or trauma. She is able to verbalize just a few issues. *7/9/15, When I listened to her lungs she would say ow. Listened to her chest she was saying ow and when I was listening to her chest and I touched her knee she was doing ow at the same time. We are going to put her on Tylenol and we will see how she does and see if this makes any difference. Discontinuing her [MEDICATION NAME]. *7/22/15, Has had more verbalizations of pain, more pain behaviors. We are going to increase [MEDICATION NAME] to 5/325 mg three times a day. *8/5/15, Still having some pain behaviors. Ultimate goal is to get a [MEDICATION NAME]. Will increase the [MEDICATION NAME] to 7.5/325 mg three times a day. Will have pharmacy consult to convert that over to a [MEDICATION NAME]. *8/14/15, Severely demented elderly person who keeps saying ouch. It is unclear if this is a depressive issue or if she actually has pain Started her on some narcotics with minimal improvement. Start her on [MEDICATION NAME] ([MEDICATION NAME]) patch 12 micrograms per hour. *8/26/15, Complaints of pain have basically resolved. *9/3/15, We put her on [MEDICATION NAME] last week at 0.5 mg and we have been giving it in the afternoon. When I went to see her today she was quieter. When I saw her last week she was going up and down the halls hollering the entire time so between the small dose of medication of the [MEDICATION NAME] and her pain medications she seems to be in much better control. *10/14/15, Nurses state since going down on the Risperal she has had more agitation, more violent behaviors. She is pulling her hair out. She is inconsolable (unable to calm). She is actually quite delusional (irrational thinking). I don't see that she is on [MEDICATION NAME] anymore per chart. Previous dose was we had put her on [MEDICATION NAME] 0.5 mg that was back about a month ago. We are going to go ahead and restart that. Review of resident 1's May 2015 through October 2015 behavior logs revealed: *May 2015, Eight occurrences of behavior (verbal behavior, wandering, and other behavior). *June 2015, Ten occurrences of behavior (wandering and other behavior). *July 2015, Thirty-one occurrences of behavior (verbal behavior, physical behavior, and other behavior). *August 2015, Sixty-four occurrences of behavior (wandering, physical behavior, and other behavior). *September 2015, Twenty-nine occurrences of behavior (wandering, verbal behavior, physical behavior, rejects care, and other behavior). *October 1 through October 21, 2015, Thirty occurrences of behavior (wandering, verbal behavior, physical behavior, rejects care, and other behavior). Review of resident 1's 8/7/15 care plan revealed: *Needs pain management and monitoring. *Will not experience a decline in function related to pain. *Patient (resident) will achieve acceptable pain level goal. *Will maintain adequate level of comfort as evidenced by no signs/symptoms of unrelieved pain or distress. *Evaluate need for routinely scheduled medications rather than PRN pain medication administration. *Evaluate need to provide medications prior to treatment or therapy. *Evaluate what makes the patient's pain worse. *Monitor for nonverbal symptoms of pain such as facial grimacing or guarding (protecting). Resident does a behavior of yelling ouch or come on. Review of resident 1's October 2015 Medication Administration Record [REDACTED] *Was not on [MEDICATION NAME] or the [MEDICATION NAME]. *Had received PRN [MEDICATION NAME] seven out of twenty days. *Was on scheduled Tylenol 650 mg twice a day with facial pain ratings of 0 to 9. Interview on 10/21/15 at 10:15 a.m. with the Alzheimer's unit director regarding resident 1 revealed: *When she had medication changes this summer they noticed a change in her behavior. *They questioned whether she was having pain. *When she was on the scheduled [MEDICATION NAME] she was sleeping a lot more. *She had been on the [MEDICATION NAME] until the end of September 2015. It was ordered for a thirty day time frame from the physician and was not followed-up on when the prescription ran out. *The pharmacist had told the nursing staff they might have been going a little fast with her medication reductions, but nothing had been done with her medications for a long time. *She agreed the nursing staff felt the resident was not comfortable most of the time. *They felt she was out of control most of the time. Interview on 10/21/15 at 11:15 a.m. with the medical director regarding resident 1 revealed: *He was unsure why the [MEDICATION NAME] had been stopped. The pharmacy or nursing staff had not called the physician's office for a renewal prescription. *They had been trying to figure out if her yelling behaviors of pain was her [MEDICAL CONDITION] (dementia), anxiety, or pain. *They had been working on trying to taper down antypsychotic (mood and behavior altering) medications on her and some of the other residents since July 2015. *They should try a long [MEDICATION NAME] narcotic for her. He would restart the [MEDICATION NAME] today. *They had just started her on [MEDICATION NAME] (antidepressant) on 10/6/15 which had good pain properties. *He would go along that her behaviors during the above observations were pain related. Review of the provider's 2/10/15 Pain Management Guideline policy revealed: *To provide guidance for consistent assessment, management and documentation of pain in order to provide maximum comfort and enhanced quality of life, in concert with the patient's/resident's plan of care and goals for pain management. *Recognizing and reporting pain as a 5th vital sign. *Intervening to treat pain before the pain becomes severe. *Anticipating pain during activities that may be uncomfortable (dressing changes). *The nurse develops a plan of care for pain management, if indicated, including the use of non-pharmacological (medication) interventions. B. Based on observation, record review, interview, and policy review, the provider failed to monitor, assess, and report to the physician in a timely manner changes in behavior for one of six sampled residents (12) related to changes in her [MEDICAL CONDITION] medication. Findings include: 1. Observation on 10/21/15 at 5:30 p.m. of resident 12 revealed she was: *Sitting quietly feeding herself at the supper table. *Pleasantly confused. *Did not show any mood or behavior concerns while eating. Review of resident 12's medical record revealed: *A 9/2/14 admitted . *Diagnoses: [REDACTED]. Review of resident 12's 9/5/15 care plan revealed: *Multiple medication use. History of hallucinations (see things that are not present to others) and delusions (hear things that are not present to others). *Provide medications as ordered by the physician and evaluate for effectiveness. *Refer to psychologist/psychiatrist for medication and behavior interventions. *I sometimes have mood and behaviors which include history of wandering in hallway and other residents' rooms which may intrude on the privacy of others. *I may get upset with family when they come to visit as they are unable to care for me at home and my dementia [DIAGNOSES REDACTED]. *History of resident to resident. Verbal behaviors directed at others-cursed, threatened staff, screamed at staff/others. *Hoarding behaviors and rejection of medications. Hit others. *Thoughts that she be better off dead or of hurting herself in someway. Review of resident 12's 5/23/15 through 10/20/15 nursing progress notes revealed: *5/23/15, It was reported by another resident that this resident had hit the other resident in the restroom. *6/1/15, Note since taper of [MEDICATION NAME] (medication for not being able to control urine) resident noted to be more cheerful. Staff reports she has been laughing and visiting more with other residents. *6/8/15, Noted to be hitting staff this morning, yelling at the recorder about her mother and her money. Shaking office door. *7/9/15, Medications include [MEDICATION NAME] (for memory) 10 mg daily, [MEDICATION NAME] (antidepressant) 30 mg daily, Trazadone (antidepressant) 25 mg at bedtime, and [MEDICATION NAME] 0.5 mg twice a day. *7/21/15, Resident was found trying to assist roommate up. CNA entered room and attempted to redirect resident. Resident was aggressive with CNA, took CNA arm and twisted it. Resident left bruise on staff arm. *7/22/15, Medications reviewed and order to continue taper of [MEDICATION NAME] and discontinue. *7/24/15, Resident has been having increased outbursts just yelling out unknown reasons. Has also grabbed staffs' arms and twisted them. Psychiatrist was here and increased [MEDICATION NAME] to 1 mg twice a day. [MEDICATION NAME] was decreased from 0.5 mg twice a day to 0.5 mg on 7/8/15 and then discontinued on 7/22/15. Psychiatrist then gave order to start [MEDICATION NAME] 0.5 mg twice a day. *7/31/25, Resident has had a few outbursts today. Yelled at staff and called another staff member names and then also backed staff into a corner and attempted to throw hot coffee on staff. *8/6/15, Pharmacy recommendation related to citalapram (antidepressant) and depression. Noted orders from physician (primary, not psychiatrist) to discontinue citalapram and start [MEDICATION NAME] (antidepressant) 30 mg daily. *8/13/15, Became angry at other resident while they were sitting at the table and stated for them to get out of her house. *8/16/15, Resident continues to anger very easily and yells at staff and other residents when becomes upset. This has been happening more frequently since she has had medication changes. *8/19/15, Resident noted to be crying this afternoon. Space and tissues provided as resident started to become agitated with staff. *8/23/15, Resident agitated this morning. Telling staff and other residents that this is her home and everyone is supposed to get out. Attempted to hit another male resident. Male resident told her to stop and held up his hand so she did not hit him. *8/24/15, Spoke with physician (primary) regarding increased agitation and suicidal ideation (ideas). Note order to discontinue [MEDICATION NAME] and see on rounds next week. *8/28/15, Resident agitated and aggressive towards staff, hollering at staff and grabbing staffs' arms. *8/29/15, Resident asked CNA to go outside after lunch. CNA said she would have to wait and resident became aggressive with CNA, grabbing her uniform and yelling she wanted to go outside. *9/2/15, Orders from physician (primary) for [MEDICATION NAME] (antianxiety) 0.5 cubic centimeters (cc) every two hours PRN. *9/7/15, Became upset after supper towards tablemate and grabbed her shirt. *9/11/15, Note order to increase Trazadone back to 50 mg every bedtime, restart [MEDICATION NAME] 30 mg daily, and reduce [MEDICATION NAME] to 0.5 mg daily per physician (primary). *9/18/15, Facsimile (fax) received from physician (primary) stating we are to increase Trazadone to 75 mg and cut [MEDICATION NAME] in half and he would see her next week. *9/22/15, Resident has been having increased episodes of crying and picking at skin. Crying she wants to go home and picking at skin the whole time she talks about going home. *9/25/15, Seen by psychiatrist and to continue on current medications. *9/28/15, Fax received from primary physician agreeing with psychiatrist's recommendations of no changes in medications. *9/30/15, Note order to discontinue [MEDICATION NAME] and increase Trazadone to 75 mg at bedtime for depression. (There was no documentation the psychiatrist had been notified of those medication changes). *10/12/15, Staff reported resident has diarrhea (loose bowel movement) this morning. Left the dining room table and went back to her room. Neighbor reported to staff that resident pulled another resident's hair. The other resident was neighbor, while the neighbor was sitting on the bed. *10/17/15, Resident has been pacing and getting more and more agitated throughout the shift. When CNA went into resident's room to assist resident's roommate, she started screaming and hitting at the staff to get out. Had been awake the entire shift. Review of resident 12's 8/26/15 through 10/14/15 physician's (primary) progress notes rev

Based on record review, interview, policy review, and manufacturer's product information and instruction review, the provider failed to maintain a safe environment with appropriate supervision and monitoring for two of five sampled residents (5 and 14) that had fallen resulting in major injuries. Findings include: 1. Review of resident 14's complete medical record revealed: *A [DIAGNOSES REDACTED]. *He had been a resident in the advanced Alzheimer's care unit (AACU). *A history of wandering and falls. *He had been assessed to be at risk for falls. *He had been assessed to be at risk for elopement (leaving the facility). Review of resident 14's nursing progress notes revealed: *On 5/17/14 at 3:06 p.m. "Was found outside without any other people. Found on ground." Vital signs taken. "Neuro check completed & (and) will not bear weight or stand. States his left hip hurts." *On 5/17/14 at 3:30 p.m. "Wife was in AACU when resident was found outside on ground. Contacted Dr. ____ at CMH (Community Memorial Hospital) & received order to transport to ER (emergency room ) via ambulance." *On 5/17/14 at 6:23 p.m. "Talked to Dr. ____ from CMH ER, resident has a minimally displace fracture of the left hip neck. Family does not want surgery. Will be admitted to hospital for pain control. Family with resident." Review of resident 14's 5/17/14, 5-Working Day Investigation report revealed "Through observation, (independently ambulatory) resident had been ambulating in outside courtyard with wife and another facility resident. This resident, along with wife and other facility resident came back into facility through an opened door from AACU to courtyard. (CNA (certified nursing assistant) reported that she opened AACU door to courtyard to allow those using courtyard free access from facility into courtyard and back into facility.) Wife and other resident sat down at an AACU dining room table to visit. Within moments, CNA staff near dining room observed this resident to not be in accompaniment of wife and other resident. At this time, CNA who was in another resident's room observed this resident through window to be ambulating in courtyard and began her way to the courtyard; at this time, RN (registered nurse) in ACU (Alzheimer's Care Unit) received a report from a resident's family member visiting in the facility, who had been looking out of another window, that there was a gentleman on the ground in the courtyard. This family member reported to the RN that it appeared that this gentleman attempted to sit in the swing (located in the courtyard) and missed the swing, falling to the ground. RN responded immediately to courtyard finding the CNA (who had seen resident ambulating in courtyard through a resident room window) had reached the courtyard and the resident who was laying on ground." Review of resident 14's 3/24/14 Minimum Data Set assessment revealed: *For transfers he had been assessed to require extensive physical assistance, staff to provide weight bearing support with two plus person assistance. *For ambulation he had been assessed to require supervision with one person for physical assistance. Review of the South Dakota Department of Health 11/7/13 recertification survey revealed the provider had been cited under F323 for the unsupervised access to the courtyard with access doors from the ACU and AACU. It also addressed the ACU door was being propped open. Refer to tag F323, finding 1, from the 11/7/13 survey. Review of the providers 12/27/13 plan of correction from that 11/7/13 survey revealed: *A directed in-service training would be provided to staff by 12/5/13 regarding provision of care that meets the resident's physical, mental, and psychosocial well being including the necessity to maintain an environment that promoted resident safety. *Maintenance personnel or designee would audit exits to ensure they alarmed, locked and unlocked properly weekly for four weeks, then monthly for three months. Interview on 8/20/14 at 10:50 a.m. with the ACU and AACU director revealed: *On the ACU residents were allowed to go outside with family. *On the AACU staff were supposed to go outside with residents. *Doors were never supposed to have been propped open. Interview on 8/20/14 at 1:15 p.m. with the maintenance director revealed the door to the AACU should never have been propped open. That door was supposed to have been locked at all times. Interview on 8/20/14 at 1:50 p.m. with the administrator revealed there had been no policy relative to the door in the AACU leading out to the courtyard. That door was supposed to have been locked at all times. If residents had been assessed to be ambulatory they could be unsupervised in the courtyard. They had not done any specific assessment for safety for residents to go outside. That door should have never been propped open. Interview on 8/20/14 at 2:25 p.m. with the director of nursing revealed the above door should not have been propped open. The best practice would have been for residents to have been supervised. All residents in the AACU should have been supervised when outdoors. There had been no policy regarding the supervision of a residents in the courtyard or propping doors open. If a door was locked the resident should have been accompanied outside. 2. Review of resident 5's medical record revealed she: *Had been admitted on [DATE]. *Had [DIAGNOSES REDACTED]. *Was at risk for falls with a score of 12 (a total score of 10 or above made the resident at risk). *Had fallen on 7/22/14 on the floor in front of her sink in her room. -She was found on the floor at 2:03 p.m. -That fall had been unwitnessed by staff. -Had been unresponsive for ten minutes after she had been found on the floor. -Had a laceration (break in the skin) to the back of her head, a bruise to her right elbow, and a skin tear to her left forearm. -Had discomfort to left shoulder reported. -Was taken to the emergency room by an ambulance at 2:15 p.m. Review of resident 5's 8/14/14 care plan revealed she: *Was at risk for falls related to impaired mobility/balance. *had a history of [REDACTED]. *Had impaired safety awareness. *Was to have been checked for wheelchair positioning frequently throughout each shift. *Was encouraged to always call for help when needed. *Was to have left her seat belt on as a reminder that it was for her own safety. Review of resident 5's 7/22/14 initial nursing facility event report required by and reported to the South Dakota Department of Health revealed: *She been been found on the floor in the room by the sink. *She had sustained an approximate two centimeter laceration to the back of head that had been bleeding profusely (excessively). *She went to the emergency room by ambulance where she had been evaluated for injuries. *She returned to the facility with no sutures (stiches) or report of further injuries. *She had an alarming seat belt on when up in her wheelchair that she could remove independently. *The alarm had not sounded when she had fallen. *Staff had stated awareness of the need to have punched the alarm 'on' when she had been transferred into the wheelchair. *The alarm light remained a constant blue on the personal alarm when the alarm was on. *Staff had found the blue alarm light had been blinking. *The battery changed the alarm light to a constant blue. *Staff had been educated on the need to have observed the alarm light to ensure the alarm was on when she was in the wheelchair. *Staff were to have reported if the light was blinking as that meant the battery needed to have been changed. Review of resident 5's physician's orders [REDACTED]. On 9/20/12 "TABS (a type of personal alarm system) Alarm for safety." *On 1/21/14 "Patient may continue to utilize Velcro seatbelt to improve positioning and safety. (Note patient is able to remove independently and on command)." *On 8/7/14 "Change battery to seat belt alarm q (every) 30 days every day shift every 30 day(s) for Prevention." *The above order on 8/7/14 was written after the resident had fallen on 7/22/14 and had sustained a major injury. Review of resident 5's treatment administration record revealed: *On 7/30/14 "Check seat belt alarm to ensure it is working properly Q (every) 2 hours while in wheelchair." *The above order on 7/30/14 was written after the resident had fallen on 7/22/14 and had sustained a major injury. Interview on 8/19/14 at 4:00 p.m. and on 8/21/14 at 10:30 a.m. with the director of nursing (DON) regarding resident 5's fall on 7/22/14 revealed: *She had been toileted at 11:00 a.m. *She had fallen at 2:00 p.m. *She had been taken to the emergency room after she had fallen. *Upon her return from the emergency room her personal alarm light had been blinking. *The battery had been changed at that time, it was no longer blinking, and it was a constant blue. *There was a nursing assignment care sheet used for communication to direct care staff regarding each resident's observation and condition changes. -She was currently listed on the care sheet with "Seatbelt alarms at ALL times (blue light must be on, not flashing)." -The DON reported the above had not been on the care sheet prior to her fall; it had been added after her fall on 7/22/14. *The DON agreed the seatbelt's blue light needed to have been more closely monitored and the battery changed on a regular schedule. -She confirmed the resident's personal alarm light had not been properly working. -She confirmed the alarm had not sounded prior to the resident's fall on 7/22/14 resulting in a major injury. -She confirmed the manufacturer's production information for the seatbelt alarm had not been followed. Review of the undated manufacturer's product sheet information for resident 5's Safe-tmate Alarmed Velcro Seatbelt revealed: *"Test the belt for proper operation. *Firmly press the switch to the ON position (blue LED light remains lit). *The alarm should sound as soon as the belt is separated." *The device was not a substitute for proper supervision. *Check fall risk patients frequently. *Change battery monthly. Interview on 8/21/14 at 11:00 a.m. with the administrator revealed the provider had no policy on personal resident alarms. Review of the provider's revised 2013 Falls Management Clinical Guidelines policy revealed at risk residents were identified through a "fall alert" communication system to caregivers. Preceptor: B. Based on record review, interview, and manufacturer's guideline review, the provider failed to ensure a sit-to-stand lift (a type of lift used to move a resident) was used in a safe manner for one of one sampled resident (3) who was mentally unable to make an informed decision regarding use of the lift. Findings include: 1. Review of resident 3's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. Review of resident 3's 6/10/14 quarterly Minimum Data Set (MDS) assessment revealed she: *Had a Brief Interview for Mental Status score of 6. That score was based on a scale ranging from 0-15 with a score of 6 meaning an inability to make informed decisions. *Needed extensive help and two staff to assist with transfers. *Did not walk and used a wheelchair. Review of resident 3's 1/6/14 care plan revealed: *She was "At risk for falls related to impaired balance, [DIAGNOSES REDACTED]. Dx (diagnosis) depression/anxiety." *"Resident refuses leg straps on sit stand lift. Resident educated on risk factors. date initiated 11/18/2013." Review of the above resident's 1/6/14 Lift/Mobility Assessment for Residents revealed she needed the Sara lift (a brand of sit-to-stand lift) with the assistance of two staff. No further assessment updates were found. Interview on 8/20/14 at 4:15 p.m. with certified nursing assistant G revealed she: *Had used the Sara lift to transfer resident 3. *Usually used the leg straps on the lift but sometimes had not. Interview on 8/20/14 at 5:00 p.m. with the director of nursing revealed she was not aware the Lift/Mobility Assessment had not been updated. It was normally updated quarterly or with significant changes. Interview on 8/21/14 at 10:10 a.m. with the administrator revealed nursing staff completed the lift assessments per the MDS assessments. No policy for the use of the above mentioned lift existed. Review of the August 2013 manufacturer's instructions revealed: *The lower leg straps of the Sara lift "are used to ensure that the lower parts of the resident's legs stay close to the knee support." *"An assessment must be made for each individual resident being raised by the SARA 3000 (lift) by a medically qualified person as to whether the resident requires the lower leg straps when using the standing sling. Use as necessary."

Based on record review, interview, policy review, and manufacturer's product information and instruction review, the provider failed to maintain a safe environment with appropriate supervision and monitoring for two of five sampled residents (1 and 2) that had fallen resulting in major injuries. Findings include: 1. Review of resident 1's complete medical record revealed: *A [DIAGNOSES REDACTED]. *He had been a resident in the advanced Alzheimer's care unit (AACU). *A history of wandering and falls. *He had been assessed to be at risk for falls. *He had been assessed to be at risk for elopement (leaving the facility). Review of resident 1's nursing progress notes revealed: *On 5/17/14 at 3:06 p.m. "Was found outside without any other people. Found on ground." Vital signs taken. "Neuro check completed & (and) will not bear weight or stand. States his left hip hurts." *On 5/17/14 at 3:30 p.m. "Wife was in AACU when resident was found outside on ground. Contacted Dr. ____ at CMH (Community Memorial Hospital) & received order to transport to ER (emergency room ) via ambulance." *On 5/17/14 at 6:23 p.m. "Talked to Dr. ____ from CMH ER, resident has a minimally displace fracture of the left hip neck. Family does not want surgery. Will be admitted to hospital for pain control. Family with resident." Review of resident 1's 5/17/14, 5-Working Day Investigation report revealed "Through observation, (independently ambulatory) resident had been ambulating in outside courtyard with wife and another facility resident. This resident, along with wife and other facility resident came back into facility through an opened door from AACU to courtyard. (CNA (certified nursing assistant) reported that she opened AACU door to courtyard to allow those using courtyard free access from facility into courtyard and back into facility.) Wife and other resident sat down at an AACU dining room table to visit. Within moments, CNA staff near dining room observed this resident to not be in accompaniment of wife and other resident. At this time, CNA who was in another resident's room observed this resident through window to be ambulating in courtyard and began her way to the courtyard; at this time, RN (registered nurse) in ACU (Alzheimer's Care Unit) received a report from a resident's family member visiting in the facility, who had been looking out of another window, that there was a gentleman on the ground in the courtyard. This family member reported to the RN that it appeared that this gentleman attempted to sit in the swing (located in the courtyard) and missed the swing, falling to the ground. RN responded immediately to courtyard finding the CNA (who had seen resident ambulating in courtyard through a resident room window) had reached the courtyard and the resident who was laying on ground." Review of resident 1's 3/24/14 Minimum Data Set assessment revealed: *For transfers he had been assessed to require extensive physical assistance, staff to provide weight bearing support with two plus person assistance. *For ambulation he had been assessed to require supervision with one person for physical assistance. Review of the South Dakota Department of Health 11/7/13 recertification survey revealed the provider had been cited under F323 for the unsupervised access to the courtyard with access doors from the ACU and AACU. It also addressed the ACU door was being propped open. Refer to tag F323, finding 1, from the 11/7/13 survey. Review of the providers 12/27/13 plan of correction from that 11/7/13 survey revealed: *A directed in-service training would be provided to staff by 12/5/13 regarding provision of care that meets the resident's physical, mental, and psychosocial well being including the necessity to maintain an environment that promoted resident safety. *Maintenance personnel or designee would audit exits to ensure they alarmed, locked and unlocked properly weekly for four weeks, then monthly for three months. Interview on 8/20/14 at 10:50 a.m. with the ACU and AACU director revealed: *On the ACU residents were allowed to go outside with family. *On the AACU staff were supposed to go outside with residents. *Doors were never supposed to have been propped open. Interview on 8/20/14 at 1:15 p.m. with the maintenance director revealed the door to the AACU should never have been propped open. That door was supposed to have been locked at all times. Interview on 8/20/14 at 1:50 p.m. with the administrator revealed there had been no policy relative to the door in the AACU leading out to the courtyard. That door was supposed to have been locked at all times. If residents had been assessed to be ambulatory they could be unsupervised in the courtyard. They had not done any specific assessment for safety for residents to go outside. That door should have never been propped open. Interview on 8/20/14 at 2:25 p.m. with the director of nursing revealed the above door should not have been propped open. The best practice would have been for residents to have been supervised. All residents in the AACU should have been supervised when outdoors. There had been no policy regarding the supervision of a residents in the courtyard or propping doors open. If a door was locked the resident should have been accompanied outside. 2. Review of resident 2's medical record revealed she: *Had been admitted on [DATE]. *Had [DIAGNOSES REDACTED]. *Was at risk for falls with a score of 12 (a total score of 10 or above made the resident at risk). *Had fallen on 7/22/14 on the floor in front of her sink in her room. -She was found on the floor at 2:03 p.m. -That fall had been unwitnessed by staff. -Had been unresponsive for ten minutes after she had been found on the floor. -Had a laceration (break in the skin) to the back of her head, a bruise to her right elbow, and a skin tear to her left forearm. -Had discomfort to left shoulder reported. -Was taken to the emergency room by an ambulance at 2:15 p.m. Review of resident 2's 8/14/14 care plan revealed she: *Was at risk for falls related to impaired mobility/balance. *had a history of [REDACTED]. *Had impaired safety awareness. *Was to have been checked for wheelchair positioning frequently throughout each shift. *Was encouraged to always call for help when needed. *Was to have left her seat belt on as a reminder that it was for her own safety. Review of resident 2's 7/22/14 initial nursing facility event report required by and reported to the South Dakota Department of Health revealed: *She been been found on the floor in the room by the sink. *She had sustained an approximate two centimeter laceration to the back of head that had been bleeding profusely (excessively). *She went to the emergency room by ambulance where she had been evaluated for injuries. *She returned to the facility with no sutures (stiches) or report of further injuries. *She had an alarming seat belt on when up in her wheelchair that she could remove independently. *The alarm had not sounded when she had fallen. *Staff had stated awareness of the need to have punched the alarm 'on' when she had been transferred into the wheelchair. *The alarm light remained a constant blue on the personal alarm when the alarm was on. *Staff had found the blue alarm light had been blinking. *The battery changed the alarm light to a constant blue. *Staff had been educated on the need to have observed the alarm light to ensure the alarm was on when she was in the wheelchair. *Staff were to have reported if the light was blinking as that meant the battery needed to have been changed. Review of resident 2's physician's orders [REDACTED]. On 9/20/12 "TABS (a type of personal alarm system) Alarm for safety." *On 1/21/14 "Patient may continue to utilize Velcro seatbelt to improve positioning and safety. (Note patient is able to remove independently and on command)." *On 8/7/14 "Change battery to seat belt alarm q (every) 30 days every day shift every 30 day(s) for Prevention." *The above order on 8/7/14 was written after the resident had fallen on 7/22/14 and had sustained a major injury. Review of resident 2's treatment administration record revealed: *On 7/30/14 "Check seat belt alarm to ensure it is working properly Q (every) 2 hours while in wheelchair." *The above order on 7/30/14 was written after the resident had fallen on 7/22/14 and had sustained a major injury. Interview on 8/19/14 at 4:00 p.m. and on 8/21/14 at 10:30 a.m. with the director of nursing (DON) regarding resident 2's fall on 7/22/14 revealed: *She had been toileted at 11:00 a.m. *She had fallen at 2:00 p.m. *She had been taken to the emergency room after she had fallen. *Upon her return from the emergency room her personal alarm light had been blinking. *The battery had been changed at that time, it was no longer blinking, and it was a constant blue. *There was a nursing assignment care sheet used for communication to direct care staff regarding each resident's observation and condition changes. -She was currently listed on the care sheet with "Seatbelt alarms at ALL times (blue light must be on, not flashing)." -The DON reported the above had not been on the care sheet prior to her fall; it had been added after her fall on 7/22/14. *The DON agreed the seatbelt's blue light needed to have been more closely monitored and the battery changed on a regular schedule. -She confirmed the resident's personal alarm light had not been properly working. -She confirmed the alarm had not sounded prior to the resident's fall on 7/22/14 resulting in a major injury. -She confirmed the manufacturer's production information for the seatbelt alarm had not been followed. Review of the undated manufacturer's product sheet information for resident 2's Safe-tmate Alarmed Velcro Seatbelt revealed: *"Test the belt for proper operation. *Firmly press the switch to the ON position (blue LED light remains lit). *The alarm should sound as soon as the belt is separated." *The device was not a substitute for proper supervision. *Check fall risk patients frequently. *Change battery monthly. Interview on 8/21/14 at 11:00 a.m. with the administrator revealed the provider had no policy on personal resident alarms. Review of the provider's revised 2013 Falls Management Clinical Guidelines policy revealed at risk residents were identified through a "fall alert" communication system to caregivers.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (5 and 8) with a seat belt had remained free from physical restraints. Findings include: 1. Review of resident 5's September 2013 current active physician's orders [REDACTED]. Review of resident 5's 5/31/13 physician's orders [REDACTED]." Review of resident 5's 7/15/13 care plan revealed an intervention for as needed seat belt physical restraint to be utilized when interventions of toileting, offering food or snack, one to one visits, evaluating of pain were not effective for restlessness related to a [DIAGNOSES REDACTED]. Review of resident 5's progress notes revealed: *10/20/13 "Resident has two scratches across right breasts approximately 2.5 to 3 centimeters (cm) and 1/2 cm wide both areas scabbed with no redness or signs of infection will continue to monitor." *10/21/13 "Scratches to right breast are without signs and symptoms of infection. Upon observation seat belt hits resident at breasts and noted that some staff members are putting belt on to tight." *10/28/13 "Does have scab and scarring under right breast from seat belt rubbing." *11/4/13 "Resident has area on chest from rubbing of seatbelt on area." Review of resident 5's October and November 2013 treatment administration record (TAR) revealed: *Resident may have PRN seatbelt when interventions of toileting, offering food/snack, one-to-one visiting, evaluation of pain were non-effective for restlessness related to a [DIAGNOSES REDACTED]. *The above treatment had not been signed off as having been used in October through 11/6/13. Interview on 11/6/13 at 9:45 a.m. with certified nursing assistant (CNA) M revealed: *She had used the seat belt physical restraint on resident 5 when the resident had been trying to transfer herself onto her bed. *She did not have to consult with the nurse before using the seat belt physical restraint. *She had not documented the use of the seat belt physical restraint, because she did not have anywhere to document it. Review of resident 5's entire medical record revealed the physician and responsible party had not been notified regarding her scratches, scabbing, and scarring related to the use of the seat belt physical restraint. 2. Observation on 11/6/13 at 2:15 p.m. of resident 8 in her wheelchair in the day room revealed she had a seat belt around her waist. Observation and interview on 11/6/13 at 2:15 p.m. in the advanced Alzheimer's care unit with CNA N and O revealed: *They had come on duty at 2:00 p.m. *They had not known who had put the seat belt on resident 8. *They had not noticed the seatbelt had been on resident 8. *Resident 8 had not been exhibiting any behaviors for the use of a seat belt physical restraint. *They had been able to utilize physical restraints without consulting a nurse. Interview on 11/6/13 at 5:30 p.m. with LPN F revealed CNAs were able to put on a seat belt and lap buddy physical restraint without consulting with the nurse. Review of resident 8's 10/4/13 physician's orders [REDACTED]. Review of resident 8's November 2013 TAR revealed the above stated physician's orders [REDACTED]. Review of resident 8's entire medical record revealed no other documentation of the PRN seatbelt having been used. Interview on 11/6/13 at 2:00 p.m. with the Alzheimer's care director and the director of nursing revealed: *They would have expected the nurse to have assessed the need for the seat belt physical restraint before utilizing it. *CNAs were unable to assess the need for a seat belt physical restraint. *They would have expected the nurse to have signed off the use of the seat belt physical restraint on the TAR. *They would have expected nursing staff to have tried and documented other interventions before utilizing the seatbelt physical restraint. *They would have expected behaviors and interventions to have been documented in the resident's medical record. Review of the provider's Restraint Evaluation and Utilization Guideline revealed: *"If a restraint is utilized to treat a resident's medical symptoms, to prevent injury and promote the highest practicable level of independence careful evaluation will precede this decision." *"A restraint will not be applied for the purposes of discipline or convenience or when not required to treat the resident's medical symptoms. The least restrictive device will be used." *"Restraint utilization should be considered only if and when other alternatives practices have been attempted and ruled ineffective." *"The center will obtain a physician order [REDACTED]. -The medical symptoms for which the device is to be used. -Type of device to be used. -When the restraint is to be used. -How long it should be applied." *"The physician order [REDACTED]."

Based on observation, interview, record review, and policy review, the provider failed to ensure 1 of 2 residents (8) identified as having a seat belt physical restraint in the 11/7/13 survey and 1 of 5 sampled residents (28) had remained free from physical restraints in the acute Alzheimer's care unit (AACU) Findings include: 1. Observation on 12/30/13 at 2:15 p.m. of resident 8 in the AACU revealed she had been sitting in her wheelchair with her head down and eyes closed in the dayroom with a seat belt physical restraint. Review of resident 8's 12/22/13 physician's orders revealed an as needed (PRN) seat belt physical restraint when interventions of toileting, offering food/snack, one to one visiting, evaluation of pain are non-effective for restlessness. This had been related to a [DIAGNOSES REDACTED]. Review of her December 2013 treatment adiminstration record (TAR) revealed: *A PRN seat belt when interventions of toileting, offering food/snack, one to one visiting, evaluation of pain are non-effective for restlessness related to a [DIAGNOSES REDACTED]. *The above seat belt physical restraint had not been documented as being used in the entire month of December. Review of resident 8's 12/10/13 restraint/positioning device assessment revealed she had been unable to remove the seat belt on command. Review of resident 8's current care plan revealed: *A revised intervention on 3/27/13 for a PRN seat belt when interventions of toileting, offering food/snack, one to one visiting, evaluation of pain are non-effective for restlessness related to a [DIAGNOSES REDACTED]. *12/26/13 "Resident applies seat belt independently and removes at times will monitor." Review of resident 8's 12/4/13 quarterly Minimum Data Set assessment revealed a brief interview for mental status (cognitive assessment) score of 3 indicating severe cognitive impairment. 2. Observation on 12/30/13 at 2:15 p.m. of resident 28 in the dining room revealed she had a lap buddy (lap restraint) physical restraint on. Review of resident 28's 11/27/13 physicians order revealed "Use a lap buddy device for the patients safety." That order had not been clarified to include when or how often to use the device. Review of resident 28's December 2013 progress notes revealed she had removed her lap buddy and had fallen four times between 12/11/13 and 12/15/13. Review of resident 28's November and December 2013 TAR revealed: *No order for a lap buddy physical restraint in November. *an order for [REDACTED]. *12/14/13 through 12/31/13 resident may have PRN lap buddy when interventions of toileting, offering food/snack, one to one visiting, evaluation of pain are non-effective for restlessness related to a [DIAGNOSES REDACTED]. *Between 12/14/13 through 12/31/13 the lap buddy had been signed off as being used two times on 12/26/13 and 12/30/13. Interview on 12/30/13 at 5:40 with the AACU director revealed resident 28 has had the lap buddy physical restraint on since 11/27/13 anytime she is up in her wheelchair. 3. Interview on 12/30/13 at 5:20 p.m. with LPN K revealed: *She had signed resident 28's TAR that her lap buddy had been on at 3:17 p.m. when she noticed it was on the resident. *The aides had put resident 28's lap buddy on without informing her. *She had not noticed resident 8's seat belt had been on so she had not signed it as being on. *Resident 8 sometimes played with her seat belt and put it on by herself. 4. Interview on 12/31/13 at 2:00 p.m. with the administrator and director of nursing confirmed: *Lisenced nursing staff should have been evaluating the use of restraints and documenting them. *Resident 8 would sometimes incorrectly apply her seat belt by her self when she was playing with it. Review of the provider's revised 2013 Restraint Evaluation and Utilization Guideline revealed: *"If a restraint is utilized to treat a resident's medical symptoms, to prevent injury and promote the highest practicable level of independence. Careful evaluation will precede this decision." *"A restraint will not be applied to purposes of discipline or convenience or when not required to treat the resident's medical symptoms. The least restrictive device will be used." *"Restraint utilization should be considered only if and when other alternatives practices have been attempted and ruled ineffective." *"The center will obtain a physician order for [REDACTED]. -The medical symptoms for which the device is to be used. -Type of device to be used. -When the restraint is to be used. -How long it should be applied." *"The physician order alone is not sufficient to warrant the use of the restraint." *"The restraint is to be checked as frequently as needed in accordance with the resident's needs." *"Residents who have physical restraints are to be reevaluated quarterly or more often as directed by the needs of the resident. This evaluation is to focus on the potential for reduction and elimination based upon resident specific information and findings."