Every finding on record at Avera Bormann Manor

Based on South Dakota Department of Health (SD DOH) complaint the review of observations, interviews, electronic medication records and policy review revealed the facility failed to allow resident their right of self-determination.* 3 of 36 residents were not allowed to eat until the end of the meal service per a nurses request (6,8,9).* 1 additional food request was not granted* Call light times were reviewed due to excess wait times. 4 of 11 residents (1,2,3,4) had negative outcomes from wait times.Findings include:1. Review of the12/2/2025 SD DOH complaint intake revealed: *Medications were given in the dining room. *Staff were available to assist residents to eat each meal. *Blood sugars were being taken at appropriate time and locations as per resident doctors' orders and care plan preferences. *Unwitnessed and unreported falls. *Licensed staff were working in the facility within their scope of practice. *Hygiene with nails, hair, bathing and shaving were completed. 2. Observation on 2/3/26 at 7:50 a.m. in the dining room during the breakfast meal service revealed that residents (6,8, and 9) were seated at 7:30 a.m., before other residents arrived in the dining room, but were the last to be served their meals. 3. Interview on 2/3/26 at 8:00 a.m. with certified nursing assistant (CNA) M revealed residents 6, 8 and 9 are usually served last. 4. Interview with on 2/3/26 at 8:25 a.m. with food service worker (FSW) P revealed that as residents entered the dining room, the dining staff pulled the resident's diet card and placed it on the bottom of the pile of resident diet cards to serve the residents in order. They would serve one table at a time if all the residents were there. FSW P stated the nursing staff requested that residents 6,8 and 9 were to be served last due to resident 6 having a high risk for falling. 5. Observation on 2/3/26 at 11:15 a.m. in the dining room revealed residents (6,8, and 9) were seated and waiting for their lunch meals to be served. 6. Interview on 2/3/26 at 11:30 a.m. with registered nurse (RN) F revealed she asked the dietary staff to serve resident 6 last because she had a high risk of falling. 7. Interview on 2/3/26 at 11:33 a.m. with RN E revealed she was not aware of an issue or a previous request to serve resident 6 last, and she did not request residents to be served last. 8. Observation on 2/3/26 at 11:34 a.m. revealed that residents 6, 8 and 9 were served their lunch meals after waiting at the table for about 19 minutes while other residents ate. 9. Observation on 2/3/26 at 11:56 a.m. revealed that resident 7 requested an apple cut up and put into a small bowl. [NAME] Q replied to the request with ok, when the meal service is done. 10. Observation on 2/3/26 at 11:58 a.m. revealed that the lunch meal service was completed. 11. Interview on 2/3/26 at 12:16 pm. with cook Q revealed the health facilities surveyor requested the apple again for resident 7 and cook Q said okay. 12. Observation on 2/3/26 at 12:19 pm. revealed [NAME] Q delivered the apple by sliding the bowl in front of resident 7 who replied, thank you and cook Q walked away without acknowledging resident 7. 13. Interview on 2/3/26 at 1:40 p.m. with director of food services (DFS) R revealed residents were to be served meals when they arrived in the dining room and were seated at their table. DFS R was informed on 2/3/26 that residents 6, 8 and 9 were to be served last due to a nursing request. She expected the residents to be served their meal when they came into the dining room for that meal service. DFS R expected any additional food requests from the residents would be addressed immediately following the meal service. 14. Interview on 2/3/26 at 8:50 a.m. with resident 3 revealed that she had to sit soiled after a bowel movement for one to two hours before she could get help. She used her pendant (small, portable, wireless, device used in healthcare settings to allow individuals to immediately request assistance) or call light to alert staff when she needed assistance. A staff member would come and turn it off and say we will be back in a few minutes but they did not always come back. 15. Review of the call light log report from 1/9/26 through 1/24/26 revealed four of the eleven residents reviewed (1,2,3, and 4) had call light response times greater than 25 minutes. *Resident 4's call light response times revealed: - On 1/17/26 at 6:32 p.m. his call light was on for 34 minutes and 28 seconds. - On 1/23/26 at 7:12 p.m. his call light was on for 25 minutes and 4 seconds. * Resident 3's call light response times revealed: -On 1/10/26 at 6:46 p.m. her call light was on for 29 minutes and 33 seconds. -On 1/11/26 at 7:13 p.m. her call light was on for 35 minutes and 42 seconds. -On 1/12/26 at 6:09 p.m. her call light was on for 49 minutes and 16 seconds. -On 1/13/26 at 12:19 p.m. her call light was on for 25 minutes and 37 seconds. -On 1/15/26 at 7:34 p.m. her call light was on for 25 minutes and 34 seconds. -On 1/17/26 at 5: 56 p.m. her call light was on for 34 minutes and 2 seconds. -On 1/21/26 at 6:54 p.m. her call light was on for 29 minutes and 1 second. -On 1/23/26 at 7:02 p.m. her call light was on for 26 minutes and 5 seconds. 16. Interview on 2/4/26 at 8:55 a.m. with resident 4 revealed: * Resident 4 felt like he waited for a long time before a staff member answered his call light. * He urinated on himself while he waited for staff to come and assist him to the bathroom. * He felt disgusted not being able to get the help he needed to use the bathroom before he urinated on himself. 17. Interview on 2/4/26 at 9:15 a.m. with resident 3 revealed: * Resident 3 felt like she waited a long time for her call light to be answered. * She sat in her bowel movements while she waited for staff to come and assist her to the bathroom, which caused her buttocks to be red and have a rash. * She felt like there was nothing she could do about the long wait time for staff to come and help her. She felt forgotten by the staff. 18. Resident 2's call light response times revealed: -On 1/9/26 at 5:51 a.m. his call light response time was 47 minutes. -On 1/10/26 at 7:16 a.m. his call light response time was 35 minutes. -On 1/11/26 at 6:55 a.m. his call light response time was 40 minutes. -On 1/11/26 at 5:41 p.m. his call light response time was 50 minutes. -On 1/12/26 at 6:12 a.m. his call light response time was 35 minutes. -On 1/15/26 at 7:56 a.m. his call light response time was 31 minutes. -On 1/20/26 at 7:34 p.m. his call light response time was 28 minutes. -On 1/22/26 at 12:34 p.m. his call light response time was 28 minutes. 19. Interview on 2/4/26 at 9:22 a.m. with resident 2 revealed: *He waited for his call light to be answered often. *When he had to use his bathroom, he was incontinent (involuntary urine or bowel leakage) before staff arrived to help him. *He asked the staff why it took them to help him, and they told him they were helping other residents. *He has yelled from his doorway to get staff to come to his room to help him when his call light was on for over 30 minutes. *He stated, It's embarrassing to have to yell in the hallway for help. 20. Resident 1's call light response times revealed: -On 1/11/26 at 11:01 a.m. his call light response time was 27 minutes. -On 1/15/26 at 12:20 p.m. his call light response time was 26 minutes. -On 1/16/26 at 7:43 a.m. his call light response time was 25 minutes. -On 1/20/26 at 7:20 a.m. his call light response time was 27 minutes. -On 1/23/26 at 11:38 a.m. his call light response time was 25 minutes. 21. Interview on 2/4/26 at 9:47 a.m. with resident 1 revealed: *He turned his call light on when he wanted to get up for meals. *He waited 20 to 30 minutes for the staff to come in and get him up. *On 2/3/26 the staff left him in his room at suppertime until they got everyone out of the dining room before they helped him up for his meal. *It frustrated him when that happened, which was for the it happens around noon and evening meal services. 22. Interview on 2/4/26 at 9:25 a.m. with certified nursing assistant (CNA) K revealed her expectation of a call light response time was one to five minutes. 23. Interview on 2/4/26 at 9:30 a.m. with CNA M revealed her expectation of a call light response time was five to ten minutes. 24. Interview on 2/4/26 at 10:25 a.m. with CNA I revealed her expectation of a call light response time was at most five minutes. 25. Interview on 2/4/26 at 10:33 a.m. with CNA L revealed her expectation of a call light response time was two minutes. 26. Interview on 2/4/26 at 1:30 p.m. with director of nursing (DON) B revealed: *Her expectation of a call light response time was nothing over 20 minutes. *Call light audits were being completed once or twice monthly. *Nothing had been done with the audits that had been completed. 27. Review of the providers revised 2/2025 Call Light policy revealed: * Objective 1. To respond to patient/resident's request and needs on a timely basis. * Procedure 2. Answer light promptly.

Based on South Dakota Department of Health (SD DOH) complaint intake review, observations, interviews, record review, electronic medication records and policy review, the provider failed to ensure the staff followed professional standards regarding the safe transfer of one of one sampled resident (5) who was transferred with a total body mechanical lift by the certified nursing assistant (CNA) K and registered nurse (RN) F after he fell and had a suspected hip injury.Findings Include:1. Review of the12/2/2025 SD DOH complaint intake revealed:*Medications were given in the dining room.*Staff were available to assist residents to eat each meal.*Blood sugars were being taken at appropriate time and locations as per resident doctors' orders and care plan preferences.*Unwitnessed and unreported falls.*Licensed staff were working in the facility within their scope of practice.*Hygiene with nails, hair, bathing and shaving were completed. 2. Interview on 2/3/26 at 9:20 a.m. with registered nurse (RN) F revealed she was at a nursing staff meeting when she heard a noise of someone falling. She then went into resident 5's room and saw him lying on his right side by the door, his walker was beside him, and the bathroom door open. RN F completed range of motion (measurement of movement around a joint or body part) (ROM) exercise with him, completed her nursing assessment (vital signs and pain assessment) of resident 5 and noticed his legs were two different lengths. She requested a medical cart from the emergency department (ED) within the attached hospital to transfer him there. She could not remember how the staff transferred resident 5 to the medical cart.3. Interview on 2/3/26 at 10:20 a.m. with certified nursing assistant (CNA) K revealed she was assisting a resident back to their room when she saw resident 5 walking alone in his room. She then turned back to sit down the resident she was walking to assist resident 5. By the time she got back to resident 5's room, she heard a noise and saw him on the floor. She stated, I saw him lying on his right side with the door partially open with the walker in front of him. She did not know how he had gotten back to his room or if someone assisted him there. She called CNA L to bring a total body lift and sling (a mechanical lift and sling used to lift a person's full body) to his room to transfer him off the floor. She stated RN F heard the noise, came into his room, and did his assessments. After the nurse completed his assessment. This included vital signs, ROM, and pain evaluation. She and other staff members placed the total body lift sling under him. Resident 5 was in pain or uncomfortable when they were trying to put the sling under him. The staff changed his incontinence (involuntary urine or bowel leakage) brief as he was incontinent of a bowel movement.4. Interview on 2/3/26 at 10:35 a.m. with CNA L revealed that she was in the dining room assisting other residents to eat when she heard CNA K ask her to get a total body lift and sling for resident 5 who was on the floor. CNA L retrieved the sling and handed it off to another staff member in resident 5's room and went back to assisting other residents in the dining room.5. Review of resident 5's electronic medical record (EMR) revealed the documentation regarding his fall on 11/20/25 did not explain how he was transferred from the floor to the medical cart.6. Interview on 2/4/26 at 10:35 a.m. with RN F revealed that if someone fell and had a notable injury, she would place a pillow under the resident's head to keep them comfortable while she completed their fall assessment. She said it was obvious resident 5's hip was broken, but she does not remember how they transferred him onto the medical cart. She stated You know the process of what you are going to do based on your assessment at that time. We don't have to call 911 to get residents off the floor and to the ED we just take them. Then family decides if they need treatment.7. Review of 11/20/25 facility reported incident (FRI) regarding resident 5 revealed resident complains of right upper leg pain with ROM on right leg. ROM on other three extremities normal. Neuro assessment normal. Resident assisted off the floor onto a medical cart by total lift, three CNAs, and two RNs. During transfer resident complains of right leg pain and is holding right thigh.8. Interview on 2/4/26 at 10:55 a.m. with RN G revealed the nurse will complete her assessments on the resident who fell while they are on still on the ground. The resident's assessment included, getting a set of vital signs, gathering a total body lift, sling and extra staff to help transfer the resident. If it was a head, neck or hip injury she called the physician before she moved the resident, and then the resident was transported to the ED.9. Interview on 2/4/26 at 12:33 p.m. with director of physical therapy U revealed that she treated resident 5 for two therapy sessions before he passed away. On 1/11/26 he was in too much pain to go from a lying down to a sitting up position.10. Interview on 2/4/26 at 12:52 p.m. with DON B revealed that the professional standards of care followed by the facility was the Fundamental and Advanced Nursing Skills Third Edition by author Gaylene [NAME] RN.11. Review of resident 5's physical therapy notes revealed The patient did not do well trying to transfer from sit to supine in order for therapy to do some manual therapy (MT). He screamed in pain and then laid on his back and would not turn to the side. We ended up sitting him up and the therapist doing manual therapy at the edge of the bed (EOB) sitting.12. Interview on 2/4/26 at 1:30 p.m. with director of nursing (DON) B revealed that it was the facility's process to lift residents with the total body lift even if the resident had a suspected injury. DON B stated resident 5's fall on 10/31/25 was a fall without injury. On 11/11/25 he was unable to get out of bed and was then sent to the ED where he was diagnosed with an L1 (lumbar one) burst fracture. On 11/13/25 he started physical therapy and his Tramadol (pain medication) 50 milligrams (mg) was increased from twice a day to three times a day. His pain was worse for 3 days and then resident 5 reported he was feeling fine and used his wheelchair as needed.13. Interview on 2/4/26 at 3:00 p.m. with RN coordinator C revealed that if a resident was identified to have an injury after falling, such as resident 5, she would not use a mechanical total body lift to transfer the resident. She would get a hard backboard (a rigid, flat device used in emergency medical services (EMS) to immobilize and transport patients with suspected spinal or limb injuries) from the ED and ask the ED staff to assist her with immobilizing the area with the suspected injury. RN C said she was an ED nurse and knows where the items are to assist with injuries like resident 5's, but she did not think that most of the staff knew what to do or where to get a back board from. RN C would not have changed a soiled incontinent brief if a resident's hip was suspected to be broken. She would only change a soiled incontinent brief if there were enough staff to immobilize the area to prevent further injury to the resident. She did not know what the facility's policy was on transferring a resident with a hip injury.14. Review of providers procedural guide Fundamental and Advanced Nursing Skills Third Edition, Skills 2-1 Proper Body Mechanics, Safe Lifting and Transferring Page 152 Special Considerations revealed, Certain clients with spinal injuries or spinal surgery may require logrolling, a technique of moving or turning a client, whereby the body is kept in a protected straight alignment during the transfer. Author: Gaylene [NAME] RN.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, interview, and policy review the provider failed to ensure the safety of one of one sampled resident (1) who fell from a full body mechanical lift (a lift and sling used to lift a person's body) while being transferred from his bed to his wheelchair by certified nursing assistant (CNA) I and CNA J which required him to go to the emergency room for evaluation. Findings include:1. Review of the 1/6/26 SD DOH FRI report revealed:*On 1/6/26 at 5:20 p.m. resident 1 was being transferred by CNA I and CNA J from his bed to his wheelchair with a full body mechanical lift CNA H was in training and was observing.*CNA's I and J and resident 1 reported hearing a snap sound before resident 1 fell out of the full body mechanical lift.*Resident 1's left leg slipped out of the sling first, followed by his left shoulder, and then the rest of his body.*Resident 1 hit his head but did not lose consciousness.*When director of nursing (DON) B entered the room, the sling was in the air with two shoulder straps and one leg strap attached to the full body mechanical lift.*Resident 1 stated he hit his hip first and complained of his neck hurting.*His vital signs (measurements of the body's basic functions such as temperature, blood pressure, pulse, and respiration rate) were blood pressure 139/106, temperature 97.7, pulse 71, respirations 22 and oxygen saturation (percentage of oxygen in the blood) 99 percent.*The neurological assessment (assessment of nerve function, reflexes, coordination, motor skills, sensation, and mental status) was completed and was noted to be normal by registered nurse (RN) S.*Resident 1 was sent to the emergency department (ED) because he had previous paraplegia (the loss of motor or sensory function in the lower extremities) after a spinal cord injury.*A Computed Tomography (CT) (a medical imaging technique that creates detailed cross-sectional pictures of the body) scan was completed on resident 1's head and neck, which were negative.*X-rays of resident 1's shoulder, hip and pelvis were completed which were negative for any abnormalities.*There were no new orders received.*Resident 1 was to be monitored for any pain changes.*The family was notified of resident 1's fall and transfer to the ED.*The investigation was completed by the provider concluded CNA I and CNA J were involved in the resident's transfer.-CNA I was operating the full body mechanical lift.-CNA J was guiding the resident into his wheelchair.-Resident 1's care plan was followed for his transfer.-A medium sling was used for the full body mechanical lift.-CNA's H, I, and J had completed mechanical lift education and competencies.-The total body mechanical lift and sling were inspected with no issues identified. 2. Review of resident 1's electronic medical record (EMR) revealed:*He was admitted to the facility on [DATE].*His 12/17/25 Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated his cognition was intact.*His 12/18/25 Fall Risk Assessment score was 3 which indicated he had fall risk precautions.*His diagnoses were:-traumatic spinal cord dysfunction (causes immediate to progressive dysfunction below the injury site, including paralysis, loss of sensation, loss of bowel and bladder control) and paraplegia. 3. Interview on 2/2/26 at 2:15 p.m. with resident 1 revealed:*On 1/6/26 he was transferred using the full body mechanical lift by CNA I and CNA J.*CNA H was training and stood against the wall.*He was going from the bed to the wheelchair, when he slid out of the sling onto the floor and hit his head and right shoulder on the wheelchair when he landed on the floor.*He thought that a strap was not hooked to the lift and that is how he slid out and fell onto the floor.*He was transferred over to the ED and they completed scans and X-rays to make sure he had no broken bones.*The scan made sure his device to his heart for filtering blood clots did not move because of the fall.*He was unsure if the CNAs were holding onto the sling when they moved him but thought that was how he normally transferred into his wheelchair.*He had no injuries from the fall.*He stated the staff were using the right sling during the transfer.*He was assessed by the nurse for the sling size to use for his full body mechanical lift transfers. 4. Interview on 2/2/26 at 3:13 p.m. with CNA H revealed:*She was observing the transfer of resident 1 on 1/6/26 when he fell out of the full body mechanical lift.*She only observed during the transfer of resident 1.*She stated it looked like the black strap on the sling was not securely hooked and slipped off the full body mechanical lift.*CNA I was operating the lift.*CNA J was holding resident 1's legs and knee while guiding him into his wheelchair. 5. Interview on 2/2/26 at 3:55 p.m. with CNA I revealed:*She has worked for the facility since 9/29/25.*She was operating the lift during resident 1's fall on 1/6/26.*CNA J was guiding the resident into his wheelchair.*The lower sling strap were to cross between the residents legs and then hook on to the bar on the full mechanical lift.*While CNA J got behind the wheelchair to guide resident 1 into his seat, she heard a snap/pop sound.*The lower sling strap from the left side of his body, which was attached to the right side of the full body mechanical lift bar had come off the bar and resident landed on his hip first, then his shoulder, and then hit his head on the floor.*The lower sling strap from the left side of his body was not attached to the bar on the right side of the full body mechanical lift after resident 1 fell, but there were no broken or missing loops to the sling when the staff checked.*Before the transfer she had double checked the straps on the right side of the full body mechanical lift.*CNA J had checked the straps on the left side of the full body mechanical lift before they had transferred resident 1.*She has never had the mechanical lift safety checklist competencies completed for her. 6. Interview on 2/3/26 at 9:55 a.m. with CNA J revealed:*She had assisted in the transfer of resident 1 on 1/6/26 when he fell out of the full body mechanical lift.*She and CNA I were transferring resident 1 from his bed to his wheelchair.*She and CNA I placed the medium sling under resident 1.*Resident 1 used his trapeze (a bar to help reposition or transfer out of bed) to lift himself off the bed while they placed the sling under him. *The sling straps were placed correctly on the full body mechanical lift, crossing the lower straps between his legs before attaching to the lift bars.*She grabbed behind him with the sling and CNA I operated the full body mechanical lift.*When she looked up she saw one of resident 1's legs in the air, and then he was on the floor.*DON B entered the room after he landed on the floor.*Resident 1 liked to adjust himself in the sling once he was in it.*She was unsure how the strap became disconnected from the full body mechanical lift.*She only observed 3 straps for the sling still connected to the full body mechanical lift after resident 1 was on the floor.*Resident 1 hit his back and grabbed his arm when he landed on the floor.*She was unsure if he hit his head.*Resident 1 was sent to the ED for evaluation after the fall.*She always double checks that the sling straps are attached to the lift bar before a resident transfer.*She watched educational videos on the full body mechanical lifts and completed a quiz.*She was unsure if she had the full body mechanical lift safety checklist competencies completed for her. 7. Interview on 2/3/26 at 2:10 p.m. with DON B revealed:*She was in her office next to resident 1's room on 1/6/26 when she heard a crash and swearing.*When she entered resident 1's room, he was on the floor.*Three straps were attached to the full body mechanical lift, one strap on the bottom part of the sling was not attached.*RN S came into resident 1's room to assess him and completed vital signs and a neurological evaluation.*Resident 1 complained of neck pain; RN S obtained a collar for protection.*Resident 1 was placed on a cot and transferred to the ED for evaluation.*RN S notified the family of his fall, and his transfer to the ED.*CNA J stated she hooked one side of the straps to the mechanical lift and CNA I had hooked the other straps to the lift.*DON B checked the sling after the incident occurred, and there were no tears or rips in the sling, she even checked it a second time the following day.*Her assumption is that the strap was not on the inside of the hook on the lift bar.*She has completed visual observations of staff using the total body mechanical lifts to transfer residents, but they were not documented.*She expected staff to double check sling straps before lifting or transferring residents with any mechanical lifts. 8. Interview on 2/3/26 at 7:47 p.m. with RN S revealed:*CNA I and CNA J were the staff that transferred resident 1 on 1/6/26 when he fell from the full body mechanical lift.*She was notified of the fall by DON B.*Resident 1 was on the floor when she entered the room and complained of neck pain.*She notified the ED and placed a collar on resident 1 for protection before transferring him to ED.*She completed vital signs, and neurological [neuro] checks on resident 1.*Resident 1 returned later that evening with no new orders, injuries or fractures from the fall.*Every shift follows-up with neuro checks and pain monitoring and vital signs for 72 hours after a fall a resident fall. 9. Review of the provider's revised 1/26 Mechanical lifts policy revealed:*The administrator of each facility is accountable for establishing policies, procedures, training and motivation to avoid injuries and prevent loss of property. Each facility shall adopt and communicate safety policies and procedures to all staff. Safety is also a responsibility of every employee. Each employee must be willing to work together to promote a safe and healthy workplace. Everyone on staff must cooperate and communicate so that potential problems can be prevented or corrected.A. All nursing personnel will have annual in-services on the correct procedures for lifting and transferring, including the correct use of gait belts and the use of mechanical lifts.

Based on South Dakota Department of Health (SD DOH) complaint report review, observations, interviews, and policy review, the provider failed to ensure physician orders were received for self-administration of medications for two of seven observed sampled residents (2 and 3) who self-administered medications. Findings Include:1. Review of the12/2/2025 SD DOH complaint intake revealed:*Medications were given in the dining room.*Staff were available to assist residents to eat each meal.*Blood sugars were being taken at appropriate time and locations as per resident doctors' orders and care plan preferences.*Unwitnessed and unreported falls.*Licensed staff were working in the facility within their scope of practice.*Hygiene with nails, hair, bathing and shaving were completed. 2. Observation on 2/3/26 at 8:20 a.m. revealed registered nurse (RN) E left resident 2's cup of medications containing 14 pills with him at the breakfast table. Resident 2 then dropped a yellow pill onto the floor and told a DOH surveyor, who then alerted RN E. 3. Observation on 2/4/26 at 7:55 a.m. in the dining room revealed registered nurse (RN) F left resident 3's cup of medications containing seven pills with her at the breakfast table. 4. Observation on 2/4/26 at 8:00 a.m. revealed registered nurse (RN) G left resident 2's cup of medications containing twelve pills with him at the breakfast table. 5. Observation on 2/4/26 at 8:07 a.m. revealed RN G left the dining room and resident 2 had yet to take his medications. 6. Interview and electronic medical record (EMR) review on 2/4/26 at 8:12 a.m. with RN F revealed resident 2 had a medication self-administration assessment completed on 12/10/25. 7. Observation on 2/4/26 at 8:30 a.m. in the dining room revealed:*RN G asked resident 2 if he wanted his MiraLAX, and instructed him that if he did not, to leave it on the table. RN G reminded resident 2 to take his medications.*At 8:37 a.m. resident 2 left the table to change the television (TV) channel and then returned to his table at 8:39 a.m.*Resident 3's medications were gone from her medicine cup at 8:37 a.m.*Resident 2 took his medications at 8:47 a.m. 8. Interview and observation with RN G on 2/4/26 at 10:55 a.m. revealed:* RN G reviewed resident 2 and 3's medication administration record (MAR) within their EMR and did not find a physician's order for self-administration of their medications. 9. Review of resident 2's EMR revealed he had a 8/19/25 physician's order to self-administer Kenalog paste for oral sores. 10.Review of resident 3's EMR revealed she had a 12/17/24 physician's order to self-administer/self-consume her nebulizer treatment after a nurse or medication aide it up for her. 11. Interview on 2/4/26 at 12:59 p.m. with RN E revealed:*She reviewed the residents' MAR which indicated if a medication could be self-administered by that resident. 12. Interview on 2/4/26 at 1:30 p.m. with director of nursing (DON) B revealed the medication self-administration assessment was completed first to ensure the resident qualified and then the nursing staff worked with the registered nurse/quality specialist (RN/QS) D to get the physician's order. 13. Interview on 2/4/26 at 2:18 pm with RN/QS D revealed she completed random resident chart audits, and if she identified a resident who may benefit and wanted to self-administer their medications, she would discuss that with the nursing team. The nursing team or herself obtained the physician's order and entered it into their electronic medical record. Any nurse was able to get the orders from the physician. She acknowledged that a resident's medication self-administration order should be checked before leaving the medication with that resident. 14. Review of the provider's revised October 2025 LTC Medication Management -System Standard Policy revealed:* It is the policy of the facility to maintain a safe and competent medication management system that is based on the best practice and the care process of the residents that includes: recognition of the problem/need, assessment, diagnosis(es), medication administration, management, monitoring and revising the individualized, person-centered approach to care as well as documentation consistent with standards of medication management and administration standards.* J. Residents may self-administer medications when assessed and determined that the practice is clinically appropriate, and authorized by the attending physician, in accordance with procedures for self-administration of medications. 15. Review of the provider's revised January 2016 Self-Administration of Medications policy revealed:* Purpose: standardize the approval and practice of allowing resident's to safely self-administer their drugs and medications by the interdisciplinary team.* Policy Statement: [NAME] will utilize a centralized, standardized and managed process to assure Self Administration of Medications by residents who desire to do so provided the interdisciplinary team (IDT), including at least a physician, nurse pharmacy and social worker has determined the practice would be safe for the resident and other residents of the facility. [NAME] policies will be distributed electronically.* Policy Scope: This policy will apply to all individuals implementing self-administration of medication at [NAME] LTC Facilities. It is the responsibility of each Director of Nursing to ensure the entities do not have policies that conflict of this policy. [NAME] entities are required to adopt this [NAME] LTC Governance Committee policy.* Policy Implementation: b. If the IDT approves a resident for self-administration of medication the facility will i. obtain physician's order for self-administration of medications after set up and/or for bedside medications. This order will be placed in the Electronic Health Record (EHR) under Self Administration of Medications.

Based on observation, interview, and policy review, the provider failed to:Ensure a controlled medication (medications at risk for abuse and addiction) was securely stored by one of one registered nurse (RN) E who placed a controlled medication (Norco) in an unsecured cabinet in the north hallway and did not administer that medication to one of one sampled resident (4) as ordered by the resident's physician.Ensure controlled medication patches were handled and securely stored for destruction according to the provider's policy.Findings include:1. Observation on 9/16/25 11:12 a.m. of the personal protective equipment (PPE) cabinet in the north hallway next to room [ROOM NUMBER] revealed: *The cabinet was recessed in the north hallway and contained washable gowns and disposable gloves on the shelves. *A medicine cup with an unidentified medication tablet on the bottom shelf of that cabinet. 2. Observation and interview on 9/16/25 at 12:24 p.m. with director of nursing (DON) B of the north hallway PPE cabinet revealed: *A medication cup on the bottom shelf of the cabinet with an unidentified medication in it. *She agreed it was not secured and should not be stored there. *She expected medications to be administered as ordered by the physician. *She took that medication to the pharmacy for identification. 3. Follow up interview on 09/16/2025 at 1:43 p.m. with DON B regarding the medication observed in the hallway PPE cabinet revealed: *The pharmacist identified the medication as Norco 5 milligram (mg)/32 mg [(Hydrocodone Bitart/Acetaminophen). A controlled pain medication] *Resident 4 had an order to receive one Norco 5-325 5mg/325mg tablet by mouth at midnight, 6:00 a.m., noon, and 6:00 p.m. *She contacted registered nurse (RN) E, who worked the night before, and RN E confirmed she placed that medication cup with the medication in it in the PPE cabinet. *RN E told DON B that she set the medication in the PPE cabinet to assist another resident, and forgot she put it in the cabinet. *She confirmed that medication was resident 4's Norco. 4. Interview on 9/17/25 at 3:55 p.m. with RN E revealed: *Resident 4 was administered her medications between 5:30 and 6:30 a.m. *She stated she must have gotten the prepared resident 4's Norco for administration and then a staff member asked for assistance with another resident. *She put the medication cup with the Norco in it in the PPE cabinet to go help with the other resident. *She forgot she put the Norco in the PPE cabinet. *She signed the medication off as given when she completed the medication count at shift change with the oncoming day nurse, and the count was accurate. *She was not sure if she placed the Norco in the PPE cabinet the morning of 9/12/25 or 9/13/25. *She knew all medications needed to be secured and administered as ordered. 5. Interview on 9/17/25 at 4:45 p.m. with resident 4 regarding her pain revealed: *She felt she received her pain medications as scheduled, and her pain was under control. 6. Interview on 9/18/ 25 at 1:15 p.m. with DON B regarding medication administration and storage revealed:*Staff were educated annually on the 5 rights of medication administration (a set of safety checks used by healthcare professionals to prevent medication errors) through an on-line learning format. *She expected staff who administered medications to follow the 5 rights for medication administration and the provider's medication administration policy. *She agreed the Norco should not have been left unattended in the PPE cabinet. 7. Interview on 9/18/25 at 1:35 pm with administrator A regarding medication administration and storage revealed: *Staff should follow the 5 rights for medication administration. *She expected the staff who administered medications to follow the provider's policy for medication administration and storage to ensure medications were secured and administered as ordered. 8. Interview on 9/17/25 at 11:50 p.m. with Medication Aide (MA) H regarding controlled medications revealed: *Controlled medications (medications at risk for abuse and addition) were to be stored in a locked box within the locked medication cart. *Resident 41 had an active order for a Fentanyl (a controlled pain medication) 12 mcg (microgram) transdermal (active ingredients are delivered across the skin) patch to be administered every 72 hours. *She had not applied or removed the Fentanyl patch from resident 41. -Only nursing were allowed to apply and remove Fentanyl (controlled pain medication) patches. 9. Interview on 9/17/25 at 12:25 p.m. with RN D revealed: *Resident 41's Fentanyl patch was ordered and scheduled to be removed by the night shift nurse. -Her process was to place the used and exposed Fentanyl patch into a medication cup after being removed from the patient and placed in the locked box within the medication cart. - The exposed Fentanyl patch had then been destroyed by placing it into the Rx Destroyer (liquid chemical solvent) by both the night and day nurse the following morning. *This process was done after nursing staff had accounted for all narcotics in the locked box at the beginning and ending of each shift. 10. Interview on 9/17/2025 at 5:51 p.m. with RN E revealed she: *She would remove the used Fentanyl patch from a resident as ordered and place it back into the locked box within the medication cart. -The used Fentanyl patch would then be destroyed by the night nurse and the oncoming nurse the following morning. -That was the process that she was taught, and she had always done it that way. 11. Interview on 9/18/2025 at 11:24 a.m. with director of nursing B regarding the provider's policy for controlled medications revealed: *Resident 41's used and exposed Fentanyl patch was not stored and destroyed according to the provider's policy. Review of the provider's 4/8/24 revised LTC Controlled Substances-System Standard Policy revealed: *”Policy” *”It is the policy of [Provider] to properly acquire, receive, store, administer, track, reconcile, document, and dispose of controlled substances consistent with State and federal guidelines.” -”A. To provide pharmaceutical services to meet the needs of each resident.” -”B. To accurately account for and reconcile controlled substances for prompt identification of loss or potential diversion.” -”C. To educate nurses to identify discrepancies and the need for reconciliation and accountability.” *”D. To provide a system that oversees that controlled substances are acquired, handled, administered, reconciled, stored, and disposed of properly.” -”E. To assure proper record-keeping for controlled substances.” *”Procedure” -“C. Place controlled substance(s) received from the pharmacy in a locked storage area with limited staff access. CII meds will be maintained in a separately locked permanent affixed compartment. Schedule III, IV, V may be stored in a separate locked container or may be integrated with other medications as long as there is a system for accountable tracking (punch cards).” Review of the provider's revised Medication Disposal Policy dated June 2024 revealed: *”Medications that may not be returned to pharmacy (i.e, opened liquid medications, opened boxes of medications (nebulizers), opened eye drop bottles, etc.) will be destroyed in the facility.” *”Controlled medications are disposed of in the facility by a pharmacist and a registered nurse. The registered nurse and pharmacist co-sign as each other's witness. Controlled medications may also be destroyed by two registered nurses if pharmacist is unavailable in a timely manner.”

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to assess for safe usage of a lift chair for one of one sampled resident (1) who had an unwitnessed fall and required hospitalization for injuries acquired from the fall and pain management. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include: 1. Review of provider's 5/27/25 SD DOH FRI for resident 1 revealed: *On 5/24/25 the resident was found on the floor in front of her lift chair laying on her right side. *Her lift chair was raised all the way up in the air. *She was unsure how she fell and ended up on the floor. *She had a large hematoma (collection of blood outside a blood vessel) to the left side of her forehead. *She had a skin tear and bruise on the top of her right hand. *She had adequate range of motion (ROM) to all four extremities. *Her neurological assessment was within normal limits (WNL). *She had good neck ROM from side to side and when looking down. *She had complained of discomfort when looking up towards the ceiling. *Ice was applied to her forehead after being assisted with a total lift from the floor into her wheelchair. *Her family was notified of fall. *Her primary care provider (PCP) was notified of the fall and he advised the staff to monitor and notify him of any change in the resident's condition. *On 5/27/25 she was having complaints of neck pain and was sent to the local clinic for evaluation. *A computed tomography (CT) scan was completed and revealed: -An acute nondisplaced fracture of the C2 (second cervical vertebra). -A suspected acute nondisplaced type 1 dens fracture (a break at the tip of the second cervical vertebra). *She was admitted to the local hospital on 5/27/25 for observation, and then admitted as an inpatient on 5/28/25 for pain control and a neurosurgery consult. *She returned to the facility on 5/29/25 at 2:57 p.m. and was admitted to hospice on 5/30/35. *No lift chair safety assessment had been documented for the resident prior to the fall on 5/24/25. 2. Review of resident 1's electronic medical record (EMR) revealed: *She admitted to the facility on [DATE]. *She was identified as having a high fall risk on her 3/6/25 and 5/24/25 fall risk assessments. *Her Brief Interview for Mental Status (BIMS) assessment score on 5/22/25 was three indicating she had severely impaired cognition. *She had the above fall with injury from her lift chair on 5/24/25. -She was admitted to the hospital on [DATE] and returned to the facility on 5/29/25. *She was admitted to hospice services in the facility on 5/30/25. *She had a lift chair safety assessment completed on 5/30/25, after her 5/24/25 fall. -That assessment found she needed total assistance from others to operate her lift chair. *Her lift chair was unplugged from the wall, and her family was notified. *She passed away on 6/4/25. 3. Interview on 6/26/25 at 9:14 a.m. with registered nurse (RN)/Minimum Data Set (MDS) coordinator C revealed: *She had worked for the facility for almost six years. *Resident 1 did not have a lift chair safety assessment completed before her 5/24/25 fall incident. *Resident 1 had a lift chair safety assessment completed after her return from the hospital on 5/30/25. *Nurses were responsible for resident assessments at the time of a resident's admission. *She completed the quarterly, significant change, comprehensive and annual assessments for residents with their MDS assessments. *Nurses should know resident assessments were due as they would be on the worklist in the resident's EMR to be completed at certain times. *She received education following the incident on 5/24/25 for resident 1 related to completing lift chair safety assessments and when they were due. *All residents who used a lift chair had lift chair safety assessments completed after resident 1's incident on 5/24/25. Interview on 6/26/25 at 9:26 a.m. with director of nursing (DON) B revealed: *She started her position on 5/19/25. *Floor nurses completed resident assessments which triggered on worklists in the EMR to be completed at certain times. *RN/MDS coordinator C would complete resident assessments when their MDS assessment was due. *She expected assessments to be completed when they were due. *She agreed that lift chair safety assessments had not been completed for any residents prior to the incident on 5/24/25 with resident 1. *She and RN D had completed all lift chair safety assessments for residents following the 5/24/25 incident. *She and RN D had also updated all resident care plans following that 5/24/25 incident. Interview on 6/26/25 at 9:52 a.m. with administrator A revealed: *She expected resident assessments to be completed when the resident assessment instrument (RAI)/MDS schedule stated they needed to be completed and upon the resident's admission to the facility. *She expected the provider's policies to be followed when they were implemented and development of a plan during the quality assurance and performance improvement (QAPI) process. *She agreed lift chair safety assessments had not been completed for residents prior to resident 1's 5/24/25 fall from her lift chair. 4. Review of the provider's October 2024 Lift Chair Safety Assessment Policy revealed: *A. Before a lift chair is used by a resident, a member of the intradisciplinary team will complete a lift chair safety assessment. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 6/26/25 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding lift chair safety assessments and care plan updating. Interviews with nursing staff revealed they understood the education provided regarding the topics. Observation of lift chairs in residents' rooms were conducted. Audits were completed for newly admitted resident's, assessments were being completed, and residents' care plans were updated. Based on the above information, non-compliance at F689 occurred on 5/24/25, and based on the provider's implemented corrective action for the deficient practice confirmed on 6/26/25, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI) review, record review, observation, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell from a mechanical bath chair lift, suffered injuries that required emergency room treatment, hospitalization , and subsequently died when one of one certified nursing assistant (CNA) (C) failed to ensure a safety belt was used. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. On [DATE] at 9:00 a.m. Immediate Jeopardy (IJ) was identified for resident safety related to a facility-reported incident that occurred on [DATE] when a resident (1) fell from a bath chair, received serious injuries, and later died . The investigation revealed staff education and competencies initiated on [DATE] removed the immediacy. On [DATE] at 5:00 p.m. administrator A was informed of the IJ and was given the IJ template. The current census was 46. Substantial compliance was confirmed on [DATE] at 4:00 p.m. after review of the providers corrective actions revealed the provider had followed its quality assurance process, the provider's whirlpool bath policy was updated to ensure safety measures would be implemented, staff education was provided, and competencies were completed regarding safety precautions, including the use of the bath chair lift safety belt, safety checks, and interventions for resident refusals to wear the safety belt. Observations and staff interviews revealed staff understood the education provided and the proper use of safety precautions. All resident care plans were updated as applicable to address resident refusals to use the safety belt. Audits were implemented and staff monitoring will continue for compliance with safety precautions. That data will be reported at the monthly QAPI meetings by the DON or designee. Findings include. 1. Review of the provider's [DATE] SD DOH FRI regarding resident 1 in the tub room revealed: *On [DATE] at 6:36 a.m. resident 1 had taken a whirlpool bath and was sitting on a mechanical bath chair lift approximately 25 to 30 inches high. *She had resisted wearing a safety belt. *CNA C had turned to grab the resident's clothing and heard a noise. *Resident 1 had fallen onto the floor. -CNA C called for assistance of other staff. -A registered nurse (RN) arrived and noted the resident had a left forehead hematoma with a laceration. -Staff used a total body mechanical lift (a mechanical lift and sling used to lift a person's full body) to assist resident 1 into a wheelchair and she was transferred to the emergency room for evaluation. *Resident 1 had a Brief Interview for Mental Status (BIMS) assessment score of 0, which indicated she had severe cognitive impairment. *Resident 1 was hospitalized on [DATE] with non-displaced fractures involving ribs 2, 4, 5, 6, 7, and 8, and a confirmed apical pneumothorax (air accumulation in the space between the lungs and the chest wall). *Resident 1 was readmitted to the facility on [DATE] on hospice services. *Resident 1 passed away on [DATE]. 2. Interview on [DATE] at 10:49 a.m. with administrator A revealed: *All CNAs who were scheduled to provide resident care in the tub room were retrained and provided competencies regarding the mechanical bath chair lift and safety strap use that were to be completed before bathing residents. *All other CNAs were retrained and provided competencies in case they worked in the tub room. *The director of nursing (DON) B or designee would be completing audits of the bathing process of the mechanical bath chair lift and safety strap use following the manufacturers guidelines five times a week for 30 days and then three times a week for 2 months. *Their next QAPI (Quality Assurance and Performance Improvement) meeting was scheduled for [DATE] and they planned to review the new policies and competencies to ensure they were effective in preventing the reoccurrence of similar incidents. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on [DATE] after a record review revealed: *The provider had followed its quality assurance process and education was provided to staff who would be providing bathing to residents. -The staff had been educated regarding safety precautions including using a safety belt on all residents, competencies were conducted, and audits had been completed on 19 residents from [DATE] through [DATE] with the expectation to complete auditing five times per week for 30 days and then three times per week for 2 months by DON B or the designee. *Audit data would be reported to QAPI monthly by the DON. *The provider's Whirlpool Bath policy was updated to ensure safety measures to be implemented. *Observations and staff interviews revealed the staff understood how to use the safety belt and perform other safety checks within the tub room before bathing residents, and what to do if a cognitively impaired resident refused to use the safety belt. *All residents care plans were updated as necessary based on refusal of using a safety belt and alternative bathing interventions. Based on the above information, non-compliance at F689 occurred on [DATE], and based on the provider's implemented corrective actions for the deficient practice confirmed on [DATE], the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to implement the following for one of one sampled resident (17): *Assess for the use of an audible chair alarm. *Document the use of the chair alarm. *Reassess for the continued use of the chair alarm. *Ensure the audible chair alarm was not causing harm. Findings include: 1. Observation on 7/9/24 at 9:58 a.m. in resident 17's room revealed: *She was seated in her recliner. *There were two alarm devices on her bedside table. One was connected to her bed, and the other was connected to her recliner and shirt. *She was wearing a pendant call light around her neck. *She pressed the pendant call light because she needed to use the bathroom. Staff promptly responded to the call light. 2. Observation and interview on 7/9/24 at 2:04 p.m. with resident 17 in her room revealed she: *Was seated in the same recliner. *Showed the surveyor a chair alarm was clipped to her shirt. *Was able to explain the purpose of the alarm. *Explained that it made a noise if she tried to move. *Said, I don't like it. It's loud and scares me. They don't want me to get up by myself. 3. Observation on 7/10/24 at around 12:55 p.m. near resident 17's room revealed that there was a loud and pulsating alarm emitting from her room. 4. Interview on 7/10/24 at 4:24 p.m. with certified nursing assistant (CNA) J about resident 17's chair alarm revealed: *She denied that the alarm physically restrained the resident, indicating that the resident could easily move, and the string attached to the resident's clothing would detach. *When she heard the alarm, she would have gone running to attend to the resident because she was a fall risk. *The resident had fallen previously and was bruised from the fall. *Resident 17 knew how to use the call light. *The resident usually attempted to get up by herself when she needed to use the bathroom. 5. Interview on 7/11/24 at 8:44 a.m. with director of nursing (DON) B about the chair alarms revealed: *If a resident tended to get up on their own and was not the safest to ambulate by themselves, they would place a tabs alarm on the resident. *The alarm would be clipped to the back of a resident's shirt so they would not be able to remove it easily. *She confirmed there was no assessment process prior to implementing a tabs alarm. *The bed alarms were silent. -If the bed alarm was triggered, the resident's call light would turn on. *The tabs alarms were loud and audible. -If the resident moved a certain way, the tabs alarm would become disconnected and emit a loud and audible alarm. *She confirmed there was no assessment to determine if the resident felt restrained by the device. *She had not considered if the resident could have been frightened by the audible chair alarm. 6. Interview on 7/11/24 at 9:34 a.m. with registered nurse (RN) N about the audible chair alarms revealed: *If a resident had an unwitnessed fall, the first intervention was usually to have placed the tabs alarm on the resident. *If a fall occurred, the resident's family would have been contacted to inform them of the fall and the implementation of the tabs alarm. *Other fall prevention interventions included signage in the resident's rooms to remind them to call don't fall. *Resident 17 was a patient in the adjoining hospital prior to her admission to the nursing home and received physical and occupational therapy to improve her strength and balance after she broke her hip from a fall at her previous living accommodations. *Resident 17 was more forgetful when she first admitted to the nursing home and would shout out for help rather than using her call light. -She understood how to use the call light now. -The resident had a habit of using the call light and standing up immediately rather than waiting for help to arrive. -She doesn't like to wait. 7. Review of resident 17's electronic medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) score was 11, which indicated she had moderate cognitive impairment. *There was no documentation of when the audible chair alarm was implemented. *There was no assessment to determine if the use of the audible chair alarm was appropriate or if it was a restraint. *There was no physician's order or duration of use for the audible chair alarm. *Her care plan included the following under the Fall risk problem initiated on 6/16/24: -An intervention of Mobility Alarm .sensory pad on in chair and in bed with a start date of 6/25/24. --A frequency of Every 8 Hours was attached to the intervention for the silent bed alarm only, not the audible chair alarm. -There were no other interventions for the audible chair alarm on her care plan. 8. Review of the provider's 6/23 Falls and Accidents policy revealed: *Purpose: To be proactive in preventing resident falls and accidents. *Policy Statement: To provide a systematic approach to fall and accident prevention and monitoring, including identifying and evaluating hazards and risk, individualizing approaches to reduce the risk of falls and accidents, and monitoring for effectiveness of interventions when necessary. *Definitions: Position change alarms: alerting devices intended to monitor a resident's movement. -The devices emit an audible signal when the resident moves in a certain way. -Types of position change alarms include chair and bed sensor pads, bedside alarmed mats, alarms clip[ped to a resident's clothing, seatbelt alarms, and infrared beam motion detectors. *Policy implementation: -2. Resident assessment and intervention --A. Upon admission/readmission, quarterly, and with status changes, staff will assess each resident's individual risk factors including fall risk, elopement risk, and risks and hazards within the physical environment. --B. Based on assessment of fall risk and elopement risk for each resident, staff will implement appropriate individualized, resident-centered interventions to reduce the likelihood of falls and elopement and communicate the risk and intervention to the staff through the plan of care. --C. Effectiveness and modification of interventions is monitored on a regular basis by the QAPI [quality assurance and performance improvement] program. - .4. Hazards in the physical environment --A. Staff will ongoingly assess the physical environment with regard to potential hazards, including .position change alarms .resident mobility devices . Any deficiencies in the safety of the physical environment will be immediately addressed. -- .C. The resident care plan will specifically address any risk factors that provide a benefit, such as use of a side rail or mobility device. -- .E. The facility will provide adequate supervision through assessing the appropriate level and number of staff, the competency and training of staff, and the frequency of supervision needed based on resident needs. 9. Review of the provider's 5/24 Restraint Policy revealed: *Policy Statement: It is the philosophy of [NAME] LTC [long term care] to keep residents unrestrained and as independent as possible. -If the results of a comprehensive, interdisciplinary assessment determine that there are no alternative to provide resident safety, or that the alternative methods have been unsuccessful, a physical and/or chemical restraint will be recommended for use. *Definitions: Physical restraint: any manual or physical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Physical restraints include but are not limited to leg or arm restraints, bolster mattresses, hand mitts, soft ties or vests, leg cushions and lap trays the resident cannot remove, and tucking a sheet around a resident so that resident cannot move. *Policy Implementation: -1. Members of an interdisciplinary team (IDT) will evaluate the resident's safety needs. -2. If a problem is identified, the least restrictive method will be tried first and the results documented. The use of restraints shall require clinical justification and shall be employed only to protect a resident from self-injury or from injuring others. -Restraints must not be used to limit mobility, for convenience of staff, for punishment, or as a substitute for supervision . -3. If a restrains is found to be necessary, appropriate health professional will complete the Pre-Restraining intervention in the electronic health record (EHR). The assessment will include medical condition requiring need for restrain and will be documented in the intervention. -4. Physician notification is required for all restraints initiated and a [physician's] order must be obtained prior to implementation. Restraint orders must be specific and include: type of restraint, specific periods of time restraint is to be used, medical symptom for restraint use, check by staff every 30 minutes, release every 2 hours, and specific times when restraint can be removed. -5. Resident and family will be educated on restraint use, reasons for use, assessment results, and risks and benefits associated with restraint use. -6. Resident or resident's family must sign a consent form for restraint use. - .8. Interdisciplinary team and physician will evaluate restraint usage monthly at minimum and will be reviewed at quarterly care conference by care planning team, resident and resident's family. -9. Restraints must be routinely observed and assessed. The restraints are to be periodically removed and range of motion, massage, or exercise applied, and hygiene, nutrition, and toileting offered. -a. Staff will check the resident's restraint every 30 minutes. -10. Quarterly documentation of attempted restraint reduction will be completed in the Restraint Assessment and noted on all applicable MDS [Minimum Data Set] assessments on the CAAs [care area assessments]. Early release and alternatives to restraint are to be continually explored. 10. Review of the provider's 3/24 Transfers policy revealed: *Purpose: To establish a protocol for staff for proper transfer techniques and decrease risk of injury to self and patient. *Protocols: Transfer Set-up: - .7. Put on tabs monitor or safety devices if needed and give call light (if inpatient or NH [nursing home]).

Based on observation, interview, record review, and policy review, the provider failed to ensure two certified nursing assistants (H and K): *Applied a mechanical stand aide sling to sampled resident (22) prior to use. *Transferred a sampled resident (22) safely from the bathroom to a specialized wheelchair. *Received documented training for the use of a mechanical stand aide and resident transfers using a specialized wheelchair (Broda chair). Findings include: 1. Observation on 7/9/24 at 2:22 p.m. in resident 22's room revealed: *Resident 22 was resting in his recliner. *Certified nursing assistant (CNA) H and K entered his room to assist him with transferring him from the recliner to his Broda (specialized) wheelchair. *They used the recliner remote to lift him upwards. *They positioned the mechanical stand aide in front of resident 22 and placed his feet on the footboard. *They guided his hands up to the handlebars and instructed him to hold on. *Without strapping the mechanical stand aide sling around him, CNA H raised the mechanical stand aide slightly so that resident 22 was standing up from the recliner. -He was visibly shaking and appeared to have been struggling to hold on. *While he was standing, CNA K put the sling behind the resident and CNA H then seated him back down into the recliner. *With the sling correctly placed around resident 22 and hooked into the mechanical stand aide, they raised him from his recliner to a standing position and transferred him to the bathroom, positioned him onto the toilet, and then exited his room. 2. Continued observation on 7/9/24 at 2:43 p.m. in resident 22's room revealed: *CNAs H and K reentered resident 22's room and attended to his needs in the bathroom. *They transferred him out of the bathroom using the same mechanical stand aide. *CNA H positioned resident 22 in front of his Broda chair. *CNA H instructed CNA K to go behind the Broda chair and lift the back two wheels off the ground to tilt the chair forward. -As CNA K held up the Broda chair, CNA H lowered resident 22 down into the Broda chair. *It was unknown if the wheels of the Broda chair were locked or not during the transfer. 3. Interview on 7/9/24 at 5:57 p.m. with CNA K about the above observation revealed: *She confirmed she was taught to lift the back wheels of resident 22's Broda chair upwards to tilt the chair forwards to easily position the resident all the way into the chair. *She said, He's a stiff guy, so they tried to tilt the chair to get him into the correct position when they transferred him into the Broda chair. 4. Interview on 7/9/24 at 4:44 p.m. with CNA H about the above observation revealed: *She confirmed the way staff had figured out how to get resident 22 correctly positioned into the Broda chair was to tilt the back end up the chair upwards. *She said, Since he is so tall and still, he doesn't bend much. We have to tilt it up to get him all the way in. *She indicated they had tried other methods, but he was not able to sit all the way back into his wheelchair. -In those cases, they required three people to hoist him into the Broda chair. *She was educated to tilt the Broda chair forward to transfer him into the chair. She did not recall who instructed her. 5. Interview on 7/10/24 at 12:55 p.m. with registered nurse (RN) M about the above observation revealed: *She was aware that staff lifted the back wheels of resident 22's Broda chair to tilt it forward to position him all the way into the chair. *She said that he is a stuff guy and had a difficult time bending to sit in the chair. *She confirmed there were functioning brakes available to use on all four wheels of the Broda chair. 6. Interview on 7/10/24 at 1:28 p.m. with CNA P about how to safely transfer resident 22 revealed: *She was able to state the correct procedure of placing the mechanical stand aide sling on the resident prior to lifting the resident with the mechanical stand aide. *She was not aware of the tilting method to place resident 22 into his Broda chair. 7. Continued interview on 7/10/24 at 1:33 p.m. with RN M about how to safely transfer resident 22 revealed: *She would have expected staff to have placed the sling around the resident first and to ensure it was secure prior to lifting the resident with the mechanical stand aide. 8. Interview on 7/11/24 at 8:58 a.m. with director on nursing B about how to safely transfer resident 22 revealed: *She would have expected staff to have secured the sling around the resident prior to lifting the resident with the mechanical stand aide. *She was not aware staff were lifting the back two wheels of his Broda chair to place him in the chair. -That's not the best thing for staff to do either due to safety concerns. *She confirmed there was no documentation that supported either CNA had been educated on how to properly operate the mechanical stand aide or the Broda chair. 9. Review of resident 22's electronic medical record revealed: *He required extensive to total staff assistance with activities of daily living due to the late stages of dementia. *His care plan indicated to use the Broda chair. However, there was nothing in the care plan that instructed staff to lift the back two wheels of the chair to place him in the chair. 10. Review of the provider's 3/24 Transfers policy revealed: *Purpose: To establish a protocol for staff for proper transfer techniques and decrease risk of injury to self and patient. *Protocols: Transfer Set-up: -1. Check physician's order and care plan to see if restrictions and weight bearing status. - .4. Lock all transfer surfaces. -5. Put transfer belt on patient. 11. Review of the January 2007 manufacturer's operating instructions for the Broda chair revealed the manual did not indicate if it was an acceptable practice to lift the back two wheels off the floor to tilt the chair forward during a resident transfer. 12. Review of the 7/30/18 manufacturer's operator's instructions for the mechanical stand aide revealed: *Page 5, Transferring the patient: -Attach harness --1) Position the harness around the upper body of the patient so the sides of the harness are between the patient's torso and arm, resting 2 - 3 inches below the underarm. --2) For the safety of the patient, securely fasten the safety strap around the patient's torso. --3) Secure the buckle and pull the strap to tighten. *The manual further explained the following steps prior to raising the patient: position shin pad and foot plate, position the mechanical stand aide in front of patient, and attach harness to the mechanical stand aide. *There was a warning on page 7 that read, Patient MUST ALWAYS wear the harness when using the [mechanical stand aide]. It can be helpful to use the seat strap or support strap during ambulation. *The manual indicated to lock the wheelchair/chair/bed/transfer surface prior to lowering the patient down onto that surface.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to ensure the safety of one of one sampled resident (47) who eloped from the facility (left without staff's knowledge) and failed to report the elopement within the required timeframe. Failure to ensure safety could have led to resident injury had he not been found. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 6/24/24 SD DOH FRI revealed: *Resident 47 was admitted to the nursing home on 6/17/24. He was previously living at the adjoining assisted living facility. *At around 5:15 p.m., director of plant operations E found resident 47 near the adjoining hospital entrance. *The resident was brought back to the nursing home. *A wander bracelet was put in place afterward. *The door alarms were functioning at the time of the incident. *The resident was not injured. *The nurse on staff that day was not aware that the incident was regarded as an elopement since the resident did not leave the campus. *All staff were reeducated about elopement and reporting requirements. The provider implemented systemic changes to ensure the deficient practice does not recur was confirmed after: *Observations throughout the survey of resident 47 revealed that his wander bracelet was in place and functioning. *Interviews with staff (certified nursing assistants, registered nurses, maintenance staff, and the management team) confirmed they knew the reporting requirements for elopement and were aware of the procedures to address a resident who had eloped. *Record review confirmed staff were regularly checking for wander bracelet placement and functioning, the interventions were added to resident 47's care plan, and education was provided to all direct care staff regarding missing residents and reporting requirements. Based on the above information, non-compliance at F689 occurred on 6/17/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 6/30/24, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to ensure current infection control policies for hand hygiene and mechanical lift disinfection were followed by two of five staff observed (certified nursing assistant (CNA) H and K). Findings include: 1. Observation on 7/9/24 at 2:22 p.m. with CNAs H and K during a transfer with resident 22 revealed: *The CNAs entered resident 22's room and discovered the hand sanitizer dispenser was empty. *CNA H exited the room to retrieve a new bottle of hand sanitizer. *CNA K proceeded to put on a clean pair of gloves without performing hand hygiene. *CNA H came back into the room and stated she could not find a new bottle of hand sanitizer. -She proceeded to put on a clean pair of gloves without performing hand hygiene. *They assisted resident 22 to stand up from his recliner using the mechanical stand aide. *While he was standing, CNA K checked his brief and discovered he was incontinent. *The CNAs brought him into his bathroom. *A few minutes later, CNA H came out of the bathroom without gloves on. -She grabbed a clean pair of gloves and brought them to the bathroom. -She came back out of his bathroom and left the resident's room without performing hand hygiene to find hand sanitizer. *CNA K exited the resident's room with a bag of trash. -She performed hand hygiene in the handwashing sink in the hallway after throwing out the trash. *The two CNAs left the resident on the toilet so he could finish going to the bathroom. 2. Observation on 7/9/24 at 2:43 p.m. with CNAs H and K in resident 22's room revealed: *They returned to transfer resident 22 from the bathroom to his Broda chair. *They both performed hand hygiene prior to putting on clean gloves. *After they were finished transferring, they placed the mechanical stand aide in the hallway. *Neither of them sanitized the stand aide prior to moving on to a different task. -There was a container of sanitizer wipes available in a pouch on the stand aide. 3. Interview on 7/10/24 at 2:59 p.m. with registered nurse (RN) N about the above observations revealed: *It was her expectation that: -Staff should have performed hand hygiene prior to putting on gloves. -Staff should have performed hand hygiene after removing gloves. -If the hand sanitizer dispenser was empty, they should have retrieved a new container. -If a new container was not available, staff should have washed their hands with soap and water. -Staff should have sanitized the lift equipment after each use. 4. Interview on 7/10/24 at 3:44 p.m. with infection preventionist G about the above observations revealed: *It was her expectation that: -Staff should have washed their hands with soap and water if hand sanitizer was not available. -The mechanical lifts should have been sanitized after each use. There was a container of sanitizer wipes with each mechanical lift. 5. Review of the provider's 5/24 Hand Hygiene policy revealed: *Purpose: Hand hygiene is the single most important procedure for the control of infection. It is a critical component of patient and employee safety. *Policy: I. Indications and Procedure for Hand Hygiene -A. Hand Hygiene with Soap and Water: 1. Wash hands with system approved soap and water: --a. When hands are visibly dirty. --b. When hands are contaminated with proteinaceous material. --c. When hands are visibly soiled with blood or other body fluid . -B. Hand Hygiene with Alcohol Hand Rub (Antisepsis): 1. If hands are not visibly soiled, use system approved alcohol-based hand rub for routinely decontaminating hands in most other clinical situations: --a. Before each patient contact. --b. Before donning sterile gloves . -- .d. After routine patient care (e.g., taking vital signs, lifting/positioning/ambulating a patient) where there is no contact with body fluids. --e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. --f. After glove removal. 6. Review of the provider's 5/23/24 Disinfection of Non-Critical Resident Care Equipment policy revealed: *I. Purpose: - .C. For the safety and comfort of residents, all reusable (non-critical) resident care items will be cleaned, disinfected, fand maintained in a safe manner between resident uses. *II. Information: -A. Reusable resident care equipment/items fall into 3 different classification categories for disinfection and sterilization: 'non-critical, semi-critical, and critical.' --1. 'Non-Critical' items are those that come into contact with intact skin but not mucous membranes. These are divided into resident care items and environmental surfaces. ---a. Noncritical resident care items (Examples include blood pressure cuffs, stethoscopes, wheelchairs, therapy equipment) are cleaned between/after each resident use. They require Low level disinfection by cleaning following manufacturer instructions with an EPA [Environmental Protection Agency]-registered disinfectant, detergent, or germicide that is approved for healthcare settings . *III. Policy: -A. Community/facility items removed from a resident's room needs to be disinfected prior to use by a different resident. -B. Resident equipment will be disinfected immediately following resident use when the item has been contaminated with blood or other potentially infectious material or is visibly soiled. - .D. All reusable resident care equipment removed from a resident room/procedure room is disinfected before use on another resident. - .J. Disinfection Recommendations- --1. Reusable resident care equipment: All applicable label instructions on EPA-registered disinfectant products must be followed. ---a. Between each resident use and when soiled.f. Lifts & slings. - .M. Monitoring of disinfection recommendations will be done by observation by management staff and no written documentation is required. However, to maintain continuity, units may maintain a worksheet with cleaning/disinfection schedules.

Based on observation, interview, and policy review, the provider failed to ensure one of one sampled resident (13) with hand contractures had a call light she was able to use and was within her reach. Findings include: 1. Observation on 7/9/24 at 10:44 a.m. of resident 13 revealed: *She had hand contractures to both of her hands. *She communicated verbally with yes or no. *She did not have her call light within her reach. Interview on 7/9/24 at 10:44 am. with registered nurse (RN) O in regard to resident 13's use of a call light revealed: *She did not believe resident 13 could push her call light button because her hands were tight due to contractures. *Staff would check on her frequently. Observation and Interview on 7/10/24 at 8:32 a.m. with resident 13 and certified nursing assistant (CNA) Q in regard to resident 13 and use of her call light revealed: *Resident 13 could use her left hand and CNA Q placed the call light in her hand. *She was unable to activate the call light when she held it with her left hand. *He stated he would check on her every hour and a half. Interview on 7/10/24 at 8:41 a.m. with RN N in regard to resident 13 revealed: *Staff were supposed to lay the call light across her, but she could not use the call light. *She stated she had a soft squeeze call light when in her previous room that she was able to use. *She had not had the soft squeeze call light for at least one month and she would get it for her. Observation on 7/10/24 at 2:08 p.m. with resident 13 revealed: *She now had a soft squeeze call light and was able to activate it. Observation and interview on 7/11/24 at 12:37 p.m. with resident 13 and RN N revealed: *She is in a specialized wheelchair. *Her call light was not within her reach, and was clipped to her bed. *She responded yes when asked if she had been up in her wheelchair for a while. *She was given the call light and she activated it. *RN N answered the call light and stated resident 13 had been at chapel and whoever brought her back to her room did not place the call light within her reach. Interview on 7/11/24 at 12:55 p.m. with director of nursing (DON) B revealed: *She was aware resident 13 had not had a call light she could use for at least a month. *She stated, are you kidding me and shook her head when it was discussed that resident 13 did not have her call light within reach when she was returned to her room after chapel. Review of the provider's call light policy dated 7/2024 revealed: *The objective, 1. To respond to patient/resident's requests and needs on a timely basis. *The procedure noted, 9. A 'soft touch' or bell was available for residents unable to use a standard call light.

Based on review of the South Dakota Department of Health (SD DOH) online report, observation, record review, interview, and policy review, the provider failed to ensure one of three sampled residents (20) received appropriate care to prevent a burn from a warm pack. 1. Review of the SD DOH online report revealed the following: *On 1/20/24 restorative aide F applied a warm pack on the back of resident 20's neck. -The warm pack was a heated wet hand towel wrapped in Chux (disposable waterproof-under pad). -Resident 20's cognition score was a 4. Observation and interview on 1/30/24 at 12:22 p.m. resident 22 in his room revealed: *He was seated in a Broda [a specialized wheelchair] chair. *He made no eye contact, and was unable to respond coherently to questions. Review of resident 20's electronic medical record revealed his: *12/27/23 Brief Interview of Mental Status score was a 4, meaning he was cognitively impaired. *Diagnoses included Alzheimer's Disease and Lewy Body dementia with behavioral disturbance, and anxiety. *Medication administration record included a 1/20/24 physician order for Silver Sulfadiazine (Silvadene 1%) to the right side of the neck for a burn. *Care plan included the following: -Resident blank stares and is verbally unresponsive to family and staff. -Staff will anticipate needs. -Chronic Pain-as evidenced by: hx [history] of headaches, GERD [gastroesophageal reflux disease], monitor for facial grimacing and nonverbal s/s [signs and symptoms] of pain. -He required the assistance of two staff members for most activities of daily living. Interview on 1/30/24 at 10:44 a.m. with restorative aide (RA) F regarding the above-referenced report revealed: *Her employment began in March, 2023, and she: -Had transferred from a sister facility. -Had worked as the RA for about three months. -Had previously worked for the provider for a a year or two a few years ago. *She had started placing warm packs on residents' necks before completing the restorative nursing care to help loosen the residents' neck muscles. -She had no training in the use of warm packs. -She had no guidance from a nurse or physical therapist in the use of warm packs. -Warm packs were heated up in the microwave for 30 seconds. *On 1/20/24 she had heated three warm packs in the microwave and she: -Took two of the warm packs and placed them on resident 21 and resident 22's necks. -Thought the third warm pack had cooled. -Then placed the third warm pack back in the microwave and warmed it for another 30 seconds. --That warm pack she wrapped in a Chux with the plastic side out, and placed on the back of resident 20's neck, was not on for 20 minutes. -She had not thought it would get that hot (to cause a burn). Interview on 1/30/24 at 12:38 p.m. with certified nursing assistant (CNA) G regarding the use of warm packs revealed: *CNAs did not use warm packs. *RA F and nurses had used them for resident care. Observation and interview on 1/30/24 at 12:45 p.m. of resident 20 with registered nurse (RN) D revealed: *The mid-back of resident 20's neck had an area of eschar (a collection of dead tissue within the wound of the skin) approximately the size of a quarter, and on the right side of the back of his neck were two areas of eschar the approximate size of dimes. *RN D stated those eschar areas were caused from a warm pack burn on 1/20/24. -CNAs and RA F were able use warm packs on residents that were cognitively aware and could tell them if the warm pack was too hot. -She was not certain who would have trained CNAs and RAs in the use of warm packs. -She thought the RA F would have known how to use them, as she had been trained in restorative. Interview on 1/30/24 at 12:56 p.m. with RN C regarding the use of warm packs for residents revealed: *On 1/20/24 she observed resident 20's neck after staff notified her of a possible burn. -The back of his neck was red, was not raised, or blistered. --She placed a cool pack on it and called his medical provider. *She stated the area had not become open and had some eschar tissue on the area where the warm pack had been placed. *Warm packs were only used on residents who were cognitively aware and could say if the warm packs were too warm. *She was not certain who had trained CNAs and RAs in the use of warm packs. Interview on 1/30/24 at 1:06 p.m. with administrator A regarding the use of warm packs and restorative nursing care revealed: *There was not a restorative nursing care training program for staff. -CNAs were trained, during their CNA certification course, and how to complete basic restorative care. *There was no documented restorative nursing care training for RA F. *A RA job description was requested from administrator A and was not provided by the end of the survey period. -She thought RA F had not signed a RA job description, as she had started her employment as a CNA. *Thought RA F had RA training during her previous employment with a sister facility. -There was no documentation to support that the training had occurred. Interview on 1/30/24 at 3:25 p.m. with administrator A and clinical care coordinator (CCC) E regarding the use of warm packs revealed: *RA F was also a CNA. *RA F was not provided initial training in restorative nursing care as: -She previously worked at this facility. -Her employment was transferred from a sister facility. *CCC E stated nurses may have known RA F was using warm packs for resident 20's neck but she was not certain. *Administrator A stated the process for warm packs had been changed on 1/24/24. -The process now included not using warm packs on cognitively impaired residents. -Training for the nursing employees regarding the new process was completed on 1/24/24. DON B was not available for an interview during the survey period. Review of the provider's September 2023 facility assessment revealed: *One RA was scheduled for five days per week. *Staff competency was to have been assessed annually. Review of the provider's November 2023 Restorative Nursing Care Program policy revealed: *The Restorative Nursing Care Program, coordinated by the Director of Physical Therapy, provides exercises for patients based on their individualized needs. A physical therapist evaluates and designs the exercise program for each patient. The patient care staff is instructed by the physical therapist on how to carry out that exercise program. Review of the provider's undated Warm Packs policy revealed: *Warm Packs -Moisten wash cloth or towel with warm water from the faucet. Wring cloth or towel out, place in microwave no more than 30 seconds, then place in a plastic bag and [NAME] with a dry cloth. Apply to affected area. Check every 15-30 minutes and reheat/reapply as needed. Do NOT place wet cloth/towel in microwave more than 30 seconds .Check area where warm pack is applied every 15-30 [minutes]. -This policy was developed as a guide for the delivery of health services and is not intended to define the standard of care. *The policy did not include who was able to apply warm packs to residents. Review of the provider's revised August 2020 Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy revealed: *Definitions of Abuse and Neglect -f. Neglect is the 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. *Abuse policy -Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. -The facility will strive to educate staff and other applicable individuals in techniques to protect all parties.

Based on a review of the South Dakota Department of Health (SD DOH) online report, interview, and policy review, the provider failed to ensure one of one sampled restorative aide (F) provided appropriate care to prevent a burn on one of one sampled resident (20) from a warm pack. 1. Review of the SD DOH online report revealed the following: *On 1/20/24 restorative aide F applied a warm pack on the back of resident 20's neck. -The warm pack was a heated wet hand towel wrapped in Chux (disposable waterproof under pad). Interview on 1/30/24 at 10:44 a.m. with restorative aide (RA) F regarding the above-referenced report revealed: *She had started placing warm packs on residents' necks before completing their restorative nursing care to help loosen the neck muscles. -She had no training in the use of warm packs. -She had no guidance from a nurse or physical therapist in the use of warm packs. Interview on 1/30/24 at 12:45 p.m. of resident 20 with registered nurse (RN) D revealed: *CNAs and RA F were able to use warm packs on residents who were cognitively aware and could tell them if the warm pack was too hot. *She was not certain who would have trained CNAs and RAs in the use of warm packs. Interview on 1/30/24 at 12:56 p.m. with RN C regarding the use of warm packs for residents revealed: *Warm packs were only used on residents who were cognitively aware and could say if the warm packs were too warm. *She was not certain who had trained CNAs and RAs in the use of warm packs. Interview on 1/30/24 at 1:06 p.m. with administrator A regarding the use of warm packs and restorative nursing care revealed: *There was not a restorative nursing care training program for staff. -CNAs were trained, during their CNA certification course, and how to complete basic restorative care. *There was no documented restorative nursing care training for RA F. *A RA job description was requested from administrator A and was not provided by the end of the survey period. -She thought RA F had not signed a RA job description, as she had started her employment as a CNA. *Thought RA F had RA training during her previous employment with a sister facility. -There was no documentation to support that the training had occurred. Interview on 1/30/24 at 3:25 p.m. with administrator A and clinical care coordinator (CCC) E regarding the use of warm packs revealed: *RA F was a CNA. *RA F was not provided initial training in restorative nursing care as: -She previously worked at the facility. -Her employment was transferred from a sister facility. DON B was not available for an interview during the survey period. Review of the provider's September 2023 facility assessment revealed: *Staff competency was to have been assessed annually. Review of the provider's November 2023 Restorative Nursing Care Program policy revealed: *The Restorative Nursing Care Program, coordinated by the Director of Physical Therapy, provides exercises for patients based on their individualized needs. A physical therapist evaluates and designs the exercise program for each patient. The patient care staff is instructed by the physical therapist on how to carry out that exercise program. Review of the provider's undated Warm Packs policy revealed: *Warm Packs -Moisten wash cloth or towel with warm water from the faucet. Wring cloth or towel out, place in microwave no more than 30 seconds, then place in a plastic bag and [NAME] with a dry cloth. Apply to affected area. Check every 15-30 minutes and reheat/reapply as needed. Do NOT place wet cloth/towel in microwave more than 30 seconds .Check area where warm pack is applied every 15-30 [minutes]. -This policy was developed as a guide for the delivery of health services and is not intended to define the standard of care. *The policy did not include who was able to administer warm packs to residents or any training that was required before to administering them those warm packs. Review of the provider's revised August 2020 Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy revealed: *Definitions of Abuse and Neglect -f. Neglect is the 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. *Abuse policy -The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Refer to F600.

Based on observation, interview, and policy review, the provider failed to ensure the privacy and confidentiality of resident electronic health records had been maintained by three of three staff (registered nurse (RN) D, RN E, and certified nurse assistant/medication aide (CNA/MA) F) during medication administration. Findings include: 1. Observation on 6/6/23 from 9:14 a.m. to 9:20 a.m. of one medication cart computer in the north hall revealed: *It was placed in the north hallway and there were no staff within view of the medication cart. *The medication computer screen had been facing the hallway and was open to a resident's medication administration record. *The unattended computer screen was visible to any resident, staff, or visitors that would have been passing by the medication cart. *It contained the following information: -The resident's name and room location. -Age and date of birth. -Gender. -Cardiopulmonary status. -Height, weight and body mass index (BMI). -Allergies -Medical record number. -Medications ordered by the physician. *RN D had come out of a resident's room, looked at the chart, then went back into the resident's room. *The computer screen was still open to the resident's medication administration record. 2. Observation on 6/6/23 at 9:45 a.m. of one medication cart computer located at the nurse's station revealed: *RN E had been at the medication cart getting the medications ready to administer to a resident. *He had walked away from the medication cart and was filling a cup with water. *The medication computer screen had been facing the hallway and was open to a resident's administration record. *The record had been visible to any resident, staff or visitors passing by the medication cart. *He walked back to the medication cart, then he walked away into the clean utility room. *The medication computer screen was still open to the resident's medication administration record. *He had walked past the medication cart and walked down the hall to the staff lounge. 3. Observation on 6/6/23 at 11:36 a.m. of one medication cart computer located in the resident's dining room revealed: *The medication computer screen had been facing a table of four residents sitting down to eat lunch and was opened to a resident's medication administration record. *RN E had walked away from the medication cart and out of the dining room. *The medication computer screen was still open to the resident's medication administration record. 4. Observation on 6/6/23 at 11:11 a.m. of one computer located at the nurse's station revealed: *The computer screen was opened to a resident's medical record. *Nurse D walked up to the computer to answer the phone that had been ringing next to it. *She talked on the phone for several minutes then she walked away from the nurse's station. *The computer screen was still open to the resident's medical record. 5. Observation on 6/7/23 at 7:57 a.m. of one medication cart computer located in the resident's dining room revealed: *CNA/MA F had been administering medications to the residents in the dining room. *The medication computer screen had been facing the door to the dining room and a table that seated three residents. *The medication administration record was visible to any resident, staff or visitors passing by the dining room door. *She administered the medications to three residents, leaving the computer screen within view of the residents seated at the table and anyone walking into the dining room throughout the entire medication administration. *All four times CNA/MA F had left the cart unattended and unlocked. -Any resident or visitor in the vicinity would have had access to the resident medications in the cart. *The medication cart drawers contained the following: -Residents' prescription medications. 6. Observation on 6/8/23 at 8:57 a.m. of one medication cart computer located in the resident's dining room revealed: *The medication computer screen had been facing the door to the dining room and a table that seated three residents. *There had been no staff at the medication cart. *While RN E sat at a table with his back to the medication cart administering medications to a resident, the medication cart was unlocked. -A visitor had walked past the dining room door, he was seen glancing at the open computer screen that reflected a resident's medication administration record. *The unattended medication cart was monitored for 3 minutes before RN B came back to the unlocked medication cart. *RN B had come back to the medication cart. Interview on 6/8/23 at 9:01 a.m. with RN E regarding the above observation revealed: *He stated that it was easier to leave the computer screen and medication cart unlocked when administering medications in the dining room when he was in view of the medication cart. *It was his understanding that the computer screen would have gone black within sixty seconds and the computer program would have locked itself after 3 minutes. 7. Interview on 6/8/23 at 9:54 a.m. with director of nursing (DON) B regarding the above observations revealed she: *Would have expected all nurses to have locked the medication carts and the computer screen prior to leaving the medication cart unattended. *Agreed that if the computer screen was not locked when unattended resident's personal medical information could have been viewed by anyone walking past that medication cart. *Agreed the staff would need to have been re-educated regarding the potential breaches in resident privacy and confidentiality. 8. Review of provider's January 2023 Confidentiality policy revealed: *POLICY: -Confidentiality: The patient/resident has the right to expect that records pertaining to his care will be treated as confidential, and the Facility has the obligation to safeguard his records against unauthorized disclosure. *PROCEDURE: -B. Computer Security -b. Position computer monitors so that visitors and others cannot see confidential information. -c. Don't leave confidential information on the screen; file documents and sign off the computer when you are done using it.

Based on observation, interview, record review, and policy review, the provider failed to ensure 8 of 37 residents (1, 13, 14, 17, 18, 21, 32, and 35) who had side rails on their beds had been assessed for use when applied and on a quarterly basis. Findings include: 1. Observation on 1/19/22 at 8:42 a.m. of resident 1 revealed: *She was seated in her wheelchair. *A quarter length side rail near the head of the bed was elevated. Review of resident 1's medical record revealed side rail assessments had not been completed. 2. Observation on 1/19/22 at 8:52 a.m. of resident 18 revealed: *She was laying in bed. *A quarter length side rail near the head of the bed was elevated. Review of resident 18's medical record revealed side rail assessments had not been completed. 3. Observation on 1/19/22 at 11:23 a.m. revealed resident 35 had a one-half length side rail on her bed. The side rail was on the side of the bed by the wall. She was seated in her wheelchair at the time of the observation. Review of resident 35's medical record revealed side rail assessments had not been completed. 4. Observation on 1/20/22 at 7:45 a.m. revealed two quarter length side rails in the up position on resident 13's bed. The resident was in bed sleeping at this time. Review of resident 13's medical record revealed side rail assessments had not been completed. 5. Observation on 1/20/22 at 7:46 a.m. revealed one quarter length side rail in the up position on resident 14's bed. The resident was not in bed at this time. Review of resident 14's medical record revealed side rail assessments had not been completed. 6. Observation on 1/20/22 at 7:47 a.m. revealed two quarter length side rails in the up position on resident 17's bed. The resident was not in bed at this time. Review of resident 17's medical record revealed side rail assessments had not been completed. 7. Observation on 1/20/22 at 1:31 p.m. a quarter length side rail in the up position on the left side of resident 21's bed. The resident was in bed sleeping at this time. Review of resident 21's medical record revealed side rail assessments had not been completed. 8. Observation and interview on 1/20/22 at 2:30 p.m. revealed she: *Had one-half side rails on her bed. *Was seated in her recliner at this time. *Stated she did use the side rails to assist her with repositioning. Review of resident 32's medical record revealed side rail assessments had not been completed. 9. Interview on 1/20/22 at 1:30 p.m. with licensed practical nurse/Minimum Data Set coordinator C revealed an assessment for the use of side rails had not been completed for residents who used side rails. 10. Review of the provider's last revised April 2019 Restraint policy for side rails revealed: *Staff would have completed the side rail intervention and activities of daily living form prior to siderail utilization to assess bed mobility needs. *Results of the resident's bed mobility needs would have been reviewed by the interdisciplinary team, resident/family, and resident's physician. *Designated interdisciplinary team member would have assisted in evaluating the resident's cognitive status *The interdisciplinary team would have determined the resident's full ability to make a safe decision regarding side rail usage. *Use of the device should have been reviewed quarterly by the interdisciplinary team, resident, and family at their care conference.

Based on interview, record review, contract review, and policy review, the provider failed to ensure care plans were integrated five of five sampled residents (17, 20, 34, 42, and 47) who had received hospice services. Findings include: 1. Review of resident 17's medical record revealed he had a 4/23/19 physician's orders [REDACTED]. Review of resident 17's updated 1/16/19 care plan revealed the hospice plan of care goals and interventions were not included in the provider's care plan. 2. Review of resident 47's closed medical record revealed: *He began hospice services on 3/7/19. *He was discharged on [DATE]. *His closed care plan revealed: -His activity involvement and communication ability problem areas stated he was on hospice. -Hospice was not mentioned in any other area of his care plan. -There were no interventions specific to hospice. -It was not integrated to include hospice care and services. 3. Review of resident 20's medical record revealed: *She had begun hospice services on 12/11/18. *Her care plan revealed: -Her hospice care area stated to coordinate care with hospice. -Her cognitive status, communication ability, behavior, nutritional status, activity involvement, and vision status each stated she was on hospice. -Hospice was not mentioned in any other area of her care plan. -There were no interventions specific to hospice. -It was not integrated to include hospice care and services. 4. Review of resident 42's medical record revealed: *She had been admitted on [DATE]. *A physician order [REDACTED]. Review of resident 42's 5/15/19 care plan revealed no coordination of care between the facility and hospice provider. 5. Review of resident 34's medical record revealed he: *Had been admitted on [DATE]. *Had a [DIAGNOSES REDACTED]. *Started hospice services on 4/18/19. Review of resident 34's 5/15/19 care plan revealed no coordination of care between the facility and hospice provider regarding hospice services. Interview with the director of nursing (DON) on 05/15/19 at 12:29 p.m. regarding integrated care plan with hospice services for resident 42 revealed: *Her care plan had not been integrated to reflect hospice services and coordination of care. *No other documentation had been found regarding coordination of care with the hospice provider. *She agreed it should have been included in the care plan and available for staff to reference. 6. Interview with the Minimum Data Set (MDS) coordinator on 05/15/19 at 12:21 p.m. regarding integrated care plans with hospice services revealed: *The care plans had not been integrated with the facility and the hospice provider. *She stated, We do not have it on the care plan. Interview with registered nurse (RN) C on 5/15/19 at 1:30 p.m. revealed: *She had been responsible for writing the baseline care plans, quarterly's, annual reviews and significant changes. *She stated staff informed her if they thought a change in condition had taken place. *She stated she felt the care plan had been integrated for hospice services between the facility and hospice provider with the current information in the plan. Review of the facility's 10/30/17 Care Plan policy revealed: *The overall plan of care was reviewed every ninety days, updated when there was a significant change of condition, and/or following hospitalization . *It was the responsibility of each staff member to know the plan of care for each resident. Review of the 6/1/16 Hospice and Nursing Facility Services Agreement revealed: *The plan of care shall identify the care and services needed and specifically identify whether hospice or facility is responsible for performing the respective functions that have been agreed upon and included in the plan of care. *The plan of care shall reflect the participation of hospice, facility and the hospice patient and such patient's (resident) family, to the extent possible, including a description of the hospice services, inpatient services, and room and board services furnished by facility. *Each party shall conduct an ongoing, comprehensive and integrated assessment of the quality and appropriateness of services provided to patients pursuant to this agreement. Individuals responsible shall report on activities and mechanisms for monitoring and ensuring the quality of patient care. The parties shall coordinate as deemed necessary by the parties but at least annually, to review findings from any continuous quality improvement (CQI) process that are relevant to the care of hospice patients.

Based on observation, interview, policy review, and manufacturer's instructions review, the provider failed to follow the manufacturer's instructions of the disinfectant for the whirlpool tub for one of one randomly observed whirlpool cleaning by one certified nursing assistant (CNA) A. Findings include: 1. Observation and interview on 5/14/19 at 10:31 a.m. with CNA A revealed: *She added the water and the disinfectant to the whirlpool tub. *She scrubbed the entire surface of the tub and chair with the disinfectant and water solution with a brush. *After approximately four minutes the areas on the arms on the chair had started to dry. *She stated she scrubbed it all once and would let it set for ten minutes. *She was unaware the disinfectant instructions were to keep it wet for ten minutes. Interview on 5/14/19 at 11:47 a.m. with CNA B revealed she was not aware the tub disinfectant should have been kept wet for ten minutes. Interview on 5/15/19 at 9:46 a.m. with the infection preventionist nurse revealed: *She was not aware the tub in the above observation needed to stay wet. *She agreed the instructions were to keep it wet for ten minutes. Interview on 5/15/19 at 10:40 a.m. with the director of nursing revealed she was not aware that the contact time instructions for the disinfectant was to have the tub remain wet for 10 minutes. Review of the provider's undated Disinfecting Instructions policy revealed: *Scrub the surface of the tub with the disinfectant and water. *Let disinfectant stay on surface for 10 minutes. -Or as recommended by the instructions on the disinfectant container. Review of the whirlpool tub instructions that was posted near the whirlpool revealed: *Scrub the surface of the tub with the disinfectant and water. *Let disinfectant stay on surface for 10 minutes. Review of the undated disinfectant manufacturer's instructions revealed: *When used as directed, this whirlpool disinfectant, was formulated to disinfect hard, non-porous whirlpools. *Wet all surfaces thoroughly. *Allow to remain wet for 10 minutes.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Repositioning had occurred in a timely manner for one of four sampled residents (3) who was at high risk for skin breakdown and was dependent upon the staff to assist him with all activities of daily living (ADL). *One of one sampled resident (34) who was dependent upon staff for all care had an individualized activities program and was properly dressed to maintain dignity. Findings include: 1. Review of resident 3's medical record revealed: *An admission date of [DATE]. *He had a Brief Interview for Mental Status score of ten meaning his cognition was moderately impaired. *[DIAGNOSES REDACTED]. *He had been dependent upon the staff to: -Assist him with all of his mobility needs including transferring from place-to-place and moving in bed, and ADLs. -Implement any preventative interventions to ensure skin breakdown would not have occurred. *On 2/17/18 his Braden pressure ulcer risk assessment score was fourteen. -That score indicated he had been at high risk for developing pressure injuries. -The mobility score was a two indicating his ability to move himself was very limited. *He was incontinent of both urine and bowel. Observation on 2/21/18 at 8:42 a.m. of resident 3 with certified nursing assistants (CNA) C and D revealed: *They had prepared to assist the resident with personal care, dressing, and transferring him into his recliner. *The resident had: -Not been able to move his right arm and leg on his own without staff support. -Been able to move his left arm and leg to assist the staff with personal care, dressing, and some positioning. -Been incontinent of urine. *He required the CNAs to use a mechanical total body lift to transfer him into the recliner. Interview on 2/21/18 at 9:00 a.m. with CNA D regarding resident 3 revealed: *He would remain in his recliner until after lunch. -They would then assist him to lay back down in his bed. *He preferred to remain in his room instead of attending large or small group activities. *They would not have: -Repositioned or moved him until he was laid back down in his bed after lunch. -Checked on him during that time frame unless he put his call light on. Observation on 2/21/18 at 11:15 a.m. of resident 3 revealed he was sitting in his recliner. Observation on 2/21/18 at 1:15 p.m. of resident 3 revealed he had been laying down in his bed. Interview on 2/21/18 at 1:19 p.m. with CNAs C and E regarding resident 3 revealed: *They had just laid him down to rest at approximately 1:00 p.m. *CNA C confirmed: -They had not been in his room to check on him or offload his bottom to relieve pressure since he was gotten out of bed at 9:00 a.m. -He was at high risk for skin breakdown. -The facility policy was to reposition residents every two hours if they were at high risk for skin breakdown. *CNA C stated He will put his call light on if he needs anything. *CNA E stated: -He knows when he is wet and will put his light on to let us know. -RC (restorative aide) comes in and works with after we get him up, maybe they shift or offload him during that time. *They both confirmed: -The resident had not put his call light on that morning to be checked or changed for incontinence or to be laid down. -Unless he put his call light on to be changed from incontinence or wanted to lay down he would not have been repositioned for long periods of time. Interview on 2/21/18 at 1:26 p.m. with restorative aide (RA) F regarding resident 3 revealed: *She confirmed he was on a restorative program for range-of-motion exercises. *She had not assisted him with those exercises yet, as he had refused that morning. *Shifting or offloading his bottom to relieve pressure was not a part of his exercise program. *She stated I can't do that as he is a two person for positioning and I can't do that, he is too heavy. Further interview and follow-up on 2/21/18 at 1:32 p.m. with CNAs C and E regarding resident 3 confirmed: *The resident had been assisted into his recliner at 9:00 a.m. and laid back down to rest at 1:00 p.m. *They had not checked on him for incontinence or assisted him with relieving pressure off of his bottom during those four hours. *They agreed by not repositioning someone who was at high risk of skin breakdown in a timely manner would have created the potential for a wound to have developed. Interview on 2/21/18 at 1:39 p.m. with registered nurse (RN) G regarding resident 3 and the interviews with CNAs C and E revealed: *She confirmed: -Their policy was to reposition all residents who were at high risk for skin breakdown every two hours. -The resident: --Was at high risk for skin breakdown. --Required assistance with repositioning and incontinence care from the staff. *She stated If he doesn't put his call light on to be changed, as he usually has a BM, then yes, there are times he probably could sit without repositioning for a long period of time like today. Review of resident 3's revised 12/7/17 care plan revealed: *A focus area: Is at high risk for skin breakdown d/t (due to)[MEDICAL CONDITION] obesity. *Interventions under that focus area had no documentation to support how often he should have been repositioned. Interview on 2/22/18 at 3:47 p.m. with the administrator revealed: *She agreed: -Resident 3 had been at high risk for skin breakdown. -All residents who were at high risk for skin breakdown should have been repositioned at least every two hours. -His care plan should have reflected how often he was to be repositioned. *She had not been aware the staff would not have assisted him with repositioning when he was up in his recliner for that length of time unless he put his call light on. *She stated He needs to be repositioned every two hours and staff should check on him and offload him every two hours even if he does not call for assistance. Review of the provider's 1990 Positioning Patient/Resident policy revealed: *Any patient/resident with decreased mobility is at risk of developing contractures, postural abnormalities, and pressure sores. *The nurse has the primary responsibility to minimize this risk, which is done by changing an immobilized client's (resident) position ever 2-3 hours. 2. Review of resident 34's medical record revealed: *Her admitted was 1/11/18. *Her BIMS had not been charted on her admission MDS. *Her [DIAGNOSES REDACTED].>-Advanced [MEDICAL CONDITION]. -[MEDICAL CONDITION] disorder. -Chronic abdominal pain. -Right gluteal ulcer with ischial osteo[DIAGNOSES REDACTED]. Random observation and interview of resident 34 on 2/21/18 from 8:00 a.m. to 6:00 p.m. and 2/22/18 from 8:00 a.m. through 6:00 p.m. revealed: *She preferred to sleep late and not have breakfast. *Staff would assist her to her Broda chair for lunch and supper. *Staff would get her up last and take her back to her room first, so she would not be in her chair too long. *She spent the rest of the day in her room in bed. *Her TV was on the Hallmark channel. -She did not appear to be watching it. *She had very limited movement of her arms and legs. *Usually made short answers to questions or no answer. *She would laugh at appropriate times. Observation and interview on 2/21/18 at 11:00 a.m. while watching care for resident 34 revealed: *She was unable to dress herself. *Only had slight movement of arms and legs. *CNA K put a button down shirt on her backwards over her gown. *She stated it was easier to put on that way, and she did not have as much pain when being dressed. *She went to the dining room for dinner and supper. Review of resident 34' of 2/22/18 activities care plan revealed: *She would listen to music. *She liked small groups. -No small groups or music were listed on her activity log since 1/26/18. Review of resident 34's activity log from 1/26/18 to 2/22/18 revealed: *She had one-to-one discussion with activity staff twenty out of twenty-eight days. *There were no time frames for those discussions charted. *There was not any activities charted on Saturdays or Sundays. Interview on 2/22/18 at 1:45 p.m. with the activities director revealed: *Any charted one-to-one discussions could have been from one to fifteen minutes in length. *Activities staff tried to visit with her five times per week. *No other activities had been provided. *She thought she should have had more activities than that. Interview on 2/22/18 at 2:32 p.m. with the DON regarding resident 34 revealed: *One-to-ones might have been the best for her. *The physician had ordered for her not to sit up too long. *an order for [REDACTED]. *She was not aware that staff were putting her shirt on backwards or over her gown. *She did not think that was appropriate.

Based on observation, interview, and policy review, the provider failed to ensure: *Proper hand hygiene, glove usage, and sanitary technique was used during personal care for two of seven sampled residents (3 and 36). *A sanitary technique was used during a dressing change by one of one physical therapist (PT) H for one of two sampled residents (4) with a stage IV pressure ulcer. Findings include: 1. Observation on 2/21/18 at 8:42 a.m. of certified nursing assistants (CNA) C and D during personal care for resident 3 revealed: *The resident had been laying in his bed and was ready to get up for the day. *They had washed their hands and put on a clean pair of gloves. *With those gloves on CNA C had: -Adjusted his covers to expose his upper torso. -Washed the resident's face and underarms with a wet washcloth. -Assisted the resident with putting on his shirt. -Removed her gloves and without sanitizing/washing her hands put on a clean pair of gloves. *With those gloves on CNA C had: -Assisted CNA D with removing the resident's soiled incontinent brief. -Opened the drawer on the bedside stand and got out a tube of perineal wash. -Opened the tube of perineal wash and put some of it on a moistened wash cloth. -Cleansed the resident's front perineal area. -Opened the bottom drawer of the bedside stand and got out a plastic bag containing 4 by 4 gauze dressings. *CNA C removed her left hand glove and without sanitizing/washing it she had: -Reached into the plastic bag, got out a 4 by 4 gauze dressing, and gave it to CNA D. --She placed that 4 by 4 gauze dressing underneath the resident's abdominal fold. *Without sanitizing/washing her hand CNA C put a clean glove on her left hand. *With those gloves on CNA C had: -Washed the resident's bottom. -Assisted CNA D with putting on an incontinent brief and finished dressing him. *At that time they both removed their soiled gloves and washed their hands. *They both assisted the resident out of his bed and into his recliner. 2. Observation on 2/21/18 at 4:09 p.m. of CNAs A and B during personal care for resident 36 revealed: *The resident was laying in her bed and was ready to get up for the afternoon. *They washed their hands and put on a clean pair of gloves. *They assisted her to the bathroom with the use of an EZ Stand mechanical lift. *After the resident had finished going to the bathroom they stood her up with that same lift. *CNA A had sanitized her hands and put on clean gloves. *With those gloves on CNA A had: -Got a package of wet wipes from a shelf by the sink. -Opened the package and got out a wet wipe. -Used the wet wipe to cleanse the resident's bottom first. -Then reached up further behind the resident, washed her perineal area, and then again her bottom. -Came around the front of the resident and washed her perineal area for a second time. -Removed her gloves and sanitized her hands. *They finished dressing the resident and assisted her into her w/c. Interview on 2/21/18 at the time of the above observation with CNA A regarding resident 36 revealed she: *Confirmed that had been her usual process for assisting the resident with personal care. *Had not realized she had wiped the resident's bottom prior to cleaning her perineal area. *Agreed: -The resident's perineal area should have been cleaned first. -The process above had not been completed in a sanitary manner. -That process had placed the resident at risk for developing a urinary tract infection [MEDICAL CONDITION]. 3. Observation on 2/22/18 at 10:04 a.m. with PT H and PT assistant (A) I during a dressing change for resident 4 revealed: *The resident was sitting up in her wheelchair (w/c). -She remained in her w/c for the dressing change. -The staff had her lean forward during the procedure. *PTA I had assisted the resident with leaning forward and pulled the back of the resident's shirt up to expose the area to be treated. -The wound was located on the resident's lower back and along the spine. *PT H had gathered supplies to provide wound care for the resident that consisted of : -An unopened plastic bag containing several 4 by 4 gauze dressings. -Two unopened packages of foam protective dressings. -One unopened package containing Sorbact ribbon gauze. -One unopened package containing [MEDICATION NAME]. -One spray bottle of wound cleanser. -One unopened package containing a sterile towel. -One unopened package of skin preparation (prep). -One unopened package containing a Qtip. *PT H sanitized her hands and put on a clean pair of gloves. *While PT H had her gloves on she: -Opened the package containing the sterile towel and placed that towel along the resident's lower back and waist line. -Removed the soiled dressing from her back. -Opened the plastic bag and got out several 4 by 4 dressings. -Got the spray bottle of wound cleanser and sprayed the wound with the cleansing solution on the inside of it. *With those soiled gloves on PT H: -Wiped off the cleansing solution with the 4 by 4 gauze dressings. -Opened the package of [MEDICATION NAME] and applied it to the clean wound. -Provided laser treatment to the wound, and once that was completed she removed the [MEDICATION NAME] dressing from the wound. *PT H removed the soiled gloves, sanitized her hands, and put on a clean pair of gloves. *While PT H had her gloves on she: -Opened the: --Packages of foam protective dressings. --Package of Sorbact ribbon gauze. --Package containing the Qtip. -Placed all of those supplies on the inside surface of the package containing the sterilized towel. -Opened the skin prep package and removed the skin prep wipe. -Wiped around outside areas of the wound with it. -Picked up both of the foam protective dressings and placed the smaller one inside of the larger one. -Picked up the Sorbact ribbon and placed it inside of the foam dressings. -Attempted to cover the wound with the foam dressings and Sorbact ribbon gauze. --The Sorbact ribbon gauze fell off of the foam dressings, she picked it up, and placed it back onto the foam dressings. -Covered the wound with the dressings. *PT H removed her gloves, sanitized her hands, and left the room. *PTA I assisted the resident back to the nursing home area. Interview on 2/22/18 at the time of the above observation with PT H revealed she: *Confirmed that had been her usual process for completing the dressing change for the resident. *Had: -Not recognized her process as unsanitary until reviewed with the surveyor. -Recognized the outside surfaces of all those packages had been considered unsanitary. *Agreed she should have removed her gloves, sanitized her hands, and put clean gloves on after removing the soiled dressing. *Confirmed the: -resident had a history of [REDACTED]. -Wound was slow healing and had worsened at times. *Agreed: -The process above had created the potential for cross-contamination of bacteria to the wound. -Poor wound care could have effected the healing process of the wound. *She could not remember anyone observing her during a dressing change to ensure the process had been completed in a sanitary manner. 4. Interview on 2/22/18 at 11:00 a.m. with RN J revealed she: *Was the infection control nurse for the facility. *Agreed: -The above processes had not been completed in a sanitary manner and created the potential for cross-contamination of bacteria to the residents. -When a dressing change was not completed in a sanitary manner it could have created a slow healing process and the potential for infection of that wound. *Confirmed gloves should been changed changed with hand hygiene performed when going from one task to another. *Had completed random audits of personal care performed by the staff in (MONTH) (YEAR). -Any concerns observed would have been addressed with the staff at that time. *She had not completed any audits or observations of the staff or PT H completing wound care. Interview on 2/22/18 at 2:22 p.m. with the administrator regarding the above observations confirmed: *They had not been not completed in a sanitary manner. *When poor technique was used for: -Perineal care that could have created the potential for the residents to acquire a UTI. -Wound care that could have created the potential for infection and a slow healing process to have occurred. *Resident 4 had a history of [REDACTED]. *Those processes had created potential for cross-contamination of bacteria to the residents. *She: -Was not aware the staff and PT H had not been observed completing wound care for the residents. -Agreed there should have been audits completed on that process to ensure proper technique was being used. Review of the provider's 9/9/17 Hand Hygiene policy revealed: *Hand hygiene is the single most important procedure for the control of infection. *It is a critical component of patient (resident) and employee safety. Review of the provider's (MONTH) (YEAR) Standard Precautions policy revealed: *Gloves: -They are used as a protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. -Must be changed between between patient contacts and hands washed after gloves are removed. -Must be changed when going from one procedure to another on the same patient. Review of the provider's (MONTH) 2003 Handwashing/Hand Hygiene policy revealed: *Hands should be decontaminated or washed after removing gloves. *Gloves should be removed between different body sites. Review of the provider's (MONTH) 1996 Perineal Care policy revealed Wash from pubis to perineum to prevent contamination (from front to back).

Based on observation, record review, interview, and policy review, the provider failed to implement appropriate interventions to prevent a facility acquired stage III (full thickness loss of skin exposing bone, tendon, or muscle) pressure ulcer (an injury to the skin and underlying tissue caused by unrelieved pressure, usually over a bony area) and an open area to the scrotum (area under penis) for one of one sampled resident (5) identified at risk for developing pressure ulcers. Findings include: 1. Review of resident 5's medical record revealed he had: *Been admitted on [DATE]. *No pressure ulcers at the time of admission. *[DIAGNOSES REDACTED]. *A history of pressure ulcers that had required surgical repair. *Developed a stage II (partial thickness of tissue loss) pressure ulcer to his right gluteus (bottom) on 9/27/15. *The pressure ulcer measured 1.8 centimeters (cm) by (x) 2.8 cm x 0 cm (length, width, depth) *Been evaluated by physical therapy (PT) on 10/6/15 for the pressure ulcers. -PT documentation was unclear regarding if the pressure ulcer was unstageable (unable to determine severity) or a stage III. -The pressure ulcer on his bottom had worsened to a stage III with measurements of 7.5 cm x 2.1 cm in length and width, and had not yet healed. Review of the Skin Basic Assessments for resident 5 revealed: *On 4/14/15 he did not have a pressure ulcer. *On 9/27/15 he had a stage II pressure ulcer to his right gluteal cleft (bottom crease). *On 10/12/15 he had an open area to his scrotum with measurements of 1.4 cm x 0.3 cm x 0 cm, along with the stage II pressure ulcer with measurements of 3.7 cm x 1.5 cm x 0 cm. Review of the following Braden Scale for Predicting Sore (ulcer) Risk assessments for resident 5 revealed: *On 4/21/15 he had scored 15 (score of 15 to 18 indicated mild risk for developing a pressure ulcer). *On 7/7/15, 9/9/15, and 9/28/15, he had scored 17. *The intervention guide included the following recommendations for someone at mild risk for the development of pressure ulcers: -Frequent turning. -Maximum remobilization (as much movement as possible). -Foam or gel cushion in wheelchair and recliner. -Protect heels. -Foot cradle (device to keep bedding off the feet). -Manage moisture. -Manage nutrition. -Manage frictions and shear (rubbing against a surface that would cause a skin injury). Review of the Physical Therapy notes and plan of care regarding resident 5 revealed: *No notes prior to 10/6/15. *There had been an evaluation and plan of care completed by PT on 10/6/15. -PT had identified resident 5 had pressure ulcers on the left buttock (all other documentation indicated the right buttock) and scrotum. -He had a history of [REDACTED]. -He had no sensation in the area. -The pressure ulcer measured 7.5 cm x 2.1 cm in length and width. -The therapist was to educate the resident and staff on floating heels to decrease pressure and increase wound healing. *On 10/8/15, 10/14/15, 10/23/15, 10/26/15, and 11/2/15 the therapist had dictated that she had told nursing to change dressing change to daily as there was significant drainage on dressing. *The measurements of the pressure ulcer documented were as follows: -10/14/15: 4.1 cm x 2.1 cm x 1.0 cm (length, width, depth). -10/23/15, 10/26/15, and 11/2/15: 3.4 cm x 1.5 cm x 1.0 cm. -11/4/15: 4.1 cm x 2.1 cm x 1.9 cm. -11/12/15: 2.1 cm x 3.9 cm x 2.3 cm. -11/16/15: 2.1 cm x 3.9 cm x 2.3 cm. -No measurement documented on 11/9/15; therapist documented the wound appeared larger than last times. *On 11/9/15, the therapist noted possible undermining (separation of tissue from the surface under the edge of a wound). *PT did not document which pressure ulcer the above information referred to. Review of the following registered dietician's notes regarding resident 5 revealed: *On 9/29/15 he: -Had a stage II pressure ulcer on his right gluteal area. -Was to receive [MEDICATION NAME] (supplement for wound healing) twice a day. *On 10/29/15: -His pressure ulcer was a stage III on his right gluteal area. -He was to receive Juven (supplement for wound healing) twice a day. *On 11/12/15 he was to receive: -Juven twice a day. -Ensure (supplement for wound healing) added to four ounces of milk with all meals. -Fortified (food with added calories and/or protein) meals. *None of those interventions had been in place prior to the development of the pressure ulcers. Review of the following Minimum Data Set (MDS) assessments regarding resident 5 revealed: *On the 4/26/15 and 7/10/15 MDS assessments: -He had no pressure ulcer. -He was at risk for developing pressure ulcers. -Pressure relieving devices were being used on his bed and in his chair. *On the 10/2/15 MDS assessment: -He had a stage II pressure ulcer (location was not identified). -He was at risk for developing pressure ulcers. *Interventions in place at the time of the above MDS were: -Pressure relieving devices on his bed and in his chair. -Nutrition intervention. -Application of ointments/medications to pressure ulcer. *He required extensive assistance (staff provided weight bearing support) of two staff for changing positioning while in bed on the above MDS assessments. *He had no limitation in range of motion in his upper or lower extremities on the above MDS assessments. -That contradicted with him having been paralyzed from the waist down. Review of resident 5's 4/26/15 care plan revealed he had: *Been paralyzed from the waist down. *Used a trapeze (a hanging bar attached above a bed) and side rails on his bed to aid with positioning and movement while in bed. *Required extensive assistance with bed mobility and personal hygiene. *The potential for skin breakdown. *A pressure reducing mattress on his bed. *A pressure reducing cushion in his wheelchair. *No specific interventions for frequent turning, maximum remobilization, perineal (peri, private area) care, nutrition, or for managing frictions and shearing. Review of resident 5's 10/8/15 care plan revealed: *The interventions listed above and the following undated additions: -On 9/27/15 a stage II area to right gluteus (bottom). -Fortified meals. -Dressing changes as needed. -Eight ounces Juven mixed with orange juice until healed. -Extra ounce of protein at meals. -Ensure clear for juice option. *A pressure ulcer temporary care plan dated 9/27/15 included the following interventions: -Keep area clean, dry, and protected. -Apply dressing and change according to PT recommendations. -Involve PT with dressing changes as able. -Check (dressing) daily for placement. -PT changed dressing one to two times a week. -Nursing to assist with (dressing) changes when PT (was) not available. -Surgeon's recommendations on 11/12/15 to be up for meals only, lay only side-to-side, and to continue cushion in wheelchair. -Increase protein intake according to RD recommendations. -Reposition resident frequently (minimum every 2-3 hours). -Administer pain medications as ordered. -Educate res. (resident) to repo (reposition) often, discuss off-loading (take pressure off an area), discuss protein intake. *The above interventions had not been implemented until after the development of the pressure ulcers. *No intervention for nursing to change the dressing daily per PT recommendations. *No specific interventions for managing moisture, peri care, or managing frictions and shearing. The medication administration records and treatment administration records were requested during the survey but were not provided. The staff were unaware how to print them from their computer system in a readable condensed format. Observation and interview on 11/16/15 at 4:15 p.m. with resident 5 revealed he: *Was in bed with a pillow under his right side. *Was paralyzed from the waist down. *Stated he could not reposition himself very well. Observation on 11/16/15 at 5:13 p.m. of resident 5 revealed he had independently driven himself in his motorized wheelchair from his room into the dining room. Observation on 11/17/15 at 8:35 a.m. of CNA E and F during a transfer of resident 5 with a Hoyer lift (equipment to move resident using a sling from one position to another) from his wheelchair to his bed revealed he offered minimal assistance with his arms when being positioned in his bed. Following the initial tour, this surveyor asked nursing staff to see resident 5's pressure ulcer, but was told PT did the dressing changes. The dressing would not be changed again until PT returned that Thursday. Nursing staff only changed the dressing if it was dirty or fell off. There was no opportunity for observation of the pressure ulcer. Interview on 11/18/15 at 2:15 p.m. with certified nurse aid (CNA) E regarding repositioning for resident 5 revealed they did not: *Reposition him every two hours or use pillows for positioning since his admission. *They started those interventions when he returned from the hospital on [DATE]. Interview on 11/18/15 at 3:30 p.m. with the director of nursing regarding resident 5 revealed: *He had more than slightly limited sensory perception (ability to feel). *His [MEDICAL CONDITION] would have been a major risk factor for developing a pressure ulcer. *He had a history of [REDACTED]. *His history of wounds placed him at a higher risk for developing a pressure ulcer. *He would have scored at a moderate or high risk for developing a pressure ulcer on the Braden Scale. *The Braden intervention guide included the following recommendations for someone at moderate or high risk for the development of a pressure ulcer: -Frequent turning with a planned schedule. -Foam wedges or pillows for 30 degree side-to-side positioning. -Small shifts in positioning. *There was no documentation the above interventions had been put into place. *He could reposition himself with his arms. *His care plan did not properly address repositioning prior to the discovery of the new pressure ulcer on his right gluteus. *He had a [MEDICAL CONDITION] (opening in the abdominal wall for collecting feces in a bag) and a catheter (tube that drains urine from the bladder into a bag). *She would have expected staff to have found the pressure ulcer earlier. *She stated the possibility of peri-care not being done as well as it should have been, because he had a [MEDICAL CONDITION] and catheter. *The nurses staged pressure ulcers. *They did not offer any training on staging pressure ulcers. *The computerized skin assessment had directions to assist with staging a pressure ulcer. *She confirmed: -He did not have a pressure ulcer when he was admitted . -He developed pressure ulcers while living at the facility. -The care plan did not have all of the proper interventions put into place when he was admitted to help prevent him from developing a pressure ulcer. -His care plan was not updated to reflect PT's recommendations for daily dressing changes. -They did not follow their policies for prevention or treatment of [REDACTED]. Review of the provider's revised June 2000 Decubitus Ulcer Prevention policy revealed to do the following: *Turn patient (resident) every 2 hours. *Position patient with pillow or pads protecting bony prominences. *Inspect skin for redness and report to nurse. *If redness is present, rub around reddened areas and change turning schedule to every hour. *Whenever possible, teach patient to change his position at regular intervals. *Wheelchair patients may be taught to shift their weight from one buttock (side of bottom) to the other. Review of the provider's revised June 2000 Decubitis Ulcer Treatment policy revealed the nursing responsibilities were: *Nursing care will consist of intensive application of the same measures as outlined in prevention of decubitus ulcers. *Assessment will be done daily and PRN (as needed).