Every finding on record at Avantara Saint Cloud

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that the physician was promptly notified of a change in condition for review and recommendations to ensure prompt assessment and treatment for one of one sampled resident (1) identified to be vomiting and with increased weakness, by one of one registered nurse (RN) E. This failure resulted in resident 1 being transferred to the emergency room (ER) for evaluation and subsequent hospitalization. The provider also failed to notify the resident's first emergency contact of the resident's change in condition. Findings include:1. Review of the provider's submitted SD DOH FRI initial report regarding resident 1revealed that on the morning of 2/11/26, resident 1experienced three to four episodes of bile-colored vomit between 6:00 a.m. and 7:00 a.m. She appeared more tired, but she was able to vocalize her needs. Certified nurse aide (CNA) H notified the day nurse, registered nurse (RN) E, about resident 1's dry heaving and episodes of bile-colored vomit. RN E completed an initial assessment and obtained vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate). Resident 1's blood pressure was 128/57, pulse 81, temperature 97.1 F (degrees Fahrenheit), and oxygen saturation (amount of oxygen circulating in blood) ranged from 88 to 89 percent on room air. Her medications were held due to the dry heaving and vomiting episodes. She also experienced an incontinent (involuntary urine or bowel leakage) episode and requested to rest in bed that morning. CNA I, who worked the night of 2/10/26, stated resident 1 had no episodes of vomiting but noted she had increased weakness during the overnight hours and slept much of the night. RN E stated that resident 1 had no additional dry heaving or vomiting after 7:00 a.m. on 2/11/26. On Wednesday, 2/11/26, around 10:30 a.m., resident 1's granddaughter arrived at the nursing home, signed resident 1's discharge paperwork, and then went to her grandmother's room. The granddaughter noticed that resident 1 did not look well and asked RN E if she should be evaluated. RN E reassessed resident 1, took her blood pressure, which was documented as 89/57, and noted that resident 1 was more lethargic after sitting up in her wheelchair. The granddaughter called resident 1's assisted living facility, where she was to be readmitted to that day, and spoke with the executive director. Resident 1's granddaughter told the executive director that resident 1 was not feeling or looking well. The assisted living facility's executive director advised resident 1's granddaughter to take resident 1to urgent care or the ER for further evaluation before being readmitted to the assisted living facility.At approximately 11:00 a.m., CNA H assisted resident 1's granddaughter with transferring resident 1 into the granddaughter's personal vehicle. During the process, CNA H observed resident 1's condition worsening in the car and not responding. The granddaughter told CNA H that she was taking resident 1 to the ER. Resident 1 was evaluated at the ER and admitted to the hospital. 2. Review of resident 4396's electronic medical record (EMR) revealed that resident 1 was admitted to the facility on [DATE] for a rehabilitation stay after hospitalization, after she fell at her assisted living facility, which resulted in a fracture of her left femur. She was taking two 81-milligram (mg) tablets of aspirin two times daily as a blood thinner to prevent blood clots. Her last skin assessment, dated 2/10/26, identified no skin issues, and her last documented fall was unwitnessed on 1/18/26. Her neurological assessments were within normal parameters. Her last lab results from 12/19/25 indicated that her hemoglobin (a protein in red blood cells that carries oxygen from the lungs to the rest of the body) and hematocrit (the total percentage of blood volume composed of packed red blood cells) were mildly low. Her hemoglobin was 10.1 g/dL(grams per deciliter), and her hematocrit was 28.9% (percent). It was determined on 2/9/26 and 2/10/26 by the physician assistant-certified (PA-C) D at the facility and the director of nursing (DON) at resident 1's previous assisted living facility, that she was doing well and was appropriate for readmission to the assisted living facility on 2/11/26 at 11:00 a.m. Resident 1 was transferred to the ER upon her discharge from the facility on 2/11/26 and then hospitalized . Her CAT (CT) scan images revealed that she had an acute and chronic subdural hematoma (an old bleed in the brain that started bleeding again), a 12-millimeter (mm) meningioma brain mass (a type of brain tumor), a pulmonary embolism (a blockage in an artery of the lungs, usually caused by a blood clot), and cholecystitis (inflammation of the gallbladder caused by gallstones blocking the bile duct). There was no documentation indicating that the resident's first emergency contact or physician C was notified at the time of resident 1's change of condition on the morning of 2/11/26 while at the nursing home. 3. Interview on 3/18/26 at 11:15 a.m. with RN E regarding resident 1's change in condition revealed that RN E stated CNA H reported to her that resident 1's symptoms of dry heaving and bile-colored vomit occurred at approximately 7:10 a.m. on 2/11/26. RN E assessed resident 1, took her vital signs, and said they were within her baseline (the initial, normal measurements). She also said that resident 1 was left in her bed at that time with the head of the bed elevated. She was provided with a vomit bag and a call light, her morning medications were held, and the garbage can was placed next to her bed. RN E stated that around 8:30 a.m., she and CNA H assisted resident 1 with personal hygiene after she had an incontinent bowel episode. At that time, RN E stated that resident 1 appeared weak and pale in color and could not remain upright at the end of her care. Resident 1 asked to return to bed. RN E said she did not contact the physician or resident 1's first emergency contact at that time because she planned to discharge her later that morning to the assisted living facility and intended to update the family member when they arrived. She did not think to call the physician about resident 1's change in condition. RN E said that resident 1's granddaughter arrived between 10:30 a.m. and 11:00 a.m. for resident 1's discharge from the nursing home to the assisted living facility. RN E said that the granddaughter was concerned about her grandmother and said to RN E that resident 1 looked pale, didn't look well and questioned RN E whether resident 1 should be evaluated before being discharged from the nursing home and readmitted back to the assisted living facility. RN E said she reassessed resident 1 at that time and took resident 1's blood pressure, which was low at 89/57 and that resident 1 was more lethargic after sitting up in her wheelchair. RN E stated that the granddaughter was on her cell phone texting but was unsure who she was texting. RN E said she and CNA H escorted and pushed resident 1 to the nurse's station; by that time, the granddaughter was on her cell phone, talking to someone, though RN E was unsure who. RN E stated that around 11:00 a.m., she asked CNA H to help the granddaughter assist resident 1 into her private vehicle. CNA H returned to the nurse's station and reported to RN E that resident 1's condition appeared to have worsened and she became unresponsive after being assisted into the granddaughter's car. CNA H also told RN E that the granddaughter said she was taking resident 1 to the ER. RN E acknowledged that she did not call resident 1's physician and her first emergency contact when her condition changed, and she knew it was her responsibility to notify them promptly. She also recognized that she should have completed this before resident 1 was discharged from the facility. 4. Interview on 3/18/26 at 1:05 p.m. with administrator A and DON B revealed that administrator A and DON B stated that neither of them saw resident 1 the morning of her planned discharge from the nursing home on 2/11/26, and neither of them was aware of her change in condition. DON B said she was updated later that day by social services designee (SSD) J about the events that occurred that morning involving resident 1 and her transfer to the ER by her granddaughter after SSD J received a phone call from the hospital regarding resident 1. DON B notified administrator A, and together they contacted physician C, resident 1's facility doctor, and provided him with the information. Administrator A stated that RN E's employment was suspended on 2/11/26, received disciplinary action and education on the facility's notification of change policy, and her employment was reinstated on 2/20/26. Administrator A and DON B acknowledged that resident 1's doctor and first emergency contact were not contacted on 2/11/26 when resident 1's condition changed, and RN E should have notified them promptly on the morning of 2/11/26 before her discharge from the nursing home. 5. A telephone interview on 3/18/26 at 2:36 p.m. with physician C regarding resident 1's change in condition revealed that physician C stated resident 1 was taking aspirin twice daily as a blood thinner for blood clot prevention, which could increase the risk of brain bleeding but would not affect her pulmonary embolism. He said it was difficult to determine exactly what had happened with resident 1, but she had several chronic conditions that put her at risk. He added that she did not experience any recent fall or trauma, but her change in condition could have been due to being over-coagulated (a state where the blood is clotting excessively) from her recent hip surgery. He also stated that he or PA-C D should have been notified of her change in condition that morning before her discharge from the nursing home. 6. Interview on 3/18/26 at 3:16 p.m. with CNA I regarding resident 1's change in condition revealed that CNA I worked the night shift on 2/10/26 and finished his shift around 6:30 a.m. on 2/11/26. He said that resident 1 did not experience any dry heaving or vomiting during that shift. CNA I did not notice anything different or unusual with resident 1, except for some weakness, and stated that she slept most of the night. 7. A telephone interview on 3/18/26 at 11:50 a.m. was attempted with the granddaughter, and a voicemail was left to return a call; no return phone call was received during the survey. 8. A telephone interview on 3/18/26 at 12:58 p.m. with CNA H was unable to be completed as she was unavailable to interview due to a family death. 9. A telephone interview on 3/18/26 at 2:28 p.m. was attempted with PA-C D, and a voicemail was left to return a call; no return phone call was received during the survey. 10. Review of the provider's 12/1/2019 Registered Nurse (RN) Floor Nurse job description revealed the nurses were, Responsible for all nursing care of assigned Guests [residents] while on duty. Must notify appropriate persons if there is any significant change in a Guest's [resident's] condition or any transfer to a hospital, and Communicates and interacts effectively and tactfully with Guests [residents], visitors, families, peers, and supervisors. 11. Review of the provider's 11/18/25 Notification of Change of Condition policy revealed, The facility must promptly inform the resident; consult with the resident's medical provider; and notify, consistent with his or her authority, the resident representative(s) when: A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 12. Review of the provider's 4/28/25 Discharge and Transfer of Residents/Bed Hold policy revealed the facility was, To ensure a safe transition is planned for any resident with a discharge or transfer to another setting. To ensure adequate care is given to any resident with a change in condition. If the resident's needs change during the discharge planning process, the discharge plan may be updated to address the resident's needs. If the location of discharge does not meet the resident's needs and preferences and does not provide needed support and resources, do not proceed with discharge and contact the resident's medical provider.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that physician orders for an antibiotic, a medicated nebulizer (a device that converts liquid medication into an inhalable mist) treatment, and cough syrup were transcribed and initiated by one of one registered nurse (RN) F which resulted in a delay of treatment for one of one sampled resident 2, which potentially contributed to his transfer to the emergency room (ER). 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 3/4/26 submitted SD DOH FRI report regarding resident 2 revealed that on 3/3/26, RN F reported that resident 2 was experiencing symptoms of cough and congestion to physician assistant-certified (PA-C) D. PA-C D then saw (evaluated) resident 2 at the facility. PA-C D reported to RN F and the director of nursing (DON) B that resident 2 should continue to be monitored. PA-C D did not report to either RN F or DON B that she was starting resident 2 on an antibiotic or other medications for his cough and congestion, nor did she enter the orders into the resident's electronic medical record (EMR) in the nursing home's computerized medical record system on 3/3/26. On 3/4/26 at 11:00 a.m., resident 2 went out to lunch with his family and returned at approximately 1:00 p.m. Upon his return to the facility, the nursing staff observed that he had an acute (urgent) change in condition with altered mental status. He was sent out to the ER for evaluation at approximately 2:15 p.m. and was admitted to a hospital with diagnosed sepsis (an infection that triggers a chain reaction that causes the immune system to stop fighting germs and start damaging the body's own organs) related to pneumonia, elevated troponin level (a blood marker indicating damage to the heart muscle), acute kidney injury (a sudden, often reversible, drop in kidney function), acute encephalopathy (a sudden, temporary brain dysfunction causing rapid onset of altered mental status), and metabolic acidosis (a condition where blood becomes too acidic). When resident 2 was getting prepared to be discharged to the ER, licensed practical nurse (LPN) G logged into the nursing home's HUCU messaging system (a secure messaging channel system) on 3/4/26 between 1:00 and 2:15 p.m. to send a notification to resident 2's primary care provider about his status and transfer to the ER. LPN G then discovered that PA-C D had entered orders into the HUCU messaging system for resident 2 on 3/3/26 at 12:16 p.m. The orders revealed that resident 2 was prescribed an antibiotic, a medicated nebulizer treatment, and cough syrup on 3/3/26. It was then discovered, on 3/4/26, approximately 24 hours later, that PA-C D's orders had not been transcribed or initiated by the day nurse, RN F, on 3/3/26. RN F did not log in to the HUCU messaging system to check for orders for resident 2 after receiving the verbal report from PA-C D to monitor him. RN F stated that resident 2 had no additional acute needs during her shift on 3/3/26 and did not inform the night shift of any new medications. The HUCU messaging system did not alert nurses when orders or messages were sent, and the only way to know if there was an order or message was to log in manually and check. There was a progress note in resident 2's EMR that was completed by PA-C D on 3/3/26 at 12:16 p.m., which documented resident 2's orders for his antibiotic, the medicated nebulizer treatment, and cough syrup. A medication error report was completed by DON B on 3/4/26 related to RN F's medication error for resident 2 on 3/3/26. RN F was called and notified by DON B of resident 2's orders, transfer, and the new process and procedure that would be put into place for the HUCU messaging system and physician visits. Physician C was notified on 3/4/26 of RN F's medication error report regarding resident 2. Resident 2 returned to the facility on 3/9/26, stable and back at his baseline health status. 2. Review of resident 2's EMR revealed that he was admitted to the facility on [DATE]. His diagnoses included pneumonia, severe sepsis, acute cough, upper respiratory infection, and vascular dementia (a decline in thinking and memory skills caused by reduced blood flow to the brain, which damages brain cells). His 1/4/26 Brief Interview for Mental Status (BIMS) assessment score was 8, which indicated his cognition was moderately impaired. Resident 2's immunizations for the pneumonia vaccinations were up to date, his emergency contact was his niece, and he was sent to the ER on [DATE] and diagnosed with pneumonia. He returned to the facility that same day and was treated with a five-day course of Azithromycin (an antibiotic), which was completed on 2/15/26. Resident 2 was discharged from the nursing home to the hospital on 3/4/26 and returned to the nursing home on 3/9/26 with no continued orders for antibiotic treatment. 3. Interview on 3/18/26 at 12:17 p.m. with LPN G revealed that she was working the day shift on 3/4/26. She stated that resident 2 appeared to be at his baseline when she saw him at the nurse's station before he left the facility with family to go out for lunch. She said that he left the facility around 11:00 a.m. with his stepdaughter and returned at approximately 1:00 p.m. LPN G reported that a CNA, whose name she could not recall, told her around 1:20 p.m. that resident 2 was weak and not responding. LPN G entered resident 2's room and found him seated in his recliner. She said he was sluggish, non-verbal, and not responding to her commands. She quickly tried to contact resident 2's niece, his emergency contact, but she did not answer. She contacted his son, resident 2's second-listed emergency contact, and he agreed to send resident 2 to the ER for evaluation. LPN G acknowledged that the orders entered for resident 2 by PA-C D on 3/3/26 were neither transcribed nor initiated, and was unsure how they were overlooked. 4. A telephone call on 3/18/26 at 12:27 p.m. was placed to resident 2's niece, a voicemail was left for her to return the call; no return call was received during the survey. 5. Interview on 3/18/26 at 1:05 p.m. with administrator A and DON B regarding resident 2's physician orders that were not transcribed or initiated revealed that both administrator A and DON B stated they were unaware that resident 2 was not feeling well with cold and congestion symptoms on 3/3/26. DON B stated that PA-C D passed by her near the nurse's station after evaluating resident 2 and told DON B that we will continue to monitor him [resident 2]. DON B reported that PA-C D did not inform her at that time that PA-C D was going to prescribe resident 2 an antibiotic or any other medication. Administrator A stated that on 3/4/26, LPN G discovered that PA-C D had entered orders for resident 2 into the HUCU messaging system. Additionally, a progress note was completed in the nursing home's computerized medical record system for resident 2, indicating the medications PA-C D wanted to initiate for the resident 2. Administrator A noted that providers (such as physicians and PA-C's) often send orders and messages through the HUCU messaging system, but nursing and management staff were unsure when those orders or messages would be sent or when the physicians would complete their progress notes in the nursing home's computerized medical record system for the nurses to refer to. Both Administrator A and DON B stated that physicians did not use the nursing home's computerized medical record system to enter resident orders, which made it difficult for the nursing staff to track orders in the resident's progress notes. Both Administrator A and DON B stated that it was inconvenient for nurses to routinely log in to the HUCU messaging system throughout their shifts to check for physician orders. Administrator A stated that they identified the issue and, about six months ago, created a new area in the HUCU system for physician orders during resident visits. After the medication error on 3/3/26, the facility developed a new written procedure for nurses to conduct secondary checks of the HUCU messaging system and for written orders related to physician facility visits, and nurse education began on 3/6/26. Nurses were required to complete the education prior to working their next scheduled shifts. 6. A telephone call on 3/18/26 at 2:28 p.m. was placed to PA-C D; a voicemail was left for her to return the call; no return call was received during the survey. 7. Interview on 3/18/26 at 3:25 p.m. was attempted with resident 2; this was unable to be completed due to his dementia, as he could not answer simple questions; he jumped from one thought to another, and he exhibited a nonsensical mixture of words. 8. RN F was not available for an interview, and no phone number for her was provided by the end of the survey. 9. Review of the provider's 3/4/26 through 3/6/26 audit information for 3/2/26 through 3/4/26 showed that all resident charts were reviewed for new physician orders. They also conducted an audit of physician facility visits with resident orders from 2/3/26 to 3/4/26. This information was reviewed, and no further errors were found. It was confirmed that resident 2's orders on 3/3/26 were not documented in the nursing home's computerized medical record system but entered into the HUCU messaging system by PA-C D. There were no physician orders, neither transcribed nor initiated by RN F, on 3/3/26 for resident 2. 10. The completion of the nurse's education materials and signature sheet was confirmed on 3/18/26. The education signature sheet indicated that RN F completed the education review before her next scheduled shift on 3/16/26. She signed the signature record form, which indicated she understood the new physician order process and procedure. 11. Review of the provider's 12/1/2019 Registered Nurse (RN) Floor Nurse job description revealed the nurses were to Administer medications within the scope of practice of the RN Licensure, and Place pharmacy orders, for and administer all newly prescribed medications and document. 12. Review of the provider's 11/18/25 Following Physician Orders policy revealed that nurses were to, Correctly and safely receive and transcribe physician's orders so correct order is followed/administered, and the Orders may be received through written communication in the resident's chart, verbally, by fax, electronically entered into PCC [PointClick Care], or per the telephone. 13. The provider's implemented actions to ensure that the deficient practice does not reoccur were verified on 3/18/26 after record reviews and interviews revealed that the facility had followed its quality assurance (QAPI) process regarding medication errors and held a nursing and management meeting on 3/6/26 regarding physician orders and physician facility visits. If staff could not attend, they were expected to review the information and sign the education signature sheet before their next scheduled shift. Audits were conducted, and the audit results are planned to be reported to the quality assurance committee at their scheduled monthly meetings for four months or until compliance is achieved. Based on the above information, non-compliance at F726 occurred on 3/4/26, and based on the provider's 3/6/26 and additional corrective action plans implemented for the deficient practice confirmed on 3/18/26, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of one observed certified nursing assistant (F) who assisted three of three sampled residents (62, 56, and 22) with eating during one of one observed noon meal service. *One of one observed licensced practical nurse (E) who assisted two of two sampled residents (1 and 38) with eating during one of one noon meal service. Findings include: 1. Observation on 1/25/26 at 11:53 a.m. in the main dining room during the noon meal revealed: *Resident 62, 56, and 22 sat at the same dining table (table 6). *Certified nursing assistant (CNA) F helped resident 62 apply a clothing protector, moved her wheelchair closer to the dining room table, and locked resident 62's wheels. *Without washing or sanitizing her hands, CNA F went to the serving counter and picked up two meal plates and served them to the residents. She returned to the serving counter and used an alcohol-based hand rub (ABHR) to sanitize her hands. She picked up two meal plates and served them to two other residents. *CNA F then sat down at a chair in between resident 56 and resident 62 and gave resident 62 a bite of food with her right hand. *CNA F stood up and adjusted resident 62's wheelchair. She removed the leg supports from the wheelchair and placed them in a storage bag on the back of that wheelchair. CNA F sat back down and readjusted resident 62's wheelchair closer to the dining table. *Without sanitizing her hands, CNA F scooped a bite of food on a spoon with her right hand. She gave resident 62 that bite of food and placed the spoon back on resident 62's plate. -CNA F then scooped a bite of food on a spoon from resident 56's plate and gave it to resident 56 with her right hand. -Without washing or sanitizing her hands, CNA F scooped a bite of food on a spoon from resident 62's plate and gave it to resident 62 with her right hand. Without washing or sanitizing her hands, she gave resident 56 a bite of food with her right hand. *Resident 22 started to back away from the dining table. CNA F got up, moved him back to the table and encouraged him to eat. Without washing or sanitizing her hands, she used her right hand to give resident 22 a bite of food. -CNA F continued that same pattern while she helped residents 62, 56, and 22 to eat their meals without washing or sanitizing her hands between assisting each of those residents. 2. Observation on 1/25/26 at 12:17 p.m. in the main dining room during the noon meal revealed: *Licensed practical nurse (LPN) E was sitting in between residents 1 and 38 at table 3. *LPN E used her right hand and gave resident 1 a bite of food. *Without washing or sanitizing her hands, she gave resident 38 a bite of food with her right hand. *LPN E continued that pattern three more times while she helped residents 1 and 38 eat their meals without washing or sanizing her hands between assisting each of those residents. 3. Further observation on 1/25/26 at 12:32 p.m. in the main dining room revealed: *CNA F remained seated at table 6. She stood up was still at the dining table with resident 62, 56, and 22. *CNA F remained seated at table 6. She stood up and walked over to the side of the table where resident 22 sat in his wheelchair. CNA F moved resident 22's plate to the side and used two forks to gather several pieces of food that had fallen off the resident's plate onto the table into a pile on the table. *CNA F scooped up that food pile with those two forks and then assisted resident 22 with eating that same food. 4. Interview on 1/27/26 at 1:36 p.m. with CNA F revealed: *She acknowledged that the table was not a clean surface and it is not her normal practice to feed residents food that fell onto the table. 5. Interview on 1/27/26 at 1:50 p.m. with administrator A revealed: *She expected the staff to wash or sanitize their hands after providing any care to a resident or after touching personal equipment such as wheelchairs. *She expected the staff to discard food that fell off a resident's plate into the trash can and not to serve it to the resident. 6. Interview on 1/27/26 at 2:01 p.m. with director of nursing (DON) B and registered nurse (RN) regional clinical consultant D revealed: *Staff were expected to wash or sanitize their hands before and after providing resident care and in between assisting each resident with eating. *They both expected staff to wash or sanitize their hands after moving or manipulating a resident's wheelchair. *They stated that the dining room table was not a clean surface and the residents should not be given food off of that surface to eat. 7. Review of the provider's 5/15/25 Hand Hygiene policy revealed: *All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *Hand hygiene consists of using alcohol-based hand rub or washing at a sink with soap and water. *Staff were expected to perform hand hygiene before and after direct contact with residents, before and after eating or handling food, after contact with a resident's intact skin, and after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.

Based on observation, interview, and policy review, the provider failed to ensure medications and biologicals were labeled, stored, and discarded regarding:*Expired medications and supplies were discarded in two of two observed storage rooms.*One of one medication cart that was left unattended and unlocked by one of one registered nurse (RN) (I) in the dining room, where residents, unauthorized staff, and visitors could access it. *Medications with shortened expiration dates (medications that expire in a timeframe after opening that is prior to the manufacturer's expiration date) stored in one of one medication carts were labeled when they were opened. Findings include:1. Observation on 1/26/26 at 1:52 p.m. in the main storage room revealed: *One box of a three-layer compression bandage system [bandages layered to provide sustained and cushioned compression for treating venous issues such as leg wounds with swelling) that expired on 9/6/24. *One box of Optifoam AG Nonadhesive Dressing with Antibacterial Silver (non-stick dressing infused with silver to act as an antibacterial agent) that expired on10/3/24.*Two boxes of Opticell Chitosan-Based Gelling Fiber (dressing with absorbent fibers that gel when soaked with wound drainage) that expired on11/21/24. *A plastic storage container filled with nine individually packaged lemon-flavored glycerin swab sticks (disposable, single-use, cotton swabs to moisten, clean, and refresh the mouth) that expired on 2/25. *A plastic storage container filled with catheter (a flexible tubing placed in the bladder to drain urine) urine collection leg bags (a bag that can strap to the leg) that expired on 10/23. *There was a metal shelf in the main storage room with an individually packaged Lidocaine 5% medicated patch (for pain) on it. 2. Observation and interview in the dining room on 1/27/26 at 8:27 a.m. with RN I revealed: *The medication cart was placed near the entrance to the dining room. RN I was across the room with her back to the medication cart, administering medications to a resident. *Multiple staff members and residents were in the dining room and walked past the medication cart. *The unattended medication cart was unlocked and accessible to any resident, unauthorized staff, or visitor who passed by. *RN I acknowledged that she did not lock the medication cart and was not directly observing it. *She should have locked the cart before she left it unattended. *She stated she usually locked the cart before walking away from it. 3. Interview on 1/27/26 at 11:53 a.m. with Administrator A in the main storage room revealed: *She acknowledged that there were various supplies in the storage room that were expired based on the manufacturer's printed expiration date on the packages. *She was disappointed because the staff were to be performing audits on the supplies and discarding expired supplies. *She stated that the specialized wound care dressings (with silver and chitosan-based gelling fiber) were no longer effective if they were past the manufacturer's printed expiration date. *She thought that the Lidocaine 5% patch on the shelf belonged to a resident. She would remove the medicated patch from the room and dispose of it. 4. Observation and interview on 1/27/26 at 2:10 p.m. with assistant director of nursing (ADON) C in the small storage room revealed: *Eight of eight sterile catheter insertion kits expired on 10/31/25, and one of those kits was opened. *ADON C confirmed that those kits were expired and should not be available for use. *She thought the opened kit was used for training and stated it should have been labeled Training. *Medical records director J was responsible for removing outdated supplies from the small storage room. 5. Observation and interview on 1/27/26 at 2:41 p.m. with director of nursing (DON) B of a medication cart in the main storage room revealed: *Resident 61' s Lispro (rapid-acting insulin) was not dated to indicate when it was opened. *Resident 61's Lantus (long-acting insulin) was not dated to indicate when it was opened. *DON B was aware that those medications had shortened expiration dates, based on the date they were opened, and confirmed there was no date to indicate when they were opened. *She was unable to tell if or when the medications were expired since they were not labeled with the date they were opened. *Resident 73's nystatin-triamcinolone (a medication used to treat fungal skin infections and reduce inflammation) expired on 9/30/25. *She confirmed that medication was expired, and should have been removed from the medication cart and discarded. 6. Interview on 1/27/26 at 3:45 p.m. with DON B regarding the observation of the unattended, unlocked medication cart in the dining room revealed that she expected the staff to lock the medication carts before they walked away from them. 7. Review of the provider's September 2018 Medication Administration General Guidelines policy revealed: *Medication Administration: -Check expiration date on package/container. No expired medication will be administered to a resident. --The nurse shall place a 'date opened' sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. --Certain products or package types . have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. -During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. Review of the provider's September 2018 Storage of Medication policy revealed: *Policy -Medications and biologicals are stored properly, following the manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. *Procedures -In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. -Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. -Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. -Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken. Review of the undated List of Medications with Shortened Expiration Dates that the provider used for reference revealed: *Lispro should be discarded 28 days after opening. *Lantus should be discarded 28 days after opening. An Outdated Supplies policy was requested, but no policy specific to outdated supplies was provided by the end of the survey.

Based on observation, interview, record review, and policy review, the provider failed to ensure staff followed professional standards of practice regarding the respiratory care for one of one sampled resident (78), who received oxygen when he previously resided at a hospital from [DATE] through his admission to the provider's facility on 1/21/26, when staff failed to clarify and provide the resident's oxygen needs. Findings include:1. Observation and interview on 1/25/2026 at 1:49 p.m. with resident 78 in his room revealed:*He was sitting in his recliner chair with an oxygen concentrator machine (a device that filters room air into purified oxygen) stored between the chair and his bed. *There was a plastic storage bag attached to the oxygen concentrator machine, which had 1/26/26 and initials handwritten on it in black ink.*An unopened package of Procure brand seven-foot nasal cannula (a flexible tube with two prongs inserted into the nostrils to deliver oxygen) was sitting on his bedside table. *He thought he used oxygen, but did not know how often. 2. Review of resident 78's electronic medical record (EMR) revealed:*He admitted to the facility on [DATE] from a hospital.*His diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), and dementia (a group of symptoms affecting memory, thinking, and social abilities).*His 1/27/26 Brief Interview for Mental Status (BIMS) assessment score was 7, which indicated he had severe cognitive impairment.*The hospital progress note from the physician dated 7/31/25 at 3:12 p.m. revealed:-He was to use 3L [3 liters of] O2 [oxygen] via NC [nasal cannula] at bedtime. *His discharge orders from the hospital dated 1/14/26 by the physician did not discontinue his admitting hospital order for oxygen dated 7/31/25.*The hospital physician's progress notes revealed that resident 78 had no new, changed, or discontinued oxygen orders. *An admission nursing note dated 1/21/26 at 1:25 p.m. regarding resident 78 read, He wears oxygen at 3 liters at night.*His oxygen saturation (percentage of oxygen in the blood) levels were documented twice since his admission to the facility and were at 92% (percent) on 1/21/26 at 11:44 a.m. and 95% on 1/25/26 at 6:09 a.m., both while on room air (without oxygen). 3. Resident 78's 1/21/26 baseline care plan revealed:*A focus area of: Alteration in respiratory functioning related to COPD.*The goal for that focus area was: He [resident 78] will not have respiratory distress, and his respiratory functioning will improve or maintain through the next review.*The interventions were:-Administer oxygen and other medications and respiratory treatments as ordered.-Assess respiratory status: Observe for shortness of breath, check lung sounds, call MD [doctor] for any changes and/or abnormalities.-Elevate head of bed as needed.-Keep call light within reach. 4. Interview on 1/26/2026 at 3:23 p.m. with certified nursing assistant (CNA) H revealed: *She did not know why resident 78 had an oxygen concentrator machine or why the unopened oxygen tubing was not connected to it. *She was unsure if he needed to wear oxygen or what his oxygen instructions were, but she would ask the nurse. 5. Interview and observation on 1/26/2026 at 3:25 p.m. with licensed practical nurse (LPN) G in resident 78's room revealed: *Resident 78 was sitting in his recliner chair.*The unopened nasal cannula tubing package remained on his bedside table. *She thought the hand-off report (communication of transferring residents' information) received from the hospital nurse and the provider's nurse indicated that resident 78 was to receive 3 liters (L) of oxygen at night.*She stated that she would have to check his orders.*She asked resident 78 if he used oxygen, and he stated, Yes, yes, I do. *She acknowledged there was an oxygen concentrator machine in the resident's room with no oxygen tubing connected to it, and an unopened package of nasal cannula tubing on his bedside table. 6. Interview on 1/26/2026 at 4:17 p.m. and again at 4:31 p.m. with LPN G revealed:*Resident 78 did not have physician's orders for oxygen use. *She stated that she called resident 78's daughter who thought the resident was to receive oxygen at night.*LPN G received an oxygen order for resident 78 from his previous hospital physician.-She [physician] indicated he was to have oxygen administered at a rate of 3 liters per minute through a nasal cannula every night. *She thought his oxygen needs were not clarified during the hand-off report when he was admitted to the facility, and he did not receive oxygen at night since his admission on [DATE]. 7. Interview and record review on 1/26/2026 at 4:42 p.m. with director of nursing (DON) B revealed:*She confirmed the hand-off report from the hospital nurse to the provider nurse indicated that resident 78 was to receive 3 liters of oxygen at night.*She stated that if any details in the nurse hand-off report between the two facilities were unclear, the nursing staff should have clarified them with resident 78's physician.*She acknowledged that resident 78's 7/31/25 admission progress note from his physician at the hospital had an oxygen order that read, use 3L [liters] O2 [of oxygen] via NC [nasal cannula] at bedtime. *She acknowledged resident 78's 1/21/26 admission nurse's note read, He wears oxygen at 3 liters at night.*She confirmed there was no current physician order for resident 78's oxygen use. 8. Interview on 1/27/2026 at 1:50 p.m. and again at 3:30 p.m. with director of nursing (DON) B revealed:*She stated that resident 78 may not have received oxygen at night since his admission on [DATE].*The facility didn't have a policy regarding the nurse hand-off reporting.*She stated that the staff followed the nurse hand-off reporting process indicated in the Fundamentals of Nursing book. 9. Interview on 1/27/2026 at 5:15 p.m. with administrator A revealed:*The facility didn't have a policy regarding nurse hand-off reporting. *She expected the nursing staff to follow the physician's order policy. *She acknowledged that the hand-off report between the nurses indicated that resident 78 was to be on 3 liters of oxygen at night. *She acknowledged that the provider's 1/21/26 admission nurse's note at 1:25 p.m. for resident 78 read, He wears oxygen at 3 liters at night. *She acknowledged that resident 78's 1/21/26 baseline care plan indicated needed oxygen at night.*She expected the nurse who received the hand-off report to notify resident 78's physician to clarify his oxygen needs upon his admission to the facility.*She agreed there was no document to support that resident 78 received oxygen for four nights. 10. Review of the providers Fundamentals of Nursing, Tenth Edition, Copyright 2021 by Elsevier Inc. revealed:*Hand-off reporting was a real-time process.*Offers accepting provider to clarify and confirm important details about a patient's [resident's] plan of care, patient progress, and continuing needs during the transfer of information.*The report should include accurate, up-to-date, and pertinent information to the next nurse assuming patient [resident] care.*Hand-off report is to ensure continuity of care for a patient [resident] and prevent errors or delays in providing nursing interventions. 11. Review of the provider's revised November 18, 2025, Following Physician Orders policy revealed:*To correctly and safely receive and transcribe physician's orders so correct order is followed/administered.*All physician's orders will be received by a licensed nurse, therapist, or dietician.*Orders may be received through written communication in the resident's chart, verbally, by fax, electronically entered into PCC, or per the telephone.*New admission/readmission physician orders and all transcription of orders should be transcribed by a nurse and be double checked by a second nurse to ensure that all steps have been carried out to avoid errors.*All physician orders should be followed as written. The prescriber should be contacted if any order is not clear/understood. 12. Review of the provider's revised November 18, 2025, Oxygen Administration policy revealed:*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).

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interview, the facility failed to protect the resident's right to be free from neglect by having failed to ensure the safety of one of one sampled resident (1) who sustained femur (thigh bone) fractures after being transferred from her wheelchair to her bed by two of two certified nursing assistants (D and E) who did not follow her care plan or the facility's policy for gait belt (a waist strap gripped as support for safe mobility and transfers) use; and by one of one licensed practical nurse (LPN) C who did not perform a physical assessment of resident 1 after being notified by CNA D and CNA E of the transfer. The failure of the CNAs to follow resident 1's care plan and the provider's policy regarding the use of a gait belt when transferring a resident may have resulted in the fractures to both of her femur bones. This citation is considered past non-compliance based on the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 7/28/25 SD DOH FRI revealed:*On 7/27/25, CNA D and CNA E were transferring resident 1 with a sit-to-stand mechanical lift (a mechanical lift used to assist from a seated to a standing position) when her knee moved.-They lowered her to her wheelchair, notified LPN C, and assisted resident 1 to her bed from her wheelchair, without the use of a sit-to-stand mechanical lift or gait belt (a waist strap gripped as support for safe mobility and transfers).*LPN C did not assess resident 1 for pain throughout that night.*On 7/28/25 at approximately 12:30 p.m., LPN F was called to resident 1's room by CNA G as resident 1's right lower leg was flaccid [limp], painful and she was clammy and shaking.*Resident 1 was sent to the emergency department to be evaluated.*An investigation was initiated by the provider, and it was discovered that resident 1 was transferred from her wheelchair to her bed by a two-person pivot assist transfer [when assisted to a standing position, the resident then turns their body to move to another surface] by CNAs D and E, without the use of a gait belt, which was not following her [resident 1's] care plan [personalized plan that addresses a resident's care needs, goals, and interventions].*CNA D and CNA E were suspended for not following resident 1's care plan.*LPN F was suspended for not assessing resident 1 after being informed that her knee had moved in the lift as she did not feel it was presented to her as being emergent. 2. Review of the provider's final report for the 7/28/25 SD DOH FRI regarding resident 1 revealed:*During the investigation into the incident, CNA D and CNA E indicated they had been in the process of transferring resident 1 from a sit-to-stand lift when her right leg slipped backwards off the lift platform, where her feet would have been. They then lowered her into her wheelchair and transferred her from the wheelchair to her bed without the use of a gait belt.*They notified LPN C of the transfer, and she did not complete an assessment of resident 1.*On 7/28/25, LPN F and registered nurse (RN) J assessed resident 1, and found her left knee flaccid, slightly smaller in length than the right knee, and Nontender to palpation other than directly over bilateral kneecaps.*Resident 1 was transferred to the emergency department on 7/28/25. Imaging was completed at the hospital, which indicated resident 1 had fractures of both femur (thigh) bones, the right fracture was near the knee replacement prosthesis. 3. Review of resident 1's electronic medical record revealed:*Her date of admission was 8/10/21.*Her 6/6/25 Brief Interview of Mental Status assessment score was a 0, which indicated she had severe cognitive impairment.*Her diagnoses included: Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), type 2 diabetes (a condition involving disruptions in how the body regulates blood sugar), morbid obesity (excessive weight that significantly impacts health and well-being), venous insufficiency, anxiety, contractures of the right and left knees, and fractures of her left and right femur bones.*Her 7/27/25 care plan included Transfers with sit to stand [mechanical lift]. Review of resident 1's nurse progress notes revealed:*No nurse progress note included resident 1's 7/27/25 transfer from her wheelchair to her bed by CNA D and CNA E, or that they reported the incident to LPN C.*On 7/28/25, she was transferred to the emergency department for pain in her legs. The transfer form revealed she was transferred as her right front knee as very painful, swollen, flaccid.*On 7/29/25, resident 1 returned to the facility. *On 7/30/25, she was placed on hospice care (provide care and comfort during the final months of a patient's life).*On 8/1/25, resident 1 passed away at the facility. Review of resident 1's 7/28/25 hospital notes revealed she had a fracture of her left femur and a fracture of her right femur that included angulation (a broken bone that tilts at an angle) of the bone fragments. 4. ­­­­Interview on 8/13/25 at 4:02 p.m. with administrator A, director of nursing B, assisting administrator H, and regional nurse consultant I regarding the 7/28/25 SD DOH FRI revealed Administrator A confirmed that the investigation into resident 1's right and left fractured femurs substantiated (proved) neglect by CNA D and CNA E for not following resident 1's care plan and the provider's policy regarding the use of a gait belt during transfers. It also substantiated neglect by LPN F for not completing a physical assessment of resident 1 after being notified of resident 1's transfer by CNA D and CNA E. Their investigation revealed the sit-to-stand lift had been used correctly and had not malfunctioned.5. Substantial compliance was confirmed on 8/13/25 after interview and record review revealed the facility had followed their quality assurance process; initiated a performance improvement project, started an audit of resident transfers for appropriate technique, and an audit of significant changes in resident care needs were reported through interviews and medical record reviews; provided education to all staff regarding abuse and neglect, gait belt use, mechanical lift use, and reporting of incidents; completed staff competencies for the use of sit to stand lifts; and staff interviews confirmed knowledge of the above.Based on the above information, non-compliance at F600 occurred on 7/27/25, and based on the provider's 8/5/25 implemented corrective actions confirmed on 8/13/25 for the deficient practice, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) complaint intake, interview, report review, facility assessment review, and policy review, the provider failed to ensure daily posted staffing information was updated to reflect the actual number of nursing staff and the hours those staff had worked on three of four overnight shifts reviewed. Findings include: 1. Review of the 6/23/25 SD DOH complaint intake report revealed the complainant was concerned there is not enough staff to care for the residents. The complainant wished to have their identity protected. 2. Interview on 7/3/25 at 9:20 a.m. with the complainant revealed: *The complainant had assumed the overnight shift was short-staffed because there were constant [job] postings for that shift. -The complainant was not able to provide specific dates or times when it was thought the overnight shift had been short-staffed. 3. Review of the provider's 6/25/25 facility assessment revealed one to two licensed nurses were needed during the overnight shift to ensure the needs of the residents had been met. Three to four CNAs were needed during the overnight shift to ensure the needs of the residents had been met. 4. Interview on 7/3/25 at 11:00 a.m. with an anonymous staff person D revealed: *Many nights there was only one licensed nurse and two certified nurse aides (CNA) who had worked the overnight shift to care for 75 residents. -June 15, 2025 was the last time that staff person recalled that had occurred. 5. Review of the provider's 6/14/25 through 6/17/25 daily posted staffing information for the overnight shift revealed: *Those postings had included the type of direct care staff, the number of those staff who had worked the overnight shift, and the amount of hours each of those staff had worked during those shifts. *On 6/14/25: -Two licensed practical nurses (LPNs) had each worked a twelve-hour shift (from 6:00 p.m. to 6:00 a.m.). -Three CNAs had each worked an eight-hour shift (from 10:00 p.m. to 6:00 a.m.). *On 6/15/25: -Two LPNs had each worked a twelve-hour shift. -Four CNAs had each worked an eight-hour shift. *On 6/16/25: -Two LPNs had each worked a twelve-hour shift. -Four CNAs had each worked an eight-hour shift. *On 6/17/25: -Two LPNs had each worked a twelve-hour shift. -Four CNAs had each worked an eight-hour shift. 6. Interview on 7/2/25 at 1:30 p.m. with administrator A and review of the provider's 6/14/25 through 6/17/25 overnight staff's time sheets compared with the above daily posted staffing information revealed: *On 6/14/25: -One LPN had worked her twelve-hour shift. A second LPN had left her twelve-hour shift at 11:42 p.m. and had not returned to work that night. -Four CNAs had each worked their eight-hour shift. *On 6/15/25: -One LPN had worked her twelve hour-shift. A second LPN had left her twelve-hour shift at 8:43 p.m. and had not returned to work that night. -Two CNAs had each worked an eight-hour shift. -A third CNA had left her eight-hour shift at 11:19 p.m. and she had not returned to work that night. -Three additional CNAs had arrived between 5:11 a.m. and 5:30 a.m. to support the overnight staff and the oncoming day staff in providing care for the residents. -One unlicensed medication aide had arrived at 4:21 a.m. to support the overnight staff and the oncoming day staff in providing care for the residents. *On 6/16/25: -Two LPNs had each worked a twelve-hour shift. A third LPN had left her twelve-hour shift at 9:21 p.m. and she had not returned to work that night. -Four CNAs had each worked an eight-hour shift. *On 6/17/25: -Two LPNs had each worked a twelve-hour shift. -Four CNAs had each worked an eight-hour shift. *Administrator A confirmed the posted staffing information for 6/14/25, 6/15/25, and 6/16/25 had not been updated to reflect the staffing changes that were made for those overnight shifts. Continued interview with administrator A regarding the process for completing the daily staff posting information revealed: *It was the responsibility of the staffing coordinator to have completed any updates to the original daily posted staffing information, but there had been no staffing coordinator since April 2025. The unit manager had assumed that responsibility until she had left at the end of May 2025. *Administrator A stated she had not, but should have then assumed that responsibility at the end of May 2025 or until she had delegated that task to another staff person to complete. 7. Interview on 7/2/25 at 1:45 p.m. with administrator A, Alzheimer's registered nurse (RN) supervisor B, and former assistant director of nursing (ADON) C regarding the overnight staffing on 6/15/25 revealed: *After former ADON C was notified of staffing concerns for the evening shift on 6/15/25, she had messaged the facility's staff to determine if any unscheduled staff would come into work that night. *A message was also left for the travel staffing agency to identify potential staff from there who may have been able to work. *The designated manager-on-duty who was a CNA and an unlicensed medication aide (UMA) stayed into the early evening and assisted with providing residents care. *Former ADON C returned to the facility and assisted with providing residents' care from about 5:45 p.m. through 8:00 p.m. that night. *Alzheimer's RN supervisor B remained in the facility and had assisted with providing the residents' cares from about 5:00 p.m. through 10:30 p.m. that night. -She had offered to stay longer or to come back to work if she was needed, but the overnight nurse had stated to her, I think we got it. *All the residents except one had been in bed and were asleep when Alzheimer's RN supervisor B had left the building that night. *Several day shift CNAs had arrived early to work the morning of 6/16/25 (between 4:21 a.m. and 5:30 a.m.) to support the night shift staff and the oncoming day shift staff in providing care to the residents. *Regarding the staffing during the overnight shift on 6/15/25, Administrator A confirmed that between about 10:30 p.m. and 4:00 a.m., there had been two CNAs and one licensed nurse who had worked. Alzheimer's RN supervisor B had offered to remain in the facility during that time and support the overnight staff, but the overnight nurse had declined that additional offered assistance. *Administrator A stated she felt the above interventions that were implemented to support the evening and overnight shifts on 6/15/25 and re-scheduling non-urgent work tasks had been sufficient to meet all of the residents' care needs. Review of the provider's 6/1/23 Posting of Daily Staffing policy revealed: *The number of hours worked each day by RNs, LPNs, and CNAs was expected to have been posted each day. *4. After the start of each shift, actual hours will be updated if there are any changes to the schedule/number of staff/hours worked.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, observation, and interview, the provider failed to protect the residents' right to be free from physical abuse for two of two sampled cognitively impaired residents (1 and 2) by one of one certified nursing assistant (CNA) (C). This citation is considered past non?compliance based on a review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 1/2/25 SD DOH FRI revealed: *On 1/2/25, dementia champion E reported CNA C forcibly grabs her [resident 1] arms back and forces her [resident 1] down to the chair, forces her [resident 1] to bend her [resident 1] knees, and she [resident 1] started crying. *CNA C was suspended immediately, pending investigation. *A full investigation was initiated that included staff interviews, video surveillance, and immediate notification to administrator/abuse coordinator A. *After the investigation was completed, the allegations of abuse towards the resident by CNA C were not verified, and he was allowed to return to work with daily check-ins with director of nursing (DON) B and assistant director of nursing (ADON) G; he was assigned dementia-related education that was completed by 1/31/25. *Education was provided to all staff that included types of abuse, how to report abuse, and the importance of timely reporting. 2. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE], and her diagnoses included Alzheimer's disease, falls, urinary tract infections, cognitive communication deficit, dementia, depressive disorder, and insomnia. *Her Brief Interview for Mental Status (BIMS) assessment score was 0, which indicated she was severely cognitively impaired. *A skin assessment was completed on 1/2/25 with no injuries noted from the incident. 3. Observation on 3/27/25 at 10:33 a.m. of resident 1 revealed she: *Was ambulating around the secured memory unit. *Was dressed, had non-slip socks on her feet, and her hair was pulled back in a pony tail *Was tearful the first time around the unit, but on the second loop around, she smiled at the surveyor. 4. Dementia champion E was a former employee and was unavailable for an interview. 5. Interview on 3/27/25 at 2:00 p.m. with administrator/abuse coordinator A and DON B regarding the 1/2/25 incident revealed: *They stated they were unsuccessful in retrieving the camera footage. *They had randomly selected 20 staff members and asked them if they had witnessed any staff abusing resident 1. -All the staff members had answered no. *They did not verify the abuse allegations for CNA C reported by dementia champion F. *CNA C was allowed to go to work and was supervised by DON B and ADON G with daily check-ins, and was assigned dementia-related education, to be completed by 1/31/25. *Education was provided to all staff on all types of abuse, how to report the type of abuse, and the importance of timely reporting. 6. Review of CNA C's personnel file revealed he had completed the dementia-related education by 1/31/25. 7. Review of the provider's 2/25/25 SD DOH FRI revealed: *On 2/25/25, activity director F reported CNA C was assisting resident 2 out of the dining room, and she began yelling, I do not want to go, don't make me go. Activity director F intervened and asked CNA C to walk away. *CNA C was suspended immediately, pending an investigation. *A full investigation was initiated that included staff interviews, video surveillance, and immediate notification to administrator/abuse coordinator A. *After the investigation was completed, the allegations of abuse towards the residents by CNA C was verified, and CNA C's employment was terminated. *Education was provided to all staff on the abuse and neglect policy. 8. Review of resident 2's EMR revealed: *She was admitted on [DATE] and her diagnoses included Alzheimer's disease, dementia, urinary tract infection, and insomnia. *Her BIMS assessment score was 1, which indicated she was severely cognitively impaired. *On 2/25/25 at 9:30 a.m. a progress note was completed as follows: CNA was noted to be pulling on [the] resident [resident 2] to have her go with him to the bathroom. Resident was yelling that she did not want to go with him. Activities Director intervened and had [the] CNA leave [the] resident alone at the time and told him that she has the right to refuse. CNA did leave [the] resident alone at the time of intervention by [the] Activities Director. Resident was assessed and found to have two small red marks on her bilateral wrists. These did resolve. [The resident's] Daughter in law [was] notified of [the] incident and [the] provider [was] notified. Both were thankful for [the] notification. *Her care plan was updated as follows: -Focus: I [am] at risk for altered mood/behaviors, I present with the following behaviors: Yelling/Screaming, Kicking/Hitting, Grabbing, Wandering seeking social interaction with others, Abusive Language, Threatening behavior, Rejection of care, delusions. --Interventions: Weekly check ins [check-ins] with Social Service Director for 4 weeks ---Date Initiated: 3/6/25 *No further notes were documented for this incident. *A skin assessment was also completed on 2/25/25. *No further skin assessment was documented regarding the 2/25/25 incident. 9. Interview with activities director F regarding the 2/25/25 incident revealed: *She was in her office and heard a resident screaming. *She observed resident 2 hanging onto a pole in the dining room while CNA C was forcing resident 2 to go with him. *She had informed CNA C that he could not force a resident to go with him. *She stated CNA C had gotten upset with her and stormed off. *She said resident 2 was better after CNA C left and sat back down into a chair in the dining room. *The activities director stated she reported what she observed to the administrator. 10. Interview on 3/27/25 at 1:18 p.m. with CNA D revealed: *She had witnessed CNA C grab resident 2 arms and force her to go with him. *She had not witnessed any other staff member being physical with the residents. 11. Observation on 3/27//25 at 1:35 p.m. of resident 2 revealed she: *Was ambulating around the secured memory unit. *Was dressed, and her hair was combed. *Would randomly stop and look around. 12. Interview on 3/27/25 at 2:30 p.m. with administrator/abuse coordinator A and director of nursing (DON)B regarding the 2/25/25 incident revealed: *They had reviewed the camera footage, and it verified that resident 2 was physically abused by CNA C as reported by activities director F. *They interviewed twelve random staff members and four staff members had said had witnessed CNA C had grab resident 2 in the dining room trying to get her to go with him before the activities director intervened. *CNA C's employment was terminated and CNA C was reported to the South Dakota Board of Nursing related to the event. The provider implemented actions to ensure the deficient practice does not recur was confirmed after record review revealed the facility had followed their quality assurance process, education was provided to all staff regarding types of abuse, how to report the abuse, the importance of timely reporting, and the abuse and neglect policy. The administrator and DON walked and observed the facility daily to ensure resident safety. Interviews and observations indicated staff understood the education provided. Based on the above information, non-compliance at F600 was determined to occur on 2/25/25, and the provider's implemented 3/26/25 corrective actions for the deficient practice confirmed on 3/27/25; the non-compliance is considered past non-compliance.

Based on observation, interview, job description review, and policy review, the provider failed to ensure: *The kitchen and dishroom were maintained in a clean and functional manner. *Food items placed on trays and delivered to residents to eat in their rooms (room trays) were kept covered during transport until they were delivered to their rooms. *Insulated dinner plate covers were handled in a sanitary manner. Findings include: 1. Observation and interviews with food service manager (FSM) E, cook N, and dietary aide O on [DATE] from 5:00 p.m. through 6:40 p.m. during the initial kitchen tour and the evening meal service revealed: *Plastic drinking cups were being filled for the evening meal by cook N. -Twelve of 20 unfilled cups on one of two trays had white-colored build-up on their bottoms and/or their insides. Scratch-like marks on the insides resembled scrub brush marks. *FSM E stated the cup discoloration was lime build-up and commented to cook P Are you the only one who knows how to use a brush? *One side of the dual plate warmer near the serving area held regular plates and the other side held adapted blue plates with raised edges. The side of the warmer that contained the blue plates was not working. -The top surface area of that plate warmer including the areas around the openings where the plates were removed from was littered with food crumbs. -FSM E was aware the warmer was not functioning properly and agreed the top of the unit was unclean. *Near the coffee makers was a four-cup plastic measuring cup that was stained brown throughout its inside. [NAME] N stated coffee from the coffee makers was poured into that cup then transferred to carafes for serving. -FSM E said the cup should no longer have been used since it was unable to be thoroughly cleaned. *The window ledge and window frame above the coffee makers was covered with a brown-colored film of unknown origin. *On the cook's prep table was a knife holder attached to the side of that table. The surface of the holder and in and around where the knives were inserted was covered with food crumbs that were not removable when swiped with a finger. -Cooking utensils were stored in a lined drawer attached to the cook's prep table. The liner resembled a plastic net. There were dried food particles in the open areas of the liner. -A Saf-T-Wrap (plastic wrap) dispenser holder was opened and was on top of the cook's prep table. The inside of the opened lid had individual compartments for holding things like packaged alcohol pads and pre-printed food labels. The bottoms of those compartments had a build-up of an unknown substance on them. The area surrounding the opening where the plastic wrap was pulled through to be torn off had an unknown build-up around it. *Beneath the Vulcan oven stand was an open area of racked storage for cookie sheets and baking pans. The surface on both sides of those racks was covered with a film of unknown origin and was unable to be removed when swiped with a finger. *A fluorescent light was on the ceiling between refrigerator units one and two and freezer units one through three. The plastic light covering was cracked and broken. *The test strips in the dishroom used to measure the concentration of sanitizer to water for disinfection had expired in [DATE] but were still being used. -FSM E was made aware of the expired strips last week by a service technician. She had not known the test strip holder was labeled with an expiration date. She had not reached out to a sister facility for unexpired test strips to use while she waited for new strips to arrive. *The individual slats of the air conditioner that was running in the dishroom were covered with a film of gray dust. -The air was blowing over clean dishware and a metal rack that held clean cooking pots, pans, soup bowls, cutting boards. *Dietary aide O was responsible for loading and transporting prepared resident food trays in an insulated cart to three of four dining rooms. -She used her bare hand to hold the inside of the insulated covers until she placed them over the top of the individually prepared resident meal plates instead of using the knob on top of the covers to hold them in a sanitary manner. -FSM E and dietary aide O both agreed not having used the knob to hold the covers increased the risk of cross-contamination of resident food items. *Room trays with covered drinking cups and uncovered dishes of mixed fruit sat on the cook's prep table from 6:15 p.m. through 6:40 p.m. At 6:40 p.m. when the room tray was completely plated and covered with an insulated cover. An unidentified aide then transported that room tray out of the dining room to a resident room with the fruit still uncovered. -FSM E had not noticed the length of time the uncovered fruit sat waiting to be delivered or that the fruit remained uncovered during transport. Interview on [DATE] at 8:45 a.m. with FSM E revealed: *Individual cleaning checklists were developed for the morning and evening cooks, dietary aides, and dishwashers. -The checklists included daily and weekly cleaning assignments that were initialed by the staff person who had completed those tasks. *FSM E was responsible for regularly reviewing the kitchen cleaning tasks checklists for completion of those tasks by her staff. Review of the provider's updated [DATE] Director of Dietary Services job description revealed: *Essential Functions: -2. Operates the dietary department in a safe and sanitary manner by ensuring compliance with federal, State, and local regulations and following established policies and procedures. -12. Assure that established infection control and prevention practices and standard precautions are maintained at all times. Review of the provider's revised [DATE] Accident Prevention In Food Transport policy revealed: 3. Food should remain covered when in transit.

Based on observation, interview, and policy review, the provider failed to maintain the environment and resident use items in a clean and odor-free condition for: *A soiled utility room located directly across from the entrance into the secured unit. *Two of sixteen sampled resident rooms (103 and 108) located in the 100 hallway. *One of one laundry room. *One of one clean utility room located in the secured unit. *A urine-soaked chair from one of one sampled resident's (58) room. Findings include: 1. Observation during the initial tour on 11/4/24 at 12:45 p.m. revealed a strong urine odor upon entrance through the double doors that led into the secured unit of the building where the 100, 200, and 400 hallways were located. Observation on 11/5/24 at 1:48 p.m. and at 1:52 p.m. revealed a strong urine odor was again present upon entrance into the secured unit described above. *A soiled utility room was located directly across the hall from the entrance into the secured unit. -That room had soiled linen and garbage containers in it that were overflowing with soiled clothing, soiled incontinence briefs, and garbage, which caused the container's lids to remain open. -A putrid odor of urine and feces emanated from those containers. -At 1:52 p.m., those items had been removed from the containers and clean liners had been placed in the container however the room continued to emit a strong odor of urine and the floor was sticky. 2. Observation on 11/4/24 at 2:00 p.m. of room [ROOM NUMBER] revealed the room had a strong odor of urine and the bathroom floor was sticky with an odor of urine. Observation on 11/4/24 at 3:02 p.m. of room [ROOM NUMBER]B revealed visible brown fingerprint smudges along the wall right above the resident's mattress. Interview on 11/7/24 at 8:20 a.m. with housekeeper Q regarding cleaning and mopping of resident rooms revealed: *He stated all resident rooms were daily wiped down, the trash was removed, toiletes were cleaned, and the floors were mopped. He had no cleaning schedule, but said he could remember which rooms needed to be cleaned. *He stated: -All resident rooms were deep cleaned once a week and that included wiping down the walls from the ceiling to the floor, cleaning windows, and washing the divider curtains. -Lately there had not been a schedule available on what rooms needed to be deep cleaned for that day or the week. -He would deep clean a room if he saw it needed a deep cleaning. 3. Observation on 11/7/24 at 9:15 a.m. of the laundry room revealed: *There was a large amount of gray dust build-up on the pipes and flat surfaces throughout the laundry room. *There were two washing machines and washer number two had a sign that read, needs repaired. -Washer number one was in use, and had a leaking hose that was dripping onto the floor behind the washer causing curled up, corroded, floor tiles that exposed the cement to water build-up. *The handwashing sink had a PVC (plastic) pipe that came out of the ceiling and was dripping a watery liquid into the sink. There was an orange-colored build-up where the water ran down into the sink. 4. Observation on 11/7/24 at 9:20 a.m. of the clean utility room on the secured unit revealed a laundry basket full of various shoes and slippers that had visible unidentified stains on their surfaces. That basket was sitting on the floor next to shelving that contained clean linens and room dividers. Interview on 11/7/24 at 9:00 a.m. with housekeeping supervisor G regarding the cleaning of utility rooms, resident rooms, and the laundry room revealed: *He had been the housekeeping and laundry supervisor for one year. -He had been working every day cleaning rooms, since they did not have enough housekeeping staff. -He stated he had been working on the floor for the past year. -They were trying to hire more housekeeping staff. *He had no housekeeping schedule for the cleaning of the soiled and clean utility closets, but he tried to have them cleaned and mopped once a week. *He was unable to verify when the soiled utility room was last cleaned. *He stated he had fallen behind on completing the room cleaning schedules for his staff and there was no deep cleaning schedule available. -He stated, I am not sure deep cleanings are being done, but it is supposed to be once a week. *He stated he used to complete a walk-through inspection of the facility every week, then it became once a month, and lately he had fallen behind and had not inspected the facility in about four weeks. *He confirmed the laundry room was not on a cleaning schedule. He was unaware of the washer's leaking hose. -He was not sure why a pipe was draining into the handwashing sink. *After a walk-through of the facility and viewing the above observations, he stated I agree it [cleanliness of the facility] could be better. Review of the 7/2/24 Administrative Policies regarding housekeeping and laundry revealed: *Cleanliness is a must for a safe, comfortable, and orderly environment. The activity of our housekeeping and laundry departments has a direct effect on the comfort, morale, and safety of the residents, the staff and our visitors. Review of the housekeeping and laundry services policies revealed they did not include on how often resident rooms and generalized cleaning should occur. 47780 5. Observation and interview on 11/4/24 at 1:59 p.m. in resident 58's room revealed: *A brown lift chair was turned around and faced the wall. *Resident 58 was seated in a different chair. *She was unsure why the brown lift chair was turned towards the wall. *She would have liked the brown lift chair turned forward to face her television. *She would have preferred to sit in that brown lift chair as the chair she was sitting in was not a lift chair. Interview on 11/4/24 at 3:10 p.m. with certified nursing assistant (CNA) M revealed the brown lift chair in resident 58's room had a soiled spot and it was to be cleaned. Observation on 11/5/24 at 10:10 a.m. revealed that the brown lift chair had been turned forward, and resident 58 was seated in it in a reclining position. Observation on 11/5/24 at 4:06 p.m. in resident 58's room revealed: *The brown lift chair had a fabric covering laid over the top of it. *When the covering was removed there was a strong odor of urine and a wet stain on the seat of the chair. Interview on 11/5/24 at 4:36 p.m. with director of nursing (DON) B and infection preventionist D revealed: *Their expectation of staff was to remove the chair when they had noticed it had been soiled and not to have covered it and left it in the resident's room for the resident to use. Review of provider's revised February 2024 Cleaning and Disinfection of Equipment policy: *Policy -1. CLEANING refers to removal of visible soil (e.g., organic, and inorganic material from objects and surfaces and is normally accomplished manually or mechanically using water with detergents or enzymatic products. -A. Supplies and equipment will be cleaned immediately after use. Gross blood, secretions and debris will be removed as soon as possible. Cleaning may be done in the resident room or the soiled utility room.

Based on observation, interview, South Dakota (SD) State Long-Term Care Ombudsman Program handbook review, and policy review, the provider failed to ensure: *Window coverings in 12 of 14 resident rooms (301, 302, 303, 304, 305, 306, 307, 309, 311, 312, 314, and 316) located in the 300 Hall had protected those residents' right to privacy. *Window coverings in 5 of 9 resident rooms (105, 107, 111, 113, and 115) located in the 100 hall had protected those residents' right to privacy. *One of 14 residents' (2) electronic medical records (EMR) were secured and not accessible to other residents, staff, or the public. *One of two medication carts were locked and medications were not accessible to other residents, staff, and the public by one of one registered nurse (RN) J in the Main dining room during the noon medication pass. Findings include: 1. Observation on 11/4/24 at 7:15 p.m. on the sidewalk leading to the main entrance of the facility revealed: *Resident rooms on the north side of the 300 hallway ran parallel to that sidewalk. -The windows in those rooms faced the visitor's parking lot. *The inside of those rooms were visible despite the window shades in those rooms having been pulled down. *Resident rooms on the south side of the 300 hallway had the same type of window shade coverings. -Those windows faced an employee parking lot. Observation on 11/5/24 at 7:30 a.m. on the same sidewalk referred to above revealed the insides of the residents' rooms on the north side of the 300 hallway were not visible through the pulled down window shades during daylight hours. Observation and interview on 11/5/24 at 4:50 p.m. with administrator A on the sidewalk above revealed: *The insides of the resident rooms on the north side of the 300 hall were visible despite the window shades having been pulled down. *Administrator A had not known the pulled window shades failed to protect the privacy of the residents who occupied those rooms. Review of the August 2019 SD State Long-Term Care Ombudsman Program revealed: *Privacy and Confidentiality -You have the right to privacy and confidentiality regarding personal, financial, and medical affairs. 42558 2. Observation on 11/5/24 at 8:30 a.m. of the 100 hallway resident rooms revealed: *Five of the nine rooms (105, 107, 111, 113, and 115) that faced the north-sided public sidewalk and parking lot contained the same type of shade observed above in the 300 hallway that allowed unobstructed night-time viewing of the resident's rooms when pulled down. -Those shades provided resident with privacy during the daylight hours only. -Those rooms did not contained any other type of window covering to ensure resident privacy at night. 47780 3. Observation and interview on 11/6/24 at 11:20 a.m. with RN J the main dining room during a medication pass revealed: *She had been preparing medications for the residents' who were seated in the main dining room. *She prepared resident 2's medications, placed the medications in a medication cup, and verified the medications were correct as indicated in the resident's medication administration record (MAR). *She returned resident 2's medication card in the medication cart. *She picked up the medication cup with the resident's medications and walked over to the resident. -She left the medication cart unlocked and the computer screen open that displayed resident 2's EMR information. -Multiple staff members walked by the unlocked cart to wash their hands at the sink. -Her back was turned away from the medication cart while she assisted the resident with her medications. *RN J agreed the screen should not have been left open and should have been shut. *RN J agreed the medication cart should have been locked when she walked away from the medication cart. Interview on 10/6/24 at 2:52 p.m. with director of nursing (DON) B regarding the above observation revealed: *She expected the staff to minimize or lock the computer screen and to make sure the medication cart was locked, and the keys were always with them. Review of provider's September 2019 Resident Dignity & Privacy policy revealed: *Policy. -It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as, care for each resident in a manner and in an environment, that maintains resident privacy. -18. Protected Health Information should not be in viewing area of public. This includes computer screens, resident room listing, report forms, etc. Review of provider's September 2018 Medication Administration General Guidelines policy revealed: *Policy -Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. -Procedures --Medication Administration --17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. --18. Resident's health information needs to remain private. The pages of the MAR [Medication Administration Record] notebook containing resident health information must remain closed or covered when not in direct use.

Based on observation, interview, and policy review, the provider failed to maintain a clean and homelike environment for: *8 of 14 resident rooms (301, 303, 304, 309, 311, 312, 314, and 316) on the 300 hallway. *5 of 22 resident rooms (202, 204, 206, 207 and 209) on the 200 hallway. *6 of 23 resident rooms (103, 104, 108, 110, 115, and 117) on the 100 hallway. Findings include: 1. Random observations on 11/5/24 between 9:30 a.m. and 3:35 p.m. inside the rooms on the 300 hallway revealed: *room [ROOM NUMBER] had areas of exposed sheetrock near the foot and head of the bed, and behind the headboard of that bed which was positioned along the wall beneath the window. -There was an area of exposed sheetrock near the head of another bed that was positioned along the wall near the doorway of that room. *In room [ROOM NUMBER], the recliner's headrest was worn and no longer a cleanable surface. *room [ROOM NUMBER]: There was an area approximately 12 inches by 12 inches on the wall beneath the window near the foot of the bed that appeared to have been a spill of a black substance that had run down that wall. *room [ROOM NUMBER] had an area of the baseboard molding along the wall between the bathroom door and the south wall that was missing. The exterior doorframe of the bathroom had multiple areas where the paint was missing. *room [ROOM NUMBER] had areas of exposed sheetrock near the foot and head of the bed that was positioned on the wall beneath the window. -There was an area of exposed sheetrock behind the headboard of another bed that was positioned along the wall opposite of the window. A crack extended from the top to the bottom of that wall. *room [ROOM NUMBER] had an approximately six inches long by three inches wide oval-shaped outline that appeared to have been made by a black marker on the wall beneath the window. *room [ROOM NUMBER] had areas of exposed sheetrock on the walls near the heads of both beds. -There were multiple scratch-like gouges exposing the sheetrock on the wall behind the recliner. *room [ROOM NUMBER] had areas of exposed sheetrock on the wall by the window near the head and foot of the bed. -There were areas of exposed sheetrock at the head and midsection of the bed positioned on the wall opposite of the window. 47780 2. Random observations on 11/5/24 between 9:00 a.m. and 5:45 p.m. of the inside of the rooms in the 200 hallway revealed: *room [ROOM NUMBER]: Had areas of missing paint on the wall behind the headrest of the recliner. -There were multiple scratch-like gouges from the bottom of the floor to 12 inches up [NAME] the entrance and the bathroom doorframes. *room [ROOM NUMBER]: There were multiple scratch-like gouges from the bottom of the floor to 12 inches up of the entrance and bathroom doorframes. -There was missing portion of the door panel on the front portion of the entrance door. *room [ROOM NUMBER]: Had an area of exposed sheetrock positioned along the wall next to the sink, and two dime-size holes inside the exposed sheetrock. *room [ROOM NUMBER]: Had multiple scratch-like gouges from the bottom of the floor to 12 inches up from the bathroom doorframe. -There was an approximate ten-inch long by ten-inch wide white square-shape patch on the wall next to the toilet. 51816 3. Observation on 11/4/24 at 3:05 p.m. in room [ROOM NUMBER] revealed: *Gouges and areas where paint was scraped off both sides of the doorframe entering the resident's room. *Multiple areas of missing paint and exposed sheetrock on the wall that extended the length of the resident's bed. *Gouges and areas where paint was scraped off both sides of the bathroom doorframe. *A large area of paint was scraped off the wall opposite the sink in the bathroom. *A privacy curtain in the room was visibly soiled and had an area with an unknown brown substance on it. 42558 4. Random observations on 11/4/24 from 1:45 p.m. through 4:55 p.m. of the resident rooms located in the 100-hallway revealed: *room [ROOM NUMBER]: Had several areas of missing paint and exposed sheetrock that included a wall above the left side of the mattress that covered a two-foot long by one-foot-wide area, and a wall near the right side of the bed's headboard that measured approximately six inches long by three inches wide. -In the opposite corner of the room, there were scattered areas of missing paint and exposed sheetrock located on the wall next to each side of a recliner chair. *room [ROOM NUMBER]: Had two linear sections of missing paint and exposed sheetrock located above the bed mattress and at the foot of the bed. *room [ROOM NUMBER]: Had several areas of missing paint and exposed sheetrock located along the wall under the window right above the resident's mattress, and a visible linear crack of peeling paint located at the resident's head of the bed where the room's outside wall and inside wall joined. It extended nearly the entire height of the room. *room [ROOM NUMBER]: Had scattered areas of missing paint and exposed sheetrock throughout the room including on a wall next to a dresser holding a television, and along the doorway entrance into the bathroom. *room [ROOM NUMBER]: Had multiple areas of missing paint and exposed sheetrock throughout the room along three of the four walls. -There was an electrical outlet cover that was broken with half of the cover missing and the interior of the outlet exposed. It was located slightly above the resident's mattress. -There were two-dime sized holes in the wall by the sink and missing paint on the doorway leading into the bathroom. *room [ROOM NUMBER]: Had several areas of missing paint and exposed sheetrock located along the wall under the outside window. Observation and interview on 11/6/24 at 1:38 p.m. with interim maintenance supervisor H during a walking tour of several of the above-mentioned rooms revealed: *He stated the prior maintenance supervisor had resigned approximately one-and-a-half weeks ago. *He worked full-time at a sister facility and had planned on coming to this facility two to three times a week. -He stated there was a maintenance supervisor from another sister facility who could fill in as needed. *They were able to receive the provider's maintenance repair requests through an electronic communication system called TELS (technology for enhanced living solutions). *He stated: -The maintenance department was responsible for overseeing the housekeeping department along with a head housekeeper. -He depended on staff and housekeeping supervisor G to submit reports of any building maintenance issues into TELS. -He was aware of some spackling and painting of resident rooms had occurred because he had to educate the prior maintenance supervisor on how to spackle drywall. -He knew there had been contract painters brought in during the last year to repair, paint, and remodel resident rooms. -He thought there were not many rooms remaining that needed to be completely painted. - .of course there is always a need for [paint] touch-ups, door jams, and those type circumstances. *He was not aware of any rooms that needed immediate repair or touch-up painting. *Following a walk-through and random inspection of several of the above-mentioned rooms, he stated he had not been aware there were multiple rooms that needed paint touch-ups and confirmed the rooms appearances were not homelike. -He had not been aware of the broken outlet cover in room [ROOM NUMBER]. *He stated his expectation as a maintenance supervisor, would be to perform a monthly walk-through inspection of resident rooms for needed paint touch-ups and repairs. He was not aware when that had last occurred in this facility. *He stated painting and repairs were difficult to complete because a resident's room had to be empty to repair or paint the room. Interview on 11/06/24 at 4:00 p.m. with administrator A regarding multiple rooms with missing paint, exposed sheetrock, and maintenance repair needs revealed: *It was her expectation for the staff to fill out a TELS maintenance request on any urgent repair needs. -She stated everyone had access to the electronic TELS system. *She had contracted painters and sheetrock repair men working on repairing each room that was identified through an audit as needing paint and repairs. -The contractors had been repairing and painting one room at a time on the weekends when they were available. -She confirmed that according to their 2022 South Dakota Department of Health survey and plan of correction for a homelike environment, there had been a designated empty room to move a resident into while the resident's room was being painted and repaired. However, they had an emergency resident admission in October and were room blocked (no empty room) from continuing with the scheduled painting and repairs. Review of the 2024 contracted drywall and paint invoices revealed seven visits in 2024 (3/20, 5/1, 6/3, 6/7, 9/18, 9/21, and 10/5/2024) had occurred. Resident rooms that had been billed as completed were listed as rooms 104, 205, 303, 308, and 314. There were other repairs listed in those invoices that were not related to resident rooms. Further interview on 11/7/24 at 7:43 a.m. with administrator A regarding paint touch-ups and room repairs performed in between complete room painting revealed: *She was actively trying to hire a full-time maintenance person. *They planned on resuming with complete room painting next week, as an empty room had just become available. She stated room painting was a slow process. *Regarding preventative room maintenance she stated: -Touch-up painting had occurred in the past, but they had backed off as we were looking at permanent fixes. -I should have given more directive to follow through with completion of touch-ups. *She confirmed paint touch-ups should have occurred in between a complete room repainting and agreed the missing paint and exposed drywall had created an uncleanable surface and was not a homelike environment for the residents who resided in those rooms. Interview on 11/7/24 at 8:41 a.m. with housekeeping supervisor G revealed: *He had worked as the housekeeping supervisor for one year. *He agreed numerous rooms had scratched paint and exposed drywall. -He stated he verbally told (name of prior maintenance supervisor) when he received a report of a room in need of repair. *He stated none of the housekeeping or laundry staff had log-in access to the electronic TELS maintenance system. Review of the provider's October 2019 Homelike Environment policy revealed: *Policy: Residents are provided with a safe, clean, comfortable homelike environment and encouraged to use their personal belonging to the extent possible. -2. i. Walls and door scuffs/chips repaired with paint/stain when needed[.] -3. The facility will have a mechanism for reporting disrepair to Maintenance personnel and staff will be educated on the process.

Based on observation, interview, record review, policy review, and South Dakota (SD) State Long-Term Care Ombudsman Program handbook review, the provider failed to ensure: *One of one sampled resident (31) had received diabetic fingernail care to maintain a dignified appearance. *One of one sampled resident (8) was dressed in a dignified manner. Findings include: 1. Observation and interview on 11/5/24 at 9:26 a.m. with resident 31 while she rested in her bed revealed: *She was chewing and sucking on her left index and middle finger and stated she was hungry. *Inspection of both hands revealed she had long, uneven, fingernails that extended approximately one-fourth of an inch beyond her finger pads. -There was a dark brown build-up of an unknown substance caked under each fingernail that extended outwards from the edge of each finger pad to the middle of each fingernail. *An odor of feces was detected at her bedside. Observation and interview on 11/6/24 at 9:40 a.m. with the assistant director of nursing (ADON) C and contracted hospice registered nurse (RN) L during resident 31's wound care to her right lateral foot revealed: *ADON C stated she was the provider's wound care nurse. *Hospice RN L stated the resident received a bed bath once weekly from the hospice aides. *Resident 31 was lying in her bed and was sucking on her left index finger during her wound care treatment. *ADON C stated: -Every resident was expected to be provided nail care on their bath days. -Resident 31 was provided fingernail care following every meal, or at a minimum of once daily as the resident liked to dig [in her feces]. -Since resident 31 was a diabetic, the resident's charge nurse was expected to provide her fingernail care. A podiatrist provided her with toenail care. *Both ADON C and hospice RN L confirmed resident 31's fingernails were long and caked with a brown substance. Review of resident 31's electronic medical record (EMR) revealed: *She had been on hospice care since April of 2024 for end-of-life care related to multiple co-morbidities that included: advanced dementia with agitation, late-onset Alzheimer's disease, congestive heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease, and type 2 diabetes mellitus with peripheral angiopathy with gangrene. *She had a Brief Interview for Mental Status (BIMS) assessment score of four, which indicated she had severe cognitive impairment. *She was dependent on staff for all her hygiene needs including bathing, personal hygiene, and incontinence care. *A nurse provided a daily dressing treatment to her right foot and completed with weekly assessments of her skin. *Review of her physician's orders, treatment orders, nursing documentation, and CNA care task documentation had not indicated when and by whom nail care was to have been completed. On 11/6/24 at 1:37 p.m., a request was made to the provider for a nail care policy and documentation of resident 31's completed fingernail care. Interview on 11/6/24 at 3:20 p.m. with the director of nursing (DON) B regarding resident 31's fingernail observations and nail care revealed: *She stated the nail care policy was included in the bathing policy. *She stated they had no documentation of when her diabetic nail care was completed, but it was her expectation the bathing policy would have been followed by staff, which indicated nail care would be performed with each bath. -Diabetic nail care was expected to be performed by the nurses and all the nurses were expected to know this was to occur on the resident's bath days. *She confirmed the performance and documentation of diabetic nail care needed to be improved. Review of the provider's August 2023 bathing policy revealed: *Fingernails and toenails should be inspected on bathing days and nails should be trimmed and filed as necessary. CNAs (certified nurse aides) will not perform nail care on residents with diabetes. *The policy had not addressed who was expected to provide and document diabetic nail care. 40788 2. Observation on 11/5/24 at 9:45 a.m. of resident 8 in her room revealed she: *Was laying on her side asleep in bed. -Wore socks labeled with her roommate's name on them. Observation on 11/6/24 at 9:30 a.m. of resident 8 in her room revealed she: *Was seated in her wheelchair watching television. -Wore socks labeled with an unknown resident's name on them. Review of resident 8's 8/27/24 Minimum Data Set assessment revealed: *Her cognition was severely impaired. -She rarely made her own decisions. Interview on 11/6/24 at 10:00 a.m. with certified nurse aide K regarding resident 8 revealed: *Staff had chosen the clothes she wore each day. *The resident had her own socks. -The socks that were put on her that morning were donated. Review of the August 2019 SD State Long-Term Care Ombudsman Program handbook revealed: *Dignity and Quality of Life: -All residents were entitled to reasonable quality of life including: 2. To be treated with consideration, respect, and dignity. Recognition of your, and every resident's, individuality.

Based on observation, interview, record review, and job description review, the provider failed to ensure physician's orders were followed for the use of: *TED Hose (thromboembolic deterrent compression stockings used by non-ambulatory residents) by one of one sampled resident (39). *Redi-Wraps (adjustable compression wrap) by one of one sampled resident (8). *Gradual compression stockings (compression stockings that are tightest around the ankle and gradually loosen up the leg) by one of one sampled resident (65). Findings include: 1. Observation and interview on 11/4/24 at 2:26 p.m. with resident 39 in her room revealed: *She was sitting in her recliner with the leg rests elevated. -On the wall behind her recliner was a sign that read [NAME] Hose on in AM and off in PM. *The resident was wearing regular socks on her feet. -She had no TED Hose that fit her and had not worn TED Hose since the summer. Observations on 11/5/24 at 9:11 a.m. and again on 11/6/24 at 9:41 a.m. of resident 39 in her room revealed she was sitting in her recliner with the leg rests elevated wearing regular socks on her feet. Review of resident 39's electronic medical record (EMR) revealed: *Her diagnoses included heart failure. *A 12/23/23 physician's order: TED hose on in the AM and off in the PM related to LE [lower extremity] edema [fluid retention]. *Her November 2024 Treatment Administration Record (TAR) revealed it was documented from 11/1/24 through 11/5/24 that TED Hose had been put on her feet each of those mornings and removed each evening. 2. Observations on 11/4/24 at 2:54 p.m., 11/5/24 at 9:45 a.m., and again on 11/6/24 at 9:45 a.m. of resident 8 in her room revealed: *She was either lying in her bed or sitting in her wheelchair during those times. *A sign near the head of her bed read Put on leg wraps in AM and off in PM. -At the time of each observation above the resident was wearing regular socks on her feet. Review of resident 8's EMR revealed: *Her diagnoses included edema. *A 2/14/24 physician's order: Redi-Wraps to bilateral LE [lower extremities] and remove per schedule. *Her November 2024 TAR revealed it was documented from 11/1/24 through 11/5/24 that Redi-Wraps had been put on the resident each of those mornings and removed each evening. 3. Observations on 11/4/24 at 3:07 p.m., 11/5/24 at 9:38 a.m., and again on 11/6/24 at 9:57 a.m. of resident 65 in her room revealed: *She was sitting in her recliner wearing regular socks on her feet and a pair of Crocs foam [NAME]. *A foot cradle [a device attached to the foot of the bed that kept sheets and blankets from touching or rubbing the legs and feet]was at the end of her bed. Review of resident 65's EMR revealed: *Her diagnoses included chronic embolism and thrombosis (blood clot formation) of the left femoral vein. *A 9/13/24 physician's order: Knee high 20-30 gradual compression stockings. On in am, off at HS [nighttime]. One time a day for left leg edema and remove per schedule. *A 9/13/24 progress note that indicated the resident's stockings were ordered through a local home health equipment provider. *Her November 2024 TAR revealed it was documented from 11/1/24 through 11/5/24 that her compression stockings had been put on each of those mornings and removed each evening. Interview on 11/6/24 at 9:50 a.m. with certified nurse aide (CNA) K revealed: *Resident 39 was waiting for a new pair of TED hose to replace her pair that were ripped. -Nursing staff were informed the resident had no other TED hose to wear. -She had been without TED hose for a few days. *Resident 8's Redi-Wraps had not returned from the laundry. -She had only one pair of Wraps. *Resident 65's compression stockings were too tight and she needed different-sized stockings. -Her family was expected to provide those. Interview on 11/6/24 at 2:50 p.m. with registered nurse (RN) J regarding the physician-ordered treatments above for residents 8, 39, and 65 revealed: *She had documented in residents 8, 39, and 65's TARs the Redi-Wraps, TED hose, and compression stockings had been put on those residents on the morning of 11/6/24. *CNA staff had dressed residents 8, 39, and 65 that morning. -That would have included their hose and stockings. *She had not known resident 8 had no Redi-Wraps, resident 39 had no TED hose, and resident 65 had no compression stockings. -Resident 8 should have had a back-up pair of wraps to wear and another pair of TED hose should have been obtained from the central supply room for resident 39. Resident 65's hospice nurse should have been contacted about providing her compression socks. Observation on 11/6/24 at 4:40 p.m. of the central supply room revealed there were: *Two packages of size large Redi Wraps and two packages of size extra-large Redi-Wraps. *Multiple packages of size small TED hose. Interview on 11/7/24 at 10:15 a.m. with Qualified Activity Director (QAD)/Central Supply staff F revealed: *She had been responsible for maintaining the facility's central supply room since August 2024. *She had known residents were without their physician-ordered compression socks, TED hose, and Redi-Wraps. -Resident 65's compression stockings were ordered through a specialty supply company a few weeks ago. -In the last week, she had unsuccessfully attempted to order the other supplies from various vendors. *She had notified the facility's corporate office of her difficulty in getting resident supplies. -On 11/6/24 she had talked with administrator A. Administrator A was contacting local sister facilities to determine if they were able to help obtain those needed resident supplies. *QAD/Central Supply staff F did not know how many residents required physician-ordered hose, stockings, and wraps or how many of those items were expected to have been on hand in the event a second pair was needed. Interview on 11/7/24 at 10:45 a.m. with director of nursing B revealed: *Physician-ordered treatments for residents 8, 39, and 65 were not provided. *Nursing staff were expected to not document completion of physician-ordered treatments delegated to a CNA in a resident's TAR without first visually confirming for themselves the treatment had been completed. *She agreed a process was needed to ensure an adequate number of supplies were kept on hand for residents who required physician-ordered compression stockings, hose, and wraps. Review of the provider's updated 12/1/19 RN Floor Nurse job description revealed 12. Administer or supervise all treatments prescribed by physicians .

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (19) who had a history of moisture-associated skin damage (MASD) and had a current pressure ulcer (PU) had physician-ordered interventions implemented to promote healing. Findings include: 1. Observations of resident 19 revealed: *On 10/24/23 at 10:00 a.m. she laid on her left side in bed with a pillow positioned behind her back to help her maintain that position. -The mattress on her bed was blue. *On 10/25/23 at 4:45 p.m. she was seated on a ROHO cushion (a pressure reducing device) in her tilt-in-space wheelchair (a customized wheelchair) in her room in front of the television. -There was a pool of liquid on the floor beneath the seat of her wheelchair that appeared to have been urine. *On 10/26/23 at 8:45 a.m. she was transferred by staff from her wheelchair to her bed to have her incontinence brief changed, barrier cream applied to her sacrum, and then she was positioned onto her left side. Review of resident 19's electronic medical record (EMR) revealed her: *Diagnoses included Alzheimer's dementia, protein calorie malnutrition, repeated falls, hypertension, anxiety, depression, pain, and a stage III pressure ulcer. -There was no indication where that pressure ulcer was located. *8/14/23 Brief Interview for Mental Status score was 99 indicating she had severe cognitive impairment. *3/1/23 Braden scale (used to evaluate a resident's risk for skin breakdown) score was 16. -That score indicated she was at high risk for skin breakdown. *A 6/13/23 facimile communication to the resident's physician revealed: -Resident noted to have new area of pressure to her sacrum . -A physician's order (PO) was requested for the resident to have a ROHO cushion for her wheelchair. *The provider responded on that same date: May order Roho cushion due to skin impairment. *A 6/20/23 Skin/Wound Note indicated the Maceration to sacrum has resolved. Interview on 10/26/23 at 8:30 a.m. with director of rehabilitation (Rehab) D revealed the department: *Had several ROHO cushions available for residents use. *Was notified by nursing staff when a physician had ordered a ROHO cushion for a residents use. -Educated staff on the purpose and how to use the cushion prior to its use. -Ensured the ongoing maintenance of that cushion while it was used. *Nursing staff had not notified the Rehab department of resident 19's 6/13/23 PO for a ROHO cushion so a ROHO cushion had not been provided to the resident. Interview on 10/26/23 at 10:15 a.m. with assistant director of nursing (ADON)/infection preventionist (IP)/wound care nurse K revealed she: *Was aware of the 6/13/23 PO for a ROHO cushion for resident 19 but had not known if she had received it. *Had thought that PO was more of a positioning order but agreed inadequate or improper positioning caused by not having had the ROHO cushion had the potential to have worsened her MASD. Interview on 10/26/23 at 2:48 p.m. with director of nursing (DON) A revealed: *It was the responsibility of the nurse who had taken the PO for the ROHO cushion to have completed the following: -Called the Rehab department and notified them of the new order and/or have placed a copy of that PO in the mailbox for Rehab staff. 2. Continued review of resident 19's EMR revealed: *An 8/11/23 Health Status Note completed by DON A had first identified a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) PU to resident's 19's sacrum. -Physician's orders for treatment of that PU had been obtained and interventions including a pressure relieving mattress, offloading, and continuation of nutritional interventions. *An 8/14/23 Braden scale score was 14 indicating the resident was at high risk for skin breakdown. *ADON/IP/wound care nurse K had completed weekly Skin Alteration Evaluations beginning on 8/15/23 at which time the PU had measured 1.0 cm (centimeters) in length X 0.5 cm wide, and 0.3 cm in depth. *Wound care certified nurse practitioner (CNP) L had been consulted and had begun caring for the resident's wound on 9/5/23. -She documented the resident's PU as a stage III (full-thickness tissue loss-subcutaneous fat might have been visible) and it had measured 1.0 cm X 0.5 cm X 1.0 cm. *Occupational therapy (OT) was consulted on 9/14/23 to evaluate resident 19 for wheelchair positioning options. -On 10/4/23 OT had recommended a tilt-in-space wheelchair with a ROHO cushion for resident 19. *Wound care CNP L ordered an air mattress (specialized pressure-reducing mattress) on 10/17/23 to replace the existing blue mattress that was observed on resident 19's bed on 10/24/23 at 10:00 a.m. -Her 10/17/23 Health Status Note read: New order for air mattress to alleviate pressure from coccyx wound. *Wound care CNP L measured resident 19's pressure ulcer on 10/24/23 as 0.8 cm X 0.3 cm X 0.2 cm. Interview on 10/25/23 at 4:00 p.m. with licensed practical nurse (LPN) F regarding resident 19 revealed: *She had not received the air mattress that was ordered by wound care CNP L on 10/17/23. -LPN G had acknowledged the PO and was responsible for ensuring someone from the management team was notified so the mattress could have been ordered. Interview on 10/25/23 at 4:45 p.m. with maintenance director M regarding resident 19 revealed: *An air mattress like the one ordered by wound care CNP L was available on-site in a storage shed. -He had kept one of those mattresses available for emergent use. *He relied on staff to have let him know when a physician-ordered air mattress for resident use so that he could have set it up. *He had not been notified of resident 19's PO for an air mattress. Interview on 10/25/23 at 11:00 a.m. with ADON/IP/wound care nurse K regarding resident 19 revealed she had: *Incorrectly staged resident 19's wound as a stage II when she first assessed it on 8/15/23. -It should have been a stage III. *Read wound care CNP L's progress notes after her visits for any new orders or recommendations that had required her follow-up. -Continued to stage resident 19's pressure ulcer as stage II through 10/11/23 even after wound care CNP L had documented it as a stage III on the first day she assessed the resident on 9/5/23. *Not known about wound care CNP L's 10/17/23 PO for resident 19 to have had an air mattress because it had not been referred to in her progress note. -Agreed resident 19 not having had prompt access to the air mattress had the potential to have worsened her PU. *Not routinely met face-to-face during or after wound care CNP L's resident visits to have discussed pertinent resident findings related to their skin conditions such as appropriate staging of the PU, a resident's need for a specific skin intervention or the need for durable medical equipment. Interview on 10/26/23 at 3:15 p.m. with DON A, interim administrator B, regional nurse consultant C, and nurse supervisor N revealed: *Nursing staff used a 24-hour report to communicate pertinent resident information between shift changes such as new POs, specific resident concerns, or significant resident changes. -That report was reviewed during daily department head briefings. *If resident 19's need for an air mattress had been identified on a 24-hour report and reviewed during a department head briefing, it would not necessarily have been rediscussed in subsequent department head briefings to ensure the air mattress had been obtained. -That process would have ensured resident 19 received her durable medical equipment (the ROHO cushion and air mattress) in a timely manner. *Face-to-face communication was expected to have occurred between ADON/IP/wound care nurse K or her designee following wound care CNP L's resident visits to ensure consistent care had occurred. Review of the revised 3/23/23 Skin and Pressure Injury Prevention Program revealed Policy: To provide care and services to prevent pressure injury development and to promote the healing of pressure injuries/wounds that are present.

Based on observation, interview, record review, review of the South Dakota Board of Nursing website, and policy review, the provider failed to ensure professional standards of care were followed for: *Medication administration practices by one of one licensed practical nurse (LPN) (H) for three of three observed residents (2, 7, 17, and 22). *Ensuring physician's orders for Tylenol were written for two-325 miligram (mg) tablets for three of three sampled residents (8, 33, and 65) to eliminate the need for a dose calculation by one of one unlicensed medication aide (UMA) (I). *Insulin administration by one of one LPN (F) for one of one sampled resident (25). *deceased note was documented in the medical record of one of one sample resident (71). *A follow-up appintment was made for one of one sampled resident (49) to receive a new lower partial denture. Findings include: 1. Observation and interview on [DATE] at 11:20 a.m. with LPN H in the 300 hallway revealed: *In one of her opened medication (med) cart drawers there were two medication (med) cups; one had resident 22's name on it and contained her crushed Seroquel and Tylenol. -She preferred to take those meds with coffee and coffee was served in the dining room with the noon meal. -LPN H planned to administer those meds to resident 22 after she was taken to the dining room. *The second cup in the opened med cart drawer was unmaked, it contained resident 2's Tylenol. -When LPN H prepared meds, she did it according to resident room numbers. -When she prepared resident 7's meds she had prepared resident 2's meds and left them in the med cart drawer. *LPN H stated the medication administration process was more time effective for her to do it as she had done it. *In another drawer of the med cart, there was a third unmarked med cup. -That med cup contained resident 17's crushed Norco (a controlled pain medication) and Tylenol. -She had prepared those meds prior to determining the resident was not in her room for administration of those medications. -LPN H thought resident 17's son had taken her to the dining room for the noon meal. *She had not wanted to take her medication cart into the dining room to administer those medications. -She agreed that she could have just taken the prepared med cup to the dining room and administered those medications. 2. Observation and interview on [DATE] at 11:00 a.m. with LPN F during resident 25's insulin administration revealed: *He prepared the insulin pen and then entered the resident's room. *After using an alcohol pad to cleanse the resident's abdominal area LPN F inserted the insulin pen needle into the resident's abdomen. *He depressed the injection button on the pen and held it for three seconds prior to withdrawing the needle from the resident's skin. *LPN F confirmed he should have left that needle inserted in the resident's abdomen for ten seconds prior to having withdrawn it. 3. Observation, review of the electronic medication administration record, and interview on [DATE] at 11:15 a.m. with UMA I during medication administration revealed: *Residents 8, 33, and 65 had physician's orders to have received one-650 mg (milligram) tablet of Tylenol. *UMA I used a stock bottle (a bulk supply of an over-the-counter medication kept on hand at the facility and not labeled for use by a specific resident) of Tylenol 325 mg to remove two-325 mg tablets from that bottle for each resident. -She was aware that she needed to administer two-325 mg Tylenol tablets to each resident because 325 mg plus 325 mg equaled a total of 650 mg as ordered by the physician. *It was not within her scope of practice as a UMA to have calculated medication doses but she thought it was acceptable if it's something simple, like Tylenol. Interview on [DATE] at 11:45 a.m. with director of nursing A regarding the observations referred to above revealed she: *Expected resident medications to have been administered at the time of the preparation and not set-up and then stored in the medication cart for administration at a later time. *Expected after depressing the insulin pen injection button that staff counted to ten prior to removal of the insulin pen needle from the resident's skin. *Agreed the physician's dosing orders for residents 8, 33, and 65's Tylenol should have been modified to reflect the administration of two-325 mg tablets in order to eliminate the need for a dose calculation. Review of the [DATE] Medication Administration General Guidelines policy revealed: Medication Administration: 4. Medications are to be administered at the time they are prepared. Review of the [DATE] Medication Administration Subcutaneous Insulin policy revealed: C. Keep the injection button pressed all the way. Slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered. Review of the South Dakota Board of Nursing chapter 20:48:04.01:12 revealed: Medication administration tasks that may not be delegated included 5. Calculation of any medication dose. 45901 4. Review of resident 71's electronic medical record (EMR) revealed: *She was originally admitted on [DATE] with Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment, was transferred to the emergency department (ED) on [DATE]. *On [DATE], she returned from ED with diagnosis of sepsis and a physician orders for comfort care. *On [DATE] at 4:25 p.m. her body was picked up by a local funeral home. Interview on [DATE] at 10:51 a.m. with director of nursing A, assistant administrator B, and regional nurse consultant C revealed: *Resident 71 returned to facility on [DATE] from the ED on comfort cares. *Resident 71 passed away on [DATE]. *Was not aware there was no decease note in resident 71's medical record. *A note regarding the resident's death was expected to have been documented in a residents EMR. -Resident death documentation should include the following information: --The time, date and location of assessment. --Describes signs of irreversible death. --Who was contacted and the date and time. *Nurses were trained during orientation to thoroughly document the required information after the death of a resident. A requested to director of nursing A on [DATE] for policy on required documentation of a resident death, and no policy was provided prior to survey exit. 43844 5. Observation and interview on [DATE] at 2:42 p.m. with resident 49 revealed: *His bottom two front teeth were missing. -He was unable to answer questions regarding his teeth. Review of resident 49's medical record revealed: *He was admitted on [DATE]. *His [DATE] Brief Interview of Mental Status score was 5, indicating he had severe cognitive impairment. *His diagnoses included: -Post-Traumatic Stress Disorder. -Alcohol-induced persisting dementia. -Alzheimer's Disease. -Anxiety. -Obstructive sleep apnea. -Hearing loss. *A [DATE] nurse's progress note revealed: -Resident returned to facility from dental appointment with tooth extraction. -Partial denture would be made to replace the missing teeth. -No complaints of pain or discomfort noted, pleasant with staff, and resting in bed. -No significant weight loss. *A [DATE] progress note that indicated he had upper dentures and lower partial. Interview on [DATE] at 3:36 p.m. with LPN F revealed resident 49: -Had received a new lower partial denture since [DATE]. -Lost the new lower partial dentures sometime in [DATE]. Interview on [DATE] at 3:38 p.m. with DON A regarding resident 49's lower partial denture revealed: *DON A was not aware of him having new lower partial denture or that the resident had lost the lower partial denture. -She would have to call the family to see if he had received a new lower partial denture or if he had lost the lower partial denture. Continued interview on [DATE] at 4:35 p.m. with DON A regarding resident 49's lower partial denture revealed: *He had not received a new lower partial denture. *DON A confirmed the provider should have followed-up on the appointment from [DATE] to determine when resident 49 would have a new lower partial denture made. Interview on [DATE] at 2:24 p.m. with social service designee E regarding resident 49's dental appointments revealed: *She was not aware that a follow-up appointment was needed for resident 49 for a new lower partial denture. *Their process included: -The family would normally transport resident 49 to his appointments. --When the family was not available the facility would have made transportation arrangements. -The family would initiate the appointment-making process. --Then the nurse would scheduled the medical appointments. -Nurses would make follow-up medical appointments that might have been needed. Review of the provider's [DATE] Hearing, Vision, and Dental policy revealed: *Policy: -The facility must, if necessary, assist the resident in making appointments and arrange the transportation to and from the office of a practitioner specializing in the treatment of vision, dental or hearing impairment and/or provide these services by professionals in-house, if able. -The resident/resident representative has the right to refuse these services, Refusals should be documented.

Based on observation, interviews, record review, and policy review the provider failed to assess, document and provide interventions per their policy for one of one sampled resident (49) who had suicidal ideations. 1. Observation and interview on 10/24/23 at 2:42 p.m. with resident 49 revealed: *His door was closed. *CNA J knocked on resident 49's door. -Resident 49 opened the door and came into the hallway. *Resident 49 was smiling and answered basic questions before returning to his room. Interview on 10/24/23 at 2:50 p.m. with CNA J revealed resident 49 often barricaded his door from the inside. Review of resident 49's medical record revealed: *He was admitted on [DATE]. *His diagnoses included: -Post-Traumatic Stress Disorder. -Alcohol-induced persisting dementia. -Alzheimer's Disease. -Anxiety. -Obstructive sleep apnea. -Hearing loss. *His 9/22/23 Brief Interview of Mental Status score was 5, indicating he had severe cognitive impairment. *A 9/22/23 nurse's progress note revealed: -His speech was clear. -He was usually able to make his needs and wants known. -He could usually understand verbal context from staff and family. Review of resident 49's behavior notes included: *A 10/14/2023 behavior progress note that read, Resident was monitored tonight for self harm. -There were no non-pharmacological interventions documented. -There had been no pharmacological interventions documented. --The summary note included, Resident was disoriented last evening and verbalized frustration as he could not remember whether that was his room or whether he had ever been there. He was reported to have verbalized to the CNA I wish I could just commit suicide, but I will be stupid to do it. He was redirected multiple times before he was able to settle down and sleep. All this time he displayed a lot of frustration to the fact that he could not remember anything. Later in the night, he did not display any negative behaviors. *There was no other documentation related to his suicidal statement or interventions that were implemented by staff. *There was no documentation that his physician was notified. Review of resident 49's 10/25/23 care plan revealed: *A 6/23/23 revised focus of Continues to barricade himself in his room, History of Threatening Behavior, Rejection of care. -Interventions for the above focus included: --My behaviors will not cause harm to myself or others through the next review. --My behaviors will not impede staff's ability to provide me my necessary care through the next revew. --Behavior Committee to monitor mood/behavior quarterly and as needed. --On 11/10/22, I am unable to have a roommate due to my behaviors. --A 3/24/22, I am territorial about my room and where I usually sit in Town Square dining room. --Revised 9/21/23 interventions of, ---If I am resistive, stop the task, leave and allow me time to calm my self. ---My ability to retain information is very short, I need frequent cueing. ---Provide reassurances as needed that I am safe and you are here to help me. Interview on 10/26/23 at 2:24 p.m. with social service designee E revealed: *She was not aware of resident 49's episode of suicidal ideation. *The process when a resident had a suicidal ideation would include the following: -The resident should been on suicide checks every 20 minutes. -There should have been a complete room search to ensure there was nothing the resident could have used to commit suicide. -The nurse should have notified her. --She would visit with the resident. --She would have completed a PHQ-9 assessment (a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression) with the resident. Interview and resident 49's medical record review on 10/25/23 at 4:37 p.m. with DON A revealed she: *Had not been aware of the documentation that resident 49 had an episode of suicidal ideation. *Should have been notified of the episode when it occurred. Review of the provider's Suicide Threats/Suicide Precautions policy revealed: *Policy -Resident suicide threats shall be taken seriously and addressed appropriately. *Procedures -1. Staff should report any resident threats of suicide or comments of wanting to die immediately to the Nurse Supervisor/Charge Nurse. 2. A staff member should remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident. 3. The Nurse Supervisor/Charge Nurse should immediately assess the situation and notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse should notify the resident's Attending Physician and resident representative. 5. Provide 1:1 [one to one] supervision and removal all equipment from room that could be used and/or cause harm (sharps, cords, belts, etc.). 1:1 Supervision will continue until the resident is transferred or deemed not a threat to themselves or others by the physician or mental health professional. 6. A psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician or mental health professional has determined that a risk of suicide does not appear to be present. 8. Document details in the resident's medical record, including entry into Risk Management. Interview and policy review on 10/26/23 at 4:05 p.m. with DON A revealed the provider had not followed their policy for residents who expressed suicidal ideation.

A. Based on observation and interview, the provider failed to ensure appropriate bed bathing techniques were maintained for one of one sampled resident (10) by one of one certified nurse assistant (CNA) (I) Findings include: 1. Observation and interview on 8/31/22 between 7:45 a.m. and 8:00 a.m. of CNA I as she provided a bed bath to resident 10 revealed: *She filled a basin with soapy water and a clean washcloth then placed it on the night stand in preparation for that resident's bed bath. *After cleaning the resident's body using the soapy water and washcloth she used that now unclean water and same washcloth she used to clean resident 10 to rinse her off. *She stated she had been a CNA for [AGE] years. Interview on 8/31/22 at 11:50 a.m. with director of nursing B, assistant director of nursing/infection control nurse C and regional nurse consultant D revealed they would have expected CNA I bring two basins and extra washcloths into resident 10's room for her bed bath. One set dedicated to washing the resident and the other dedicated to rinsing her. B. Based on observation, interview, and policy review, the provider failed to ensure appropriate infection prevention and control practices were maintained for: *Cleaning of shared vital sign equipment (blood pressure cuff, thermometer, and pulse oximeter) used by three of three CNAs (K, L, and M) with five of five observed residents (6, 11, 40, 48, and 62). *Appropriate hand hygiene, glove use, and use of cleaned vital sign equipment (thermometer) by one of one CNA (I) with one of one observed resident (16). *Transportation of clean linen by one of one CNA (J). Findings include: 1. Observation and interview on 8/29/22 at 2:30 p.m. of CNA K taking routine vital signs revealed: *She obtained a blood pressure, temperature, and oxygen saturation, on resident 62. -Without sanitizing and using the same shared equipment, she obtained a temperature and oxygen saturation on resident 11. *CNA K stated it was a routine expectation to sanitize the shared equipment between each resident use. -Verified she had not sanitized the equipment between each resident's use. Interview on 8/30/22 at 9:49 a.m. with assistant director of nursing/infection control nurse C revealed: *They (CNA's) know they are supposed to clean the equipment between each use and it is a constant battle. *The expectation was to disinfect the equipment between each use. *We have tried to audit this in the past but the focus right now is staffing. We are very staff challenged. -Management is currently picking up three to four floor shifts per week. *We know this is a constant issue and realize the potential to spread infection. Further observation on 8/30/22 at 9:57 a.m. of CNA L and CNA M taking routine vital signs revealed: *CNA L had obtained a blood pressure on resident 6. -Without sanitizing and using the same shared equipment, she obtained a blood pressure on resident 40. -Without sanitizing the equipment she moved the vitals cart into resident 48's room and left for a break. *CNA M took over and without sanitizing the equipment she obtained a blood pressure on resident 48. -Without sanitizing the equipment she placed the vital sign equipment in hallway 300 and walked away to perform another task. Interview on 8/31/22 at 9:05 a.m. with administrator A revealed: *A recent in-house mock survey revealed several issues including the cleansing of high touch surface areas. -This had included the use of shared equipment. *They had a current performance improvement project (PIP) on cleaning of high touch surface areas. *It was her expectation the equipment would be cleaned between each resident use. Review of the provider's November 2019 policy on 'Cleaning and Disinfection' revealed: *Purpose: To provide supplies and equipment that are adequately cleaned and disinfected. *Policy: I. Cleaning: A. Supplies and equipment will be cleaned immediately after use. 2. Observation and interview on 8/29/22 between 3:11 p.m. and 3:35 p.m. with CNA I revealed she: *Performed hand hygiene prior to entering resident 16's room, put on a pair of gloves then placed a second set of gloves inside her smock pocket. *Cleaned the blood pressure cuff off with a Clorox wipe and hung it from the vitals cart to dry. *Cleaned the thermometer with a Clorox wipe and laid it directly on an uncleaned over the bed table to dry. *Cleaned the pulse oximeter probe and placed it upright in a holder on the cart to dry. *Removed her gloves, exited then returned to the room, and without performing hand hygiene removed the second set of gloves from inside her smock pocket and put them on. *Took resident 16's blood pressure, pulse oximeter reading, and temperature. *Removed her gloves, washed her hands, turned the water off with her wet hand, and wiped her wet hands with paper towel. *Had not realized the risk for glove contamination when they were stored inside a smock pocket. *Had not known a barrier should have been placed on the bedside stand before placing the cleaned thermometer on it. *Knew she should have turned the bathroom faucet off with a clean paper towel but had not done that. 3. Observation on 8/29/22 at 2:30 p.m. of CNA J in the 200 resident hallway revealed: *She pushed an uncovered wheeled cart containing incontinence briefs, incontinence wipes, and clean resident gowns down that hall. -Removed contents from that cart to stock resident rooms on that hallway. *She picked up a gown that had fallen out of the cart onto the hallway floor between rooms [ROOM NUMBERS] and placed that now unclean gown on top of the clean gowns in that cart. Interview on 8/29/22 at 2:37 p.m. with CNA J regarding the observation referred to above revealed she: *Had not realized she dropped the unclean gown and returned it to the cart on top of the clean gowns. *Had not known clean laundry was expected to be covered when it was transported. Observation on 8/30/22 at 7:30 a.m. in the 200 resident hallway revealed an unattended and uncovered cart with resident gowns, incontinence wipes, and incontinence briefs in it. 4. Interview on 8/31/22 between 11:50 a.m. and 11:59 a.m. with director of nursing B, assistant director of nursing/infection control nurse C and regional nurse consultant D revealed they expected: *Hand hygiene had occurred prior to applying gloves and that extra gloves had not been kept in a potentially unclean smock pocket prior to use. *A papertowel not cleaned wet hands had been used to turn off the bathroom water. *The bedside table had been cleaned prior to placing the cleaned thermometer on top of it or that a clean barrier had been between the bedside table and the cleaned thermometer. 5. Review of the May 2021 Standard Precautions policy revealed on page 2: Hand hygiene should be performed prior to application and after removal of gloves. Review of the October 2019 Hand Hygiene policy revealed on page 2: 4. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. A Laundry Transport policy was requested at 4:00 p.m. on 8/30/22 from administrator A. On 8/31/22 at 8:00 a.m. administrator A stated there was no such policy but her expectation was that clean laundry was covered during transport and any unclean laundry was placed in a soiled laundry container and not co-mingled with clean laundry.

Based on observation, interview, and policy review, the provider failed to ensure: *Clean fitted bed sheets and pillow cases had been available in three semi-private residents' rooms (203, 205, 211) and two private residents' rooms (212 and 302). *Routine cleaning and maintenance for ten observed residents' (5, 6, 12, 17, 19, 24, 33, 48, 49, and 55) wheelchairs. *Routine maintenance of one of four dining rooms (Town Square). *Routine maintenance of 12 of 12 rooms (301, 302, 303, 305, 306, 307, 308, 309, 310, 312, 314, and 316) and one of four hallways (300 wing). Findings include: 1. Observation and interview on 8/30/22 at 9:00 a.m. with certified nurse aide (CNA) K assisting resident 17 revealed she: *Completed the resident's peri-care and laid her on the bare mattress on her bed. *Left the room for clean linens, returned to the room, and stated there were no linens in either of the two linen storage closets. *Had informed laundry prior to breakfast there were no linens available to make beds. Observation on 8/30/22 at 9:12 a.m. of the two linen closets referred to above revealed: *In the 300 wing linen closet there were some flat sheets and blankets but no fitted sheets or pillow cases. *In the south wing linen closet there were some blankets but no fitted sheets or pillow cases. Observation on 8/30/22 at 9:28 a.m. of resident rooms on the 200 and 300 wings revealed: *Mattresses on both beds in rooms 203, 205, and 211 were bare. *Mattresses in private rooms 212 and 302 were bare. Observation and interview on 8/30/22 at 9:40 a.m. with resident 23 sitting in the doorway of her room revealed she had wanted to lay in her bed, but her mattress was bare. Interview at that same time with CNA I regarding resident 23 revealed she was unable to help that resident to bed because there was no clean linen to place on her mattress for her to lie on. Observation and interview on 8/30/21 at 9:40 p.m. with laundry supervisor H revealed: *There were two washing machines and two dryers running with bed linen in them. *Apparently, today we don't have clean sheets. *The facility had an adequate supply of linen. -Staff were stashing clean linen in areas other than the designated storage closets. -Staff were not getting soiled linen to the laundry room for prompt processing. *She often collected linens herself from dirty linen storage and from resident rooms to be laundered. *Lack of clean linen was not a new issue and administrator A, assistant director of nursing/infection control nurse (ADON/ICN) C, and maintenance director F were aware of the problem. Interview on 8/30/22 at 9:50 a.m. with maintenance director F revealed: *Lack of available clean linen had been an issue in the past, but administrator A had told him today it was again a problem. *Staff had been educated at staff meetings and by director of nursing (DON) B about expectations to ensure clean linen was available. *He stated I don't have a clear fix for the problem. *He agreed residents not being able to lie down in their beds after breakfast due to not having linen on their beds was not acceptable. Interview on 8/31/22 at 12:01 p.m. with DON B, ADON/ICN C and regional nurse consultant D revealed: *There was a back stock of linen available for staff use so there should not have been unmade beds. *Available flat sheets or blankets both resident linen storage closets should have been used until fitted sheets had been made secured. *They agreed some staff may have been stashing clean linen, but did not believe staff had not gotten soiled linen to laundry for timely processing. Review of the undated Laundry Policies and Procedures for Laundry Personnel policy revealed: *Collection of Soiled Linen: -Soiled linen must be removed from the unit for 2 reasons: to keep the area infection free and laundry needs the soiled linen picked up regularly to keep the flow of wash moving through the Laundry Room. -The housekeeping/laundry supervisor should check with nursing to coordinate these pickups. The timing of nursing activities such as getting residents up, breakfast feeding, showers, and changing beds will dictate the best times for soiled pickup. 2. Observation on 8/29/22 at 12:53 p.m. in Town Square dining room revealed: *Resident 12 had brown splattered spots on the spokes of her wheelchair wheels. *Resident 24 had dried food and residue of sticky fluid on the cushion of the wheelchair. *Resident 5 had hair bound in the left axle of her wheelchair. Random observation on 8/29/22 at 5:20 p.m., on 8/30/22 at 11:30 a.m. and on 8/31/22 at 10:00 a.m. revealed: *Five observed residents' (6, 17, 48, 49, and 55) wheelchairs had hair bound to the axles of their wheelchairs. *Resident 33 had dried food and residue of sticky fluid on the cushion of her wheelchair. *The tips of both armrests on resident 19's wheelchair were torn exposing the blue foam padding beneath them. Interview on 8/31/22 at 9:05 a.m. with administrator A regarding wheel chair cleanliness revealed: *The quality assurance and performance improvement (QAPI) committee had identified cleaning of high-touch surface areas as a systemic issue. -This had included wheelchair cleanliness. *In June of 2022 they had a facility-wide wheelchair cleaning event. -Each wheelchair was taken outside and was sprayed off with a pressure washer. *Wheel chair wipe downs were a part of the daily routine and were expected to occur. On 8/31/22 at 11:45 p.m. a Wheelchair Cleaning policy was requested of administrator A. She stated there was no such policy, but provided a September 2018 Care and Storage of Personal Care items instead. Wheelchair cleaning was not referred to in that policy. 3. Observation on 8/30/22 at 8:09 a.m. of Town Square dining room revealed: *Chipped and peeling paint above the electrical outlet next to the main dining room door entrance. *The bottom of the main dining room door had about a seven and a half inch bottom edge of the door protector gone and a big gouge in the door. *The dining room wall in the barber shop area had a crack in the wall from the floor to the ceiling. 4. Observation on 8/30/22 at 3:00 p.m. of 12 out of 12 residents' rooms revealed the bifold closet doors (301, 302, 303, 304, 306, 307, 308, 309, 310, 312, 314, and 316) had not been connected to the closet track. 5. Random observations on 8/29/22 between 1:00 p.m. to 4:00 p.m. revealed: *Hallway 300 had various scuff marks with missing paint measuring approximately twelve inches above the floor that extended down both walls of the entire hallway. *Room 303: -The wall under the window had a dry wall repair that was unpainted measuring approximately five inches by twelve inches. -The wall adjacent to the hallway door had an approximate five by six inch area with two smaller areas above it that were missing paint. *Room 305: -The wall adjacent to the hallway door had an approximate four inch by five inch area of missing paint. -The bathroom wall opposite the toilet had missing paint in various areas. *Room 307: -The wall adjacent to the hallway door had vertical lines of missing paint along each edge were the bed's headboard met the wall. -The bathroom walls had a two inch high strip of missing paint located above the mop boards that encircled the room. *Room 310: -The wall under the window had an approximate twelve inch by twelve inch area of missing paint located above the bed. Interview on 8/30/22 at 3:29 p.m. with maintenance director F revealed he: *Had a preventative maintenance binder of various topics he monitored on a daily, monthly, quarterly, semi-annual, and annual basis. -This binder had not included the monitoring of chipped paint or scuff marks. *Was in charge of senior maintenance for six facilities including two in Montana. -Usually spent about three weeks out of every month at this facility. -Was the only maintenance person for this facility. -Had been cross-trained as a certified nurse's aide (CNA) and medication aide (MA). -Was recently required to work as a CNA and a MA to cover empty shifts. --This had prevented him from performing routine repairs or maintenance. *Walked through the building often, but also depended on staff to place maintenance work orders with any environmental repair issues. -This was done either by paper or through the TELS (electronic work order and building management) system. *Had not received any work orders from staff about chipped paint or scuff marks. -Staff could improve on notifying me on things that need repaired. *Had crash guard railings he planned on installing in all the hallways to prevent wheelchair scuff marks. -This would require two people to install. -A housekeeper would occasionally help him with projects that required two people, but had not been available to assist him as much as he would have liked. *Some resident rooms need a good touch-up. Interview on 8/31/22 at 7:50 a.m. with administrator A revealed: *Staff had been educated on maintenance reporting and were encouraged to use the TELS system. *Agreed there were areas in the facility that had scuff marks and missing paint. *Maintenance had been working on the scuff marks and missing paint in the main corridors. -This had been difficult as resident's would often bang their wheelchairs into the walls and doors. -Had plans to install crash guard railings in all the main corridors. *Lack of staffing had played a part in the general maintenance of the facility. -The maintenance director had been pulled to cover empty CNA and MA shifts three times in the last schedule period. -Filling empty resident care shifts had been her main priority. Review of the provider's October 2019 Homelike Environment policy revealed: *2. 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: -i. Walls and door scuffs/chips repaired with paint/stain when needed. *3. 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: *15 of 15 randomly observed residents in one of four resident dining rooms (Town Square) had been treated with dignity and respect during one of two observed meals by one of one certified nurse aide (CNA) I. Findings include: 1. Observation on 8/30/22 at 7:50 a.m. of the Town Square dining room revealed CNA I was the only staff person in that dining room assisting 15 residents put their clothing protectors on in preparation for breakfast. Continued observation between 7:58 a.m. and 8:12 a.m. revealed: *At 7:58 a.m. CNA I sat down at an unoccupied dining room table and periodically strummed her fingernails on the tabletop looking around the room. -She exited the dining room for a few minutes, returned with a piece of paper and a pen, and sat back down at that table. -Had not interacted with any residents in that dining room. *One unidentified ambulatory resident tapped on the keys of the piano then attempted to have a conversation with a few of the other residents while he waited for breakfast. *Another unidentified resident worked on a crossword puzzle book. *The remaining unidentified residents sat in silence or had their heads down towards their chests with their eyes closed. *There was no music, television or any other type of stimulation occurring during that time. Continued observation at 8:12 a.m. revealed: *Activity director E entered the dining room and asked, How about some music to which one unidentified resident responded, That would be nice. *She went around to each of the four dining room tables occupied by residents and interacted them. -They opened their eyes and verbally or non-verbally responded to her. Continued observation between 8:12 a.m. and 8:20 a.m. of CNA I revealed she: *Remained seated alone and silent at the same dining room table. *Got up from that table at 8:20 a.m. and assisted an unidentified resident with a clothing protector who had been brought into the dining room. *Remained up and assisted residents with their meals after the breakfast cart arrived at 8:23 a.m. Interview on 8/30/22 at 3:25 p.m. with CNA I regarding the above dining room observation revealed she: *Had not considered it disrespectful towards residents when she sat herself apart from them and not interacted with them during the observation period referred to above. -Was just waiting for breakfast trays to arrive. Interview on 8/31/22 at 11:50 a.m. with director of nursing B and regional nurse consultant D regarding the observation referred to above revealed all staff were expected to create a homelike dining atmosphere for residents that included talking and engaging with residents while they waited for the meal service to begin. Review of the September 2019 Resident Dignity and Privacy policy revealed: *Policy: -It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as, care for each resident in a manner and in an environment that maintain resident privacy.

Based on observation, interview, record review, policy review, and job description review, the provider failed to: *Identify a decline condition and physical capabilities for one of one sampled resident (70) who had a fall with a major injury. *Ensure one of one sampled resident (70) who was at risk for pressure injuries had preventative measures and interventions in place to ensure no skin breakdown had occurred. Findings include: 1. Observation on 9/16/19 at 2:46 p.m. of resident 70 revealed: *The resident's door to her room had been shut. *Upon knocking on the door there was no answer. *Shortly thereafter the resident opened the door and yelled out in a harsh, deep, and brogue voice yeah. -She wanted to know what I was about and just who I was. *She had been walking in her room independently and transferred herself on/off the chair with ease. Interview on 9/16/19 at 2:48 p.m. with certified nursing assistant (CNA) O regarding resident 70 revealed she stated: *She's pretty independent, but you have to watch out for her. *She can be harsh at times and might kick you out of the room. *We don't help her with much. Interview on 9/16/19 at 3:45 p.m. with the director of nursing (DON) revealed she: *Confirmed the resident had behaviors and preferred her independence. *Stated: -She fell a while back and fractured her hip. -She had two deep tissue injuries. -They are facility acquired, but we think they came from the hospital; we did notice the reddened heels but just didn't document it. -Unfortunately they worsened, and she is followed by therapy and the wound nurse. Review of resident 70's paper and electronic medical records revealed: *She was admitted on [DATE]. *[DIAGNOSES REDACTED]. *She had periods of confusion and problems with both short and long term memory recall. *On 3/3/19 she had a fall in her room when attempting to get her suitcase out of the clothes closet. -That fall had resulted in a right [MEDICAL CONDITION] and required admittance to the hospital for surgical repair. *She returned on 3/8/19 on skilled nursing and therapy services for rehabilitation with her goal to return to her prior function and capabilities. *Prior to her fall on 3/3/19 she had required limited assistance from the staff for all activities of daily living (ADL) and supervision with walking. -That had included bed mobility and repositioning from side-to-side. *After her fall on 3/3/19 she had: -Received physician's orders [REDACTED]. -Orders to bear weight on her right leg as she could tolerate. -Required the use of a positioning wedge for six weeks between her legs while laying in bed. -Been dependent on the staff to assist her with all ADLs. --Including bed mobility and repositioning from side-to-side. -A Braden Scale for Predicting Pressure ulcers score completed on 3/8/19. --That score was fifteen indicating she was at low risk for skin breakdown. -Been unable to walk and required the use of a wheelchair (w/c) to go from place-to-place in the facility. *On 3/13/19 the staff: -Identified a deep tissue injury to her right heel. --That wound measured 3.6 centimeters (cm) x (by) 2.2 cm and was purple in color. -Identified a deep tissue injury to her left heel. --That wound measured 3.4 cm x 2.0 cm and was purple in color. *The skin on the wounds had been intact and nonblanchable. *The family and physician had been informed of those above wounds. *There was no documentation to support preventative measures had been put in place in a timely manner to ensure she had not acquired those injuries. Review of resident 70's 3/8/19 nursing evaluation upon admission to the facility revealed: *She had: -Two nursing evaluations completed upon readmission to the facility. -The presence of wounds. *No documentation to support: -What and where those wounds were located. -A complete and full assessment of those wounds. -What treatments and been put in place for those wounds. -What interventions had been put in place to decrease the risk of skin breakdown occurring. Review of resident 70's 3/8/19 hospital discharge summary had not documented deep tissue injuries to her heels. The only wound treatment and care that was ordered was for her surgical site. Review of resident 70's physician's orders [REDACTED]. *She had required treatment and wound care for her surgical site. *There was no documentation to support she had required any other type of wound care and treatment prior to 3/13/19. *On 3/13/19 the physician wrote: Wound care: Apply sheep skin heel protectors to both feet and float heels when in bed two times a day for DTI (deep tissue injury). Interview on 9/19/19 at 9:37 a.m. and again at 10:58 a.m. with resident 70's primary physician revealed: *To her knowledge the resident had not acquired those wounds during her stay at the hospital. *She reviewed the resident's entire hospital stay prior to our interview and confirmed there was no documentation of those wounds during her stay there. *She reviewed and assessed the resident upon her return to the facility on [DATE]. -There was no documentation in her progress note to support deep tissue injuries were assessed by her nor was she informed of any by the staff. *She stated: -I think she can be pretty noncompliant with things. -We tried to keep her from wearing her shoes, but she was very resistive to that. -Yes, we should document any noncompliance. *She agreed there should have been preventative interventions put in place prior to the wound occurrence. *She stated: We need to be more proactive versus reactive. Review of resident 70's 3/8/19 through 3/31/19 skilled nursing documentation revealed: *No documentation to support noncompliance with any preventative interventions for wounds. *On 3/11/19 the nursing staff had documented the refusal of using the wedge cushion between her legs. -That was the only noncompliance documented prior to 3/13/19. Review of resident 70's wound evaluations from 3/8/19 through 3/13/19 regarding her deep tissue injuries revealed: *On 3/13/19: -Lotion had been applied to both of her feet and legs after identification of those wounds. -The staff had reported she was noncompliant with interventions and treatments. --There was no documentation to support what those interventions and treatments had been. -It supported the physician's orders [REDACTED].>-Sheep skin to be worn on both of her heels. -Her heels to have been floated or elevated to relieve pressure on them. Review of resident 70's revised comprehensive care plan revealed: *It had different initiation and revision dates for all focus areas developed for her. *A focus area for pressure ulcers to both of her heel wounds. -That focus area had no initiation or revision date for both of those heels. *Interventions for that focus area were initiated on 3/13/19. *Those interventions had been: -Attempt to float heels when in bed - I frequently refuse. -Avoid positioning the resident with pressure on heels. -I may be non compliant with keeping the sheep skin heel protectors on. -I may not be cooperative with allowing my heels to float while in bed. *The interventions were not put in place until pressure injuries had been identified. Interview on 9/19/19 at 9:30 a.m. with the Minimum Data Set (MDS) assessment coordinator regarding resident 70 revealed she: *Confirmed: -The deep tissue injuries to her heels. -She had acquired those wounds while receiving care in the facility. -She had a significant change for the worse upon readmission to the facility on [DATE]. -The direct care givers used those care plans to guide them with care for all the residents. *Would not have: -Assisted with determining those residents who had been at risk for skin breakdown. -Assisted the staff with determining pressure relieving measures for the residents at risk for skin breakdown. *Agreed: -The pressure relieving measures put in place for her had not occurred until after she had acquired those wounds. -They had not been timely when putting those interventions in place for her. *She stated: The wound nurse is responsible for putting preventative measures in place. *All her information for the MDS assessment had been from data. *She would not have: -Assessed the residents and been proactive with determining any type of preventative measures for them. All her information for the residents had been data driven. -Attended care conferences to assist the interdisciplinary care team with reviewing the care plans on the residents and with their representatives. -A part of the care conference to ensure the care plan was accurate and true to support care for the residents had occurred. -Been a part of determining processes and preventative measures for the residents to ensure proper care and services was delivered. *She had completed her interviews as directed by the MDS document, but nothing further to support her information for that assessment was accurate. *She stated: -That process all changed under different ownership a while back. -They thought a nurse should be attending (care conferences) instead of the MDS nurse. -So the unit coordinator does this and started to go instead. -I do the nursing part of the care plan, but I'm not responsible to make sure everyone else does their part. -The wound nurse is supposed to put the preventative measures in place. Interview on 9/19/19 at 9:09 a.m. with the administrator and regional director regarding the above medical record review and interviews revealed they would have expected a team approach on determining preventative interventions for those high risk residents. Interview on 9/19/19 at 11:20 a.m. with the assistant director of nursing (ADON) and wound nurse revealed she: *Was not sure who was responsible for determining pressure relieving measures and devices for those residents who were at high risk for skin breakdown. *Stated: Going forward it should be an interdisciplinary care team approach. Interview and chart review on 9/19/19 at 9:35 a.m. with the DON, ADON, and nurse consultant regarding resident 70 revealed: *They confirmed: -The medical record review above. -The resident had acquired both of the deep tissue injuries while receiving care in the facility. *They were unsure if there was documentation to confirm she was noncompliant with any of the interventions. *They agreed the documentation supported reactive versus proactive when putting preventative measures and devices in place to ensure no skin breakdown had occurred. Interview on 9/19/19 at 12:13 p.m. with the DON, ADON, nurse consultant, regional director, corporate regulatory specialist, and administrator regarding resident 70 revealed: *They confirmed the above medical record review and interviews regarding the resident and her deep tissue injuries. *They were aware the MDS assessment nurse was not: -Involved in determining preventative measures to ensure skin breakdown had not occurred. -A part of care conferences and should be to ensure the necessary care and services the residents required had occurred. -Proactive in ensuring all the information she put on her assessments for the residents was accurate. *The DON: -Agreed it should be an interdisciplinary care team approach when determining the care and services the residents required and they would be going forward. *A copy of the MDS assessment coordinator's and wound nurse's job descriptions were requested for review. -There was no job description for them. Review of the provider's (MONTH) 2019 Skin Program policy revealed: *To ensure a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable. *To provide care and services to prevent pressure injury development, to promote the healing of pressure injuries/wounds that are present and prevent development of additional pressure injuries/wounds. *Nursing personnel will utilize the results of the physical exam and the Pressure Injury Assessment tools to determine an individualized pressure injury prevention program for each at-risk resident. Review of the provider's (MONTH) (YEAR) Documentation System policy revealed: *The plan of care is documented and reflects current standards of professional practice, including measures to facilitate the medical care prescribed that will restore, maintain or promote the resident's highest practicable level of functioning. *The resident's care plan should be maintained to be up-to-date. Review of the provider's (MONTH) 2019 Care Planning policy revealed: *Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. *Care planning is constantly in process; it begins the moment the resident is admitted to the facility and doesn't end until discharge or death. *The DON will be responsible for holding the team accountable to initiating and completing the Admission care plan within 48 hours and the long-term care plan by 21 and updated as necessary thereafter. Review of the Director of Nursing 8/24/18 job description revealed: The Director of Nursing is responsible for the planning, development and overall operation of the Nursing Department which ensures Guests (residents) receive quality care 24 hours a day. Review of the Assistant Director of Nursing 8/24/18 job description revealed: The Assistant Director of Nursing assists the Director of Nursing (D.O.N.) in the planning, development and overall operation of the Nursing Department which ensures Guests (residents) receive quality of care 24 hours a day.

Based on observation, interview, record review, and policy review, the provider failed to appropriately assess, investigate, document, and provide notification to the physician and family for three of three sampled residents (10, 30, and 74) who had injuries from an unknown origin. Findings include: 1. Review of resident 30's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] without behavioral disturbance. -Pain in right shoulder. -Pain in left shoulder. -Cerebral infarction, unspecified. -Chronic obstructive [MEDICAL CONDITION]. -Anxiety disorder, unspecified. *She had been admitted to hospice on 9/13/19. Review of resident 30's 7/31/19 Minimum Data Set (MDS) assessment coordinator revealed: *She was rarely or never understood. *She sometimes understood others. *She had long and short term memory problems. *She was totally dependent on two staff members for bed mobility and dressing. *She was totally dependent on one staff member for locomotion on and off the unit and for eating. *She required extensive assistance of two staff members for transferring and using the bathroom. *She required extensive assistance of one staff member with personal hygiene. *She did not walk. *She had no swallowing concerns. *She was always incontinent of bladder and frequently incontinent of bowel. The following observations of resident 30 revealed: *On 9/17/19 at 9:41 a.m. she was in a hospital gown sleeping in her bed with music playing in the room. *On 9/17/19 at 12:24 p.m. of resident 30 revealed she was in a hospital gown laying in bed with her eyes opened. -Interview at that time with certified nursing assistants (CNA) L and M revealed since she had gone on hospice she was not getting out of bed or eating. Interview on 9/18/19 at 10:23 a.m. with resident 30's guardian revealed: *On 4/8/19 she had noticed a large bruise around the resident's chest. -It extended over her breasts and around her sides. *She had informed the resident's son, and he e-mailed the social services designee (SSD) wanting to know what had happened. *On 4/11/19 the son had received an e-mail from the SSD stating there was a bruise noted on 4/5/19 consistent with the use of a gait belt. Staff had been re-educated on the use of the belt. *She felt the staff were rough with the resident and always rushed her. *She had brought those concerns and others up to the SSD and other staff but felt nothing was ever done. *She also had come to visit on different occasions, and the gait belt had been left on her while she was laying in bed. *There was a sign on the wall Gait Belt for Transfers ONLY. Remove when in chair, wheelchair, or bed. *She stated the sign had been put on the wall after the incident on 4/5/19. Review of resident 30's nursing progress notes revealed: *On 4/5/19: Report from LPN (licensed practical nurse) of bruising noted to bilateral breasts and around the upper torso of the resident that correlates with the height of the breasts. This nurse assessed the area and noted older bruising that is consistent with a gait belt being on too tightly. Staff was educated about proper positioning and tightness when using a gait belt. -There had been no prior documentation regarding any other bruising to correlate when the older bruising had occurred. *There had been no documentation regarding the physician being notified. *There had been no documentation until 4/11/19 regarding the family being notified. Interview on 9/18/19 at 2:00 p.m. with the assistant director of nursing (ADON) regarding the above bruising on resident 30 revealed: *She had written the note on 4/5/19. *She could not find any other documentation regarding the older bruising mentioned in the note. *They had determined CNAs were using the gait belt incorrectly and provided education to the staff. *It was unclear how they had made that determination. Interview on 9/18/19 at 2:23 p.m. with the director of nursing (DON), ADON, and the corporate regulatory specialist revealed they had not completed an investigation into the bruising documented on 4/5/19. There was no report sent to the South Dakota Department of Health (SD DOH). They had been told by the nurse consultant at the time if they could determine what happened they did not need to report it to the SD DOH. They had not considered it to be neglect. There was no documentation of the staff involved. There was no other documentation other than the nurses note on 4/5/19. Interview on 9/19/19 at 12:05 p.m. with the ADON revealed there was no documentation of the re-education regarding gait belt usage. 2. Observation on 9/16/19 at 2:39 p.m. of resident 10 revealed: *She had been laying in her bed sleeping. *The bed had been in a low position with a long mat laying on the floor next to the bed. *Her pants had been pulled half way up her leg to expose the lower part of her ankles and shins. *The posterior part of her left shin had an opened wound on it. *That wound had: -Been opened to air and covered with a dark brown colored scab approximately 1.5 centimeters (cm) by (x) 1.5 cm in diameter. -Reddened skin surrounding the entire outside surface of it. Observation on 9/16/19 at 3:48 p.m. with CNAs O and P with resident 10 revealed: *They had prepared to assist the resident with personal care and transfer into her wheelchair (w/c). *She had been laying in her bed, awake, and making occasional nonsensical statements. *She required the CNAs to assist her with all activities of daily living (ADL). -That had included bed mobility, personal hygiene and care, dressing, and transferring from one surface to another. *She required both CNAs to assist her with transferring. -They had assisted her with a stand-pivot transfer. *With that transfer they had not used a gait belt to ensure protection of her shoulders and dignity from pulling on her pants. -Both the CNAs had gait belts wrapped around their waists and would have been available for use. *She required the use of a w/c for transportation and mobility purposes. -The staff assisted her with going from one location to another. Interview on 9/17/19 at 10:46 a.m. with resident 10's significant other revealed: *He had shown the surveyor the wound on the resident's left shin and stated: -They are good at telling us about things that happen but not always. -One day not to long ago (pointing to the wound on her leg) it was covered with gauze, but today it is not. -I thought it came from a fall she had not too long ago but I'm not sure. *The family had not been notified of the wound located on her left shin. Review of resident 10's medical record from 6/1/19 through 9/18/19 revealed: *She had short and long term memory problems. *She sometimes understood others. *She was dependent upon the staff to meet all her ADLs and anticipate her needs. -That had included bed mobility, transfers, toileting, dressing, and locomotion. *There was no documentation to support: -She had a wound on her left shin. -The staff had been aware of the wound on her left shin and how she acquired it. -The family or physician had been notified of that wound. -That anyone had been monitoring and checking on the healing process of the wound. -That an incident report with an investigation completed to rule out abuse and neglect had not occurred *She had a history of [REDACTED]. -Her last documented fall had been in (MONTH) 2019. Interview on 9/18/19 at 10:25 a.m. with licensed practical nurses (LPN) Q and T regarding resident 10 revealed: *They had been aware of the wound to her left shin. *LPN T stated: -About a week ago a night nurse who rarely works reported a skin tear on her left leg. -She wrapped it with gauze. -I didn't see an incident report done or any documentation on it, so I never checked it. -I never have looked at it. *They agreed: -There should have been an incident report completed on an injury of unknown origin. -With that incident report there should have been an investigation completed to rule out abuse. *When an incident report was completed the family and physician should have been notified. *They confirmed the direct care givers should have reported any and all injuries the residents acquired to rule out abuse. Interview on 9/18/19 at 1:44 p.m. with CNA J regarding resident 10 revealed she: *Had been aware of the wound on the resident's left shin. *Had noticed it about two to three weeks ago while assisting the resident with personal care. *Was not sure how she got it. *Had reported the observation of that wound to LPN Q. *Stated: -Yes, that is our process, with any bruise or injury we see we are supposed to tell the nurse. -I don't know what happened after I told (nurse's name). -I don't ever see her picking at her legs or skin. -To my knowledge she doesn't do that. Interview on 9/18/19 at 1:55 p.m. with the DON regarding resident 10 revealed: *She was not aware of the wound on the resident's left shin. *She confirmed: -The medical record review above, and the staff support the resident required to meet her ADL. -Any and all injuries of unknown or known origin should have been reported to the charge nurse. -All injuries of unknown origin required an incident report to be completed with an investigation to ensure abuse had not occurred. -The family and physician should have been notified of any and all injuries the residents had acquired. *She would have expected the professional staff to have followed-up and documented on any injury that had been reported to them. 3. Observation on 9/16/19 at 4:36 p.m. of resident 74 revealed: *She had been sitting in a wheelchair (w/c) sitting in the unit dining room drinking a glass of juice. *She had been quiet and offered little to no conversation when spoken to. *She had a small scabbed wound on her left elbow. *That wound had been opened to air with no signs of infection. Observation on 9/17/19 at 11:00 a.m. of CNA M with resident 74 revealed: *She had prepared to assist the resident with going to the bathroom. *The resident had been in her w/c and required staff support to: -Stand and pull down her pants. -Sit down on the toilet. -Provide perineal care and personal hygiene. Review of resident 74's medical record revealed: *She had problems with short and long term memory recall. *She required extensive assistance from the staff with ADLs. -Those ADLs had been transfers, bed mobility, personal hygiene and care, dressing, and locomotion. *On 8/2/19 a skin evaluation had been completed on the resident. -That evaluation supported a skin tear to her left forearm. -There was no documentation to support the size of the wound and if the family and physician had been notified. -The skin tear had been draining and was covered with a bandaid. *On 8/8/19 a skin evaluation had been completed. -That evaluation confirmed the skin tear to her left forearm and the size of it. -The wound had partial flap loss with no infection or pain during the dressing change. -The physician had been notified and was requested to order a treatment for [REDACTED]. -That had been the first documentation to confirm physician notification. -No documentation to confirm the family had been notified. Review of resident 74's nursing progress notes from 8/1/19 through 9/18/19 revealed: *On 8/3/19: the charge nurse had documented: Resident has a 2 skin tears on the left forearm, moist and draining with serous fluid. Cleansed with normal saline, pat dry, applied with [MEDICATION NAME] and covered with silicone absorbent dressing. *On 8/8/19: the physician had faxed an order with a treatment for [REDACTED]. *There was no documentation to support: -How she had acquired those wounds. -An incident report with an investigation had been completed to rule out abuse. -A consistent pattern as to whether she had one or two skin tears on her left forearm. -The physician was notified prior to 8/8/19. -The family had been notified of those wounds and change in condition. Interview and document review on 9/17/19 at 2:52 p.m. with the ADON regarding resident 74 revealed: *She: -Was the wound nurse and assessed and treated the wounds in the facility. -Had been aware of the skin tear on the resident's left forearm. -Had a weekly skin care report dated 9/11/19 and showed: --What residents had wounds that required a treatment. --What type of wound the resident had and the location. --The original size of the wound, the date it was acquired, and the type of treatment. *The resident had been listed on that report and supported: -The resident had acquired a skin tear to her left forearm on 8/1/19. -The wound had been healing and was open-to-air. *The resident had acquired that wound when going through the entrance of her room. Interview on 9/18/19 at 9:20 a.m. with the DON, corporate regulatory specialist, and ADON regarding resident 74 revealed: *The DON had been aware of the skin tear on the resident's left forearm. *She had seen it a few days after it occurred and had asked a CNA how she acquired that wound. *She stated: -She apparently caught it on the door of her room. -I didn't think I needed to do an incident report if we knew how they got the wound. *She confirmed the medical record review above and the amount of staff she required to complete ADLs. *She agreed: -There should have been documentation to support how the resident had acquired those skin tears. -The staff should have completed an incident report upon the identification or occurrence of the injury. -An investigation should have been completed to ensure abuse had not occurred. -The physician and family should have been notified of that injury. Review of the provider's (MONTH) (YEAR) Documentation System policy revealed: *To document in the resident's medical record all services provided to the resident and any changes in the resident's medical or mental condition. *The resident's medical record should be up-to-day at all times reflecting the current status of the resident. *The plan of care is documented and reflects current standards of professional practice, including measures to facilitate the medical care prescribed that will restore, maintain or promote the resident's highest practicable level of functioning. Such measures include physiological, psychosocial and environmental factors, as well as resident and family education and discharge planning. Review of the provider's (MONTH) (YEAR) Abuse, Neglect, and Exploitation policy revealed: *Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. *Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. *Investigation of alleged abuse, neglect and exploitation. - When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting had occurred, an investigation should be conducted. Components of an investigation may include: -Interview the involved resident, if possible, and document all responses. -If there is no response from the resident, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident. -Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. -Document the entire investigation chronologically. *In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: -Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official in accordance with State Law (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities). -Have evidence that all alleged violations are thoroughly investigated. -Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process. -Report the results of all investigation to the administrator or his or her designated representative and to the other official in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on record review, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who had a history of [REDACTED]. 1. Interview on 4/8/15 at 3:00 p.m. with resident 1's son revealed: *The son found his mother lying on her side on the floor beside her bed on 9/17/14 about 9:45 a.m. when he came to visit her. *Her pants were pulled down and her buttocks were exposed with bowel movement on her skin. *He went to the doorway of the room and called out for staff assistance to get her off the floor. *The nursing staff assisted her off the floor and checked her over for injuries, and none were found. *The nursing staff had told him they had assisted the resident to the bathroom (time unknown) and then all the staff had a "stand-up" meeting they had every morning. They thought the resident was in the bathroom alone "for only maybe a minute." "There should have been some staff left on the nursing wing to attend to residents." *"The resident should not have been left alone in the toilet." *The resident was dependent on the staff to get in and out of the bathroom, but he thought she got tired of waiting for the staff to come get her. She was unsteady on her feet, and her balance was impaired. *The resident had an unwitnessed fall on 5/19/14 and sustained a facial laceration. *The resident had a few other falls (unsure of dates) where she did not sustain injuries. *They had gotten her a different chair in her room to make it easier for her to get out of if she forgot and tried to get up on her own. *After the fall nursing staff told him they were not going to use the toilet anymore for her due to her dementia (memory loss) and inability to understand using the toilet any longer. The nursing staff told him in the care plan meeting they were "going to check and change her adult undergarment every hour." *Sometimes family came to visit her and no nursing staff come into her room for two to three hours. *The family had told the provider they would still like her taken to the toilet especially for her bowel movements. *There was some nursing staff that were better than others with making sure the resident's soiled undergarment was changed more often, but they were not sure it was every hour. Review of resident 1's 9/19/14 at 9:50 a.m. post fall analysis/plan revealed: *Fall details- "Lost balance." *Prior to fall- "Resident ambulating." *History of falls. *Impaired safety/awareness/judgement. *Time last toileted/voided- "Wet." There was no time for that entry. *Medications given in the last eight hours prior to fall- "Antidepressant and antypsychotic." *Recommendations and interventions post fall- "Bed in low position. Toileting schedule. Do not leave resident unattended in the bathroom." *Care plan revised- "No." Review of resident 1's 5/19/14 through 3/15/15 nursing progress notes revealed: *5/19/14- "Resident ambulating (walking) in hallway. Certified nursing assistant heard a noise and saw resident laying in doorway on left side. Has history of falls as well as needing encouragement to slow down while ambulating. Ambulates in hallway frequently. Large laceration (cut) to left side of eye brow and down side of left eye. Swelling to left lower lip. Abrasion (scraped area) to left hand knuckles. Redness to both knees. Glasses are bent and at nurse's station for repair by family. Sent to emergency room ." *5/28/14- "Resident witnessed falling. Poor safety awareness." *8/3/14- "Resident found laying on the floor in front of the chair in the room. She appears to have slid out of the chair onto the floor. She has a history of falls and impaired judgement. Resident does have dementia." *9/19/14- "Resident's son came into room and found resident laying on floor next to bed and reported to staff. Resident is [AGE] year old and diagnosed with [REDACTED]. *12/6/14- "Resident is found on the floor in her room. History of dementia and impaired safety awareness. A small amount of blood is noted to be coming from an abrasion to her posterior (back) scalp." *1/17/15- "Found lying on the mat on the floor in another resident's room. History of falls and dementia." *1/19/15- "Resident attempting to sit down on the bed and slid off bed onto the floor. Writer witnessed event. Resident is a [AGE] year old with dementia. Resident is able to ambulate without assist. Gait is slow and unsteady." *3/1/15- "Resident began to slide out of shower chair and was lowered to the floor. No injuries." *3/15/15- "Resident found sitting on floor in front of couch at end of west. History of falls and dementia. No new injuries noted." Review of resident 1's undated care plan revealed: *At risk for falls related to wandering, use of medication, and history of falls. Date initiated 1/17/13. *Footwear to prevent slipping. *Do not leave resident unattended in the bathroom. *Incontinence of bowel and bladder. History of urinary tract infections. Date initiated 1/17/13. *Assist to the bathroom upon arising in the morning, before and after meals, before going to bed at night, and during nightly rounds as resident allows. *Use of briefs/pads for incontinence protection. *Incontinence care and comfort as needed. Review of resident 1's 1/1/15 through 4/8/15 activities of daily living flow sheet log revealed: *Twenty-nine, eight hour shifts where no toileting assistance was documented. *Three night (10:00 p.m. to 6:00 a.m.) shifts toileting assistance was coded 8/8 (indicative activity did not occur). Interview on 4/8/15 at 3:30 p.m. with registered nurse Minimum Data Set coordinator A regarding resident 1 revealed: *Their policy was for residents who were considered at high risk for falls were not to be left unattended in the bathroom. *The resident had been identified as a high fall risk prior to her 9/19/14 fall when she had been left unattended in the bathroom. *During the morning stand-up meeting the nursing wing was never left unattended. When the certified nursing assistants had about a ten minute meeting the supervisors usually watched the wing. *Whoever had assisted her into the bathroom on 9/19/14 should have stayed with her or gotten someone else to remain with her in the bathroom. Review of the provider's 1/13/15 Incontinence Management/Bladder Function Guideline policy revealed: *Care plans reflect individualized program. *Observation of care provided matches the plan of care. *There was no documentation residents who were considered at high risk for falls were not to be left unattended in the bathroom. Review of the provider's 1/22/15 Falls Management Guideline policy revealed: *Each living center implemented the falls prevention and intervention program. *"At risk residents are identified through a fall alert communication system to care givers." *"The interdisciplinary team evaluates the fall prevention plan of care for residents at risk for falls." *Following a resident's fall appropriate interventions were implemented, and the care plan was updated.

Based on observation, interview, record review, and guideline review, the provider failed to ensure two of two sampled residents (2 and 7) with facility acquired pressure ulcers (an area of skin breakdown where something keeps rubbing or pressing against the skin) had interventions implemented to prevent worsening. Findings include: 1. Observation and interview on 4/8/15 at 8:15 a.m. during personal care and a dressing change with certified nursing assistants (CNA) M and N and registered nurse (RN) E for resident 2 revealed: *He had been incontinent (lacking control) of bowel and bladder at that time. *He had a pressure ulcer to his left lower part of the buttocks with slough (injured tissue that was tan or black colored) noted. *RN E completed the dressing change with the Santyl ointment (debridement medication (to get rid of the injured tissue)) and the foam dressing as directed. *She stated the ulcer had been there a couple weeks. *He had a saddle type cushion in his wheelchair that appeared slightly worn. *He had a regular mattress on his bed. Review of resident 2's medical record revealed: *He had been admitted on [DATE]. *He had a [MEDICAL CONDITION] in November 2014 and was hospitalized and had been re-admitted on [DATE]. *A 2/9/15 Quarterly Interdisciplinary Resident Review indicated: -He had skin concerns. -A Braden Scale (measurement for predicting risk of pressure ulcers) score of 17 indicating he was at risk for them. *On 3/16/15 a pressure ulcer was noted to his left "glut" (gluteus (buttock)). Review of resident 2's wound evaluation flow sheet revealed: *On 3/16/15 there was a new stage 2 pressure ulcer measurement indicating partial thickness of tissue loss noted to his left "glut." -They were using a foam dressing to the area. -Current preventative interventions were a wheelchair cushion and pressure redistribution mattress. *On 3/23/15 the ulcer continued to be a stage 2 with the same type of dressing. *On 3/30/15 the ulcer had deteriorated (gotten worse) to an unstageable (indicating more tissue loss covered by slough) pressure ulcer. -The nurse requested new orders from the physician for Alginate AG (medication used for debridment). *On 4/6/15 the ulcer was listed as a stage 2 again, but checked that slough was present. -Wound status/additional comments indicated the wound continued with slough, and they would request new wound care orders. *On all the above entries there was a box checked that indicated the care plan had been reviewed. Review of the March 2015 medication and treatment administration records (MAR/TAR) revealed: *Weekly skin reviews were done every Friday at 8:00 a.m. *There was no treatment or dressing for the pressure ulcer. Review of the April 2015 MARs and TARs revealed: *Weekly skin reviews were done every Friday at 8:00 a.m. *There was a treatment for [REDACTED]. -That had an ordered date of 4/2/15 and discontinued date of 4/6/15. *There was a treatment for [REDACTED]. -That was to be changed daily, and had an ordered date of 4/6/15. Review of resident 2's last revised 3/16/15 care plan revealed: *A handwritten entry on 3/16/15 indicated a stage 2 (measurement scale for pressure ulcers) to his left "glut." *No new interventions were added related to the pressure ulcer. *No entries had mentioned the ulcer was currently an unstageable pressure ulcer. *No mention of the wheelchair cushion or pressure redistribution mattress. Interviews on 4/7/15 at 4:00 p.m. and again at 4:55 p.m. with licensed practical nurse (LPN) D revealed: *The pressure ulcer was originally noted on 3/16/15. *She was the nurse who started the initial foam dressing treatment. -There was no order for that original treatment. *The current treatment of [REDACTED]. *The ulcer was not currently draining but was covered with slough. -She agreed it was an unstageable ulcer at this time. *She thought she had notified the physician by phone of the pressure ulcer on 3/16/15 but was unable to find that documentation. *She should have made a progress note about the notification of the physician at the time but had not. Review of resident 2's interdisciplinary progress notes revealed: *A 3/16/15 at 10:33 a.m. note that indicated: -An open area (pressure ulcer) was noted to his left lower buttocks. -It appeared his skin integrity (health) was compromised by breakdown associated with incontinence (lack of bladder or bowel control) combined with shearing (friction against the skin). -A wheel chair cushion was in place. -A message was left to notify his wife. *A 4/2/15 late entry note for 3/16/15 at 12:35 p.m. note that indicated: -Therapy had a discussion with nursing regarding the ulcer and type of mattress. -Due to his cognitive (memory) level, lack of ability to use the call light, and decline in awareness of his body location, the resident would be at more risk of falls out of bed with an air mattress. *A 3/16/15 at 12:53 p.m. note that indicated his wife was notified. *A 4/7/15 late entry note for 3/16/15 at 6:36 p.m. note that indicated: -The nurse had spoken to doctor (Dr.) ___ in the facility about the new ulcer. -The Dr verbalized an okay to continue the dry dressing per the provider's protocol. Interview on 4/8/15 at 11:05 a.m. with LPN D revealed: *She would have initiated the treatment for [REDACTED]. *She usually did not put the treatment on the MARs or TARs until she received an order from the Dr. *Normal facility protocol would have been to change the foam dressing when soiled or dirty, because it could be left in place for more than one day. *She agreed there was no treatment indicated on the March 2015 MAR indicated [REDACTED] -She agreed there was no way to prove he had received pressure ulcer care by the nurses in March. *She stated the charge nurses should have known from the communication book or report about the ulcer. Interview on 4/8/15 at 11:10 a.m. with RN E confirmed as a charge nurse they would use the MARs and TARs to know what treatment would be needed for a resident each day. Further interview on 4/8/15 at 3:50 p.m. with LPN D revealed: *She had worked in the facility about two and a half years. *She had been the wound nurse for the facility for the last several months. *She worked on wound care primarily one day a week. *She had not received formal training for wound care. -Her only training had been on-the-job with the previous wound nurse. -The previous wound nurse was the current director of nursing (DON). *She would have consulted the dietitian on new ulcers. *She thought the facility also had a consultant wound nurse but was unsure of where she was from or her name. -She stated she had never met the consultant wound nurse. *When a new pressure ulcer had been identified by her or the charge nurse she would have been expected to: -Assess the area. -Measure the area. -Fax a request to the Dr for orders. -Put interventions into place, such as a new mattress, booties, or something specific to the ulcer. *She agreed there was no specific repositioning or toileting schedule in place for resident 2. *She agreed the resident typically spent several hours a day sitting in his wheelchair. *She agreed he needed a new wheelchair cushion. *She confirmed the resident's pressure ulcer had declined since 3/16/15. Interview on 4/8/15 at 10:00 a.m. with the DON regarding resident 2 revealed: *The interdisciplinary team should have made adjustments and additions to the care plans by handwriting them onto the current printed care plan. -The MDS nurse should have then added the handwritten entries into the computer when she did the resident's MDS assessment. *She agreed there were no interventions on the resident's care plan specific to the pressure ulcer, and there should have been. *They would try to get the correct mattress and interventions in place for a resident at risk for pressure ulcer. *LPN D was the wound nurse in the facility and would have decided an initial treatment for [REDACTED]. *She would have expected the Dr to be notified of a new ulcer on the same day. *She agreed there was no treatment for [REDACTED]. *She agreed if the nurse did not work every day they might not have known about the pressure ulcer, and therefore would not have done a treatment to the area. *She stated the CNAs used different care sheets to know what care the resident needed. -She confirmed there was no mention of the resident's pressure ulcer on the CNA care sheet. *She agreed the resident did not have a specific repositioning or toileting schedule. *She confirmed there was no way to prove the resident had received pressure ulcer care in March. *She further stated if something was not documented then it was not done. 2. Review of resident 7's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She had required extensive assistance with all of her mobility needs (transferring from location to location and moving in bed) and ADL needs. Review of resident 7's 7/30/14 Braden Scale Assessment revealed a score of a 13 indicating she was at moderate risk for developing pressure ulcers. Review of resident 7's 7/30/14 physician's admission orders [REDACTED] *Two skin tears and a surgical wound to the left hip had been identified. *No other skin problems were documented on or identified by the hospital discharging physician. Review of resident 7's 7/30/14 admission head-to-toe physical assessment revealed: *Two skin tears to the upper portion of her left arm. *Three red and blanchable (skin loses redness with pressure) areas to her left buttock. *Both of her heels were soft and red. The left heel had a scab on it. *There was no documentation regarding: - The size of the scab. -The appearance of the scab. -If there was drainage from the wound or not. *Prevalon boots (pressure relieving) were to have been used on both feel. Review of resident 7's nursing progress notes from 7/30/14 through 9/15/14 revealed: *On 9/9/15 the nursing staff had documented "RN (registered nurse) called to resident's room to change dressing as it was falling off on the left posterior (back) heel. Under the dressing was noted a 2 centimeter (cm) diameter superficial open area appearing red with minimal drainage. A [MEDICATION NAME] (protective dressing) foam adhesive was applied after cleansing with sterile NS (normal saline)." *On 9/15/14 the nursing staff had documented: -"Weekly wound assessment - resident admitted to facility with areas of concern. Stage 2 pressure ulcer to left heel. Wound bed is pink and moist. Scan serosanguineous drainage noted." -"MD (medical doctor) notified via fax and wound care orders requested." -"Son was notified via phone." *No documentation to support the wound had been assessed for worsening or health conditions, and was free from signs and symptoms of infection until 9/9/14. *No documentation to support the physician and family had been aware of the wound until 9/15/14. Review of resident 7's physician's orders [REDACTED]. The nursing staff had requested a treatment for [REDACTED]. Review of resident 7's weekly pressure ulcer record revealed: *The wound evaluation flow sheet had not been initiated for her left heel until 9/15/14. That had been forty-seven days after the initial identification and documentation of her wound on 7/30/14. *She had a stage 2 pressure ulcer to her left heel with serosanguineous drainage (yellow in color with small amounts of blood). Review of resident 7's Medication Administration Record [REDACTED] *She had an order for [REDACTED]. *No documentation to support the resident's left heel had a treatment or protective dressing in place until 9/15/14. Review of resident 7's 8/6/14 admission Minimum Data Set (MDS) assessment revealed the resident had: *Been at risk for pressure ulcers. *No pressure ulcers identified during that assessment period. *Not been placed on a repositioning program. There had been no MDS assessment identifying the pressure ulcer and skin issue to the resident's left heel until 9/24/14 with her change of therapy assessment. Review of resident 7's 8/6/14 MDS Comprehensive Area Assessment documentation revealed: *She had been at risk for obtaining pressure ulcers. *The following documentation: -"Triggered due to resident requires extensive assist with bed mobility, is frequently incontinent, and is at risk for pressure ulcers." -"She does have a history of ulcers." -"Skin was assessed on admission and will be assessed weekly by nursing staff." -"Staff assists with turning repositioning throughout the day." -"Goal is to avoid complications." Interview on 4/8/15 at 9:15 a.m. with the DON and MDS coordinator regarding resident 7 revealed: *They had not been aware of a wound to the resident's left heel at the time of admission. *The MDS coordinator would have reviewed all documentation regarding the resident from the time of admission through the MDS date of 8/6/14. *They confirmed there had been no documentation to support a pressure ulcer or wound to the resident's left heel after 7/30/14 until 9/9/14. *The staff should have assessed and documented weekly on the resident's left heel wound upon identification on 7/30/14 until it was healed on 12/18/14. *They were not able to locate any documentation to support the wound had been assessed weekly or monitored after identification on 7/30/14 until 9/9/14. 3. Review of the provider's undated Skin Integrity guidelines revealed: *Purpose: -"To decrease pressure ulcer and/or wound formation by identifying those patiens/residents who are at risk, and implementing appropriate interventions." -"To promote healing of wounds of any etiology (known source), whether admitted or acquired." *Objective "Decrease the prevalence and incidence of patients/residents who develop pressure ulcers." *General guidelines: -"Patients/residents will be assessed or observed for risk of skin breakdown with 24 hours of admission or readmission, quarterly, before transfer or discharge to any setting, and as necessitated by change in condition." -{Provider name) "Develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings." -"DNS or designee will be responsible to implement and monitor the skin integrity program." -"Wound status is monitored on a weekly basis."

Based on observation, interview, and record review, the provider failed to have a policy and procedure in place to determine the type of transfer required for one of three sampled residents (7). Findings include: 1. Review of resident 7's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She had required extensive assistance with two staff members to assist her with transfers. Observation on 4/7/15 at 3:05 p.m. in resident 7's room revealed: *Certified nursing assistants (CNA) H and I prepared to transfer the resident from her recliner into the wheelchair (w/c). *They retrieved a standing transfer aide (device to assist the resident with transferring) and had secured her to the lift prior to the transfer. Interview on 4/7/16 at 3:15 p.m. with CNA H regarding resident 7 revealed: *The resident had required staff assistance with all transfers. *She would have done two different types of transfers with the resident. *She would have used: -The Standing Transfer Aide when she had transferred the resident by herself. -A gaitbelt (belt that secured around the waist of the resident to assist with transfer) when another staff member would have assisted her with the transfer. *Today CNA I had preferred to use the transfer aide with two staff members. Review of resident 7's updated 1/20/15 Lift/mobility Assessment for Residents revealed "No lift needed, unless off of floor." Review of resident 7's 1/29/15 care plan revealed: *A focus area of "I have physical functioning deficit (lack of) related to self care impairment, mobility impairment." *An intervention provided under that focus area was "Transfer assistance of extensive assist." *No documentation to support how the resident was to have been transferred or the number of staff required to assist her during a transfer. Interview on 4/8/15 at 9:30 a.m. with the director of nursing (DON) and the Minimum Data Set (MDS) assessment coordinator regarding resident 7 revealed: *They agreed resident 7's care plan had not reflected the type of transfer she required or how many staff members were needed to assist her with a transfer. *The therapy department had worked with resident 7 on transfers after her 7/30/14 admission. *The CNAs would have known the type of transfer to use on the resident from the training they received from the therapy department. *The MDS coordinator was responsible for the assessment, documentation, and care planning on transfers for the residents. She could not clarify the type of transfer the resident required. *The DON stated "The CNAs can use a lift if a resident is weak, tired, or unable to transfer safely. They should inform the charge nurse when that occurs." *The DON confirmed the CNAs should not have been determining the type of transfer for resident 7. The 6/24/14 Facility - Lift/Mobility Assessment for Residents form had been what the provider used for their policy and procedure to use for determining the transfer type on all the residents.

Based on observation, interview, record review, and policy review, the provider failed to intervene in a timely manner to address a severe weight loss for one of seven sampled residents (12) with weight loss. Findings include: 1. Observations on 4/7/15 of the noon and evening meals with resident 12 revealed: *At the noon meal the resident was seated at the Rushmore dining room table. -From 11:45 a.m. to 12:00 noon a therapist was assisting her to eat then left her by herself. -The resident then sat at the table without eating. -At 12:20 p.m. the aide working in that dining area helped the resident eat a few bites of food, then left to assist other residents. -Nothing more was eaten by the resident. She had consumed about half of her meal. *At the evening meal the resident was seated at the Rushmore dining room table. -She took a few bites of food then just sat there with no staff helping her. -She appeared to be unsure of what to do for eating her meals. She sat there and looked around. Review of resident 12's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *An admission weight of 176 pounds (lb). *On 3/9/15 her weight had decreased from 176 lb to 166 lb and was currently at that weight. This was a 5.6 percent weight loss which was considered a severe loss. *A 2/10/15 nutrition note from the dietary manager including "refer to RD (registered dietician) for new admit". No other notes or mention of weight loss were made. *There was no RD assessment. *The physician had not been notified of the resident's weight loss. Review of resident 12's 1/29/15 Minimum Data Set assessment revealed a Brief Interview for Mental Status of 2, indicating a severe mental impairment. Review of resident 12's 2/10/15 care plan revealed: *Resident is "at nutritional risk due to Alzheimer's" with the following interventions: -Regular diet order. -Will monitor labs (labroratory tests) per physicians orders. -Will monitor weight and meal intakes weekly. *There was no mention of weight loss or interventions for that had been found. Review of resident 12's 2/1/15 to 4/7/15 meal logs revealed: *Her meal intake had been decreasing, and she currently averaged between forty to fifty percent of her meals. *She had taken a bedtime snack only twice in that time period. Interview on 4/9/15 at 9:50 a.m. with the dietary manager regarding resident 12's weight loss revealed: *She agreed the RD had not seen the resident yet. *She had noticed the resident's decreasing meal intake, and had arranged for an assessment by occupational therapy to determine its cause. That assessment was currently being done. *She had not noticed the weight loss nor had checked into why the resident was not taking bedtime snacks. *She would wait until after the assessment to start any supplements or other interventions to address the resident's weight loss. It had been a month since resident 12's severe weight loss had happened. Review of the provider's 2011 Weight Monitoring policy revealed: *"All weights will be reviewed by the DSM (dietary service manager) and the RD will be notified of any significant weight changes or trends through the referral process." *A weight loss of greater than five percent was considered to have been a severe loss. *"When weight change is significant or severe, the licensed nurse will notify the patient's physician, and obtain and carry out treatment orders if given. The licensed nurse will also notify the patient's family member or legal representative. Additionally, the LivingCenter will notify the dietician." *"A nutritional screen will be completed by the DSM and referred to the dietician for any patient needing additional nutritional interventions."

Based on observation, interview, policy review, and record review, the provider failed to prevent and appropriately stage a pressure ulcer for one of three sampled residents (2). Findings include: 1. Review of resident 2's right heel wound evaluation flow sheet revealed: *He had acquired a stage 1 pressure ulcer on 10/19/11. The area was bruised, skin was intact, and was blanchable (the area would whiten when pressure was applied). It measured 0.8 centimeters (cm) by 1.2 cm with no depth documented. Prevention included reducing pressure to his right heel and foam booties to both feet. *On 10/26/11 the right heel was noted to be spongy also. *On 11/30/11 the right heel was changed from a stage 1 to a deep tissue injury. It measured 1.8 cm by 1.6 cm with no depth documented. A deep tissue injury is described as damage of the underlying soft tissue from pressure and/or shear according to the National Pressure Ulcer Advisory Panel. *On 11/16/11 he acquired a stage 1 pressure ulcer to his right outer ankle. The area was intact and non-blanchable and measured 0.7 cm by 0.4 cm with no depth documented . Prevention included foam booties and a specific turn/reposition program. Observation on 12/5/11 at 2:30 p.m. revealed: *Resident 2 was lying on his back in his bed. *The bed had a pressure relieving air mattress on it. *He had bilateral Prevalon (pressure relieving heel protector) boots on his feet. *His right foot was noted to be turned to the side. Observation on 12/5/11 at 5:25 p.m. revealed certified nursing assistant (CNA) D removed both Prevalon boots and replaced them with tennis shoes. She then assisted resident 2 into his wheelchair using a total body lift. Observation on 12/6/11 at 8:30 a.m. revealed resident 2 was in his room seated in his wheelchair. At 10:20 a.m. in an interview with CNA E revealed resident 2 was not laid down in his bed until after lunch. He stayed in his wheelchair as he had a nebulizer treatment after breakfast. He would be laid down after lunch. Observation on 12/6/11 at 2:00 p.m. until 5:05 p.m. revealed: *Resident 2 was lying on his back in his bed. *He had the bilateral Prevalon boots on his feet. *His right foot was noted to be turned to the side. Interview on 12/6/11 at 3:15 p.m. with nurse specialist consultant C revealed: *There was no formal way to track repositioning. *The CNAs used an erasable white board to track when residents had last been repositioned. Interview on 12/6/11 at 5:10 p.m. with CNA F revealed:*She was not aware of when resident 2 had last been repositioned. *She was not aware of any erasable white board to document repositioning on. *She was not aware if resident 2 had any skin concerns. Review of resident 2's 9/30/11 annual Minimum Data Set record revealed: *He required extensive assistance with transfers with a mechanical lift. *He required extensive assistance with bed mobility. *He required total assistance with locomotion and used a wheelchair. *He had a catheter. *He was incontinent of bowel. *He had no skin concerns. *He had a pressure reducing cushion for his wheelchair. Review of resident 2's clinical health assessments revealed his Braden scale score (an assessment for predicting pressure sore risk) was: *A 12 on 1/21/11. *A 12 on 4/15/11. *A 12 on 7/15/11. *A 13 on 9/30/11. *A score of 10-12 indicated high risk and a score of 13-14 indicated moderate risk. *The Braden scale is based on sensory perception, moisture, activity, mobility, nutrition, friction, and shear. *His score had increased as his moisture score indicated his skin was usually dry and required changing of linens at routine intervals. Review of resident 2's 7/26/11 care plan revealed: *A focus area for the risk of pressure ulcer's had been identified on 11/10/10. *Interventions related to that focus area included: -Weekly skin inspections. -Turning and repositioning every 2 to 3 hours and as needed. *His care plan was updated on 11/9/11 for a right heel pressure ulcer due to decreased mobility and dementia. *Interventions related to that focus area included: -Monitor for healing/deterioration. -Reposition resident. -Foam/heel booties. *His care plan was updated on 11/16/11 for a right ankle pressure ulcer due to decreased mobility and dementia. *Interventions related to that focus area included a pressure redistribution mattress. Review of the provider's pressure redistribution devices weekly document for resident 2 from 1/1/11 through 12/3/11 revealed: *He had a pressure redistribution mattress for the week of 3/19/11. *He had a pressure redistribution mattress starting the week of 11/5/11. Review of resident 2's medical record revealed no documentation of why his air bed had been discontinued in March 2011. Continued interview on 12/6/11 at 3:15 p.m. with nurse specialist consultant C revealed: *Resident 2 had a air bed on his bed in March 2011. *The mattress had been discontinued due to his falling out of bed. *The mattress had been re-applied after he had developed a pressure ulcer to his right heel. *She stated the reason would have been documented in his chart. *She stated there was no guideline that was followed when an air bed would be applied or discontinued. *She stated there was no guidelines or policy for prevention in relationship to a resident's Braden score. Review of the provider's revised 2/25/10 clinical guideline for skin integrity revealed: *If an identified risk was present the interventions would be documented in the care plan. *Initiate positioning schedule to meet individual resident needs and minimize concentrated pressure to skin. *If identified at risk in skin integrity of feet, footwear would be addressed for appropriateness.

Based on observation, record review, interview, and policy review, the provider failed to individualize care for one of three sampled residents (2) who acquired a pressure ulcer. Findings include: 1. Review of resident 2's medical record revealed: *He acquired a stage 1 pressure ulcer to his right heel on 10/19/11. *He also acquired a second stage 1 pressure ulcer to his right ankle on 11/16/11. *He had been assessed on 1/21/11, 4/15/11, and 7/15/11 with a high risk for developing a pressure ulcer. *He had been assessed on 9/30/11 with a moderate risk for developing a pressure ulcer. *His interventions for prevention included turning and repositioning and a pressure reducing chair cushion. Refer to F314.