Every finding on record at Avera Brady Health and Rehab

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, observation, interview, document review, record review, and policy review, the provider failed to protect the resident's right to quality of care according to the resident's assessment and needs for one of one sampled resident (41) whose call system cord was not working and was on a commode (portable toilet) for one hour and fifteen minutes, which was 30 minutes longer than the resident's preference, by one of one certified nursing assistant (CNA) N who did not return to resident 41's room to check on her. That failure resulted in emotional distress for the resident, who was observed by administrator (A) as being distressed, upset, and having tears in her eyes when discussing the incident. The provider failed to assess other residents' call system cords to ensure they were functioning to enable them to call for staff assistance, putting all residents who needed staff assistance with their care at risk of serious adverse outcomes such as pressure ulcers, falling, emotional distress, injury, and/or serious harm, specifically if the resident attempted to call for help with no response. Findings include: 1. Review of the SD DOH FRI revealed that on 3/5/26 at 5:15 p.m., resident 41 was heard yelling from her room by a registered nurse (RN) who was working nearby. The RN entered the room and found resident 41 sitting on the commode. The resident was upset and stated that she had been waiting for someone to answer her light [call light]. Resident 41 stated she had tried to call for help to get off the toilet at 4:45 p.m. The RN tried to activate the call light, and it would not turn on. The RN determined the call light was not activated when resident 41 had pushed the call button attached to the call system cord. She unplugged the cord from the call system box, and after plugging it back in, the call system cord began to work. Maintenance staff were notified and came at 6:30 p.m. and changed the call system cord that did not activate properly. An additional call system and call system cord were placed in resident 41's room that would be closer to the resident when she was using the commode.The provider's final report for the SD DOH FRI indicated CNA N was educated on the importance of placing an orange magnet on the outside of a resident's room door to indicate that a resident was on the toilet to ensure the resident was checked on by staff for the resident's safety, especially if the resident's room door was closed. All staff were re-educated on the use of orange magnets. Resident 41 had no signs of skin damage related to the incident. Resident 41 stated she would like to make sure her cell phone was within her reach when using the commode, so she would be able to call in the future when she needed assistance. The provider determined the resident was on the commode for approximately 30 minutes longer than she had wanted to be.2. Observation and interview on 4/21/26 at 5:20 p.m. with resident 41 in her room revealed that there was a bariatric-size (for plus-size residents) commode next to the bathroom door. Resident 41 stated she always wore an incontinence (involuntary urine or bowel leakage) brief as she was having problems with her bowels. She indicated that she had really big and really messy BM's (bowel movements) at least three times in the last two days. Resident 41 indicated she used the commode rather than the toilet and would sit on the commode for a while. She preferred to have her door left open only a crack, she indicated she was a very private person and liked to make her own decisions.3. An interview was attempted on 4/23/26 at 12:46 p.m. with resident 41. She declined to speak to the surveyor as she was watching television and I don't want to be interrupted.4. Interview on 4/22/26 at 1:51 p.m. with maintenance supervisor D regarding the monitoring of the residents' call systems revealed that all call systems were checked yearly to ensure they were working.5. Interview, document review, and policy review on 4/22/26 at 3:15 p.m. with administrator A regarding the process for ensuring residents were monitored while being assisted with their toileting needs and the residents' call system revealed that the staff was to leave the call system cord within the residents' reach when the resident was assisted to the toilet or commode in their room. After the staff exited the residents' room, they were to place an orange magnet on the outside of the residents' doorframe to indicate that the resident was on the toilet or commode.Administrator A indicated that the 3/5/26 incident regarding resident 41 being left on the commode for an extended period of time, was investigated and that the root cause analysis of this incident was related to the orange magnet not being placed on the resident's door frame.Administrator A stated that on 3/6/26, she had provided education to staff members regarding the Orange Magnet Process Reminder. That documented education indicated This is a reminder that it is an important safety measure to remember to use orange magnets outside a resident's door when they are on the toilet or commode. This should be done on ALL shifts to let the nurse and your partner [co-worker] know that someone is on the toilet if they are covering for you or you are ending your shift.Administrator A stated she had visited with resident 41 about the incident on 3/5/26 and stated that resident 41 was distressed, she was upset, and had tears as she had sat on the commode for 30 minutes longer than she had wanted to be there, as her call system cord had malfunctioned and did not alert staff members she needed assistance.Administrator A reviewed the provider's 2/6/25 Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy that included, Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress.Administrator A acknowledged that, based on this policy, the 3/5/26 incident of resident 41's call system cord not functioning resulted in the neglect of resident 41.Administrator A stated, We just changed out the call light computer recently, so we did a review of all call lights. She then stated, We do skin monitoring, and she [resident 41] had no [skin] issues [after the incident].6. Interview conducted on 4/23/26 at 8:00 a.m. with maintenance supervisor D regarding the residents' call system boxes revealed that, in late 2023 or sometime in 2024 (exact date uncertain), the provider began replacing the call system boxes located in resident rooms. This replacement process included ongoing updates, with several call system cords being replaced each year as part of the project.Maintenance supervisor D indicated that staff members could submit work orders for any issues related to the call light system, including instances where a device was not functioning properly or when a warning, such as a low battery alert, was triggered.Maintenance supervisor D indicated that the call light monitoring system was reviewed each morning. The system generated alerts that were displayed on workstation computers and on monitors located at the end of each hallway, which alerted the staff to issues such as missing devices or low batteries of the call system. If an alert was not promptly addressed, the system would continue to alarm every five minutes until the issue was resolved.The call system was designed to support up to three call system devices in each resident's room. Maintenance supervisor D reported that a new server for the call system was installed on 4/2/26 after an attempted update to Windows 12 rendered the system incompatible with the existing call light software. Following installation of the new server, all call light components, including each resident's call system cord to ensure they were functioning.Maintenance supervisor D stated that the call system was audited manually, once each year, usually in July, to ensure the entire system was working, including each resident's call system cord. The annual call light system audit was not completed for 2026.Regarding resident 41, maintenance supervisor D reported that on 3/5/26, he was notified by a staff member of an issue with resident 41's call system. Upon his inspection, it was determined that the zip ties securing the call system cord to the call system box had been cut. As a result, the resident pulled the cord with sufficient force to bend the internal components of the call light box, resulting in the call system cord not being able to activate the call system.Maintenance supervisor D stated, I relocated the call system box to the north wall between the bathroom wall and the sink, installed a new call system box and call system cord, and adjusted the placement so the cord could reach the resident's chair without requiring excessive tension when the resident was on the commode. He further indicated that he provided education to the staff members on duty at the time regarding the incident. He did not document this education.7. Interview conducted on 4/23/26 at 10:10 a.m. with administrator A regarding the call light system revealed that the investigation into resident 41's call system not functioning on 3/5/26 determined the issue was not with the call light system itself, but with CNA not using the orange magnet to indicate resident 41 was using the commode. The orange magnet serves as a secondary check when the call light was not functioning.Administrator A indicated there was no call system delay for resident 41's room on 3/5/26 recorded by the monitoring system, as the call system cord was not operating. She further explained that the call monitoring system was capable of detecting when a call system cord is missing, but it could not detect whether the call system cord was functioning or not.Administrator A acknowledged that a non-functioning call system cord could potentially result in an accident or injury to a resident. She stated, That is why maintenance was contacted immediately upon discovery of the issue. If the cord had deactivated the box, the monitoring system would have identified it.Administrator A explained that the call system monitoring operates on an external network device and is electronically monitored through a continuous system sweep. This call light monitoring system identifies issues such as low battery levels or missing components, including call system cords that may be missing.The facility's investigation regarding resident 41's incident on 3/5/26, determined that a secondary issue with Resident 41's call light was the call system cord not working. Administrator A reported that when the nurse tested the cord several minutes after the call system cord malfunctioned, it successfully activated the call system.8. Interview and review of the provider's call system monitoring checklist, which maintenance personnel were to document any repairs to a resident's call system on 4/23/26 at 8:54 a.m. with maintenance supervisor D revealed that the checklist was not consistently utilized by all maintenance personnel, although maintenance supervisor D indicated he made efforts to keep it current.There was no documented evidence on the checklist regarding resident 41's 3/5/26 incident involving the call system cord. Maintenance supervisor D stated that some information related to the incident might be on the old [computer] server, but he was unable to access those records.9. Review of resident 41's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her 4/3/26 Brief Interview of Mental Status (BIMS) assessment score was a 13, which indicated her cognition was intact. Resident 41's diagnoses included morbid obesity (excessive weight that significantly impacts health and well-being), depression, anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), chronic pain, constipation, fibromyalgia, and overactive bladder.Resident 41's 4/22/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated she required the assistance of two staff members and a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) for her toileting needs. She used a bedside commode and liked to watch television when using it. She had bowel and bladder incontinence and wore an incontinence brief during the day and night. Resident 41 wanted to be toileted at 4 a.m. and would use her call light the rest of the time. She was at risk for falling, and her door was to be left open unless sleeping then it may be closed but I need to be checked on frequently. Staff members were to continue to educate on fall risk reinforce use of call light [system]. She had a cell phone and was able to use it independently. 10. Review of the provider's 4/8/26 Quality Assurance Performance Improvement (QAPI) meeting revealed Quality Measures included call lights. The minutes did not include how the call lights were included in the Quality Measures. Under the title of State Notifications there was an indication that resident 41 was left on commode [the staff] moved placement of [the] call light; updated care plan; question why she is sitting a long [time] . BM or bladder? The column of Action included Nursing: Assess with [resident 41's name redacted] why she is sitting for so long.11. Review of the manufacturer's Call Station Installation Guide revealed the [NAME] ES Call Station is a wireless, battery-operated, fixed-location resident call device. The alarm may be activated by a large, easy to press push-button, a pull cord, or an optional remote pushbutton. The ES call Station is also equipped with a dual-purpose Call Cancel/Check-In button. In concert with Arial software, residents can check in using the ES Call Station.The general operation of the call station was completely wireless and easy to use. The call station sends a supervision signal to the Arial server approximately every 5 minutes. The resident initiates an alarm by pressing the large blue call button, by pulling the red cord, or by pressing an optional push-button cord. The red LED would turn on and remain lit until the alarm was cancelled. A Warning listed in the manufacturer's instructions included If using optional push-button cords, inspect all connectors following every alarm. If good electrical connections are not being made, subsequent use of the push-button cord may not issue an alarm, which could lead to the injury or death of a resident.12. Review of the provider's August 2024 Call Light(s) policy revealed that a functioning call light system was required. Call system scores were calculated monthly. The goal was to answer call system lights within 10 minutes 87% of the time. If the call light was defective, the staff were to report it immediately to maintenance.

Based on observation, interview, employee education review, and policy review, the provider failed to ensure standard food safety practices were followed for one of one observed cook I who did no perform hand hygiene (washing or sanitizing hands) after she dropped and picked up a butter container lid from the floor, and coughed into her right hand and drank from her personal beverage cup while preparing and serving resident meals during the lunch meal service. Findings include:1. Observation on 4/21/26 from 12:15 p.m. through 1:00 p.m., in the [NAME] kitchenette and dining room, revealed that cook I dropped the lid to the butter container onto the floor. She then picked the lid up and placed it on the counter next to an open bag of bagels. Cook, I did not perform hand hygiene after handling the lid that had fallen onto the floor. [NAME] I prepared a plate of food for a resident. While holding the plate in her left hand, cook I turned her head to the right and coughed into her right hand. She then continued preparing additional plates of food for residents without performing hand hygiene. There was one bottle of hand sanitizer on the counter next to the steam table line and one hand sanitizer dispenser on the North wall of the dining room. [NAME] I had her personal cup sitting on top of the food transport cart ( a cart used to transfer food from the main kitchen to the residents' room). The cart was located within the [NAME] kitchenette next to the serving line. She took a drink from the cup placed it back on top of the food transport cart and without performing hand hygiene and prepared additional plates of food for the residents 2. Interview on 4/21/26 at 1:36 p.m. with assistant dietary manager (ADM) F revealed that the personal cup that belonged to cook I, which was on top of the food transport cart, was an appropriate space for cook I to place it. 3. Interview on 4/22/26 at 1:15 p.m. with cook I revealed that on 4/21/26 at 12:30 p.m., she had coughed into her right hand while holding a plate of food in her left hand she was plating for the residents during the lunch meal. [NAME] I stated she should have set the plate down and washed her hands after she coughed into her right hand. She indicated she should have started over with a clean plate to serve the resident's food on. 4. Interview on 4/22/26 at 1:20 p.m. with ADM F revealed that cook I should have set the plate of food down that she had in her left hand and washed her hands after she had coughed into her right hand. ADM F indicated they had designated spaces for the staff to keep their personal cups with lids. She stated areas where food was being prepped for the residents were not considered safe spaces for the staff beverages. 5. Interview on 4/22/26 at 1:40 p.m. with dietary manager (DM) E, revealed she expected that cook I wash her hands after she coughed into her right hand before she started serving the resident's food. DM E indicated that the top of the food transport cart was not a designated space for the staff to keep their personal cups on. She expected the staff to follow the provider's hand hygiene policy. 6. Review of [NAME] I's Continuing Education Transcript Report revealed she had received annual education on Infection Control and Prevention on 3/21/26 and Food Safety and Sanitation education on 8/2/25. 7. Review of the provider's revised May 2023 [NAME] Handwashing policy revealed the purpose was to prevent the spread of disease or other contamination of food or food utensils. The staff were to wash their hands after handling soiled dishes and utensils, sneezing and using a tissue. 8. Review of the provider's revised April 2026 [NAME] LTC-Infection Prevention Program and Authority policy revealed: a. Long Term Care (LTC) employees are given information and education in the infection prevention and control. Education will be completed as needed at the direction of the QAPI Committee. 1. Mandatory education for infection prevention and control will be held on a routine basis and may include such information as bloodborne pathogens, Tuberculosis (TB) Standard Precautions, hand hygiene, disinfection, Healthcare-Associated Infection (HAI) prevention, and proper Personal Protective Equipment (PPE) use. Documentation of annual education is retained by the Department Supervisor and/or Education Department.

Based on record review, interview, observation, policy review, and manufacturer's manual review, the provider failed to ensure a safe environment for one of one sampled resident (1), who chose not to wear the whirlpool tub chair's safety belt by not educating the resident of the risks for adverse outcomes of not using the belt, to make an informed safety decision regarding the use of that safety belt. That failure put the resident at risk for falling and potential injury. Findings include:1. Review of the providers (02/19/26 and 02/02/26) South Dakota Department of Health (SD DOH) facility-reported incidents (FRIs) revealed two sampled residents (3,4) fell after the staff did not use an assistive device (mechanical lift and sling used to lift a person's full body to transfer to another location) or a safety device (whirlpool chair safety strap) correctly. Review of the provider's corrective actions indicated that the provider corrected the noncompliance that occurred for those two FRIs. 2. Further review of the provider's undated Bath Chair Safety staff education for direct care nursing staff revealed that All residents are to use the bath chair strap unless care planned that they refuse the bath chair strap. 3. Interview on 2/26/26 at 12:15 p.m. with assistant director of nursing (ADON) C revealed that resident 1 was the only resident who did not use the whirlpool chair safety belt. 4. Review of resident 1's electronic medical record (EMR) revealed that she was admitted to the facility on [DATE]. Her 2/9/26 care plan indicated that she was offered the whirlpool tub chair safety belt, but she may or may not use it and she had hand tremors (involuntary shaking). No documentation in the resident's EMR indicated she was assessed as not requiring the safety belt. Her 01/29/26 Brief Interview for Mental Status (BIMS) assessment score of 14, indicated her cognition was intact. The resident had a diagnoses of Parkinson's (neurodegenerative disorder causing motor symptoms like tremors, stiffness, and slow movement), diabetes (disruptions in how the body regulates blood sugar), osteoarthritis (chronic degenerative joint disease), degenerative joint disease (DJD) of the neck, and a history of L2 (second vertebra of the lower back) compression fracture and falls. No documentation indicated that resident 1 was educated on the risks and potential adverse outcomes of not using the whirlpool safety belt. 5. Interview and observation on 2/26/26 at 8:19 a.m., with certified nursing assistant (CNA) G revealed CNA G gave resident 2 a whirlpool bath with the tub chair safety belt on. She indicated that all residents wore the safety belt unless the resident's care plan indicated it was not required. 6. Interview on 2/26/26 at 12:53 p.m. with resident 1 revealed that she used the whirlpool tub chair without the safety belt. She stated, I wasn't really aware that I could fall by not using the safety belt. 7. Interview and record review on 2/26/26 at 3:00 p.m. with the director of nursing (DON) B and administrator A revealed that resident 1 chose not to wear the safety belt on the whirlpool tub chair. She indicated that resident 1 made that decision and it was put on her care plan on 8/1/25. DON B indicated that she had provided education to resident 1 about the safe use of the safety belt, but there was no documentation of that education in the resident's EMR. DON B and Administrator A acknowledged that the manufacturer's instructions stated that all residents must always be securely safety belted when using the whirlpool tub chair. 8. Review of the provider's 10/31/2024 LTC Falls and Accidents-System Standard Policy revealed: To be proactive in preventing resident falls and accidents. 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. Hazard: elements of the resident environment that have the potential to cause injury or illnesses. 1. Staff education and involvement. A. Upon hire and annually, all staff will receive education on preventing resident falls and accidents and demonstrate competence. B. Staff will be educated about the facility's systems approach, which evaluates and analyzes hazards and risks for each individual resident based on the individual's unique status, physically and cognitively, and appropriateness for allowing some potential risks that have inherent benefits for quality of life. C. All staff will be educated about and have access to care plans which are individualized for each resident and address the potential hazards. 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 other risk/hazards within the physical environment. 9. Review of the provider's whirlpool tub manufacturer's [NAME] Bathing 6/10/2020 Transfers and Stretcher Safe Operation and Maintenance Manual revealed: Route the safety belt through the safety belt loops of the chair frame prior to placing the resident into the chair. Transfer the resident into the [NAME] Transfer using the proper nursing transfer techniques. Bring the safety belt around the resident to the buckle connector. All residents must always be securely safety belted at the waist when using any of the [NAME] Lift Systems. Ensure that the safety belt is routed through the loose buckle end as shown in the picture to the left. Pay close attention to the placement of the serrations of the buckle. If routed the opposite way, the safety belt will slip. Tighten the safety belt by pulling on the loose end of the safety belt. Warning: Failure to secure the resident properly with the safety belt could result in injury to the resident or operator.

Based on observation, interview, record review, and policy review the provider failed to maintain the physical, mental, and psychosocial well-being by ensuring staff promptly responded to call lights for two of eighteen sampled residents (1 and 16) who used call lights to alert staff of their assistance needs. Findings include: 1. Observation and interview on 12/10/24 at 9:51 a.m. with resident 1 in her room revealed: *She was seated in her recliner. *Her call light was within her reach. *She stated it had taken staff at least 30-60 minutes go answer her call light at times. *She said she had waited so long that she had been incontinent of bowel and bladder. 2. Observation and interview on 12/10/24 at 10:50 a.m. with resident 16 in her room revealed: *She was seated in her recliner, with her feet elevated. *She had a flat touch call light attached to her recliner that was within her reach. *She needed a total body lift (a mechanical lift and sling used to lift a person's full body) to transfer between surfaces. *She stated it could take staff forever to come to her room when she turned her call light on, and they blame that on the call light not working properly. *She stated there had been instances when she had pushed her call light for over an hour before someone arrived. *She pushed her call light and stated she needed to be put in her wheelchair for lunch. 3. Review of resident 1's call light audit report from 11/2/24 to 12/10/24 revealed: *There were eighty-three call light response wait times over 10 minutes. *There were eighteen call light response wait times over 20 minutes. *There were seven call light response wait times over 30 minutes. *On 11/26/24 at 5:37 a.m. the call light response time was 72 minutes and 39 seconds. 4. Review of resident 16's call light audit report from 11/1/24 to 12/10/24 revealed: *There were one hundred and forty-three call light response wait times over 10 minutes. *There were forty-four call light response wait times over 20 minutes. *There were ten call light response wait times over 30 minutes. *On 11/25/24 at 8:46 a.m. the wait time was 68 minutes and 56 seconds. 5. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated cognitively intact. *She was diagnosed with atrial fibrillation, hypertension, chronic kidney disease stage 4, osteoarthritis, hypothyroidism, and overactive bladder. *She needed staff assistance with transfers. 6. Review of resident 16's EMR revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated cognitively intact. *She needed the assistance of two staff and the use of a total body lift to transfer between surfaces. 7. Interview on 12/12/24 at 8:26 a.m. with director of nursing B regarding call light response revealed: *The goal was for staff to respond to call lights within ten minutes 87% of the time. *All staff were responsible to answer call lights if they could. *She agreed thirty minutes is excessively long for residents to wait for assistance. *They were completing monthly audits on call lights. 8. Review of the providers Call Light Policy updated on 08/24 revealed: *Objective: To respond to patient/resident's requests and needs on a timely basis. *Call light scores are calculated monthly. Goal to answer call lights is within 10 minutes 87% of the time. *If call light is defective, report immediately to maintenance.

Based on record review, interview, and policy review the provider failed to review with the resident, their representative, or their responsible family member and provide a written summary of the baseline care plan for five of eighteen sampled residents (2, 26, 68, 69, and 71) within 48 hours of their admission. Findings include: 1. Review of resident 26's electronic medical record (EMR) revealed: *She had been admitted on [DATE]. *Her diagnoses included acute ischemic left MCA (middle cerebral artery) stroke, with right hemiplegia (paralysis or weakness on one side of the body), aphasia (a communication disorder, dysphagia (difficulty swallowing), depression, anxiety, malnutrition, weakness, and a history of GI (gastrointestinal) bleed. *Her Brief Interview for Mental Status (BIMS) assessment score was 4, which indicated she was severely cognitively impaired. *A care plan intervention of I have difficulty expressing my needs so please anticipate my needs; I usually do not volunteer my needs. *A progress note (PN) on 7/30/24 Baseline CC [care conference] held in resident[s] room with nursing and resident. Resident was able to verbalize fine when asked how she was Current medications and POC [plan of care] reviewed and [a] copy was provided for family and resident on [the] nightstand -That was completed on the fourth day of her stay. *The provider's Plan of Care Participation Agreement was signed unable to sign on 7/30/24. 2. Review of resident 71's electronic medical record (EMR) revealed: *She had been admitted on [DATE]. *Her diagnoses included failure to thrive, urinary tract infection with sepsis, pain, compression fracture, and a head injury. *Her Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated she was cognitively intact. *A PN on 9/16/24 Baseline CC held in resident[s] room with resident, nursing, and ss [social services]. [C]urrent medications and POC reviewed and [a] copy [was provided] to [the] resident . -That was completed on the twenty-fifth day of her stay. *The provider's Plan of Care Participation Agreement was signed on 9/16/24. *A copy of her care plan was requested but the provider was unable to provide a printed copy as the resident had been discharged . 50916 3. Review of resident 68's EMR revealed: *He had been admitted on [DATE]. *He was admitted from home due to a fall. *He was diagnosed with right and left pelvic fractures, weakness, falls, Leukocytosis (high white blood cell count), diabetes mellitus, pulmonary hypertension, and chronic obstructive lung disease. *His Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated he was cognitively intact. *His baseline care plan was signed as completed on 11/11/24. 43021 4. Review of resident 2's EMR revealed: *She had been admitted on [DATE]. *Her diagnoses included congestive heart failure, pneumonia, coronary artery disease, hypertension, diabetes mellitus, and osteoarthritis. *Her BIMS assessment score was 15 which indicated she was cognitively intact. *Her baseline care plan had been completed on 10/13/24. *There was no documentation of her baseline care plan being provided to her or her family. Interview on 12/11/24 at 5:14 p.m. with director of social services (DSS) C revealed there was no documentation that resident 2's baseline care plan was discussed or provided to her. DSS C agreed that the requirement for the baseline care plan to be provided to the resident was not met for this resident. 5. Review of resident 69's EMR revealed: *She had been admitted on [DATE]. *Her diagnoses included hypertension, fibromyalgia, anxiety, and osteoarthritis. *Her BIMS assessment score was 15 which indicated she was cognitively intact. *Her baseline care plan had been completed on 11/14/24. *A social services progress note on 11/18/24 that was signed by DSS C indicated her baseline care conference was held with the resident. *A care plan participation form was signed by resident 69 and DSS C on 11/18/24. Interview on 12/11/24 at 5:14 p.m. with DSS C regarding resident 69's baseline care plan revealed: *Resident 69's baseline care plan was discussed and provided to the resident on 11/18/24. *DSS C agreed the requirement for the baseline care plan to be provided to the resident was not met for this resident. 6. Interview on 12/11/24 at 5:55 p.m. with administrator A and director of nursing (DON) B regarding the requirements for baseline careplans revealed: *The provider used their EMR's comprehensive care plan as their baseline care plan and built upon that care plan to complete the resident's comprehensive care plan. *They agreed they had not provided all of the residents and/or family with the summary of the baseline care plan within 48 hours of admission and that there were residents that had Plan of Care Participation Agreements signed by residents after the second day of admission. *They stated the regulation was not clear on when that baseline summary needed to be provided to the resident and family. Interview on 12/12/24 at 12:45 p.m. with DSS C revealed she would wait three to four days after the resident's admission before giving a copy of the baseline care plan to the resident or their family as a means to check with the resident and family to see how things were going. 7. Review of the provider's 6/5/23 LTC (Long Term Care) Baseline/Comprehensive Care Plans policy revealed: *A baseline care plan will be developed within 48 hours of a resident's admission: -To promote continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission; . -To ensure the resident and representative, if applicable are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan.

Based on Observation, interview, record review, and policy review, the provider failed to correctly administer medication for one of one sampled resident (8) by registered nurse (RN) (E) who did not verify resident had a self-administration medication order for her nebulizer treatment. Findings include: 1. Observation on 12/11/24 at 11:23 a.m. with RN E while administering medications to resident 8 revealed: *She had set up the albuterol/ipratropium (medication for breathing problems) 3 ML(milliliters) nebulizer (neb) treatment and handed the neb tube to resident 8. *She paused the treatment because resident 8 was talking on the phone. *Once the resident was done with her phone call, RN E started the treatment and left the room. *RN E did not monitor resident 8 while she self-administered her neb treatment. 2. Observation and interview immediately following the above observation with RN E regarding self-administration medication orders revealed: *If a resident had a self-administration medication order, it would appear as an intervention on their charting for the nursing staff to check off on. *She verified resident 8 did not have a self-administration medication order on her electronic medical record (EMR). *She verified resident 8 did not have a self-administration medication evaluation completed on her EMR. *A self-administration medication evaluation was to be completed first on a resident then a self-administration medication order was to be obtained. *She agreed resident 8 should not have been left unsupervised while she received her neb treatment. 3. Review of resident 8 EMR revealed: *She was admitted on [DATE]. *Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should), and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). *She had an order for albuterol/ipratropium 3 ML neb to be taken four times a day. *Her Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated cognitively intact. *A self-administration of medication intervention was entered into the care plan on 12/11/24 at 12:17 p.m. 4. Interview on 12/12/24 at 8:51 a.m. with director of nursing B revealed: *Residents can only self-administer their own medications if they have a self-administration medication order. *If residents do not have a self-administration medication order, then they must be supervised while medications are given. *She agreed RN E should have waited and monitored the neb treatment for resident 8. 5. Interview on 12/12/24 at 9:29 a.m. with resident 8 revealed the staff would set up her neb treatments and then leave the room while she administered the neb treatments. 6. Review of the provider's updated 9/6/23 Self-Administration-of-Medications -System Standard Policy revealed: * .the interdisciplinary team (IDT) will assess the resident to determine if the practice of self-administration of medications is clinically appropriate, safe, and feasible. *A resident may only self-administer medications after the IDT has determined which medications may be safely self-administered. *C. Determination of the residents' ability to self-administer medication by the IDT will be documented in the resident's medical record and on the care plan. The documentation will also include the participation of the resident and resident representative, if applicable, in the assessment and care plan process. *E. A physician's order will be obtained and recorded in the chart. *G. Nurse or medication aide to check with resident each shift for appropriate medication administration.

Based on observation, interview, menu review, and policy review, the provider failed to follow written menus and serve adequate portion sizes that would have had the potential to effect all residents who dined in the main dining room for one of one meal observed. Findings include: 1. Observation and interview on 8/17/23 at 11:56 a.m. with cook E during the lunch service in the main dining room revealed: *The regular diet lunch menu consisted of a hotdog on a bun, 1/2 cup of steak fries, 1/2 cup of coleslaw, and 1/2 cup of mandarin oranges. -The alternative menu included 3 ounces of rancher's chicken, 1/2 cup of mashed potatoes with gravy, and 1/2 cup of broccoli. *The following scoops were used for the following foods: -A green handled scoop for the coleslaw and mashed potatoes. -A blue handled scoop for the minced broccoli. *There was a chart on a door in the serving area that showed the serving sizes according to the color of the handle. -The blue scoops were 1/4 cup. -The green scoops were 1/3 cup. Continued interview on 8/17/23 at 2:26 p.m. with cook E about menu serving sizes revealed she: *Thought the green handled scoops were a 1/2 cup. *Had been trained to use the green scoops for the vegetables, and the blue scoops for the minced vegetables. *Agreed she should have double-checked the menu to use the correct sized scoops. Interview on 8/17/23 at 2:33 p.m. with certified dietary manager D about the above observations revealed: *She expected staff to review the menu for serving sizes to correctly set up their serving station. *Laminated menus were available in both dining rooms for staff to have utilized. *Cook E should have used the gray 1/2 cup scoops for the coleslaw, broccoli, and the mashed potatoes rather than the green 1/3 cup and blue 1/4 cup scoops. *She confirmed the residents received a smaller amount of food than what was posted on the menu.

Based on observation, interview, and policy review, the provider failed to minimize potential cross-contamination by improperly sanitizing the food thermometer in between checking temperatures of different food items during one of one meal service observation. Findings include: 1. Observation on 8/17/23 at 11:24 a.m. of cook E temping the food for lunch revealed she: *Removed the thermometer probe from its sheath and pierced several hot dogs with the probe. She had not sanitized the probe prior to checking the temperature of the hot dogs. *After removing the probe from the hotdogs, she used a new alcohol-based thermometer probe wipe to sanitize the probe. -She used that same wipe after temping each of the food items that were going to have been served. -She temped the hotdogs, then the rancher's chicken, then the ground meats, then the steak fries, then the mashed potatoes, and then the gravy. *She used a new alcohol-based thermometer probe wipe before placing the probe back in its sheath. Interview on 8/17/23 at 11:35 a.m. with certified dietary manager (CDM) D about the above observation revealed: *She expected staff to sanitize the thermometer probe before placing it into the first food. *She expected the dietary staff to use two separate thermometer probe wipes in between each food item that was being temped; the first wipe to clean the physical food off the probe, then the second wipe to sanitize the probe. *She stated that cook E should have at least used a new thermometer probe wipe in between each food item. Interview on 8/17/23 at 11:56 a.m. with cook E revealed: *She had spoken with CDM D about the above observation and brought forward that she should not have used the same thermometer probe wipe throughout temping the different foods. *She now knows to use a new wipe in between temping different foods. Review of the provider's March 2023 Sanitation in Holding and Serving Food policy revealed: *A. Employees shall use properly cleaned and sanitized utensils. Review of the provider's undated Directions for using digital thermometer revealed: *Press button to turn on---thermometer will shut off automatically after 50 min [minutes] *Sanitize stem *Insert stem at least 2 inches into the thickest part of the product *Do not let the stem touch bottom of the pan *Record temp *Before temping next item, clean and sanitize stem *Sanitize stem before returning thermometer to holder Review of the alcohol-based thermometer probe wipe packaging revealed there was a statement of Single use.

Based on observation, interview, and policy review, the provider failed to ensure: *Four of four certified nursing assistants (CNA)(A, B, C, and D) performed hand hygiene and glove use per their policy for four of four observed residents (16, 27, 48, and 53). *One of one CNA (B) performed cleaning and/or disinfection of resident care equipment including equipment shared among residents. *Two of two observed residents' (13 and 36) nasal cannulas were not on the floor. Findings include: 1. Observation on 1/6/20 at 3:15 p.m. with CNAs A and B during personal care for resident 48 revealed: *Both CNAs: -Performed hand hygiene and put on gloves. *CNA A had: -Assisted the resident to stand using a standing lift. *CNA B had: -Removed the resident's soiled brief and put it in the garbage. -Performed perineal care. -Obtained personal wipes and cleaned bowel movement (BM) off the resident's bottom. -Put a new brief on the resident and pulled up the resident's pants up with her soiled gloves. -Removed her gloves and did not perform hand hygiene. *Without doing hand hygiene she had: -Removed the resident's sling -Applied heel protectors to her feet. -Brushed her hair. *CNA A had: -managed the stand lift controls. -removed the lift from the resident's room. -removed her gloves, and performed hygiene. Interview on 1/8/20 at 9:55 a.m. with CNA B regarding the above observation of personal care with resident 48 revealed: *She agreed that after perineal care was performed she should have taken off her soiled gloves and done hand hygiene before putting on the resident's clean brief and clothes. *She should have done hand hygiene every time she took off her gloves. 2. Observation on 1/8/20 at 7:48 a.m. with CNA C during personal care for resident 27 revealed the CNA: *Performed hand hygiene and put on gloves. *Assisted the resident to the bathroom. *Pulled down the resident's pants and soiled brief. -Removed the soiled brief and put it in the garbage. -Removed her gloves. *Without performing hand hygiene she had: -Got a new brief from the resident's dresser and hung it over the walker. -Made the bed and left the room. *Went to the clean linen closet and got a clean top sheet. -Returned to the resident's room and continued making the bed. Interview on 1/8/20 at 9:59 a.m. with CNA C concerning personal care with resident 27 revealed: *She agreed hand hygiene should have been done: -After removing gloves. -After leaving a resident's room when personal care had been done. -Before going to a clean linen closet when she had just been in a resident's room doing care. 3a. Observation on 1/8/20 at 8:15 a.m. with CNA D during personal care for resident 16 revealed: *The CNA had knocked on the resident's door, and went into the residents room and without any hand hygiene put on gloves. *With those gloves on she: -Assisted the resident with putting on socks. -Assisted the resident to sit up in bed. -Put a gait belt on the resident. -Walked with the resident to the bathroom. -Pulled down the resident's soiled pull-up and assisted her to sit on the toilet. -Removed the soiled pull-up and put it in the garbage. *With those soiled gloves she: -Got a new pull-up and pad from the dresser. -Put the pull-up on her and pulled it up to the resident's knees. *The resident continues to sit on the toilet while the CNA: -Put pants on and pulled them to resident's knees. -Put shoes, and a brace on her. -Turned on the water, wet a washcloth, and applied soap, and gave it to the resident to wash her face. *CNA removed those soiled gloves and without doing hand hygiene she put on new gloves and continued to assist the resident with cleaning and dressing while she was sitting on the toilet. *CNA D removed her gloves, performed hand hygiene, and left the room to allow the resident to finish going to the bathroom. 3b. Observation on 1/8/20 at 8:27 a.m. with CNA C during personal care for resident 16 revealed: *The CNA entered the resident's room, performed hand hygiene, and put on gloves. *With those same gloves she: -Assisted the resident to stand up from sitting on the toilet. -Went to the sink, got a washcloth, turned on the water and wet the washcloth. -Returned to the resident and washed the resident by reaching through her legs to the front of her, sliding the washcloth from the front to the back. -Did that same technique five to six times without changing the washcloth. --The front area of the resident would have been contaminated by the back area. -Went to the sink, got a dry towel, and then dried the resident. *With those same soiled gloves on the CNA: -Assisted the resident to stand up from sitting on the toilet. -Pulled up the resident's clean pull-up and pants. -Walked with her to her wheelchair. -Assisted her to sit down, and removed the gait belt. *She removed her gloves and without doing hand hygiene she: -Assisted her to the sink and brushed her hair. -Picked up lipstick, removed the cap, and applied it on the resident's lips. 4. Observation on 1/8/20 at 8:40 a.m. with CNA C and CNA D during the transfer of resident 53 with a full body lift: *Both CNAs: -Applied the sling around the resident while readjusting and touching the resident. -Hooked up the sling to the full body lift and transferred the resident to the bed. -Touched the resident, the bed covers, and the lift with their hands. *CNA D: -Without doing hand hygiene put on gloves. -Opened the resident's brief and checked the resident for incontinence of urine or bowel movement (BM). -Stated, She is dry. -Removed her gloves and washed her hands: --Turned on the water, wet her hands, and applied soap to her hands. --Rubbed her hands under the running water, rinsed off the soap while she rubbed for five to six seconds. --Dried her hands with a paper towel, and turned off the water with a dry paper towel. *CNA C: -Performed hand hygiene. -Then pushed the full body lift into resident 67's room and left it there. -She did not clean the lift when she took it from resident 53's room. *Later that day at 10:52 a. m. the lift was pushed up to resident 67s bed and touching it. Interview on 1/8/20 at 10:09 a.m. with CNA's C and D confirmed there were missed opportunities for hand hygiene while doing personal care with above observation of resident 53. *CNA C was not sure about cleaning the lifts between residents. She said someone comes in and disinfects them at another time. 5. Interview on 1/8/20 at 5:43 p.m. with assistant director of nursing (ADON), director of nursing (DON), and the administrator about the above observations with those residents' personal care confirmed: *There were missed opportunities for hand hygiene. *Hand hygiene should have been done before putting on gloves and after removing gloves. *Soiled gloves should have been removed and hand hygiene done before dressing a resident. *When washing a resident's perineal area a different part of the washcloth should have been used with each wipe. *Cleaning and disinfecting of shared equipment should have been performed between resident use. *The ADON said she had done some audits in areas but had not documented anything. Review of the provider's (MONTH) 2020 Hand Hygiene and Other Infection Prevention Practices policy revealed: *C. Handwashing with soap and water and/or with alcohol based handwash agents is to be done: - 1. For the patients and residents protection: --Before applying gloves. --After contact with patient or resident's intact skin when taking a pulse or blood pressure, lifting a patient or resident, etc. --When moving from contact with contaminated body site to a clean body site. -2. For the employee's protection. --After removing gloves. *D. Handwashing Procedure: -1. Turn on water to comfortable temperature. -2. Wet hands up to wrists. -3. Apply soap. Work into a lather, wash all surfaces of the hands, finger, and nails for at least fifteen seconds. -4. Rinse well, keeping hands pointed down . -5. Dry hand well with paper towels. -6. Use a paper towel to turn off the faucet. -7. Dispose of paper towels properly. *F. Other Aspects of hand hygiene. -5. Change gloves during patient care if moving from contaminated body site to a clean body site. *H. Any electronic equipment or paper documents used in direct patient care areas in the hospital and long term care areas are frequently found to be contaminated with pathogenic organisms. -2. They are to be cleaned daily, whenever visibly soiled and if in direct contact with patients or contaminated surfaces. Review of provider's (MONTH) 2020 Disinfection of Non-Critical Patient Care Equipment policy revealed: *Non-Critical items were those that came into contact with intact skin but not mucous membranes. *Noncritical resident care items were to be cleaned between/after each resident use. *All reusable resident care equipment removed from a resident room/procedure room was disinfected before use on another resident. 6a. Observations of resident 36's room on 1/6/20 at 2:44 p.m., on 1/7/20 at 10:04 a.m., and on 1/8/20 at 8:06 a.m. revealed: *Her oxygen concentrator was turned off and located next to her recliner. -The tubing and nasal canula were lying directly on the floor. b. Observations of resident 13's room on 1/6/20 at 3:06 p.m. and on 1/7/20 at 10:19 a.m. revealed: *Her oxygen concentrator was turned off and located next to her bed. -The tubing and nasal canula were lying directly on the floor. c. Interview on 1/08/20 at 5:48 p.m. with the ADON, the DON, and the administrator revealed: *They were unaware the oxygen tubing in resident 36 and 13's rooms were located directly on the floor. *They would expect the staff to follow infection control practices and ensure the tubing was placed in a bag off the floor when not in use. Review of the revised (MONTH) 2019 Care/Cleaning of O2 Concentrators policy revealed: Purpose: To maintain clean O2 concentrators/tubing to control source of infections. *Use standard precautions. -The policy did not address how the oxygen tubing was to be stored when not in use.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two randomly observed residents' (60 and 230) controlled narcotic medications had not been taped back into the medication blister packs. Findings include: 1. Observation and interview on 11/15/18 at 1:26 p.m. with registered nurse (RN) A revealed: *She was standing by the mediation cart taping a medication back into the blister pack. *It was a narcotic resident 230 had refused. *He could take [MEDICATION NAME] 4 milligrams (mg) every two hours as needed. *Resident 230 decided he did not want it, however the nurse had already taken it out of the blister pack. *She stated it was routine to tape a tablet back into the blister pack. Observation and interview on 11/15/18 at 2:40 p.m. with RN B while inspecting the narcotic drawer of the medication cart revealed: *Resident 60's [MEDICATION NAME] had been taped back into the 26th slot. *On 11/11/18 a [MEDICATION NAME] entry had been crossed out on the narcotic sheet with the initials of RN C. *RN B stated if the resident had refused the medication it should have been destroyed by two staff. Review of the provider's (MONTH) (YEAR) Controlled Substance policy revealed: When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container or inventory. It must be destroyed according to the facility policy and documented.

Based on observation, record review, interview, and policy review, the provider failed to ensure two of three sampled residents (4 and 7) with significant weight loss received fortified foods to maintain or prevent further weight loss. Findings include: 1. Observations on 10/2/17 at 5:25 p.m., on 10/3/17 at 11:30 a.m., and on 10/4/17 at 7:40 a.m. of resident 7 revealed: *She did not receive foods from the fortified food list on her diet card for any of the three meals observed. *Once the resident received her meal the menu card was discarded in the trash. Review of resident 7's complete medical record revealed: *She had been admitted on [DATE] from the hospital following a left ankle fracture. *The quarterly Minimum Data Set assessment on 8/9/17 revealed a Brief Interview for Mental Status score of twelve indicating she was cognitively intact. *She was non-ambulatory and wore a cam boot on the left lower extremity. Review of the 5/1/17 through 9/26/17 nutritional information notes completed by the registered dietician (RD) revealed: *On 5/17/17 an admission assessment for resident 7 revealed: -An admit weight on 5/11/17 of 158 pounds (lb). -Her weight on 5/16/17 was 153 lb. -She had recommended the resident continue the current meal plan and would be monitored per nutrition protocol. -Goal weight 153# + (plus)/- (minus) 5#, prevent skin breakdown, encourage > (greater than) 75% oral intakes. *On 8/1/17 she was reviewed for significant weight change/loss: -A weight loss of 11 lb in the last ninety days. -Weight history per EMR (electronic medical record): --7/27/17: 141 lb. --5/16/17: 153 lb. --5/11/17: 158 lb -admit weight. -She had recommended to continue the current meal plan, begin fortified foods, and to update her goal weight. -A nutrition goal was set to prevent further weight loss, prevent skin breakdown, and encourage oral inake of greater than 75%. *On 9/6/17 a thirty day assessment was completed for significant weight change, she: -Had a current weight of 148 lb. -Thirty day weight was 140 lb. -Had a 6% weight loss in the last sixty days. -She had recommended the resident continue her current meal plan and fortified foods. She would continue to monitor her per nutrition protocol and as needed. -Had a nutrition goal to prevent further weight loss, prevent skin breakdown, and encourage greater than 75% of oral intakes. *On 9/26/17 she reported: -Resident had a current weight of 143 lb. -RD visited with res(resident) this morning. Res reported to RD that her appetite is good with no changes. Res reports she does not snack throughout the day due to not being hungry. RD discussed res weight loss with res and res was unsure as to why. RD asked res about supplement and res refused. RD explained if weight continues to decline will need to look into something and res reported understanding. -She recommended to continue with the current meal plan and fortified food. The resident would continue to be monitored per nutrition protocol and as needed. -The goal was to prevent further weight loss, prevent skin breakdown, and encourage greater than 75% of oral intakes. *The RD's documentation did not address: -A plan to improve the resident's weight. -The individual likes or dislikes of the resident. -If the primary physician had been notified of the weight loss or any other physician involvement. -Specific education provided to the resident to ensure the resident understood what fortified food options were. -How the RD was made aware if the resident was consuming greater than 75% of oral intake. -How the RD was made aware if the resident was receiving fortified foods. Review of resident 7's care plan initiated on 5/10/17 and last reviewed on 9/23/17 revealed: *Problem: Nutritional Status. *Goals: Nutritional Status - Maintain Goal: prevent further wt loss. *Interventions: Fortified foods *It did not address: -Their individual plan for ensurring she received the fortified foods. Review of resident 7's undated diet card revealed she was to receive a heart healthy cardiac diet with fortified foods. The likes and dislikes area of card was left blank. Interview on 10/3/17 at 2:40 p.m. with the certified dietary manager (CDM) revealed: *Dietary did not complete intakes for residents with significant weight loss. *Intakes were only done for the first five days of admission, if the resident was placed on supplements, or was at high risk. *Resident 7 was not flagged as high risk. Observation on 10/4/17 at 7:45 a.m. revealed dietary aide C assisted resident 7 with breakfast choices and submitted the menu to the cook. The resident chose cold cereal (cheerios), orange juice, half a banana, a piece of toast, and peanut butter. *At 7:55 the dietary aide prepared cold cereal at the food counter with 2% milk. -Resident consumed 100% of the food and drink. *She did not pour half and half on the cereal as was stated in her interview. 2. Observation on 10/2/17 at 5:35 p.m., on 10/3/17 at 11:40 a.m., and on 10/4/17 at 7:45 a.m. of resident 4's meal times revealed: *He received cold cereal for breakfast on 10/4/17 prepared with 2% milk. *He did not receive fortified foods for any of the three meals observed. *Once he was served his meal the menu card was discarded in the trash. *He ate 100% of his observed meals. Review of resident 4's complete medical record revealed: *The 9/12/17 care plan showed the need for fortified foods. *Minimum Data Assessment on 6/17/17 indicated the resident's weight 178 lb. *Minimum Data Assessment on 9/5/17 indicated the resident's weight 170 lb. *His undated diet card indicated he was on fortified foods. -Disliked oatmeal. -It did not indicate what to offer for fortified foods. Observation on 10/4/17 at 7:55 a.m. revealed dietary aide C prepared resident 4's breakfast tray with cold cereal and 2% milk, two packets of Sweet and Lo, half a banana, scrambled eggs, one slice of wheat toast with peanut butter and jelly, and cranberry juice. *She did not pour half and half on the cereal as was stated in her interview. -Resident consumed 100% of the food and drink. 3. Interview on 10/3/17 at 2:40 p.m. with licensed practical nurse (LPN) A revealed: *She was unaware of the above resident's diet order or if those residents were on fortified foods, and she would have to check the residents' charts. *All residents were offered snacks and given choices. *If a resident triggered for weight loss they were discussed in the At Risk meetings. *Weight loss was guided by dietary and the dietitian for weight loss of five pounds or more. *The At Risk team discussed when to involve the physician. Interview on 10/3/17 at 3:30 p.m. with dietary cook B revealed: *Fortified foods were indicated on a diet card for residents. *The meals were based on resident choice, and fortified foods were an option for the resident. *Dietary aides were not taught to encourage fortified food options. *Fortified potatoes were prepared by the cook for lunch and supper every day and available on the steam table. *Oatmeal/hot cereal at breakfast was listed as a fortified food option. *If the resident refused the hot cereal then the dietary aide was encouraged to add half and half to cold cereal. Interview on 10/3/17 at 5:30 p.m. with dietary aide C revealed: *All residents had a choice of what they wanted to eat for all meals. *If the potatoes on the menu were not mashed they did not offer or suggest the fortified food option. *Dietary staff did not document fortified foods, and they only tracked supplements. *There were not many options for fortified foods. *If the resident refused hot cereal at breakfast then we put half and half on their cold cereal as the fortified food option before taking it out to the resident at the table. Interview on 10/4/17 at 10:45 a.m. with the RD, the CDM, and dietary aide C revealed: *The residents that were at risk for weight loss would flag weekly for the RD on a report. *A resident would be at risk due to: -Poor intake. -A loss of greater than 5% in one month, 7.5% in ninety days, or 10% in six months. *When a resident flagged for weight loss the RD would first speak with the resident regarding the weight loss to find out likes and dislikes, and then start on fortified foods. *If weight loss continued the RD would meet with the nursing staff and recommend they obtain a physician order [REDACTED].>*Intakes were only done for residents receiving supplements and for the first five days after admission. *Poor intake and/or resident eating less at meals was verbally communicated by dietary staff. *Resident on fortified foods was still allowed a choice of menu options. -The expectation of the RD and the CDM was the dietary aide would use half and half on the cold cereal and not milk. *The physician was not normally consulted unless done by the nurse. *High risk weight loss/gain residents were to be followed by the RD monthly. *There was no system to track or document meal percentages. *There was no system to track/document if a resident received fortified foods. Interview on 10/4/17 at 1:55 p.m. with the RD regarding clarification of the nutritional information in the Summary and Recommendation portion of the document where she had written Will continue to monitor per nutrition protocol and as needed she stated: *The term nutrition protocol was not specified in the obtained policies. *It was an indication of how often she would meet with the resident whether it be monthly or sooner if needed. *That verbiage should have been added to the policy for clarification. Review of the provider's March 2017 Nutrition Screening and Assessment policy revealed: *II. Procedure: -E. Nutrition Care Plan: the care plan is based on the medical nutrition therapy assessment and the risk factors and nutritional needs identified. --Problems, risk factors or concerns are described along with nutrition interventions and goals for improvements are updated according to the facility's policy, State and Federal guidelines and as needed due to any significant changes such as weight loss, food intake, diet order, etc. --Goals and approaches (interventions) should be individualized and should be coordinated within the interdisciplinary team. -F. The reassessment process is ongoing throughout the resident's stay --1. The following are used to continually screen for nutrition problems: meal intakes, monthly weight lists, communication from Nursing Service indicating a pressure ulcer, communication from speech therapy or occupational therapy, communication from Nutrition Services personnel or communication from family. --2. Documentation shall include the current status and changes in the nutritional status including: ---Resident's acceptance of prescribed diet. ---Resident's food and fluid consumption. ---Significant weight loss or gain. ---Resident's ability to eat independently or what adaptive devices are used to assist with eating. ---Current status and changes in resident's physical or behavioral condition. ---Summary of resident's condition which includes the extent which nutritional goals are achieved. -G. Education: The FSS and/or RD will educate the resident and their family members regarding the prescribed therapeutic/modified diet prior to discharge or if their medical status changes and warrants nutrition education. Education is documented in resident's medical record Review of the provider's March 2017 Fortified Foods policy revealed: *Purpose: To provide a standard procedure for providing residents at increased nutrition risk with nutrient dense foods. *High nutrition risk residents will be evaluated for appropriateness of the fortified food program. *High risk residents may include residents who have significant weight loss, poor food intake, or decline in food intake. *Nutrition Services staff will fortify the foods with the following measures: -Breakfast: 8 oz half & half, 4 oz high vitamin C juice, Fortified Hot Cereal -Lunch: 8 oz milk, Fortified Mashed Potatoes -PM: Protein -Dinner: 8 oz milk, Fortified Mashed Potatoes -HS: Protein *It did not indicate a system to track/document consumption of fortified foods. Review of the provider's March 2017 Nutritional Risk Monitoring policy revealed: *It was a guide to identify residents at increased nutrition risk and the specific interventions utilized. *If resident was at risk the dietitian will document the amount of calories and protein the resident requires. *The resident will be evaluated for fortified foods. Refer to Fortified Foods Policy. *Evaluate based on resident preference for food at snacks/mealtimes for additional calories/protein.

Based on record review, interview, and policy review, the provider failed to: *Follow the plan of care and have appropriate documentation for one of one sampled resident (10) that resulted in a major injury. *Implement or change interventions for one of one sampled resident (6) who had multiple falls that resulted in minor injury. Findings include: Surveyor: 1. Interview on 8/23/16 at 3:45 p.m. with resident 10's family member revealed: *He had transferred from an assisted living to long term care on 3/17/16, because he had dementia and had needed more assistance with activities of daily living. *On 7/9/16 he had fallen, had hit his head, and had fractured his elbow. *She was concerned, because since that fall he had required more care and assistance from staff. Surveyor: Review of resident 10's 7/9/16 initial fall report revealed: *The fall had occurred at 6:40 p.m. *There was an injury, but it was not major. *He had been identified to be at risk for falls. *The trauma event was listed as Resident ambulated with walker to the bathroom. The CNA (certified nursing assistant) assisted him with pulling down his slacks. As the resident went to sit down, he fell over onto the floor. Stated, 'I think I passed out.' Resident was lifted from the floor with a Hoyer and 4 staff. Assisted into the recliner. Ice and pressure applied to his head and nose. *Under range of motion it had new limitation. *He had a new onset of pain. -The pain limited functional activity. *There was a new condition of swelling. *He had hit his head. *Under the section What can be done in the future to prevent another fall it had remain with resident during cares. *There was no other documentation regarding what the limitation in his range of motion was, where the pain was, or where the swelling was. Review of the 7/9/16 internal notification form for resident 10 revealed there was no documentation a thorough investigation had been completed. That form was not a part of the resident's medical record per interview on 8/24/16 at 10:35 a.m. with the assistant director of nursing and the director of nursing. Review of the 7/9/16 initial and final investigation fall report sent to the South Dakota Department of Health regarding resident 10 revealed: *Resident was ambulating with his walker into the bathroom. *The CNA was with him and assisted him to pull his slacks down. *Resident was going to sit down on the toilet, he lost his balance, and fell to the floor. *CNA had just left the room and went back into the bathroom to find the resident on the floor. *The resident stated that he felt like he had passed out. *Resident was seen by eLTC and it was recommened that he go to the emergency room . -That information had not been included in the nurses notes or assessments in his medical record. *At the emergency room , an X-ray of the right elbow was completed and resident has a likely humeral fracture. *He had also bumped his head as he fell forward. *He was admitted to the hospital due to a possible fracture and head injury as resident is on Coumadin and his INR was 3.8. *There had been no documentation of interviews with staff. *The CNA had not been identified. Review of resident 10's medical record revealed: *He had been admitted on [DATE]. *There had been no documentation regarding the new limitation in his range of motion. *There had been no pain assessment completed. Review of the 7/9/16 eLTC report revealed: *The time of service had been 7:00 p.m. *Under comments it was noted: Nurse called to request that patient be transferred via ambulance per family request. Patient fell and has nose bleeding, and face/head bruising in the resident's bathroom. *There had been no mention of pain, the range of motion limitation, or the possibility of a fracture. Review of resident 10's 6/13/16 Minimum Data Set (MDS) assessment revealed he required extensive assistance from one staff person to use the bathroom. Review of resident 10's 6/21/16 MDS note revealed he received extensive assistance of one staff person with bed mobility, transfers, ambulation with walker in his room, dressing, toileting, bathing, locomotion on the unit, and personal hygiene. Review of resident 10's 6/14/16 care plan revealed he required extensive assistance of two staff to go to the bathroom. Interview on 8/24/16 at 10:35 a.m. with the assistant director of nursing and the director of nursing regarding the investigation into the 7/9/16 fall for resident 10 revealed: *The initial and final report sent to the state was the whole investigation. *There had been no other documentation in the medical chart. *There was no documentation of the interviews with staff. *They agreed extensive assistance of one staff person would include helping the resident sit on the toilet. *They were not sure why the CNA had left the room. *They stated sometimes he did not like help but had no documenation to confirm that was why the CNA had left the room. *They had not considered abuse or neglect even though she had not followed his care plan. *They were not sure why the fall report stated the injury was not major. *He had been sent to theER on [DATE] based on the family request and not the nursing assessment per the documentation. *He returned to the facility on [DATE] with a cast and sling applied to his right arm. 2. Review of resident 6's medical record revealed: *He had an admission date of [DATE]. *He had falls on the following days: -1/10/16 with a minor injury. -1/22/16 with a minor injury. -2/6/16 with no injury. -2/7/16 with a minor injury. -6/8/16 with a minor injury. -8/3/16 with a minor injury. *The only intervention listed on the fall follow-up forms was remind to use call light. *Fall risk assessments had been done on 3/14/16 and 6/16/16. *There had been no documentation of investigations into the above mentioned falls. Review of resident 6's 12/15/15, 3/16/16, and 6/13/16 care plans revealed: *He was at high risk for falls. *Encourage/remind to use call light and the one closest to him was the only intervention listed on all three care plans. Interview on 8/24/16 at 10:05 a.m. with the director of nursing, clinical coordinator F, and licensed social worker G revealed: *They were unable to provide interventions that had been attempted prior to or after each fall. *They only completed an internal investigation for falls. Review of the 1/10/16, 1/22/16, 2/6/16, 2/7/16, 6/8/16, and 8/3/16 internal notification forms for resident 6 revealed there was no documenation thorough investigations had been completed. Those forms were not a part of the resident's medical record. 3. Review of the provider's Fall Risk Assessment policy revealed recommendations for changes in resident care should have appropriate documentation completed.

Based on record review, interview, and policy review, the provider failed to obtain treatment orders in a timely manner and implement interventions for one of one sampled resident (7) who developed a pressure ulcer. Findings include: 1. Record review and interview on 8/23/16 at 2:30 p.m. with the director of nursing (DON) and clinical coordinator D regarding resident 7 revealed: *He had developed a stage two pressure ulcer on 5/7/16. -The measurements had been length 0.4 centimeters (cm) x width 1.0 cm with no depth documented. -An opti foam dressing had been applied. *The nurses were required to complete weekly wound measurements. *They would also document in the chart if they looked at it or if a dressing was changed. *On 5/9/16 measurements had been length 1.8 cm x width 1.3 cm x depth 0.1 cm. -The area had been cleaned and Tena barrier cream applied. -It was left open to air. *Interventions listed had included: -A gel cushion in his recliner and a honeycomb cushion in his wheelchair. -A pressure redistribution mattress on his bed. *On 5/10/16 length 1.8 cm x width 1.8 cm with no depth documented. -It had been left open to air. -A barrier cream had been applied. *On 5/11/16 there had been no measurements documented, but it stated it had been left open to air and a barrier cream applied. *On 5/13/16, 5/14/16, 5/15/16, and 5/16/16 there had been no measurements documented, but it stated it had been left open to air and [MEDICATION NAME] applied. *On 5/17/16 length 0.4 cm x width 0.3 cm x depth 0.0 cm. -It had been left open to air and [MEDICATION NAME] applied. -A new intervention had included staff were to assist the resident into his bed and lay him on his side. *On 5/18/16, 5/19/16, 5/20/16, 5/21/16, 5/22/16, and 5/23/16 there had been no measurements documented, but it stated it had been left open to air and [MEDICATION NAME] applied. *On 5/24/16 length 0.1 cm x width 0.1 cm. with no depth documented. -It had been left open to air and a barrier cream had been applied. *On 5/25/16, 5/26/16, 5/27/16, 5/28/16, 5/29/16, 5/30/16, 5/31/16, 6/1/16, 6/2/16, 6/4/16, 6/5/16, and 6/6/16 there had been no measurements documented, but it stated it had been left open to air and [MEDICATION NAME] applied. -There had been no documentation for 6/3/16. *On 6/7/16 it was open, but there had been no measurements. *On 6/8/16 it was intact. *There was no notification to the physician until 5/13/16 after it had gotten bigger. *They had been unsure if they had standing orders for pressure ulcer treatment. Review of the physician's standing orders and interview on 8/24/16 at 8:50 a.m. with registered nurse E (RN) regarding the standing orders for resident 7 revealed there were no standing orders for pressure ulcer treatment. Review of the physician's orders [REDACTED]. They had asked for an order for [REDACTED]. On 6/21/16 they had notified the physician by fax the area on the coccyx was healed. That had been fourteen days after the documentation in the chart stated it had been intact. The notification to the physician and request for treatment had been six days after the pressure ulcer had developed. Review of the provider's July 2015 Notification of Condition Changes policy revealed: *The charge nurse was responsible for notifying the attending physician when a change occurred in the resident's condition. *Those changes would have included significant changes in physical, mental, or psycho-social status as well as any accident that had resulted in injury. *The charge nurse should have documented the notification of the physician in the resident's medical record.

Based on record review, interview, professional standard review, and policy review, the provider failed to appropriately assess, monitor, document, and intervene for one of one resident (15) after an unwitnessed fall until the time of her death. Findings include: 1. Review of resident 15's medical record revealed: *She had been in the facility since January 2012. *She had [DIAGNOSES REDACTED]. *Her most recent 9/21/15 Brief Interview for Mental Status (BIMS) assessment score was 8. That score reflected moderate mental impairment. *Her 9/21/15 care plan revealed: -She was incontinent of bladder and bowel and had frequent loose stools. She wore disposable briefs. -She was identified as a fall risk related to her [DIAGNOSES REDACTED]. -She used an edge mattress, and her bed was to have been in a low position. -She would attempt to transfer herself at times. -She needed extensive assistance of one staff person. Review of her fall record for 11/18/15 revealed the following documentation by licensed practical nurse (LPN) B: *Her vital signs at the time of that fall were: -Temperature: 95.4 degrees Fahrenheit (F) (normal 97.8 F to 99.1 F). -Heart rate: 148 beats per minute (bpm) (normal 60 to 100 bpm). -Respiratory rate: 26 breathes per minute (normal 12 to 18 per minute) -Blood pressure: 168/135 millimeter of mercury (mm/hg) (normal 90/60 mm/hg to 120/80 mm/hg). *Narrative nurses notes reflected: -The resident was found lying on her floor positioned between her bed and the recliner. -Had a loose BM and was vomiting. -She was assisted back to bed with the assistance of 3 staff and the Hoyer mechanical lift was used. She continued to have a small emesis. -Vital signs and neurological checks were started as resident could not state if she had hit her head. -She kept asking for staff to help her. Her respiratory rate was again acknowledged as fast and oxygen saturation was 94%. *She was noted to be confused at the time of the fall. Continued review of resident 15's medical record revealed: At 10:30 p.m. per the Neuro Checks Post Injury: *She was alert and agitated. *Her Glasgow Coma Scale score was 14 (normal is 16). *She had confused conversation. *Her pupils were both non-reactive, 4 mm in size and round. *Vital signs: -Temperature: 97.4 F. -Heart rate: 136 bpm. -Respiratory rate: 26 breaths per minute. -Blood pressure: 171/95 mm/hg. -Oxygen saturation: 93% *LPN B noted Presenting with lung sounds rales bil. all lobes. At 11:00 p.m.: *She was alert and awake. *She Glascow Coma Scale score was 14. *she had confused conversation. *Her pupils were noted as: -Right pupil was non-reactive, 4 mm in size and round. -Left pupil was non-reactive, 3 mm in size and round. *Vital signs: -Temperature: 96.5 F. -Heart rate: 26 bpm. -Blood pressure: 171/95 mm/hg. -Oxygen saturation: 88% and LPN B had Turned up the oxygen level to help with Sats. At 11:30 p.m.: *Vital signs: -Temperature: 97.4 F. -Heart rate: 128 bpm. -Blood pressure: 154/78 mm/hg. -Oxygen saturation: 81% and LPN B had Turned O2 up to 3 to help Sats up to 88 on 3 L(liters). Lung sounds continued to be rales bilaterally. At 2:00 a.m. on 11/19/15 LPN B documented an IV assessment (assessment of IV access site). At 3:00 a.m. on 11/19/15 per Provider/Family Notification LPN B contacted eLTC per phone and Talked to ___ (name) about resident and my concern of aspiration, went over her meds and what I am doing. He stated to just cont to monitor resident at this time. *There was no clarification of identity or credentials of the individual at eLTC. *There was no further documentation to show what information was made available to the above unidentified individual. At 3:30 a.m.: *Resident 15 was lethargic and drowsy. *Her Glasgow Coma Scale score had decreased to 10. *Her pupils were noted as: -Right pupil was non-reactive, 3 mm in size and round. -Left pupil was non-reactive, 3 mm in size and round. *Vital signs: -Temperature: 97.4 F. -Heart rate: 123 bpm. -Respiratory rate: 24 breaths per minute. Oxygen saturation was 81%. -Blood pressure: 141/86 mm/hg. At 3:39 a.m. per a narrative note LPN B revealed: *Resident 15 fell at 2200 on 11/18 vitals are in fall and vitals but lung sounds have been rales bil, with O2 Sats dropping. *Questioning possible aspiration as resident did have an emesis while on the floor and while we were getting her up. *Did a prn (as needed) [MEDICATION NAME] treatment that did help. O2 Sats cont to be at 81% so I called ELTC and went thru what happened, her meds, and what I had been doing. *___ (name) stated to cont to monitor. *Resident 15 continued to have low Sat and O2 is on 4L. *The following addendum to the above note was added on 11/19/15 at 11:39 p.m. by LPN B. -Resident had c/o nausea after supper while getting ready for bed but had no emesis at that time. Had stated she was feeling better when I checked on her at 2000 (10:00 p.m.). At 4:20 a.m. per Provider/Family Notification LPN B revealed a family member was contacted at that time and Notified daughter of resident's death. At 5:20 a.m. per narrative note LPN B revealed: *Resident found with no pulse and no respirations at 0415 (4:15 a.m.). CNAs prepared her for the family and funeral home while I called the family and Dr. --- (name). *Family arrived at 0515. Resident's glasses will be sent with her to the funeral home. *The following addendum to the above note was added on 11/19/15 at 11:39 p.m. by LPN B. -Resident did have coffee ground emesis at the time of death and another loose stool which was also coffee ground in appearance. *There was no further documentation LPN B had intervened in any other way than the call placed to the unidentified eLTC individual at 3:00 a.m. *There was no documentation LPN B had conferred with or involved the RN on duty in the facility about the care needs of resident 15. Review of the staffing schedule for the night of 11/18/15 revealed: *LPN B was on duty on the Vasek and Brooke halls. -She was unavailable for interview at the time of the survey due to leave status. *An RN was on duty in the other half of the facility on the Harmony and Rehab halls. Interview and review of resident 15's record, LPN job description, and facility policies on 8/24/16 at 1:00 p.m. with the director of nursing (DON) revealed: *She agreed the LPN job description indicated LPNs were: -Able to assist with an assessment. -Were to identify and communicate information to the health care team. -To adhere to professional practice standards. -To recognize critical physical assessment data, use nursing judgment, and notify the RN and/or physician. *She would have expected LPN B to have documented notification to the RN had she notified her of resident 15's medical status. *She was not aware who the unidentified individual was at eLTC that LPN B had contacted. *She acknowledged they had used eLTC in addition to the local providers and had used the services in the past for urgent care needs. *She was not aware of all of the details of resident 15's fall and care surrounding the event. -Felt they had investigated and fall and event appropriately. *Following review of the record: -She agreed there was not a thorough fall investigation. -She agreed not all of the details in the investigation report were consistent in the nurse notes. -She agreed there was a lack of documentation in the resident record to support appropriate monitoring and care interventions had occurred. *Review of the following provider policies reflected: -She agreed LPN B had not followed the intent of the Notification of Condition Changes July 2015 and Emergency Physician Care July 2007 policies. LPN B had not notified the attending physician or the physician on call for him, nor involved the RN on duty. -She agreed in completing the investigation they had not followed the intent of the Abuse Prevention July 2015 policy that included, . Neglect was defined as A failure, through inattentiveness, carelessness, seclusion, or omission, without a reasonable justification, to provide timely, consistent and safe services, treatment and care to a resident. and .When all sources of information have been exhausted and a conclusion has been reached, complete a final report that includes what measures will be taken to prevent reoccurrences of the same or similar event. Review of the current Administrative Rules of South Dakota 20:40:04:01 Scope and standards of nursing practice acknowledged on 08/24/16 at 2:00 p.m. with the administrator as what the provider utilized as their standard of practice policy revealed: *The LPN shall: -Contribute to the nursing assessment. -Participate in care planning and nursing interventions. -Contribute to nursing interventions. *They may practice as follows: -With at least minimal supervision when providing supervision in a stable nursing situation. -With direct supervision when providing supervision when providing care in a complex nursing situation. *Consult with an RN or other health team members and seek guidance as necessary and shall obtain instruction and supervision as necessary. Review of Patricia A. Potter et al., Fundamentals of Nursing, 8th Ed., St Louis, MO, 2013, page 279, regarding clinical decisions revealed: *Your ability to make clinical decisions depends on application of the nursing process. *When you begin a patient (resident) assessment, the first activity involves a focused but complete assessment of the patient's condition so you are able to make an accurate judgment about his or her nursing [DIAGNOSES REDACTED]. *You develop a plan of care, implement nursing interventions, and evaluate patient outcomes. *The process requires clinical decision making using a critical thinking approach. *If you do not make accurate clinical decisions about a patient, undesirable outcomes will probably occur.

Based on interview and record review, the provider failed to have an effective quality assurance (QA) program in place to identify concerns, develop action plans, and implement appropriate interventions to improve performance measures for their facility. Findings include: 1. Review of the recertification survey on 9/30/15 revealed the following deficiencies had been cited: F281 and F514. During the current survey the following deficiencies had been cited and/or recited (*): F157, F223, F226, F281*, F314, F323, F514* and F520. Review of the provider's 4/1/16 through 6/30/16 quality improvement report revealed they had collected data on falls, medication notification, infections, newly acquired pressure areas, hand washing percentage, call light response, and readmission rate. No action plans or interventions had been documented for those issues. Interview on 8/24/16 at 1:35 p.m. with the assistant director of nursing revealed the quality improvement committee met quarterly and reviewed the data mentioned above. They had a separate committee that met two times per month that had addressed falls. The medical director was not part of the separate committee meetings. She could not identify any other areas of concern the quality improvement committee had addressed and created an action plan for.

Based on record review, interview, and policy review, the provider failed to ensure complete and accurate medical information was documented in the medical records regarding care for 4 of 15 sampled residents (6, 7, 10, and 15). Findings include: 1. Review of resident 6's medical record revealed there was a lack of documentation for several falls. Refer to F323, finding 2. 2. Review of resident 7's medical record revealed there was lack of documentation regarding a pressure ulcer that had developed. Refer to F314, finding 1. There was lack of documentation in his medical record regarding investigations into his falls. Refer to F226, finding 3. 3. Review of resident 10's medical record revealed there was lack of documentation in the medical chart regarding a fall that had resulted in a major injury. Refer to F323, finding 1. 4. Review of the medical record for resident 15 revealed there was a lack of documentation related to her fall on [DATE]. The events thereafter leading up until the time of her death on [DATE]. Refer to F223, finding 1. 5. Interview and review of the provider's [DATE] Abuse prevention policy on [DATE] at 1:00 p.m. with the director of nursing (DON) revealed: *Neglect was defined as A failure, through inattentiveness, carelessness, seclusion, or omission, without a reasonable justification, to provide timely, consistent and safe services, treatment and care to a resident. *Under administrative direction, the DON and/or others initiates further investigation of the event. *When all sources of information have been exhausted and a conclusion has been reached, complete a final report that includes what measures will be taken to prevent reoccurrences of the same or similar event. *Physical abuse- Evidence from Care plan/Patient History: prolonged time between illness/injury and medical care. *Physical Neglect-Physical Indicators-General Body Features: Not receiving medical care/untreated medical condition. *Physical Neglect-Untreated Injuries or Medical Conditions: -Vomiting. -Blood in excretion. -Shortness of breath. -Falling. -Prolonged interval between treatment and injury. *She agreed with the above policy and definitions of abuse and neglect. *She agreed the final report of the investigation had not included documentation of all sources of information or measures to prevent reoccurrences. Interview on [DATE] at 2:00 p.m. with the administrator revealed they had no policy regarding documentation. Review of the current Administrative Rules of South Dakota 20:40:04:01 Scope and standards of nursing practice acknowledged on [DATE] at 2:00 p.m. with the administrator as what the provider utilized as their standard of practice policy revealed: *A nurse must exercise professional judgement when a physician transmits orders through a third party, who may or may not be unlicensed, via telephone or otherwise. *If an order is transmitted through third party, all persons, including the thirds party, must be identified by name and title before the order may be implemented. Review of Patricia A. Potter et al., Fundamentals of Nursing, 8th Ed., St Louis, MO, 2013, page 279, regarding clinical decisions, revealed: *Your ability to make clinical decisions depends on application of the nursing process. *When you begin a patient assessment, the first activity involves a focused but complete assessment of the patient's condition so you are able to make an accurate judgement about his or her nursing [DIAGNOSES REDACTED]. *You develop a plan of care, implement nursing interventions, and evaluate patient outcomes. *The process requires clinical decision making using a critical thinking approach. *If you do not make accurate clinical decisions about a patient, undesirable outcomes will probably occur.

A Based on record review, interview, professional standard review, and policy review, the provider failed to ensure one of one licensed practical nurse (LPN) B followed facility policies and practiced within her scope of nursing practice when providing care for one of one resident (15) after a fall and later death. Findings include: 1.Review of resident 15's record revealed: *She had been in the facility since [DATE]. *She had a fall on [DATE] and died [DATE]. Refer to F223. 2. Review of the provider's [DATE] Acute Care Policy revealed: *All residents were to have received timely and accurate assessments and interventions for acute care episodes, and they must have been documented. *All acute care episodes were to have been assessed by the charge nurse. *Shortness of breath assessments were to have included lung sounds each time. *Falls were to have included the assessment for the cause of the fall. Review of the current Administrative Rules of South Dakota 20:40:04:01 Scope and standards of nursing practice acknowledged on [DATE] at 2:00 p.m. with the administrator as what the provider utilized as their standard of practice policy revealed: *The RN shall: -Make nursing assessments regarding the health status of a client. -Implement nursing care. -Evaluate responses to nursing interventions. -Recognize the legal implications of delegation and supervision. -Delegate to another only those interventions which that person is prepared or qualified to perform. -Provide minimal or direct supervision to others whom nursing interventions are delegated. *The LPN shall: -Contribute to the nursing assessment. -Participate in care planning and nursing interventions. -Contribute to nursing interventions. *They may practice as follows: -With at least minimal supervision when providing supervision in a stable nursing situation. -With direct supervision when providing supervision when providing care in a complex nursing situation. *Consult with a RN or other health team members and seek guidance as necessary and shall obtain instruction and supervision as necessary. *A nurse must exercise professional judgement when a physician transmits orders through a third party, who may or may not be unlicensed, via telephone or otherwise. *If an order is transmitted through third party, all persons, including the thirds party, must be identified by name and title before the order may be implemented. Review of Patricia A. Potter et al., Fundamentals of Nursing, 8th Ed., St Louis, MO, 2013, page 279, regarding clinical decisions, revealed: *Your ability to make clinical decisions depends on application of the nursing process. *When you begin a patient assessment, the first activity involves a focused but complete assessment of the patient's condition so you are able to make an accurate judgement about his or her nursing [DIAGNOSES REDACTED]. *You develop a plan of care, implement nursing interventions, and evaluate patient outcomes. *The process requires clinical decision making using a critical thinking approach. *If you do not make accurate clinical decisions about a patient, undesirable outcomes will probably occur. Review of the above reference, pages 488 and 511, regarding physical examinations, revealed: *Physical examinations are conducted: -As part of an initial evaluation in triage for emergency care. -To admit a patient to a hospital. *After considering their current condition, a nurse selects a focused physical exam or area. *Observe the pupils for size, shape equality, accommodation, and reaction to light. They are normally black, round, regular, and equal in size. *Any abnormality along the nerve pathways may have altered the ability of the pupils to have reacted to light. *Changes in intracranial pressure, and trauma may have altered pupillary reaction. Interview on [DATE] at 2:00 p.m. with the administrator revealed they had no policy regarding documentation. B. Based on closed record review the provider failed to ensure there was appropriate conclusionary documentation by the nurse at the time of death and care of or release of the body for two of two residents (14 and 15.) Findings include: 1. Review of the closed medical record for resident 14 revealed: *She died on [DATE] at 2:18 a.m. with her family at the bedside. *Her body was released to the funeral home at 6:15 a.m. *The primary care provider was notified by fax at 6:27 a.m. *No documentation was found that indicated registered nurse (RN) A had notified the physician in a timely manner that respirations and pulse had ceased. *An physician's orders [REDACTED]. Interview on [DATE] at 1:30 p.m. and at 1:45 p.m. with the director of nursing regarding resident 14's death revealed: *It was usual procedure to notify the physician by fax during the night or by a phone call in the morning if a resident had passed away. *She felt RN A followed the procedure during the above resident's death. *When a resident died a death record note was printed from the electronic medical record. -It was signed by the funeral home personnel and the nurse on duty. -A copy of the signed document was kept in the resident's medical record. *There was no order from the physician to release the body to the funeral home. Review of the provider's [DATE] Death Checklist revealed the funeral home was notified and would have picked up the body before the physician was notified. Review of the provider's [DATE] Care of the deceased policy revealed: *Notify the physician and on-call administrator when death occurs. Can call in early AM if death occurs through night. *It did not address notifying the physician to: -Let them know pulse and respirations had ceased, so they could pronounce death. -Obtain an order for [REDACTED]. Surveyor 2. Review of resident 15's closed medical record revealed: *She had died on [DATE] at 4:15 a.m. *The nurse on duty Notified daughter of resident's death at 4:20 a.m. *At 4:25 a.m. the physician was notified of her death. *The funeral home was notified at 5:40 a.m. 3. Interview, record review, and [DATE] Death Checklist policy review on [DATE] at 1:00 p.m. with the director of nursing (DON) revealed she: *Agreed the nurse should not have pronounced death. *That was not within her nursing scope of practice. *Agreed the order of the Death Checklist the nurses were to have followed listed the family was to have been called first. *Agreed step #10 on the Death Checklist, labeled Notify physician needed to be changed to step #1. *With that change the physician would pronounce death and give the order to release the body to the funeral home. Review of Patricia A. Potter et al., Fundamentals of Nursing, 8th Ed., St Louis, MO, 2013, page 724, revealed, documentation of end of life included the name of the health care provider who certified death. Review of South Dakota Codified Law [DATE] and [DATE].1 revealed: *The signing of the death certificate was a medical act by a physician, physician's assistant, or nurse practitioner. *Since the Legislature did not provide that the act was delegable to anyone else the South Dakota Board of Nursing did not believe a licensed nurse could officially pronounce death.

Based on record review, interview, and policy review, the provider failed to thoroughly investigate falls for the potential of abuse and neglect for four of four sampled residents (6, 7, 10, and 15). Findings include: 1. Review of resident 10's medical record revealed he had a fall on 7/9/16 that resulted in a fracture to his right elbow. There was no documentation to support a thorough investigation had been done. Refer to F323, finding 1. 2. Review of resident 6's medical record revealed he had the following falls: *1/10/16 with a minor injury. *1/22/16 with a minor injury. *2/6/16 with no injury. *2/7/16 with a minor injury. *6/8/16 with a minor injury. *8/3/16 with a minor injury. *There was no documentation to support a thorough investigation had been done for each of the above falls. Refer to F323, finding 2. 3. Review of resident 7's medical record revealed he: *Had the following falls: *3/17/16 with a minor injury. *4/8/16 with no injury. *4/11/16 with no injury. *7/19/16 with minor injury. *8/5/16 with no injury. *8/13/16 with no injury. Review of the internal notification forms for resident 7 revealed there was no documentation that a thorough investigation had been completed for each of the above falls. That form was not a part of the resident's medical record. There was no documentation in the chart an investigation for each fall had been conducted. 4. Interview on 8/24/16 at 10:35 a.m. with the assistant director of nursing and the director of nursing regarding the investigation into the falls for the above residents revealed: *The only investigation they had was an internal notification form that went to staff. -That form was not part of the medical record. *There had been no other documentation regarding the investigations in the residents' medical charts. 5. Review of the Review of the Incident/Fall Investigation report for resident 15 regarding her fall on 11/18/15 revealed: *A report filed to the South Dakota Department of Health on behalf of the provider, gave a brief desciption of the events surrounding the incident. *Those details were: -The resident reported nausea after supper. -No emesis at that time. -At 2000 (8:00 p.m.) resident reports feeling better. -Resident noted to fall at 2200 (10:00 p.m.). -When resident was found on the floor, also noted emesis and loose BM on the floor. -She continued to have further emesis after assisted back to bed with a total lift. -Family notified of fall . -No injury noted from fall. -The resident did have her call light within reach but did not use it. -She also had a low bed in place with the bed in the lowest position. -Staff had last been in the room with her 45 min prior to the fall. -Unsure if resident hit her head as she was unable to verbalize so initiated neuro checks which remained unchanged throughout the night. -Checked respiratory status throughout the night-Noted decreased O2 (oxygen) saturations so resident's oxygen increased as needed. -Lung sounds noted to be congested. -PRN (as needed) nebulizer treatment given. -At 0300 (3:00 a.m.) ELTC called and provider (person licensed practical nurse (LPN) B spoke with) was notified of situation and concern for aspiration during emesis. -No new orders recieved and instructed just to monitor. -At 0529 (5:29 a.m.) resident noted to be without respirations/heartbeat. -Noted coffee ground emesis and loose stool of same appearance at time of death. *Details of the above information conflicted with the information located in the resident's chart documented by LPN B. Refer to F223, finding 1. 6. Interview and review of the provider's July 2015 Abuse prevention policy on 8/24/16 at 1:00 p.m. with the DON revealed: *Neglect was defined as A failure, through inattentiveness, carelessness, seclusion, or omission, without a reasonable justification, to provide timely, consistent and safe services, treatment and care to a resident. *Under administrative direction, the DON and/or others initiates further investigation of the event. *When all sources of information have been exhausted and a conclusion has been reached, complete a final report that includes what measures will be taken to prevent reoccurrences of the same or similar event. *Physical abuse- Evidence from Care plan/Patient History: prolonged time between illness/injury and medical care. *Physical Neglect-Physical Indicators-General Body Features: Not receiving medical care/untreated medical condition. *Physical Neglect-Untreated Injuries or Medical Conditions: -Vomiting. -Blood in excretion. -Shortness of breath. -Falling. -Prolonged interval between treatment and injury. *She agreed with the above policy and definitions of abuse and neglect. *She agreed the final report of the investigation had not included documentation of all sources of information or measures to prevent reoccurrences. There was no additional investigative report information that could be provided by the director of nursing (DON) or the assistant DON prior to exit by this surveyor.

Based on record review, interview, and policy review, the provider failed to notify the physician in a timely manner of: *The development of a pressure ulcer for one of one sampled resident (7). *An unwitnessed fall for one of one sampled resident (15) who died . Findings include: 1. Review of resident 7's medical record revealed he had developed a stage two pressure ulcer on [DATE]. The physician had not been notified until [DATE]. Refer to F314, finding 1. 2. Review of resident 15's medical record revealed: *She had fallen on [DATE] at 10:00 p.m. *Her physician or the on-call physician was not notified at the time of her fall. *At 3:00 a.m. on [DATE] per Provider/Family Notification LPN B contacted eLTC per phone and Talked to ___ (name) about resident and my concern of aspiration, went over her meds and what I am doing. He stated to just cont to monitor resident at this time. *There was no clarification of identity or credentials of the individual at eLTC. *Her local physician was not notified until after her death on [DATE] at 4:25 a.m. Refer to F223, finding 1. 3. Review of the provider's [DATE] Acute Care Policy revealed: *All residents were to have received timely and accurate assessments and interventions for acute care episodes, and they must have been documented. *All acute care episodes were to have been assessed by the charge nurse. *Shortness of breath assessments were to have included lung sounds each time. *Falls were to have included the assessment for the cause of the fall.

A. Based on record review, interview, and policy review, the provider failed to ensure physician's orders had been followed for three of six sampled residents (2, 11, and 18) that received sliding scale insulin (injected medication given to lower blood sugar with the dose based on current blood sugar level). Findings include: 1. Review of resident 2's last signed 9/28/15 physicians's orders revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She was on a constant carb (carbohydrate) diet. *She had orders for glucometer (blood sugar checks) testing four times a day with sliding scale insulin. -There was a specific dose to give based on the glucometer results. -There was no order to hold the sliding scale if she did not eat. *She also had orders for two oral medications for her diabetes. Review of resident 2's diabetic flowsheets from March 2015 through September 2015 revealed her sliding scale insulin had been held by the nurse: *In March, four times at 12:00 noon. -On the back of the sheet documentation had included not eating lunch. *In April, four times at 12:00 noon. -On the back was refusing to eat, not eating, resident do not eat, and ref (refused) lunch. *In May, four times at 12:00 noon. -On the back was not eating lunch and not eating. *In June, four times at 12:00 noon. -On the back was ref lunch and ref to eat. *In July, three times at 12:00 noon and one time at 4:00 p.m. -On the back was due to not eating, due to emesis (vomiting), and refused to eat. *In August, one time at 6:00 a.m., ten times at 12:00 noon, and one time at 6:00 p.m. -On the back was refused to eat, ref lunch, due to not eating, refused supper. *In September, ten times at 12:00 noon. -On the back was ate poorly at lunch and ref lunch. Review of resident 2's interdisciplinary notes from March 2015 through September 2015 in the electronic medical record and the paper medical record revealed: *One nursing note on 7/18/15 that stated the noon insulin was held due to the resident refused to come out for dinner and refused to eat. *There were no other notes regarding the insulin being held. *There was no mention the physician had been notified of the insulin that was held by the nurse. Interview on 9/28/15 at 2:45 p.m. with registered nurse (RN) A revealed: *Resident 2 had orders for sliding scale insulin ordered by her physician. *If the nurse held the sliding scale insulin they would have documented on the back of the flow sheet the reason it was held. *The nurse typically gave the insulin after they knew the residents had eaten. *If the resident did not eat they might have held the insulin because of the potential risk of low blood sugar. *The physician would not be updated each time it was held but would have been updated on glucometer test results on rounds. Interview on 9/29/15 at 9:30 a.m. with RN B revealed: *The nurse would have decided if the sliding scale insulin should be held when the resident was not eating. *Sometimes they had a physician's order to hold the insulin if a resident did not eat. *Resident 2 did not have an order to hold her sliding scale insulin if she did not eat. Interview on 9/29/15 at 9:35 a.m. with the director of nursing (DON) revealed: *She was not aware of resident 2 having a history of low blood sugar levels. *Resident 2 refused to eat sometimes. *She felt the nurses used their judgement to decide when to hold sliding scale insulin. *They would not necessarily update the physician every time they held a medication. Further interview on 9/29/15 at 11:55 a.m. with the DON revealed: *Per their pharmacy consultant it was okay to hold sliding scale insulin at the nurse's discretion. *She agreed resident 2 did not have physician's orders to hold her sliding scale insulin if she did not eat. *She was unable to find documentation the physician had been notified regarding the held insulin by nursing. *She agreed the insulin was not given as ordered by the physician. *They had no specific policy about holding medications. Interview on 9/30/15 at 8:20 a.m. with licensed practical nurse (LPN) C regarding resident 2 revealed: *She held the sliding scale insulin per nursing discretion, because she knew the resident did not eat well at times. *The resident had not had a low blood sugar in the past, but she held the insulin to keep that from happening. *She had not updated the physician on holding the resident's insulin in a long time, and she stated she probably should have. *She agreed there was no physician order to hold the insulin when the resident did not eat. Surveyor: 2. Review of resident 11's paper medical record and electronic medical record (EMR) revealed: *A 2/3/11 date of admission. *[DIAGNOSES REDACTED]. *She had orders for glucometer testing twice a day (BID) at 6:00 a.m. and 4:00 p.m. *There were orders to administer sliding scale Novulin insulin depending on her glucometer readings: -Under 60: Supplement (food or drink). -60-140: No insulin. -141-200: 2 units insulin. -201-250: 4 units insulin. -251-300: 6 units insulin. -301-350: 8 units insulin. -Greater than 350: Call doctor. *There was no physician's order to hold the sliding scale insulin. Review of resident 11's March 2015 and June 2015 Medication Administration Record [REDACTED] *3/30/15 at 4:00 p.m., Glucometer reading 170. Sliding scale insulin held due to refusing to eat supper. *6/5/15 at 4:00 p.m., Glucometer reading 198. Sliding scale insulin held as resident didn't eat supper. *6/28/15 at 3:00 p.m., Glucometer reading 143. Held sliding scale insulin. Resident sleepy. *There was no documentation the physician had been informed of the above held insulin. 3. Review of resident 18's paper medical record and EMR record revealed: *A 10/14/14 date of admission. *[DIAGNOSES REDACTED]. *She had orders for glucometer checks three times a day (TID) at 6:00 a.m., 11:00 a.m., and 5:00 p.m. *There were orders to administer the following sliding scale Humalog insulin depending on her glucometer readings: -60 to 150: No insulin. -151-200: 2 units insulin. -201-250: 4 units insulin. -251-300: 6 units insulin. -301-350: 8 units insulin. -Greater than 350: Call doctor. *There were orders to administer Humalog insulin 4 units every morning and 6 units at noon and at suppertime in addition to the sliding scale insulin orders. *There were no physician's orders to hold the sliding scale insulin or scheduled insulin. Review of resident 18's June 2015 through September 2015 MAR indicated [REDACTED] *There was no documentation (blank area on MAR) on 6/7/15 at 6:00 p.m., 6/16/15 at 8:00 a.m., and on 6/29/15 at 8:00 a.m. her scheduled Humalog insulin had been administered. *There was no documentation of glucometer readings on 7/10/15, 7/18/15, and on 7/19/15 at 5:00 p.m. or if sliding scale insulin had been administered. *There was documentation on 7/4/15 at 6:00 a.m. Initial sugar (glucometer reading) was 59. Recheck glucometer 157. No insulin given prior low blood sugar. *There was documentation on 7/19/15 at 6:30 a.m. Blood sugar 171. Aide gave resident snack. Was cold and clammy. There was no documentation the sliding scale insulin was held or administered. *There was documentation on 7/29/15 at 6:00 a.m. Held morning insulin blood sugar was 31 at 2:15 a.m. After snack was up to 171. *There was documentation Humalog insulin 4 units (scheduled dose) was held at 8:00 a.m. There was no documentation why the insulin had been held. *There was documentation on 9/6/15 at 12:00 noon Insulin held related to not eating. 4. Interview on 9/30/15 with RN B regarding residents 11 and 18 revealed: *The nurses held insulin usually if a resident did not eat or ate poorly at meals. *If there was no documentation an insulin had been administered, it was likely the nurse had administered it but had not documented the administration. Surveyor: Review of the provider's June 2015 Non-Controlled Medication Order Documentation policy revealed: *B. Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. *C. The prescriber is contacted by nursing to verify or clarify an order (e.g. (for example), when the resident has allergies [REDACTED]. *D. The prescriber is contacted by nursing for direction when delivery of a medication will be delayed or the medication is not or will not be available. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St Louis, MO, p. 588, for medication administration related to assessing the patient's (resident) current condition revealed: *The ongoing physical or mental status of a patient affects whether a medication is given or how it is administered. Assess a patient carefully before giving any medication. *Notify the patient's health care provider if he or she is unable to take a medication. Assessment findings serve as a baseline in evaluating the effects of medication therapy. B. Based on observation, record review, interview, and drug handbook review, the provider failed to administer insulin according to the manufacturer's recommendations for five of six sampled residents (2, 11, 13, 14, and 18) receiving insulin. Findings include: 1. Review of resident 2's last signed 9/28/15 physician's orders revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She was on a constant carbohydrate (carb) diet. *She had orders for glucometer (blood sugar checking device) tests four times a day with sliding scale [MEDICATION NAME] R (fast acting) insulin. -The sliding scale determined the specific dose to give based on the glucometer results. *She also had orders for two oral medications for her diabetes. Review of resident 2's diabetic flowsheets from March 2015 through September 2015 revealed: *The [MEDICATION NAME] R sliding scale physician's order remained the same. *The time for administration had been 6:00 a.m., 12:00 noon, 4:00 p.m., and 8:00 p.m. Observation and interview on 9/29/15 at 11:35 a.m. with RN B during and following resident 2's glucometer check revealed: *[MEDICATION NAME] R was considered a fast acting insulin. *On the day shift she typically did glucometer checks before lunch and supper, and then gave the insulin after the resident had eaten. *The day nurse started that shift at 7:00 a.m. *The a.m. sliding scale was completed by the night nurse before leaving that shift. *Breakfast was typically around 8:00 a.m. *She was unsure when the night nurse actually would have given the a.m. insulin but agreed it would have been before 7:00 a.m. *She agreed the a.m. insulin would have been administered at least a half hour or more prior to the resident eating breakfast. 2. Review of resident 13's last signed 9/8/15 physician's orders revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She was on a diabetic diet. *She had orders for glucometer testing three times daily with sliding scale [MEDICATION NAME] (rapid acting) insulin. -The specific dose to give was based on the glucometer results. *She also had orders for scheduled [MEDICATION NAME] (long acting) insulin twice a day. Review of resident 13's diabetic flowsheets from March 2015 through September 2015 revealed: *The [MEDICATION NAME]sliding scale physician's order was four times daily from March through 7/24/15. -The time for administration had been 7:00 a.m., 11:00 a.m., 4:00 p.m., and at bedtime. *On 7/25/15 the [MEDICATION NAME] sliding scale changed to three times a day. *The time for administration had been 7:00 a.m., 11:00 a.m., and 4:00 p.m. 3. Review of resident 14's last signed 9/24/15 physician's orders revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He was on a constant carb diet. *He had orders for glucometer testing twice daily with sliding scale [MEDICATION NAME] R (fast acting type) insulin. -The specific dose to give was based on the glucometer results. Review of resident 14's diabetic flowsheets from July 2015 through September 2015 revealed: *The [MEDICATION NAME] R sliding scale was four times daily from 7/7/15 through 7/23/15. -The time for administration had been 6:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. *On 7/23/15 the insulin sliding scale had changed to twice a day and remained the same through September. -The time for administration had been 6:00 a.m. and 5:00 p.m. Surveyor: 4. Review of resident 11's paper medical record and EMR record revealed: *[DIAGNOSES REDACTED]. *She had orders for glucometer testing BID at 6:00 a.m. and 4:00 p.m. *There were orders to administer sliding scale Novulin insulin depending on her glucometer readings: -Under 60: Supplement (food or drink). -60-140: No insulin. -141-200: 2 units insulin. -201-250: 4 units insulin. -251-300: 6 units insulin. -301-350: 8 units insulin. -Greater than 350: Call doctor. Review of resident 11's August 2015 MAR indicated [REDACTED] *8/20/15 at 7:01 a.m. for a glucometer reading of 201. *8/27/15 at 6:17 a.m. for a glucometer reading of 166. 5. Review of resident 18's paper medical record and EMR record revealed: *A 10/14/14 date of admission. *[DIAGNOSES REDACTED]. *She had orders for glucometer checks TID at 6:00 a.m., 11:00 a.m., and 5:00 p.m. *There were orders to administer the following sliding scale Humalog insulin depending on her glucometer readings: -60 to 150: No insulin. -151-200: 2 units insulin. -201-250: 4 units insulin. -251-300: 6 units insulin. -301-350: 8 units insulin. -Greater than 350: Call doctor. Review of resident 18's June 2015 through September 2015 MARs revealed Humalog sliding scale insulin was documented at the following times and for the following test results as administered on: *6/5/15 at 6:00 a.m.: 182. *6/6/15 at 5:17 a.m.: 151. *7/1/15 at 6:00 a.m.: 169. *7/21/15 at 6:00 a.m.: 166. *7/27/15 at 5:06 a.m.: 166. *9/4/15 at 6:36 a.m.: 171. *9/6/15 at 6:14 a.m.: 247. *9/18/15 at 4:20 a.m.: 154. *9/19/15 at 4:39 a.m.: 222. *9/22/15 at 4:58 a.m.: 155. *9/25/15 at 5:05 a.m.: 157. *9/27/15 at 6:40 a.m.: 181. *9/29/15 at 4:34 a.m.: 186. Surveyor: 6. Interview on 9/29/15 at 11:55 a.m. with the DON revealed: *[MEDICATION NAME] R, [MEDICATION NAME] R, Humalog, and [MEDICATION NAME] were considered fast acting insulins. *Per the consultant pharmacist it did not have to be given with food. *She agreed the night nurse would have completed the a.m. glucometer and sliding scale insulin administration prior to leaving that shift. *Breakfast was not until around 8:00 a.m. *She confirmed the night nurse would have given the sliding scale insulin prior to knowing if the resident had eaten breakfast or not. *She agreed the a.m. sliding scale insulin administration was completed differently than the lunch and supper administrations. Interview on 9/30/15 at 8:30 a.m. with LPN C revealed: *She would have done glucometer checks before lunch and supper, and then administered the insulin after the meals when she knew what the resident had eaten. *She was unsure why the a.m. sliding scale insulin was administered differently. *She agreed the night nurse would have completed the a.m. sliding scale insulin prior to the day shift starting at 7:00 a.m. -They would not have known what the resident would have eaten for breakfast, since their shift ended prior to that meal. *[MEDICATION NAME] R was a fast acting insulin and would have been working in an hour or so. -Administering it could have caused a potential low blood sugar for that resident if they had not eaten. Interview on 9/30/15 at 11:25 a.m. with the DON revealed: *She confirmed there were some a.m. glucometer tests documented as being done between 4:00 a.m. and 5:00 a.m. -That was a long time prior to the 6:00 a.m. and 7:00 a.m. scheduled sliding scale time of administration. -She would have expected them to be done within the hour before or after the time scheduled for administration. *She was unable to confirm when the night nurses actually administered a.m. insulin. *She agreed there was a potential to cause a low blood sugar if the resident had not eaten and had been administered fast or rapid acting insulin. *The nursing department would have used their Nursing 2015 Drug Handbook as a reference regarding medication administration. Interview on 9/30/15 at 1:30 p.m. with the consultant pharmacist regarding sliding scale insulin revealed: *She had been consulting for this facility for over ten years. *She felt Humalog or [MEDICATION NAME] should have been administered 15 minutes before or after a meal. *She felt [MEDICATION NAME] or [MEDICATION NAME] R was a little slower acting and could have been given 30 minutes before a meal. *She would have liked insulin given closer to the time residents would have eaten due to the risk of [DIAGNOSES REDACTED]. Review of Wolters et al., Nursing 2015 Drug Handbook, 35th Ed., revealed: *Pages 756 through 759 covered regular (short acting) insulins, including [MEDICATION NAME] and [MEDICATION NAME] R, and [MEDICATION NAME] (rapid acting) insulins, including Humalog. -Indications and dosages for adults and children older than age 3 included to inject subcutaneously (injected under the skin) within 15 minutes before or after a meal. -The onset of action was one-half to one hour for rapid insulins and one to two and one-half hours for intermediate insulins. -The peak action was two to three hours for rapid insulins and four to fifteen hours for intermediate insulins. -Possible adverse reactions included [DIAGNOSES REDACTED] (low blood sugar). -Possible interactions included drug to food. May cause [MEDICAL CONDITION] (high blood sugar) or [DIAGNOSES REDACTED]. Urge caution and monitor patient's diet. *Pages 759 through 762 covered [MEDICATION NAME] (rapid acting) insulin. -Indication and dosages for adults and children age 2 and older included to give 5 to 10 minutes before start of meal by subcutaneous injection in the abdominal wall, thigh, or upper arm. -The onset of action was 15 minutes. -The peak action was one to three hours. -Possible adverse reactions included [DIAGNOSES REDACTED]. -Contraindications and cautions included Use cautiously in patients susceptible to [DIAGNOSES REDACTED] and [DIAGNOSES REDACTED] (low potassium), such as those who have autonomic [MEDICAL CONDITION] (symptoms caused by nerve damage) or are fasting, taking potassium-lowering drugs, or taking drugs sensitive to potassium level. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th ED., St Louis, MO, p. 603, for insulin preparation (administration) revealed: *Insulin is classified by rate of action, including rapid, short, intermediate, and long acting. To provide safe and effective care, you need to know the onset, peak, and duration for each of your patients' ordered insulin doses. Refer to a medication reference or consult with a pharmacist if you are unsure of this information. *Insulin is ordered by a specific dose at select times. Correction insulin, also known as sliding-scale insulin, provides a dose of insulin based on the patient's blood glucose level. *The term correction insulin is preferred because it indicates that small doses of rapid or short-acting insulins are needed to correct a patient's elevated blood sugar. C. Based on observation, record review, interview, and policy review, the provider failed to ensure physicians' orders were followed for the administration of medications for two of eight sampled residents (19 and 21). Findings include: 1. Observation of resident 19 on 9/29/15 at 8:40 a.m. revealed: *She was sitting at the dining room table in her wheelchair. *She had not started to eat her breakfast. *RN B administered her morning medications to her that included her [MEDICATION NAME] (stomach medication). Review of resident 19's September 2015 MAR indicated [REDACTED] Interview at that time with RN B regarding resident 19 revealed: *She knew the [MEDICATION NAME] should be given thirty minutes prior to eating, but the resident's appetite was often poor and she did not eat her meal. *They usually always gave her the [MEDICATION NAME] when she was at the breakfast table. 2. Observation of resident 21 on 9/28/15 at 5:35 p.m. revealed: *She was sitting at the dining room table. *RN E administered the following medications to her: -[MEDICATION NAME] (stool softner). -[MEDICATION NAME]. -Donzepezil (memory). -[MEDICATION NAME] (pain). -Levetiracetam (control [MEDICAL CONDITION] (abnormal body movements)). -[MEDICATION NAME] (blood pressure). -[MEDICATION NAME] (depression). -Ropinirole ([MEDICAL CONDITION] (nerve disorder)). *RN E punched out the above medications from the 9/27/15 slot in the medication cards that were left in the card from that date. *The above medications were not documented as administered on 9/27/15 at 5:30 p.m. The slots next to all the medications were left blank. Interview at that time with RN E regarding resident 21 revealed: *She was not sure why the 9/27/15 5:30 p.m. medications remained in the medication cards. *It was likely they had been omitted since the nurse had not initialed the MAR. Review of the provider's June 2015 General Rules for Administration of Medication policy revealed: *Check MAR. If in doubt, check with original order on the chart. Give on time or within an hour before or after scheduled time. *MAR's must be checked at end of shift to be sure all appropriate spaces are initialed. Do not initial or chart medications in any way for another nurse.