Every finding on record at Avera Mother Joseph Manor Retirement Community

Based on observation, document review, and interview, the provider failed to ensure the posted nurse staffing information included the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift, and that the form was posted daily.Findings include:1. Observation on 10/2/25 at 10:00 a.m. of the provider's nursing services staff posting revealed the number of nursing staff working was listed, but not the number of hours they worked was not included.2. Interview on 10/2/25 at 11:12 a.m. with registered nurse (RN) health unit coordinator F revealed:*She was responsible for posting the nursing services staff form.*She was not aware of the requirement that the posting was to include the number of hours worked by nursing services staff, including the RN, LPN, and CNAs.*She posted the nursing services staff form daily when she worked, so it was not completed when she was gone, on weekends, or on holidays.3. A policy that addressed the nursing staff posting was requested, but according to administrator A, the facility did not have a policy regarding that.

Based on observation, document review, interview, and policy review, the provider failed to:*Ensure appropriate hand hygiene was performed by six dietary staff (K, T, U, BB, and CC) to meet professional food cleanliness standards.*Maintain three of three dishwashers and three of three sanitation solution containers in a manner that met professional food service sanitation standards.Findings include:1. Interview on 9/29/25 at 4:32 p.m. with resident 67 revealed she:*Preferred to eat her meals in her room.*Stated her food was often cold when she received it in her room.*Told the kitchen staff that her food was often cold, but no one had followed up with her regarding that concern, and her food continued to be delivered to her cold.2. Review of the provider's 2025 monthly resident council meeting minutes revealed:*At the 2/19/25 resident council meeting an identified concern was that the Scalloped potatoes are never done*At the 6/18/25 resident council meeting an identified concerns was that the Food temps [temperatures] need to be hotter-The response to this concern was that a plate warmer and another food warmer was being ordered.3. Interview on 9/29/25 at 4:04 p.m. with resident 53 revealed:*She ate in the dining room.*The food was sometimes cold when it was served to her, and it sat in the window for a while before it was served by the staff.*Sometimes the noodles were hard, and the meat was difficult to eat. *She thought the kitchen was short of help.A review of resident 55's electronic medical record (EMR) revealed her 9/15/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. 4. Observation on 9/29/25 in the kitchen revealed:*At 4:55 p.m., cook U did not wash his hands before he put on gloves and poured drinks into glasses for the room trays and left them on a cart, uncovered.*At 5:00 p.m. cook U moved food and soup cans from the warmer into the steam table. *At 5:01 p.m., food service worker BB, did not wash his hands before he put on gloves and, then cut strawberries while holding them in his hand. *At 5:02 p.m., hospitality services manager K took off her gloves, did not wash her hands, gathered containers of prepared food, removed utensils from a drawer, and then scooped food into another container and saran-wrapped sandwiches, with her bare, unwashed hands.*At 5:20 p.m., cook U did not wash his hands and took the temperature of the brats, broccoli, and the beans before he plated meals for the residents' room trays.*He did not check the temperature of the pork chops, which was an alternate food choice, or the pureed foods. *At 5:34 p.m., just before serving the residents' room trays, surveyors requested food service worker GG to check the temperature of the soup and milk. -The temperature of the chocolate milk was 50.6 degrees Fahrenheit (F), and the chicken noodle soup was 96.9 degrees F. -Food service worker GG was unsure what temperature the milk should have been, but stated she thought it needed to be in the 40s F range. -Hospitality services manager K directed the food service worker GG to dump the warm milk, obtain new milk from the fridge, and to warm up the chicken noodle soup to an appropriate temperature before serving to the resident.*At 5:23 p.m., cook U washed his hands, dried them off on his pants, and then put food containers in the steamer.*At 5:34 p.m., just before serving the residents' room trays, surveyors requested food service worker GG to check the temperature of the soup and milk. -The temperature of the chocolate milk was 50.6 degrees Fahrenheit (F), and the chicken noodle soup was 96.9 degrees F. -Food service worker GG was unsure what temperature the milk should have been, but stated she thought it needed to be in the 40s F range. -Hospitality services manager K directed the food service worker GG to dump the warm milk, obtain new milk from the fridge, and to warm up the chicken noodle soup to an appropriate temperature before serving to the resident.*At 5:38 p.m., cook U pushed his glasses up on his nose frequently while plating residents' meals and did not wash his hands. *At 5:38 p.m., cook U opened the tomato and chicken noodle soup cans, checked the temperature of the soups, and stated, It did not meet temp. -He was not sure what temperature the soups needed to be to be safe to serve. -Hospitality services manager K warmed up the soup, rechecked the temperatures and it was above 135 degrees F.*At 6:06 p.m., before cook U plated the pureed foods, surveyors requested him to check the temperature of those foods. The pureed meat was chicken, and it was 114 degrees F. The pureed broccoli was 118 degrees F.-He was unsure what temperature those foods needed to be.-Hospitality services manager K warmed up the food so it was above 135 degrees F.*At 6:11 p.m., before cook U plated a pork chop, surveyors requested and had him take the temperature of the pork chops. The pork chops' temperature was 109 degrees F. -Hospitality services manager K warmed up the pork chop to above 135 degrees F.5. Interview on 9/30/25 at 9:06 a.m. with resident 55 revealed:*She ate in the dining room.*She felt the hot food was sometimes served cold, and the milk was sometimes served warm. A review of resident 55's electronic medical record (EMR) revealed her 8/15/25 BIMS assessment score was 15, which indicated her cognition was intact.6. Observation on 9/30/25 in the kitchen revealed:*At 11:04 a.m., food service worker W took her gloves off, did not wash her hands, touched her hands on her glasses and pants, and then pureed (blended to a smooth consistency) angel food cake in a blender.*At 11:14 a.m., hospitality services manager K touched her glasses, did not wash her hands, took bowls of food out of the warmer, checked the temperature of the food in those bowls, and placed them back into the warmer.*At 11:20 a.m., cook T finished wiping the counters with a wash rag, did not wash her hands, opened a bag of dinner rolls, put on gloves, took the dinner rolls out of the bag, put them into a container, removed food containers from the warmer, checked the temperature of the food from the warmer, and then put the containers of food back into the warmer.*At 11:21 a.m., cook CC took his gloves off, did not wash his hands, wiped his nose on his forearm, and put clean dishes away. *At 11:39 a.m. hospitality services manager K took the food out of the warmer, which was at the appropriate temperature, and placed it in the steam table to serve.*At 11:42 a.m., hospitality services manager K, did not wash her hands, plated residents' food for residents' room trays, touched her glasses, and continued to plate food for residents in the main dining room while touching her glasses many times without washing her hands.*Hospitality services manager K started to serve residents lunch in the main kitchen at 11:48 a.m.*At 12:17 a.m., without checking the food's temperature, she started to serve pureed noodles, meat, and cauliflower.-The meat temperature was at 140 degrees, the noodles at 136 degrees, and the cauliflower was at 129 degrees.-She thought the food needed to be between 140-145 degrees, so she rewarmed all the food before serving it to the residents.-Those food items were in an uncovered bowl that was in a shallow pan on the steam table, which was covered with a metal lid.7. Review of the August 2025- September 2025 food temperature logs revealed:*For the Dakota dining room:-From 8/1/25-8/29/25 holding (before serving) food temperatures were not documented eighteen times that month.-From 9/22/25-9/30/25 holding food temperatures were not documented five times.-The following did not meet the required holding temperature of 135 degrees, per the food service code:- On 9/26/25 at dinner time, the cauliflower was 116 degrees, the fish-herb and lemon was 116 degrees, and the mashed potatoes were 131 degrees.-On 9/28/25 at dinner, the meat lovers pizza was 120 degrees.-On 9/29/25 at dinner, broccoli with cheese sauce was 125 degrees, and the pork roast with noodles and sauce was 105 degrees.-No corrective action was documented for any of the above low food holding temperatures.*For the main dining room:-From 8/1/25-8/31/25 the cooking temperatures were not documented 36 times.-From 8/1/25-8/31/25 the holding temperatures were not documented 63 times.-From 9/13/25-9/30/25 the cooking temperatures were not documented 23 times.-From 9/13/25-9/30/25 the holding temperatures were not documented 37 times.-On 9/28/25 at dinner, the vegetable blend was 116 degrees.-There was no documentation of corrective action taken for the low food temperature.8. Review of the provider's May 2025-September 2025 dishwasher temperature and sanitizing solution logs on the Cedar wing revealed:*The Quaternary and Water Temperature Monitoring Form indicated the test strip results should be between 200-400 parts per million (ppm) and the water temperature should be between 65-85 degrees.*The May 2025, June 2025, and July 2025 sanitation solution logs were not provided for review.*The sanitation solution was not documented as checked 119 times in August 2025 and 62 times in September 2025.*The dishwasher temperature log for August 2025 was not provided for review.*The dishwasher temperatures were not documented 26 times in May 2025, 12 times in June 2025, 8 times in July 2025, and 6 times in September 2025.*The dishwasher wash temperature did not meet the required temperature on 6/22/25, 7/6/25, 9/2/25, 9/10/25, 9/14/25, 9/15/25, 9/17/25, 9/24/25, and 9/27/25.*The dishwasher rinse temperature did not meet the required temperature on 6/14/25, 6/16/25, 6/20/25, 6/22/25, 7/3/25, 7/6/25, 7/14/25, 7/19/25, 7/21/25, 7/22/25, 7/25/25, 9/2/25, 9/3/25, 9/4/25, 9/10/25, 9/12/25, 9/13/25, 9/14/25, 9/15/25, 9/17/25, 9/18/25, 9/24/25, 9/26/25, and 9/27/25.-There was no documentation that any corrective action was taken to resolve the temperatures that were out of range.9. Review of the provider's May 2025-September 2025 dishwasher temperature logs and sanitation solution logs on the Dakota wing revealed:*The sanitation solution was not documented as checked 118 times in May 2025, 109 times in June 2025, 120 times in July 2025, 100 times in August 2025, and 88 times in September 2025.*The dishwasher temperatures were not documented 31 times in May 2025, 14 times in June 2025, 11 times in July 2025, 11 times in August 2025, and 18 times in September 2025.*The documented rinse temperatures did not meet the required temperature on 5/28/25 and 5/29/25, 6/12/25, and 6/29/25.-There was no documentation that any corrective action was taken to resolve the temperatures that were out of range.10. Review of the providers' May 2025-September 2025 dishwasher temperature logs and sanitation solution logs for the main kitchen revealed:* Instructions: Dip QUATS test QUAT solution (Not foam surface) for ten (10) seconds, Do not shake; compare colors to color guide at once. Parts Per Million (PPM) must be a minimum of: 300. Record Sanitizer concentration.*The May 2025, June 2025, July 2025, and August 2025 sanitation solution logs were not provided for review.*The sanitation solution was not documented as checked 70 times in September 2025 and did not meet the required sanitation level on 9/19/25 and 9/22/25.-There was no documentation that corrective action was taken to resolve the sanitization level that was out of range.*The dishwasher temperatures were not documented 28 times in May 2025, 22 times in June 2025, 18 times in July 2025, 32 times in August 2025, and 25 times in September 2025.*The dishwasher did not meet the required wash temperature on 5/10/25, 5/22/25, 5/23/25, 6/3/25, 6/16/25 at breakfast and lunch, 6/18/25, 7/5/25, and 8/18/25.*The dishwasher did not meet the required rinse temperature on 5/1/25, 5/5/25, 5/7/25 at breakfast and supper, 5/9/25, 5/10/25, 5/11/25, 5/17/25, 5/18/25, 5/21/25, 5/22/25 at breakfast and lunch, 5/23/25, 5/26/25, 5/27/25, 5/28/25, 5/29/25, 5/30/25, 5/31/25, 6/2/25, 6/19/25, 6/22/25, 6/26/25, 6/27/25, 6/28/25, 7/1/25, 7/3/25, 7/6/25, 7/9/25, 7/15/25, 7/17/25, 7/25/25 at breakfast and supper, 8/5/25, 8/6/25, 8/9/25, 8/12/25, 8/14/25 at breakfast, lunch, and supper, 8/16/25, 8/17/25, 8/22/25, 8/25/25, 9/26/25, 9/25/25, and 9/30/25.-There was no documentation that any corrective action was taken to resolve the temperatures that were out of range.11. Interview on 10/1/25 at 8:13 a.m. with food service worker DD revealed:*She took the holding temperature of the food before each meal.*If the food temperature was out of range, she took that food item back to the kitchen to have it reheated.*She would check the temperature of the altered diets, such as pureed food items, before serving them.*She did not check the temperature of the cold foods.* The dishwasher was a high-temp dishwasher.*The wash temperature was to be 160 degrees, and the rinse temperature was to be 180 degrees, and she would notify maintenance if it did not meet those temperatures.*The wash and rinse temperatures were to be documented at breakfast, lunch, and dinner.*Buckets with sanitizer solution were prepared for use at 6:30 a.m., and changed at 11:00 a.m., and before supper.*She was the one to obtain the sanitation solution and was to document the sanitation level each time it was filled.*The sanitizer solution was to be at 300 ppm, and the water was to be at 75 degrees.12. Interview on 10/1/25 at 9:05 a.m. with hospitality services manager K and dietician L revealed:*The hospitality services manager was new in her role, and she started at the end of May 2025.*Providing education to dietary employees who were students was difficult, but she will have the leads (supervisors) help with that and provide more supervision.*The temperature of the food should be checked when it was removed from the oven (cooking temperature) and just before serving it (holding temperature) to ensure it was in the safe range.*Food temperatures should be documented on the food temperature logs in the kitchen and each dining room.*If food temperatures were out of range, any staff member was to let the kitchen staff know and bring it back to a safe temperature before serving it. Corrective active steps taken to correct the food temperature should have been documented on the food temperature log, and it was not.*They did not monitor the temperatures of cold foods or the cold drinks.*They acknowledged the warm milk temperature of 50.6 degrees F was not a safe temperature for serving and was considered a potentially hazardous food.*They agreed that if the food temperatures were not at safe serving temperatures and dietary staff did not document if interventions were taken on the food temperature log, then the staff may have served those foods to the residents, which may have put the residents at risk for foodborne illness.*They agreed that if food temperatures were not documented, they could not be sure they were at a safe temperature to prevent foodborne illness.*Modified diet food temperatures should have been checked and documented on the logs.*They reviewed the food temperature logs and determined which dining area they were from, since they were not labeled, and verified that some of the dates were missing.*Warming soup while still in the can was something hospitality services manager K learned from another cook, and she will no longer warm it up in the can, as the instructions on the soup can were microwave it by emptying the contents into a microwave-safe bowl or to heat it on the stove by emptying the contents into a small saucepan.*Hospitality services manager K verified she did not check the food temperatures before serving lunch on 9/30/25, and she should have.*The three-compartment sink sanitation level was monitored each time it was changed.*The sanitizer solution in the buckets for each wing's dining room was monitored each time it was changed.*She was not able to find all the sanitation level logs that were requested.*The sanitation solution was to be changed every two to four hours, and as needed if it was dirty.*Staff were to document the sanitation level each time the sanitation solution was changed in the third compartment sink and the buckets.*They verified that staff were not documenting the sanitation solution per policy, and they should have been.*If the sanitation level was out of range, staff were to empty the sanitation solution and retest it.*Sometimes the water did not always function properly when using both the soap and sanitizer solution at the same time.*If the sanitation solutions did not meet the required sanitation level, staff were to put a work order into maintenance so it could be fixed.*They were not able to ensure proper sanitation of the dishes or the wiped surfaces if the sanitation level was not documented as being in the correct range, which could potentially cause residents to be sick.*They expected the dishwasher wash and rinse temperature to be checked and documented at breakfast, lunch, and supper.*The dishwasher temperatures were not always documented and should have been.*She was unable to find all of the dishwasher temperature logs as requested.*They expected the dishwasher wash temperature to reach 165 degrees and the rinse temperature to reach 180 degrees for effective sanitization.*Reviewing policies and log sheets, they verified that the expected dishwasher temperatures did not match.*Hospitality services manager K asked the maintenance supervisor, who said the dishwasher wash temperature was to reach at least 150 degrees. *They verified that not all the documented wash and rinse temperatures met the required temperature to ensure sanitation was achieved.*Maintenance staff were to be notified if the dishwasher wash or rinse temperature did not meet the required temperatures.*There was no documentation that the maintenance staff was notified when the dishwasher did not meet the required temperatures.*They agreed that if the dishwasher temperatures and sanitization solution levels were not checked and documented, they could not ensure effective sanitation of the dishes and equipment used to prepare and serve residents' food, which could make the resident sick.*When asked, hospitality services manager K did not say how often she reviewed at the sanitation solution and dishwasher logs. *They expected handwashing to be performed when staff entered the kitchen, after touching their face, before putting on gloves, after removing gloves, when changing tasks, and when moving from a dirty to a clean task.*They verified, if a staff member dried their hands on their pants, they should wash their hands.13. Review of the providers' September 2025 Food Temperatures policy revealed:* All potentially hazardous food must be kept below 41 degrees.during transportation.14. Review of the providers' May 2024 LTC Food Safety and Sanitation-System Standard Policy revealed:* Food Safety is paramount to prevent food borne illness.For nursing home residents who are older or sick with compromised immune systems, food borne illness is certainly more serious and may even be life threatening.* The food safety/sanitation program is designed to identify, implement, monitor, evaluate, and correct food sanitation procedures from food production to food consumption. All local, state, and federal standards and regulations are followed in order to assure a safe and sanitary food service department.* Responsibilities:-Nutrition Services Director:-Establish and maintain sanitary standards of cleanliness and food handling practices. All Hazard Analysis Critical Control Point (HACCP) procedures are followed.-Provide and document education to employees on personal hygiene, food handling, and sanitation yearly, or as needed.* Ensure proper maintenance, operation and cleaning of all equipment.* Evaluation practices of food handling to meet sanitary standards.* In collaboration with the Infection Prevention Committee, review and update policies and procedures related to infection control.* Documentation of education/training is maintained and monitored by department leader.* Cooked foods must reach the temperature recommended by the Food Service Code.* Hot food is held at a temperature of 140 degrees or above.* Cold foods are held at a temperature of 40 degrees or less.* Anytime a contaminated surface is touched, the gloves must be changed-washing hands after removing the gloves and before putting on a new pair.* Hands must be washed before serving/distributing meals, & or after picking up soiled plates/waste.* Sanitizer buckets are changed when visibly soiled or per manufacturer directions. The sanitizer is checked for proper concentration with test tape (per manufacturers [manufacturer's] direction).*Cloths must be soaking in sanitizer until use, changing solutions every 4 hours to maintain active concentration.* The dishwasher is maintained and operated according to manufacturer's instructions.-1. Hot water dish machines need to run at 155 [degrees] for wash cycle and minimum of 180 [degrees] for rinse cycle. Always follow manufacturer guidelines to ensure appropriate sanitation levels, regardless of what machine is used. Temperature/appopriate sanitation levels are checked & recorded daily.15. Review of the providers' September 2025 Food Handling policy revealed:* Staff were to wash hands prior to preparing, serving and distributing food. 16. Review of the providers' September 2025 Dishwashing policy revealed:* Wash temperature should reach 150 degree F. * Rinse temperature should reach 180 degree F.17. Review of the providers' September 2025 Hand Washing policy revealed:* Staff will use proper handwashing to prevent the spread of pathogens.

Based on interview and policy review, the provider failed to implement an effective grievance process to ensure residents' satisfaction with the resolution of voiced grievances for:*Two of two sampled residents (55 and 76) regarding long call light response times and noise at night.*One of one sampled resident (89) regarding long call light response times and receiving medications late.*One of one sampled resident (67) regarding cold food and menu choices.*One of one sampled resident (90) regarding lost hearing aides. Findings include: 1. Interview on 9/29/25 at 4:21 p.m. with resident 89 revealed: *Resident 89 stated that she felt that one nurse aide had treated her poorly. Resident 89 explained that she went to bed at approximately 8:30 p.m. one evening and, about three hours later, activated her call light to request assistance to use the bathroom. When the nurse aide responded, the aide stated, I just took you. Resident 89 insisted on being taken to the bathroom, and the aide assisted her but commented, I can't be coming in every five minutes. Resident 89 told another nurse aide about it the next day, whom she described as one of my favorites, but she was not offered or asked if she wanted to file a grievance. She declined to identify that staff member. She did not report that incident to any other staff and stated, All of the other staff are great. *Resident 89 was also concerned regarding the timing when she was given her morning nausea medication, Zofran. She stated the medication was consistently administered late in the morning, by which time she was already experiencing nausea and was unable to eat several noon meals as a result. Resident 89 tried to be more insistent to staff about receiving her Zofran earlier, but there was no change to the time the medication was administered. 2. Interview on 9/30/25 at 9:06 a.m. with resident 55 in her room revealed: *She had experienced urine incontinence episodes when waiting long times for staff to respond to her call light. She unsafely took herself to the bathroom, at times, when she felt she had to wait too long for staff to respond to her call light. *She felt staff were loud at night, laughing and joking in the hallway, and her roommate yelled out her name at times, which kept her awake. *She notified the previous director of nursing and registered nurse (RN)/quality and infection prevention supervisor B about long wait times for staff response to her call light and needing to take herself to the bathroom, loud staff and roommate at night, but it was still happening.3. Interview on 9/29/25 at 4:28 p.m. and 10/1/25 at 3:35 p.m. with resident 76 in her room revealed: *She had to wait a while for the staff to answer her call light, especially in the morning. *The resident across the hall hollers and bangs at night, keeping her awake. *She complained to a staff member about the long call light times and the resident across the hall being loud at night, but she was unsure who she told, and it continued to happen. *She was unsure how to file a grievance. 3. Interview on 9/29/25 at 4:32 p.m. with resident 67 revealed she: *Preferred to eat her meals in her room. *Stated her food was often cold when she received it in her room. *Told the kitchen staff that her food was often cold, but no one had followed up with her regarding that concern, and her food continued to be delivered to her cold. Observation and interview on 9/30/25 at 9:03 a.m. with resident 67 in her room revealed she: *Had her breakfast tray on her over-the-bed table. *Was only given water to drink, and she reported she preferred to have milk with her meals. *Did not fill out her menu choice and she was not sure who had. Interview on 10/2/25 at 8:40 a.m. with resident 67 revealed she: *Had not filed a grievance. *Did not know how to file a grievance. *Did not remember being told she could file a grievance or what the process was to file a grievance. 4. Interview on 9/29/25 at 5:21 p.m. with resident 90 revealed she stated that her hearing aid was lost, which she believed occurred yesterday. She reported that staff had looked in her trash and in her recliner for the hearing aide. The resident stated she was not aware of how to file a grievance and had not been offered assistance by anyone to do so. She also reported she was unsure what actions, if any, the facility was taking regarding her lost hearing aid. 5. Interview on 10/1/25 at 8:32 a.m. with certified nursing assistant (CNA) R revealed: *Residents complained about the staff being loud a few months ago, and management talked to the staff about it. *Resident 76 complained to her about the resident across the hall from her (resident 30) being loud at night. 6. Interview on 10/1/25 at 2:45 p.m. with business office coordinator I revealed: *There had been a recent change within the social worker position. *For 2025, the only grievance logs the provider had been from 1/1/25 through 3/31/25. 7. Interview on 10/2/25 at 7:30 a.m. with CNA EE who worked the night shift revealed: *Resident 30 was loud and would wake up the other residents at night. -She told registered nurse (RN)/quality and infection prevention supervisor B about resident 30 being loud about a week ago, and was told RN/quality and infection prevention supervisor B would get the social worker and licensed practical nurse (LPN)/resident care supervisor J involved. She was unsure if anything had been done about it yet. *Some CNAs were loud at night, and they were told to be quieter by management. She had not heard anything else about that. 8. Interview on 10/2/25 at 8:05 a.m. with CNA Q revealed: *If a resident had a complaint, she would tell the nurse and try to find out the source of the problem. *She did not know how to help the resident file a grievance. *Resident 55 told her about the staff and her roommate being loud at night. CNA Q did not tell anyone about the resident's concerns because she thought the nurses already knew about it. *Resident 30 banged his call light on the bedside table at times. A management staff person talked to him to let him know he was disturbing others, and that behavior decreased for a little while, but he was doing it again. 9. Interview on 10/2/25 at 8:20 a.m. with social worker (SW) G revealed: *If a resident had a complaint, there was a form they could fill out, and she would then review it and log it in the grievance book. -No one had filled out a grievance form that she knew of since she had started at the nursing home. *If a resident told a CNA about a complaint, the CNA should report it to the department that the complaint was about. *If a resident told a nurse about a complaint, the nurse should tell the director of nursing or the administrator. *Morning staff meetings were held to discuss facility happenings (ie. falls and complaints). -She heard in the morning meeting that a resident had yelled and banged on things at night, but she only heard about that once. -She stated that concern was addressed with the resident who was loud and with the residents who complained about it about a month ago, on one of her first days of working at the nursing home. -She was not aware that resident 30's disruptive behavior continued to be an issue. *Resident 55 reported to her that she had not received good personal hygiene care provided by a night CNA. -Administrator A talked to that CNA and resident 55 and SW G thought that resolved the issue. *She did not have any documentation of the resident's grievances being followed up on by other staff. She would document in the resident's chart regarding grievances she followed up on. *She received residents' complaints regarding long call light times a few times, and she talked to that resident. The resident care coordinator, for that resident, was to run a call light report and then talk to the nursing staff regarding long call light wait times. *Complaints brought forward by the resident council were to be brought to the leaders of the department the complaints were about. *If a complaint was received during a care conference, she would notify the leader of the department the complaint was about, so the department lead could follow up with that concern. She documented in the residents when she followed up on grievances. *She was unsure if the morning staff meetings were documented to indicate if residents' grievances or concerns were discussed. 10. Interview on 10/2/25 at 8:38 a.m. with LPN FF revealed: *If a CNA or resident told her a complaint, she would try to solve it, and if she was unable to solve it, she would tell her supervisor. *She was not sure how to file a grievance for a resident. 11. Interview on 10/2/25 at 8:40 a.m. with resident 67 revealed she: *Had not filed a grievance. *Did not know how to file a grievance. *Did not remember being told she could file a grievance or what the process was to file a grievance. 12. Interview on 10/2/25 at 8:54 a.m. with certified nursing assistant (CNA) P revealed: *She had not filed a grievance for a resident. *If a resident had a concern, she would notify her supervisor or the nurse on duty about the resident's concern. *She thought the grievance form was available online and was to be completed if she had an issue with a coworker. *She did not know who the provider's grievance officer was. 13. Interview on 10/2/25 at 9:07 a.m. with registered nurse (RN) E revealed: *She had worked at the facility for three months. *She had not filed a grievance for a resident or a resident representative. *If a resident brought a concern to her attention, she would attempt to address that concern immediately. If she was unable to resolve the resident's concern, she would either email or tell the manager responsible for that area what the grievance was about and who reported it to her. *There were grievance forms available in a drawer at the nurses' station and at the front desk. *If a resident asked to file a grievance, she would assist that resident if needed. *She was not aware of any grievance forms that were available for anyone without asking a staff member for the grievance form. *She did not know who the provider's grievance officer was. 14. Interview on 10/2/25 at 9:12 a.m. with social worker G revealed: *She was the grievance officer for the facility. *The process to file a grievance was gone over with the resident or the resident representative on admission and was in the resident 's admission packet. *She was not aware of any material posted in the facility related to the facility's grievance process. *She did not know if there were any grievance forms available for residents or family members to complete without asking a staff member for the form. 15. Interview on 10/2/25 at 10:55 a.m. with administrator A revealed: *She would try to handle a complaint as soon as it was received. *Social worker G handled the grievances, had the grievance forms, and kept copies of all the grievances in a book for two years. *A grievance would be any complaint that was not resolved with the resident and/or family. -They only had four documented grievances in the past year. *She expected complaints brought up in resident care conferences and their resolution to be documented in the resident's electronic medical record (EMR). *If a resident reported a complaint to a CNA, she expected the CNA to tell the nurse supervisor. *She expected the resident care coordinators to address resident complaints, and if they were not able to resolve them, then they should notify her. 16. Review of the provider's September 2024 Grievance/Complaint- System Standard policy revealed: *It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination of reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding the LTC [long term care] facility stay. *The facility grievance process will be overseen by a designated Grievance Official who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations, maintaining the confidentiality of all information associated with grievances, communicate with residents throughout the process to resolution and coordinate with other staff. *The facility will provide a mechanism for filing a grievance/complaint without fear of retaliation and/or barriers of service; will provide residents, resident representatives and others information about the mechanisms and procedure to file a grievance; provide a designated individual to oversee the grievance process; provide a planned, systematic mechanism for receiving and promptly acting upon issues expressed by residents and resident representatives and will provide and ongoing system for monitoring and trending grievances and complaints. *The facility will inform residents orally and in writing of their right to make Complaints and Grievances and the process to do so during admission, readmission and the care planning process. The notice shall include: -a. Information on how to file a grievance or complaint -b. Resident right to file grievances orally or in writing -c. Resident right to file grievance anonymously -d. Contact information of the facility designated Grievance Official -e. Reasonable time frame for completing the review of a complaint -f. Resident right to obtain a written decision regarding his or her grievance -g. Contact information of independent entities with who grievances may be filed in each of the various states [the corporation] facility operates in. -h. Additional notices of the facility grievance process will be displayed in prominent locations throughout the facility (Front entrance and Administration). *A grievance or concern can be expressed orally to the Grievance Official, facility staff or in writing using a grievance form. *Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official. *The grievance Officer will maintain a log of all grievances and/or entered into EMR Risk Management Reporting System for a period of 3 [three] years including; -1. Date of the Grievance -2. Tracking number or identification -3. Type of Grievance -4. Location/Department -5. Person assigned to investigate -6. Date response letter sent -7. Comments/Actions. *The facility will track, trend and analyze the grievance process and findings for trends, performance gaps and opportunities for individual education, system and systemic improvement. The facility will incorporate the Grievance/Complaints into the Quality Assurance and Performance Improvement program.

Based on interview, observation, record review, call light report review, and policy review the provider failed to ensure prompt staff response to resident call lights for seven of seven residents (30, 34, 45, 55, 71, 73, and 76 ) who complained of slow responses to call lights.Findings include:1. Interview on 9/29/25 at 4:26 p.m. with resident 71's husband in the hallway revealed: *He turned on his wife's call light when she was incontinent and needed staffs assistance, and it took the staff over 45 minutes to help his wife. *His wife was dependent on the staff to have her incontinence brief changed as she was immobilized. Observation on 9/30/25 at 8:44 a.m. of resident 71 in her room revealed: *She was sitting in a wheelchair, chewing on her clothing protector, and did not verbally respond to questions. Review of resident 71's EMR revealed: *She was admitted [DATE]. *Her 8/15/25 BIMS score was 0, which indicated her cognition was severely impaired. *She had diagnoses of Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), urinary incontinence, and a history of urinary tract infections. 2. Observation and Interview on 9/29/25 at 4:28 p.m. with resident 76 in her room revealed she: *Was sitting in a wheelchair. *Reported she had to wait a while for the staff to answer her call light, especially in the morning. *Missed going for a walk when she had to wait for staff assistance. *Complained to a staff member about the long call light wait times, but she was unsure who she told. Review of resident 76's EMR revealed: *She was admitted on [DATE]. *Her 7/24/25 BIMS score was 15, which indicated her cognition was intact. *She had diagnoses of major depressive disorder (a mental health condition characterized by persistent sadness or a loss of interest in activities, significantly affecting how you feel, think, and act), anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable worry and fear about everyday situations), spinal stenosis (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves), spondylolisthesis (a spinal condition where vertebra slips out of its proper position and moves forward onto the vertebra below it), and dependence on supplemental oxygen (the need for oxygen to treat conditions where the body's tissues are not getting enough oxygen). Review of resident 76's 9/15/25 care plan revealed that staff were to encourage her to use her call light to communicate her needs. 3. Observation and Interview on 9/30/25 at 8:20 a.m. with resident 30 in his room revealed: *He was lying in bed watching television. *He received hospice services. *He had to wait 45 minutes in the middle of the night after he was incontinent of bowel, and that made him feel mad. *Staff took a while sometimes during the day to answer his call light, but it was mostly at night when he had to wait for staff assistance. Review of resident 30's EMR revealed: *He was admitted to the facility on [DATE]. *His 9/25/25 BIMS score was 15, which indicated his cognition was intact. 4.Observation and interview on 9/30/2025 at 8:33 a.m. with resident 34 in her room revealed: *She was in her wheelchair watching television. *She said she waited 30 to 40 minutes at dinner time and supper time for her call light to get answered from the staff. *The staff told her they did not have enough help for the people who needed assistance. *She felt that made the other residents have to wait to go to meals and use the bathroom. *She stated she had to wait the longest for help from the staff at night. *There were times, at night, when she could not hold her urine any longer waiting for staff to bring her a bedpan. *Staff would answer her call light and say they would be right back, but she would have to turn her call light back on to get them to come back and help. *She felt it affected her dignity to have that happen to her. Review of resident 34's electronic medical record (EMR) revealed she had a BIMS (Brief Interview for Mental Status) score of 15 which indicated she was cognitively intact. 5. Observation and Interview on 9/30/25 9:06 a.m. and 10/1/25 at 3:59 p.m. with resident 55 in her room revealed she: *Was sitting in her wheelchair and had on a CAM boot (a device to protect and immobilize the leg after injury or surgery) on her left leg, and a wound vacuum (a device that uses gentle suction to help wounds heal) tubing coming out from that. *Reported she had to wait up to 30 minutes for her call light to be answered by staff at night. *Had been incontinent (involuntary leakage) of urine when she had to wait a while for staff to assist her to the bathroom, and that made her feel embarrassed. *Required staff assistance to use the bathroom due to the wound on her leg that required a wound vacuum, and she was unable to bear weight on her left leg without the CAM boot on. *Needed the staff's assistance to put her CAM boot on and to take it off. *Took herself to the bathroom at night at times when she did not have her CAM boot on because she had to wait a while for staff and did not want to be incontinent. *Previously notified the old director of nursing and her assistant B about her long call light times and needing to take herself to the bathroom without her CAM boot on when staff did not answer her call light quickly enough. Review of resident 55's EMR revealed: *She was admitted to the facility on [DATE]. *Her 8/15/25 BIMS score was 15, which indicated she was cognitively intact. *Her diagnoses included a healing fracture (broken bone) to her left lower leg, a sprain to her left ankle (injury to the joint causing overstretching or tearing of the ligaments), a history of falls, an overactive bladder (a condition characterized by a sudden, urgent, and frequent need to urinate, often leading to involuntary leakage), muscle weakness, and a need for assistance with personal care. Review of resident 55's 8/25/25 care plan (personalized plan that addresses the resident's care needs, goals, and interventions) revealed: *Per her orthopedic doctor, physical therapy, and occupational therapy, the staff were to put her CAM boot on before transfers, as she could bear weight on her left leg during stand pivot transfers only, if she had it on. *She required staff assistance with her activities of daily living (ADL) related to impaired mobility related to surgery on her left ankle. *Staff were to encourage her to use her call light and assist her to the bathroom. 6. Observation and interview on 9/30/25 at 9:36 a.m. with resident 45 in her room revealed: *She was resting in her recliner. * She waited a long time for staff to respond to her call light at times, especially when other residents were being assisted in the dining room. *She got disgusted when she waited a long time for staff to help her get to activities and meals. *She felt sorry for the residents who depended on staff to help them to the bathroom because she thought they waited a long time for help. Review of resident 45's EMR revealed: *She had a BIMS score of 15 which indicated her cognition was intact. *She was a total assist for transfers. 7.Observation and interview on 9/30/25 at 3:35 p.m. with resident 73 in his room revealed: *He was sitting in his recliner. *He stated he waited long periods of time to get help from staff, especially during meals. *He felt irritated when no one would answer his call light because he depended on staff for help. Review of resident 73's EMR revealed: *He had a BIMS score of 15 which indicated his cognition was intact. *He was an assist of one for transfers. 8. Interview 10/1/25 at 8:32 a.m. with certified nursing assistant (CNA) R revealed: * When a call light was turned on by a resident, it sent a notice to staff pagers, was on the screen in that hallway that beeped, and it was displayed on the computers at the end of each hallway. *When a call light was turned on, and she was in another resident's room, she would leave that resident's room to go check on the call light or would call someone on her work phone to assist that resident. *When college started in the fall, the staffing level in the facility was worse, but it was improving. *She felt the staffing levels at night had been good. 9. Interview on 10/2/25 at 7:30 a.m. with night shift CNA EE revealed: *There were typically four CNAs scheduled to work the overnight shift, and she felt they had enough staff working the overnight shifts to meet the residents' needs. *Only a few overnight nurses would help the CNAs answer call lights. *Regarding resident 30: - She felt he was not nice to staff, particularly staff of color. -If staff did not answer his call light within three minutes, he would bang his call light on his bedside table. -He did not sleep at night and turned his call light on for snacks, pop, to empty his urinal, and to change his brief. -She told him she could not be there every two minutes to help him. When he was rude to her, she asked him not to talk to her like that, and she told him she would leave his call light on if he talked to her that way. 10. Interview on 10/2/25 at 8:05 a.m. with CNA Q revealed: *Call lights should be answered within 10 minutes. *If a resident's call light was on when she was busy, she would go acknowledge the resident, turn their call light off, and tell them she would be back to help them. 11. Interview on 10/2/25 at 8:20 a.m. with social worker G revealed: *Resident 55 reported to her a few weeks ago that she was having trouble with the care she received from an overnight CNA. Administrator A followed up, and education was provided to that CNA. *She received complaints regarding long call light response times a few times, and she talked to that resident about that. The resident care coordinator, for that resident, would run a call light report and then talk to the staff. 12. Interview on 10/2/25 at 8:46 a.m. with CNA S regarding residents' call lights revealed: *The staff were expected to answer call lights in a timely manner. *She thought a timely manner meant five minutes or less. *She knew the residents' call lights were on longer around mealtimes when the residents that needed assistance with dining were a priority. 13. Interview on 10/2/25 at 9:18 AM with RN/unit coordinator F regarding call lights revealed: *Staff were expected to answer call lights in a timely manner to ensure the residents' needs were being met. *She was unsure if there was an actual expected time frame that would mean in a timely manner. 14. Interview on 10/2/25 at 9:24 a.m. with RN resident care supervisor C regarding residents' call lights revealed: *She thought an average of ten minutes was the expectation for staff to answer call lights. *The quality and infection prevention supervisor could print out the call light reports, and she would monitor those reports. *the reports were reviewed monthly or if there was a concern from a resident. *Call lights were a priority to ensure they were meeting the residents' needs. 15. Review of the call light alarm report for resident 34 from 9/1/25 through 10/1/25 revealed there were 60 instances where the call light wait time was from 20 minutes up to 1 hour and 33 minutes. 16. Review of the call light alarm report for resident 45 from 9/1/25 through 10/1/25 revealed there were 50 instances where the call light wait time was from 20 minutes up to 2 hour and 5 minutes. 17. Review of the call light alarm report for resident 73 from 9/1/25 through 10/1/25 revealed there were 18 instances where the call light wait time was from 20 minutes up to 52 minutes. 18. Review of the call light alarm report for resident 55 from 9/1/25 through 10/1/25 revealed there were 7 instances where the call light wait time was from 20 minutes up to 35 minutes. 19. Review of the call light alarm report for resident 30 from 9/1/25 through 10/1/25 revealed there were 90 instances where the call light wait time was from 20 minutes up to 1 hour and 5 minutes. 20. Review of the call light alarm report for resident 76 from 9/1/25 through 10/1/25 revealed there were 9 instances where the call light wait time was from 20 minutes up to 50 minutes. 21. Review of the call light alarm report for resident 71 from 9/1/25 through 10/1/25 revealed there were 2 instances where the call light wait time was from 20 minutes up to 52 minutes. 22. Interview on 10/2/25 at 10:35 a.m. with RN/quality and infection prevention supervisor B revealed: *Call light issues were reviewed at the montly quality assurance meetings if a concern was identified by a resident. *The expected time for staff to answer call lights was 10 minutes. *She agreed a call light over 20 minutes was to long for residents to wait for assistance. *All staff were expected to answer call lights to ensure the residents' needs were being met. 23. Interview on 10/2/25 at 10:55 a.m. with administrator A revealed: *She expected staff to answer residents' call lights within ten minutes. *Anyone who could help that resident should answer their call lights. *She expected the nurses to complete call light audits for residents with complaints or concerns regarding long call light times. 24. Review of the provider's 2/2025 revised Call Light policy revealed: *Objective: To respond to patient/resident's requests and needs on a timely basis. *Procedure: 1. Instruct patient/resident upon admission in regards to use of the call light. 2. Answer light promptly. 3. Be courteous when entering room. Ask patient/ resident May I help you? 4. Turn off call light. Avoid duplication of services. 5. Listen to patient/resident's request. Do not make him/her feel that you are too busy to help. 6. Respond to request. If item is not available, or request questionable, get assistance from charge nurse. Return to patient/resident with prompt reply.

Based on observation, interview, record review, and policy review, the provider failed to protect the resident's rights and ensure a resident's advance directive code status (an individual's desire to be resuscitated with cardiopulmonary resuscitation (CPR), specific limited interventions, or not resuscitated (DNR) if their heart stopped) wishes were identified accurately on the physician's orders and the care plans for one of 32 sampled resident (55).Findings include:1. Observation on [DATE] at 2:53 p.m. outside of resident 55's room revealed she had a red dot on her name plate on her door.2. Interview and review of resident 55's electronic medical record (EMR) on [DATE] at 4:30 p.m., and on [DATE] at 4:43 p.m. with licensed practical nurse (LPN)/resident care supervisor J revealed:*Residents' code statuses (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) were ordered by their physician.*The residents did not sign code status forms.*If a resident's code status changed, the provider would request an order from the physician to change it. *She looked in resident 55's EMR and determined the resident had a full code status (life sustaining measures if one's heart or breathing stop).*If resident 55 was found not to have a heartbeat, she would perform CPR immediately.*She reviewed resident 55's [DATE] living will and stated that the resident's code status was supposed to be DNR.*She reviewed the resident's physician's orders, and her full code order was ordered on [DATE], upon her admission to the nursing home.*She reviewed the resident's hospital discharge orders from [DATE], and those orders indicated she had a full code status.*She completed resident 55's assessments and care plan upon admission to the nursing home.*She was to verify the resident's code status wishes with the resident when the resident admitted to the nursing home.*She did not have documentation to support that resident 55's code status was reviewed with her to ensure her wishes would have been followed.3. Interview on [DATE] at 8:32 a.m. with certified nursing assistant (CNA) R revealed the red dots on the residents' name plates of their door meant they had full code status. 4. Interview with resident 55 on [DATE] at 3:59 p.m. revealed:*No one talked to her about her code status wishes since she arrived at the nursing home.*She did not want CPR performed if her heart or breathing stopped, and she was upset that she was ordered to have CPR.*She had a living will that stated she did not want CPR, and she signed that document while in the hospital, shortly before she was admitted to the nursing home.5. Further review of resident 55's EMR revealed:*Upon her admission on [DATE], she had orders from her physician for her code status to be full resuscitation, which were entered by licensed practical nurse (LPN)/resident care supervisor J.*Her [DATE] living will stated, If my death is imminent or I am permanently unconscious, I choose not to prolong my life. If life-sustaining treatment has been started, stop it, but keep me comfortable and control my pain.*Her living will declaration stated: This is an important legal document., and This living will remains valid and in effect until and unless you revoke it.*Her [DATE] Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact.*Her printed baseline care plan's first page listed her code status as full code, in smaller writing, which was signed on [DATE] by LPN/resident care supervisor J and resident 55.6. Interview on [DATE] at 11:22 a.m. with registered nurse (RN)/quality and infection prevention supervisor B and interim director of nursing (IDON) AA revealed:*The residents' code status wishes were reviewed with the resident and/or family representative, and then they would request an order from the resident's physician that reflected the resident's code status wishes, unless their code status was listed in the resident's admission orders.*The residents did not sign code status forms.*When asked how they ensured they were following the residents' code status wishes and not just the physicians' orders if there was no document signed by the resident or the resident's representative, RN/quality and infection prevention supervisor B stated, the designated staff member was to discuss it with the residents.*IDON AA stated the admitting staff member needed to look at both the physicians' orders and the residents' advance directives upon admission to determine the resident's code status wishes were followed based on the resident's wishes.Review of the provider's [DATE] Advance Care Planning Policy revealed:* The goals of the advance directive policy are to promote human dignity and self-determination, to ensure that patients' advance directives are honored, and to ensure compliance with the Patient Self-Determination Act of 1990.* When an advance directive document is provided to the facility.an active problem list item Advance care planning is created and a permanent comment is entered that states the type of document.* Advance care planning allows the resident to consider and express their values, goals and wishes regarding care and treatment.Review of the provider's undated Nursing Facility admission Handbook and Resident Care Policies revealed:*During the admission process all new residents will be presented with information regarding Code-No Code. This will be explained to the resident, resident representative and all the available family members by the Social Services Department. The resident or the resident representative must sign the form designating the desired status. The family will be made aware of the fact that the physician must be in agreement with this decision before an order is written.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed respiratory professional standards for:*The clean storage of nasal cannulas (flexible tubing with prongs that delivers oxygen through the nose) for three of three sampled residents (5, 50, and 90) who used them.*The cleaning and storage of nebulizer masks (a mask worn when using a nebulizer machine that converts liquid medication into an inhalable mist) for three of three observed sampled residents (5, 42, and 63) who used them.*The cleaning of Continuous Positive Airway Pressure (CPAP) machines (a device that uses air pressure to keep breathing airways open) for two of two observed sampled resident (5 and 90) who had CPAP machines in their rooms.Findings include: 1. Observation and interview on 9/29/25 at 4:05 p.m. with resident 63 revealed that she was seated in a recliner in her room. Her right hand was contracted, and she was unable to move the fingers of her left hand. A nebulizer machine was on the bedside table, with liquid in the medicine chamber, approximately three-fourths full. Resident 63 stated that nursing staff assisted her with the nebulizer treatments, as she was unable to physically operate the machine independently. The nebulizer had liquid remaining in it, which indicated the nebulizer was not disassembled, cleaned, and left to air dry prior to reassembling it. Review of resident 63's electronic medical record (EMR) revealed she was admitted on [DATE]. Her 7/31/25 Brief Interview of Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact. 2. Observation on 9/29/25 at 2:37 p.m., of resident 90's room was revealed the resident was not in the room. An oxygen concentrator (a device that filters room air into purified oxygen) was on and set at two liters (L) per minute. The tubing and nasal cannula was draped over the top of the concentrator. A CPAP machine was on the bedside table. The CPAP machine had a reservoir that was approximately three-fourths full of a clear liquid that appeared to be water. Condensation was visible on the top half of the reservoir. 3. Observation and interview on 9/29/25 at 5:21 p.m. with resident 90 revealed: *She did not use her CPAP machine because she used oxygen at night instead. *A CPAP machine was on her bedside table. The water reservoir was about three-fourths full of clear liquid, with condensation on the top half. The tubing had a blue connector that allowed oxygen to be added to the CPAP. *Resident 90 said she was unaware that the machine could be used with oxygen. The oxygen concentrator flow rate was set at two liters and turned on, with the tubing and nasal cannula draped over the top. The improper storage of the nasal cannula posed a risk of contamination, which then would have been transferred into resident 90's nasal passage when it was placed in her nose. Resident 90 stated that the concentrator was always left on, even when she was not using it. She said she had asked the staff to turn it off, but they told her it needed to always remain on. Review of resident 90's EMR revealed her admission date was 9/17/25. Her 9/30/25 BIMS assessment score was a 13, which indicated her cognition was intact. 4. Observation on 9/29/25 at 3:00 p.m. of resident 50's room revealed: *The resident was not in his room. An oxygen concentrator at the foot of his bed and was turned on. *The nasal cannula and tubing attached to the oxygen concentrator was draped over resident 50's unmade bed. 5. Observation on 9/29/25 at 4:25 p.m. of resident 50 in his room revealed him sitting in a wheelchair beside his bed wearing the nasal cannula. 6. Observation on 10/2/25 at 8:37 a.m. of resident 50's room revealed his nasal cannula and tubing was lying on the floor behind his oxygen concentrator. 7. Observation on 10/2/25 at 10:13 a.m. of resident 50 in his room revealed him sitting in his wheelchair beside his bed, wearing a nasal cannula. Review of resident 50's EMR revealed: *He was admitted on [DATE]. *His 8/1/25 BIMS assessment score was 6, which indicated his cognition was severely impaired. *His diagnoses included respiratory failure (a condition when the lungs cannot properly exchange gasses resulting in abnormal levels of carbon dioxide). 8. Observation and interview on 9/30/25 at 11:18 a.m. with resident 5 in her room revealed: *She was seated in a recliner. A nebulizer machine was on the bedside table next to the recliner. The nebulizer mask had a hazy appearance and appeared to have residue on it. Resident 5 stated that a staff member would place the nebulizer mask on her face at the start of the treatment, and she would remove it and place it on the table when the treatment was completed. *A CPAP machine was on a small dresser. The water reservoir of the CPAP appeared to be dry. Resident 5 stated that she did not use the CPAP machine because she needed water in the reservoir, as her mouth and throat became too dry without it. She said that the night staff would not assist her with filling the water reservoir and told her that she did not need water in it. *There was an oxygen tubing and a nasal cannula stored on top of a puzzle that was on a card table. Resident 5 stated that the cannula and tubing were used for her portable oxygen concentrator. The placement of the nasal cannula on the puzzle posed a risk for the nasal cannula to become soiled. When the nasal cannula was later placed in resident 5's nose she would be exposed to the soiled nasal cannula. Review of resident 5's EMR revealed she was admitted on [DATE]. Her 7/29/25 BIMS assessment score was a 15, indicating her cognition was intact. 9. Observation on 9/29/25 at 3:06 p.m. of resident 42's room revealed: *There was a nebulizer machine with an assembled nebulizer administration set (the cup and mouth piece or mask attached the nebulizer machine to hold and dispense the inhaled medication) on his bedside table. *There were clear liquid drops inside of the nebulizer administration set. Observation on 9/30/25 at 8:00 a.m. of resident 42's room revealed: *The assembled nebulizer administration set was on the side of his nebulizer machine. *There was a small amount of clear liquid inside the nebulizer administration set. 10. Observation and interview on 9/30/25 at 2:05 p.m. with resident 42 in his room revealed: *He administered his nebulizer medication after the nurse placed medication in the nebulizer administration set. *Once the nebulizer treatment was completed, he would place the nebulizer administration set on the side of the nebulizer machine. *He stated licensed practical nurse (LPN) M would come back after he finished his nebulizer treatment, and she would rinse his nebulizer administration set but some of the other nurses did not. 11. Observation and interview on 10/2/25 at 9:01 a.m. with resident 42 in his room revealed: *The nebulizer administration set was on the side of his nebulizer machine. *The nebulizer administration set had clear liquid drops inside the medication chamber and mouthpiece. *Resident 42 stated his nebulizer administration set was cleaned last night, but it was not cleaned after his morning nebulizer treatment, which he received around 7:00 a.m. that day. Review of resident 42's EMR revealed he: *Was admitted on [DATE]. *Had a 9/11/25 BIMS assessment score of 15, which indicated he was cognitively intact. *Had a 4/8/25 physician's order for albuterol/ipratropium [ a medication used to open the air passages in the lungs to make it easier to breathe] 3 ML [milliliters] neb [nebulizer] [Duoneb] 3 ML INH [inhaled] TID [three times per day]. 12. Interview on 10/1/25 at 1:39 p.m. with registered nurse (RN)/quality and infection prevention supervisor B revealed: *Nebulizer administration sets were to be disassembled, rinsed with sterile water or distilled water, and placed on a towel to air dry after each use by the nurse or certified medication aide. *Nebulizer administration sets were to be washed with soap and water every night at bedtime. *Nebulizer administration sets were to be replaced weekly and as needed if they became soiled. *Nasal cannulas were to be stored in the plastic bag attached to the resident's oxygen concentrators when not in use to prevent contamination of the nasal cannula. *She expected oxygen concentrators to be turned off when they were not in use. *She agreed that a nasal cannula draped over a resident's bed or on the floor had the potential of having become contaminated and should have been replaced. 13. Interview on 10/2/25 at 8:59 a.m. with certified nursing assistant (CNA) P revealed: *Nasal cannulas were to be rolled up and placed in the plastic bag on the resident's oxygen concentrator when it was not in use. *Staff were to assist resident 50 with his nasal cannula and to turn his oxygen concentrator on and off. 14. Interview on 10/2/25 at 9:04 a.m. with RN E revealed: *Nebulizer administration sets were to be rinsed after the administration of the nebulizer medication was completed by the nurse or certified medication aide. *Nasal cannulas were to be stored in the plastic bag attached to the resident's oxygen concentrator when it was not in use. *Resident 42 would turn off his nebulizer once he completed his nebulizer treatment and place the nebulizer administration set on the side of the nebulizer machine. *RN E would return to resident 42's room later in the morning, disassemble his nebulizer administration set, rinse it, and place it on a towel to dry. *Resident 50 was not able to turn his oxygen concentrator on or off or to put his nasal cannula on, remove it, and store it without staff assistance. 15. Review of the provider's 5/22/25 Respiratory Equipment Care policy revealed: *CPAP/BIPAP -1. Clean according to manufacturer's instructions for use (MIFU) if available. If no MIFU is available: -2. Daily – wipe out the mask with a clean wash cloth [washcloth] and empty water chamber -3 Weekly – a. soak mask and head gear with mild soap and water for 30 minutes, wash, rinse and air dry *Nebulizers -1. Clean according to manufacturer's instructions for use (MIFU) if available. If no MIFU is available: -2. Rinse after every treatment a. Empty excess fluid b. Rinse nebulizer with sterile (preferred) or distilled water c. shake off excess moisture d. Store --i. place on a clean, dry paper towel (change the paper towel after each treatment) and store in a clean, dry location in the resident's room to air dry for the next treatment OR --ii. in a designated vented respiratory bag that is changed weekly. -3. Daily, or more often when visibly soiled, disassemble and wash with soap and water, rinse and air dry as above. -5. Discard and replace with new Nebulizer set if grossly contaminated with the patient's secretions, it malfunctions, or is dropped on the floor. Review of the provider's December 2024 Oxygen Therapy policy revealed: *Oxygen is administered to residents per physician order. *Procedure for use of concentrators: -Procedure for cleaning and maintenance of concentrator: --Filters are washed weekly with tubing change. --Humidifier jars are changed weekly when used. --Cannula and tubing are changed weekly. --The above procedures will be documented weekly in the EMR.

Based on observation, interview, and policy review, the provider failed to ensure standard infection prevention practices were followed by:*Two of two certified nursing assistants (CNA) ( R and Y) and 1 of 1 registered nurses (RN) (Z) removed their gloves prior to entering the hallway.*Two of two CNAs (R and Y) and one of one RN (Z) performed hand hygiene (handwashing) prior to the application and after the removal of gloves for one of one residents (51).*One of one CNA (R) who used a phone with soiled gloves while in one of one sampled resident's (51) room who was on enhanced barrier precautions (glove and gown use) after assisting that resident with personal hygiene. Findings include:1. Observation on 9/30/25 at 9:18 a.m. in the [NAME] hallway revealed: *CNA Y exited a resident room with a glove on his right hand. *That resident's room had personal protective equipment (such as gowns, gloves, face shield, and masks) (PPE), and a sign posted on the door which indicated a resident who resided in that room was on EBP. *He removed the glove from his right hand and disposed of it in the garbage on the side of the medication cart. *He did not perform hand hygiene after he removed the glove. *Then he opened the doors to three other resident rooms, looked in the rooms, and then closed the doors. 2. Observation and Interview on 9/30/25 at 9:43 a.m. with CNA R in resident 51's room revealed: *Resident 51 was lying in bed, the lights were dimmed, and relaxing music was playing. *Resident 51 would not respond verbally to questions asked. *Resident 51 was on EBP due to having a history of Methicillin-resistant Staphylococcus aureus (MRSA) infection. *Before providing care, CNA R washed her hands and put on a gown and gloves. -She moved the resident's bedding and clothing, then took off her gloves, threw them away, and did not perform hand hygiene. -She put on clean gloves, cleaned the resident's bottom with a wet wipe, then took off those gloves, threw them in the garbage, and did not perform hand hygiene. -She put clean on clean gloves, washed the resident's perineal area (genitals), took off those gloves, threw them in the garbage, and did not perform hand hygiene. -She put on clean gloves, assisted the resident with brushing her teeth, took off those gloves, threw them in the garbage, and did not perform hand hygiene. -She put on clean gloves, washed the resident's face with a washcloth, took a phone out of her pocket, called someone, and asked that person to bring her a clean gown for the resident. -With those same gloved hands, she removed the resident's nasal cannula of oxygen from her nose, applied lotion to the resident's face, took off the resident's gown, applied the resident's deodorant, put a clean gown on the resident, put on her nasal cannula, cleaned the resident's nails, and brushed her hair. -CNA Q entered the room wearing a gown and gloves, and assisted CNA R in repositioning resident 51. -After repositioning resident 51, CNA R took off her gloves, threw them away, and did not perform hand hygiene. -She put on a clean pair of gloves, took a cleaning wipe out of a container, wiped the resident's bedside table off, and then took off her gloves and gown, and threw them in the garbage. -With her ungloved hands, she removed the full garbage bag from the garbage container, replaced it with a new bag, and put the resident's fall mat down on the floor beside her bed. -She then performed hand hygiene and exited the residents' room. *Interview immediately following the above observations with CNA R revealed: *She was to wash her hands before going into a resident's room, before applying gloves, before moving from a clean to dirty task, after removing gloves, and when exiting a resident's room who was on EBP. *She confirmed she had not performed hand hygiene when she moved from a dirty task back to a clean task, when she changed her gloves, and when touching the phone during resident 51's care. 3. Observation on 10/1/25 at 10:59 a.m. of RN Z revealed: *RN Z did not wash her hands and then put on a pair of gloves while in the medication room. *She walked from the medication room to resident 83's room with those same gloves on, opened resident 83's door, and laid out her equipment on resident 83's over the bed table. *RN Z collected blood from resident 83's finger and completed a blood sugar check. *She removed those gloves, threw them in the garbage can while in resident 83's room and did not perform hand hygiene. *RN Z then walked down the hallway to the medication room, put on another pair of gloves without first performing hand hygiene, cleaned the glucometer with a sanitizing wipe, removed those gloves, and then performed hand hygiene. 4. Observation on 10/1/25 at 11:18 of RN Z as she administered a nebulizer (a device that converts liquid medication into an inhalable mist) treatment to resident 49 revealed: *She did not perform hand hygiene prior to preparing the nebulizer medication and placing the nebulizer mask on resident 49's face. She removed her gloves, performed hand hygiene, and then exited the room. *After the nebulizer medication was administered, without first performed hand hygiene, RN Z put on gloves while at the nurse's station, walked down the hall and entered resident 49's room. She removed the nebulizer mask from resident 49's face, rinsed off the nebulizer mask in the resident's sink, removed her gloves and discarded them in the garbage, and then performed hand hygiene. 5. Interview on 10/1/25 at 1:23 p.m. with RN/quality and infection prevention supervisor B revealed: *She expected no gloves to be worn by staff in the hallways due to staff having to touch potentially contaminated surfaces in order to enter a resident room to provide resident care. *Hand hygiene was to be performed before staff put on gloves and after the gloves were removed. *She stated that RN Z should not have been wearing gloves in the hallway before she checked resident 83's blood sugar and before discontinuing resident 49's nebulizer treatment because she expected the staff to put gloves on in the resident's rooms after performing hand hygiene and prior to performing care. *RN/quality and infection prevention supervisor B stated CNA Y should have removed his gloves and performed hand hygiene before exiting the resident's room. 6. Interview on 10/2/25 at 11:22 a.m. with RN/quality and infection prevention supervisor B and interim director of nursing (IDON) aa revealed: *They expected CNAs to perform hand hygiene before putting gloves on and after taking them off. *Before using the phone, staff should have removed their dirty gloves, performed hand hygiene, used the phone, performed hand hygiene again, and then put gloves on. 7. Review of the providers' May 2025 Gloves-LTC Infection Prevention policy revealed: * Gloves are to be changed between patient contacts and when moving from contaminated to clean tasks for the same patient. * Hand Hygiene is to be completed before putting on gloves and after removing them. 8. Review of the provider's 11/14/24 LTC-Hand Hygiene policy revealed: *HH [Hand hygiene] either with soap and water or with alcohol based hand rub (ABHR): .after removing gloves. 9. Review of the providers October 2024 LTC-Transmission Based Precautions and Enhanced Barrier Precautions revealed: * Transmission of infectious organisms within a healthcare setting requires three elements to be linked: -A source (or reservoir) of infectious organisms -A susceptible host -A means of transmission of the organism. -Interruption of this link in the chair of infection is achieved primarily by.using a barrier (Enhanced Barrier Precautions). * Multidrug Resistant Organism (MDRO): bacteria that are resistant to one or more classes of antimicrobial agents. Examples.MRSA. * Enhanced Barrier Precautions (EBP): use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. *.Facilities will incorporate the use of.Enhanced Barrier Precautions.as indicated for known, suspected or incubating infections, or communicable diseases, and for the protection of residents, visitors, and staff from potential exposure to communicable and transmissible diseases. * Enhanced Barrier Precautions are used during high contact resident care activities for the following residents and should be implemented as facilities are able: -Infection or colonization with an MDRO when contact precautions do not otherwise apply. -.gown and gloves must be used during high contact care activities including (but not limited to) -dressing -providing hygiene -changing briefs.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, and interview, the provider failed to withhold cardiopulmonary resuscitation (CPR) for one of one resident (1) with a do not resuscitate/do not intubate (DNR/DNI) code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) who experienced a choking episode, choked, and had no pulse or respirations after her airway was cleared.Findings include:1. Review of the provider's 7/27/25 SD DOH FRI revealed:*On 7/27/25, resident 1 choked while eating her lunch.*The nurse was called over to the table where resident 1 had been eating and finger swept a large bite of meat out of resident 1's mouth and did several back blows.*Staff members assisted resident 1 to stand, and the nurse did abdominal thrusts for several minutes with no luck dislodging the food.*911 was called and the EMTs [emergency medical technicians] and police arrived within minutes and were able to remove a piece of meat from her [resident 1's] throat using a camera and long pinchers.*Resident 1's daughter was called several times by the nurses and police with no answer.* The EMTs started CPR (cardiopulmonary resuscitation) and transported resident 1 to the hospital.*Resident 1's daughter was reached by phone and said she did not want CPR continued.*Resident 1's cause of death was asphyxia [lack of oxygen] due to foreign body [an object in a part of the body where it does not normally belong] and cardiopulmonary arrest cardiopulmonary arrest [sudden, unexpected loss of heart function, breathing, and consciousness].*Resident 1's code status was DNR/DNI: Medical treatment OK. 2. Review of resident 1's electronic medical record (EMR) revealed:*She was readmitted to the facility on [DATE] after a hospitalization on 6/23/25 for aspiration pneumonia (lung infection caused when substances, such as food, are inhaled into the lungs).*Her diagnoses included dysphagia (difficulty swallowing foods or liquids) and cerebral vascular accident (stroke).*Resident 1 had appointed her daughter as her Power of Attorney (someone designated on a legal document to act on behalf of a resident) (POA)*On 9/8/21, resident 1's POA had signed a NO CODE (Care and Comfort ONLY) directive.*A 6/16/25 physician's order for DNR/DNI: Medical Tx [treatment] okay.*A 6/30/25 physician's communication Resident [1] was re-admitted to [provider initials] today. She returned with orders for Nectar thickened liquids. [A] swallow study was done and no aspiration [was] noted. [The] report states [the] resident is safe to advance to [consume] thin liquids. [The] resident is refusing thickened liquids. Daughter [name omitted] is requesting the order be changed. Risk of aspiration reviewed with the resident and daughter. They are still asking to advance liquids to thin. May we have an order for thin liquids and also an order for ST [Speech Therapy] to follow?*A 7/1/25 physician's order for IDDSI [International Dysphagia Diet Standardization Initiative (a categorized food and drink consistency system)] 6 Soft and Bite-Sized Diet and thin liquids.*A 7/8/25 physician's order OK for straws.*A 7/10/25 physician communication May we have an order for [resident 1] to have bread products OK'd as an exception to [the resident's] IDDSI 6 soft and bite-sized [ordered diet], was signed by the physician on 7/11/25 with the physician having added agree w/ [with] above]. 3. Review of resident 1's 7/27/25 [Ambulance name] Prehospital Care Report Summary revealed:*An initial emergency call was received on 7/27/25 at 12:12 p.m. that resident 1 was choking, not breathing and the Heimlich maneuver [a first-aid procedure for dislodging an obstruction from a person's airway] was being attempted.*The paramedics made contact with resident 1 at 12:17 p.m. as nursing home staff were assisting her to her room in her wheelchair.*Resident 1 was unresponsive, had weak radial (wrist) and carotid (neck) pulses, her dentures were removed, she did not respond to verbal or painful stimuli, and she did not have breath sounds.*She was moved from the wheelchair to the ambulance stretcher, and a video laryngoscope (a device used to visualize the throat and top of the windpipe) and forceps (a surgical tool resembling tongs with pincers) were used to remove a chunk of meat from the epiglottis opening (the entrance of the windpipe) and clear her airway which was confirmed with the use of a Bag-Valve-Mask (BVM) (a device used to assist a person who is not breathing or breathing inadequately).*An i-gel (a medical airway device) was used to provide ventilation (rescue breaths).*Resident 1 was assessed by the paramedic after clearing her airway. She did not have a radial or carotid pulse and was hooked to a cardiac monitor.*The paramedic then confirmed with facility staff that the resident was a DNR/DNI, contacted the emergency medical doctor, and was instructed by that doctor to continue ventilation and to monitor the resident.*The paramedics were provided a copy of resident 1's DNR/DNI and were told by the facility nurse (licensed practical nurse (LPN) D) that the daughter of the patient would wish for CPR in this case.*The paramedics initiated CPR and completed two rounds of CPR. A carotid pulse returned, and the resident was prepared for transport to the hospital.*Resident 1's daughter met the paramedics and the resident on the stretcher in the hallway on the way to the ambulance and shares that this is not what the patient would [have] wanted (CPR), and she wished for no further resuscitation efforts.*The paramedics left the facility at 12:46 p.m. 4. Phone interview on 7/31/25 at 11:20 a.m. with LPN D, who worked on 7/27/25 revealed:*On 7/27/25, while serving residents lunch in the dining room, she was alerted by resident 1's tablemates that resident 1 needed help.*LPN D immediately identified that resident 1 was choking, did a finger sweep, and started to perform the Heimlich maneuver.*911 was called immediately by food service worker E.*Food service worker E and certified nursing assistant (CNA) F assisted resident 1 to stand while LPN D continued to perform the Heimlich maneuver which was unsuccessful in dislodging any object from the resident.*Resident 1 became unresponsive and was being transported to her room in her wheelchair when the paramedics arrived.*Multiple attempts were made to get in contact with resident 1's daughter, who was her POA, by phone. LPN D had left a message that resident 1 had choked and she needed to come to the facility right away.*A paramedic had come out of resident 1's room to confirm what resident 1's code status was, and to obtain the code status form.*LPN D confirmed that resident 1 was a DNR/DNI, but that medical treatment was ok and stated that the daughter would want the resident to receive CPR.*LPN D thought it took about 45 minutes before resident 1's daughter was contacted. During that time, LPN D stated she left another message for resident 1's daughter notifying her that the paramedics needed to know if CPR should be initiated, and that she had said to start CPR.*When resident 1's daughter arrived, she was upset that CPR had been started.*LPN D recalled that the food remaining on resident 1's plate had been cut into small pieces. 5. Interview on 7/31/25 at 1:28 p.m. with registered dietitian G and hospitality director H revealed:*The lunch menu on 7/27/25 included cheesy mashed potatoes, sliced pork with gravy, a vegetable, and a dinner roll.*Resident 1 was on an IDDSI 6 Soft and Bite-Sized Diet, but she was allowed bread, thin liquids, and to use a straw. Her meat would have been cut before her plate was served to her. 6. Phone interview on 7/31/25 at 2:04 p.m. with resident 1's daughter revealed:*On 7/27/25 at 12:20 p.m., she had a missed call and voice message from the facility notifying her that her mother had choked and that she needed to come to the facility right away.*At 12:29 p.m., she called the facility and told them that she was coming to the facility.*At 12:31 p.m., she received a missed call and voice message from LPN D, stating that they needed her to call back right away because they knew that her mother's code status was DNR/DNI and they needed her approval to provide CPR, and that LPN D had told the paramedics that she (resident 1's daughter) would have wanted CPR started.*Resident 1's daughter confirmed that her mother's code status was DNR/DNI and that she had not wanted CPR started.*She arrived at the facility as the paramedics were transporting her mother (resident 1) to the ambulance at approximately 12:45 p.m. and questioned why CPR had been started when the facility staff had been aware that resident 1's code status was DNR/DNI. 7. Interview on 7/31/25 at 3:32 p.m. with administrator A and quality and infection prevention RN C revealed:*Resident 1's code status was DNR/DNI with an OK for medical treatment at the time of her choking incident on 7/27/25.*That the facility policy was that CPR was performed in response to a choking resident, even if a resident's code status was DNR/DNI for clearing of the airway.*The paramedics had taken over resident 1's care when they arrived. The paramedics were aware that resident 1 was a DNR/DNI, and the paramedics performed CPR on resident 1.*They were unsure if CPR had been started for resident 1 before or after resident 1's airway had been cleared.*LPN D did not have the authority to decide if CPR should have been performed for resident 1 when attempts to contact resident 1's daughter had been unsuccessful, even if that was what she thought resident 1 and her daughter would have wanted.*They confirmed that LPN D had not followed resident 1's physician-ordered DNR/DNI code status. 8. Review of the provider's 2/20/25 Advance Care Planning policy revealed:*The goals of the advanced directive policy are to promote human dignity and self-determination, to ensure that patients' advance directives are honored, and to ensure compliance with the Patient Self-Determination Act of 1990.*The provider honors a patient's right to make advance directives.*Advanced care planning allows the resident to consider and express their values, goals and wishes regarding care and treatment.*Any.health care provider, and healthcare facilities shall comply with a person's EMS cardiopulmonary resuscitation directive that is apparent and immediately available. Review of the provider's 1/15/25 LTC [Long Term Care] Emergency Response, CPR policy revealed:*If a resident with a DNR order has a choking episode that requires the Heimlich maneuver, at any point during the episode the resident ceases to have a pulse, in order to continue with the manual clearing of the airway, chest compressions will be applied until emergency personnel arrive and take over to care for the resident.*If an advanced directive includes a request for a Do Not Resuscitate (DNR) order:. DNR orders are communicated to staff through documentation in the medical record and the patient's care plan.

Based on South Dakota of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure professional standards of nursing practice were followed by licensed practical nurse (LPN) H who had failed to document and communicate one of one sampled resident (1) newly observed wound to the physician to initiate timely evaluation and treatment. Failure to document and communicate the new wound delayed wound treatment and may have delayed the healing of that wound. This citation is considered past non-compliance based on the review of the corrective actions the provider implemented immediately after they became aware of the wound and the provider's internal investigation. Findings include: 1. Review of the provider's 5/23/25 SD DOH FRI revealed: *On 5/22/25 resident [name] had been seen at a clinic appointment. *An ulceration to the dorsal aspect (back) of her left foot had been diagnosed and identified. *Treatment orders had been sent with resident 1 after her clinic appointment. *An order to apply optifoam (a type of wound dressing designated for advanced wound care) to be changed daily. 2. Review of resident 1's electronic medical record (EMR) revealed: *She had been admitted on [DATE] with diagnoses of a middle cerebral artery stroke on the right side of her brain that had affected the left side of her body and peripheral artery disease (narrowed blood vessels reduce blood flow to the limbs). *She had been receiving physical and occupational therapy. *Resident 1 had been able to eat independently required set up for oral hygiene. *She required moderate staff assistance with personal hygiene, and maximum assistance of staff with upper/lower dressing and mobility. *She was dependent on staff assistance with her footwear and bathing. *A skin risk assessment completed on 4/21/25 which indicated she was at risk for skin wounds. *Staff were to observe skin daily with all cares and report any changes to the charge nurse. 3. Interview on 6/3/25 at 8:50 a.m. with LPN G regarding new observed skin wounds revealed: *She would measure the wound and then document those measurements on the wound/incision complex flowsheet in the resident's EMR. *The resident's wound measurements should also be documented on a paper communication sheet that was kept in a binder at the nurse's station. *She would have notified the resident's physician and family of the new skin wound. Information would have also been communicated to the nursing staff in a shift-to-shift report for their awareness. *She had recently received education on the provider's skin assessment/pressure injury prevention policy. 4. Interview on 6/3/25 at 9:10 a.m. with LPN J regarding new observed resident skin wound revealed: *She would have documented the resident's new skin wound in the physical assessment and then documented the measurements of the wound in the wound/incision complex flowsheet. *She would have also notified the resident's physician and family of the new skin wound. *If the skin alteration was from an unknown origin she would have completed a risk management form. *She would have documented the measurements of the wound in the resident's paper chart used to communicate the resident's wound healing. The paper chart had been kept in the nurse's station. 5. Interview on 6/3/25 at 10:10 a.m. with LPN F regarding a new observed resident skin wound revealed: *She would have measured the new skin wound and documented it in the wound/incision complex flowsheet in the resident's EMR. *She would have notified the resident's physician and family of the new skin wound. *She would have reported the new skin wound in the nursing staff shift-to-shift report for their awareness. 6. Interview on 6/3/25 at 1:00 p.m. with LPN supervisor E regarding resident 1's left foot ulcer revealed: *LPN supervisor E had been unaware that resident 1 had an ulcer to her left foot, until she was notified by resident 1's nephew following the resident's clinic appointment on 5/22/25. *Once resident 1 had returned from her clinic appointment, LPN supervisor E measured the skin ulcer and documented the measurements in the resident's wound/incision complex flowsheet. *She notified resident 1's physician of the new skin ulcer on 5/22/25. *She had informed the charge nurse who had been caring for resident 1 of the new skin ulcer on 5/22/25. 7. Interview on 6/3/25 at 1:40 p.m. with LPN H regarding resident 1's left foot ulcer revealed: *She had been notified by certified nursing assistant (CNA) M on 5/18/25 of resident 1's newly observed skin wound. *LPN H assessed the skin wound and documented those measurements on her report sheet. *She thought she had documented the new skin wound in resident 1's EMR. -She confirmed there was no documentation of the resident's skin wound in the EMR. *She thought she had communicated the new skin wound in the nursing shift-to-shift report on 5/19/25. *LPN H had been unaware that new skin wounds needed to be documented in the wound/incision complex flowsheet in the resident's EMR. *She had received additional education following that incident regarding the provider's skin assessment/pressure injury prevention policy,and required documentation. 8. Interview on 6/3/25 at 2:15 p.m. with CNA M regarding resident 1's new skin wound revealed: *She had assisted resident 1 with bathing and discovered the new skin wound on 5/18/25. *She had immediately notified LPN H on 5/18/25. *CNA M had asked resident 1 if she had been experiencing any pain, resident 1 denied any pain. *Resident 1 required the assistance of one to two staff members and the use of a gait belt to transfer due to her left-sided weakness. 9. Interview on 6/3/25 at 2:45 p.m. with LPN J regarding information she had received in the shift-to-shift report on the morning of 5/19/25 revealed she did not recall that she had heard resident 1 had a new skin wound to her left foot from LPN H. 10. Further review of resident 1's EMR revealed: *On 5/18/25 at 8:00 p.m. through 5/22/25 at 2:00 p.m. a physical assessment had been completed for resident 1 once per shift. -There was no documentation resident 1 had an alteration to her skin. *There was documentation resident 1 had her TED hose (stockings to help prevent blood clots to the legs) put on in the morning and removed at bedtime. 11. Interview on 6/3/25 at 3:15 p.m. with assistant director of nursing (ADON) C regarding the skin assessment portion of the resident physical assessment revealed: *A head-to-toe skin assessment would have been completed weekly by a nurse. *She had agreed that if a nurse had documented normal skin condition on the physical assessment in the resident's EMR, the nurse assessed all of the areas of the resident's skin. 12. Interview on 6/3/25 at 3:30 p.m. with LPN I and LPN J regarding documentation of resident's skin on the physical assessment revealed: *The resident's skin that had been visible would have been assessed and documented in the skin assessment portion of the physical assessment. *A more thorough skin assessment would have been completed weekly on all residents. 13. Interview on 6/4/25 at 9:00 a.m. with CNA K regarding his documentation of putting on resident 1's TED hose on 5/19/25 revealed: *He had not observed any open areas to resident 1's feet that day. *If he had observed any new wounds in a resident skin, he would have notified the nurse immediately. 14. Interview on 6/4/25 at 10:00 a.m. with director of nursing (DON) B and ADON C regarding nurse assessments of resident's skin in the physical assessments revealed: *DON B had not expected nurses to complete a head-to-toe skin assessment on residents while completing the physical assessment. *Resident's skin would be assessed weekly by the nurse usually while the resident was bathed or if a new skin wound had been observed. 15. Interview on 6/4/25 at 2:45 p.m. with CNA L regarding her documentation of the removal of resident 1's TED hose on 5/20/25 revealed she had not observed any open areas to resident's feet at that time. 16. Review of LPN H's department orientation checklist completed on her hire date of 5/12/25 revealed: *She had been validated for the completion of the following tasks: -Documentation of condition change of resident (observing, recording, and reporting). -Documentation of skin assessment/Braden Scale (an assessment tool used to identify resident's at risk for developing pressure ulcers) turn and reposition. 17. Review of the provider's May 2025 Skin Assessment/Pressure Injury Prevention policy revealed: *A full head to toe skin assessment will be completed on admission and weekly for four weeks then quarterly thereafter or with change in status. *The physician will be notified of skin integrity issues/wound presence, if unrelated to admission, if unrelated to admission reason to long term care. 18. Review of the provider's June 2025 RN/LPN Orientation Program policy revealed: *It is the policy of this facility that all newly hired RNs/LPNs Orientation Program. This program is competency based to assure quality care for residents. The program follows completion of general orientation. *The RN/LPN must satisfactorily complete all areas of the RN/LPN Orientation Checklist prior to working independently in the facility. *The main content areas included on the orientation checklist are: -Policy/Regulation. -Documentation. The provider's implemented actions to ensure the deficient practice does not recur confirmed on 6/4/25 after: record review revealed the facility had followed their quality assurance process, education was provided to all direct care staff regarding the documentation of new skin alterations, skin assessment/pressure injury prevention policy and followed residents' care plan, interviews related to staff understood the education that had been provided. Monitoring will be conducted to prevent the reoccurrence of a deficient practice. Based on the above information, non-compliance at F658 occurred on 5/18/25, and based on the provider's implemented corrective actions for the deficient practice confirmed on 5/27/25, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell from his wheelchair while being pushed by facility staff. Failure to use wheelchair pedals may have contributed to resident 1's fall. This citation is considered past noncompliance based on the corrective actions the provider implemented immediately after the incident. Findings include: 1. Review of the provider's 7/26/24 SD DOH FRI report revealed: *On 7/26/24, occupational therapy assistant (OTA) C was wheeling the resident back to his room. The resident was holding his feet off the floor; wheelchair pedals were not attached to wheelchair. During the transport, resident 1's feet dropped to the floor, causing him to fall forward out of the wheelchair. *He hit his head on the floor during the fall, causing a laceration and bleeding. *He was evaluated in the emergency department at the local hospital. *A chest X-ray revealed he had multiple left side rib fractures. Interview on 8/28/24 at 8:44 a.m. with director of nursing (DON) B revealed: *After the 7/26/24 fall, resident 1's care plan had been updated to always use foot pedals when transporting him in the wheelchair. *A trial was conducted with foot pedal bags attached to resident's wheelchair instead of keeping foot pedals in the resident's closet, making foot pedals easily accessible when needed. *The trial was successful, and they ordered foot pedal bags for all wheelchairs. Review of employee education records revealed staff had been educated on topics related to safe resident transport and workplace safety as part of the provider's annual education for all employees reviewed. The provider implemented actions to ensure that the deficient practice does not reoccur. That was confirmed on 8/28/24 after record review revealed that resident 1's care plan was updated to always have foot pedals on his wheelchair when transporting, education had been provided to employees regarding safe resident transport and workplace safety, and staff were able to verbalize when wheelchair pedals should be used during transports. Based on the above information, non-compliance at F689 occurred on 7/26/24, and based on the provider's implemented corrective actions, the deficient practice confirmed on 8/28/24, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review the provider failed to ensure: *Two of two sampled residents (38 and 68) home narcotic medications had been reconciled and accounted for. *Three of five residents (8, 29, and 55) did not receive expired medications. Findings include: 1. Observation and interview on 05/15/24 at 10:31 a.m. with registered nurse (RN) C at the medication cart located on the Dakota unit while reviewing the controlled medication reconciliation process revealed: *The locked controlled medication drawer contained: -Two bottles of resident 68's medications in a biohazard bag. --One bottle contained 43 gabapentin 300 milligrams (mg) capsules. --The second bottle contained 50 oxycodone 5 mg tablets. --The sheet of paper was dated 4/17/24 and contained a handwritten note Send home with family. *RN C stated the medication had been removed from resident 68's room and placed in the medication cart. *There was no controlled substance record form to confirm the count of the controlled medication. 2. Observation on 5/15/24 at 10:59 a.m. with RN D at the medication cart located on the [NAME] unit while reviewing the controlled medication reconciliation process revealed: *The locked controlled medication drawer contained: -A home medication bottle with a sheet of paper attached to it with a rubber band. --The bottle contained one hydrocodone 5 mg acetaminophen 325 mg tablet. --The sheet of paper dated 4/19 identified the medication belonging to resident 38 was to have been sent home with family. *There was no controlled substance record form to confirm the count of the controlled medication. 3. Interviews on 5/15/24 at 10:35 a.m. and again at 11:05 a.m. with director of nursing (DON) B revealed: *A controlled substance sheet should have been started when the medications were found. *Controlled substance medications from home should have been counted to confirm the amounts of those medications each shift. *The medications should have been sent home or destroyed. 4. Review of the provider's 4/2024 LTC Controlled Substances -System Standard Policy revealed: *It is the policy of [the provider] to properly acquire, receive, store, administer, track, reconcile, document, and dispose of controlled substances . *To accurately account for and reconcile controlled substances for prompt identification of loss or potential diversion. 5. Observation and medication administration record (MAR) review on 5/15/24 at 10:59 a.m. with RN D at the medication cart located on the [NAME] unit revealed: *Resident 55's box of ondansetron 4 mg orally disintegrating tablets was marked as opened on 9/20/22 and expired on 4/30/24. -The last dose was provided on 5/9/24 at 8:25 a.m. *Resident 8's ondansetron 8 mg tablets that expired on 3/28/24. -The last dose was given on 5/13/24 at 12:40 a.m. 6. Observation and MAR review on 5/15/24 at 11:05 a.m. with RN E at the medication cart located on the Boardwalk unit revealed: *Resident 29's bottle of stomach relief opened on 9/9/23 and expired on 1/24. -The last dose was provided on 5/10/24 at 5:18 a.m. 7. Interview on 5/16/24 at 11:17 a.m. with DON B revealed she: *Was unaware the above residents had been given expired medications. *Would have expected expired medications to have been removed from the medication cart and sent back to the pharmacy. *Would have expected an incident report to have been completed, and the residents, the residents' family members, and the residents' physician to have been notified that they were given expired medications. 8. Review of the provider's 12/2022 Pharmaceutical Services policy revealed: *Medications having an expiration date will be checked periodically, properly disposed of if the expiration date has been reached, and replaced as indicated.

Based on observation, interview, record review, and policy review the provider failed to ensure two of two sampled residents (1 and 2) had not had their medical reasons for the use of contact precautions posted on signage in the hallway. Findings include: Observation on 8/2/23 at 9:15 a.m. of resident 1 in her room revealed: *On the wall, outside of the room was her room number and her name. *A sign above her room number and her name was another sign that indicated, contact precautions. -That sign had in bold black marker the words hazardous drug and chemo [chemotherapy] gloves. *She was lying on her bed, with her eyes closed. Review of resident 1's medical record revealed she: *Was admitted on [DATE]. *Her Brief Interview of Mental Status (BIMS) had not been completed. *Was taking the medication Anastrozole (Prescribed for cancer). *Had a diagnosis of malignant neoplasm of upper-outer quadrant of the left breast. 2. Interview on 8/2/23 at 11:15 a.m. with resident 2 revealed she: *Was admitted on [DATE]. -Had rheumatoid arthritis and was taking the drug methotrexate (a chemotherapy drug). -During the month of May 2023 there was a notice placed on the wall outside of her room above the room number and her name that indicated she was on a hazardous drug and to use chemo gloves. *Had become aware of the sign when she heard visitors outside of her room talking about her and being on chemotherapy. *Said that made her feel singled out and felt that was a violation of her privacy. -She then went to the hallway and tore down the sign. *Stated a similar sign was posted in her room with that same information and she had removed that sign too. *Showed the surveyor a picture she had taken of the sign with her phone that had been placed outside of her room. -It had her first name at the top. -It also included the following information: --Gloves and incontinent products were to have been placed in a yellow bag and disposed of in the chemotherapy barrel. --Soiled linens were to have been double bagged. --The toilet was to have been double flushed. --At the bottom in bold, black, large print was the word Chemotherapy. Review of resident 2's medical record revealed: *She was admitted on [DATE]. *Her BIMS was a 15, meaning her cognition was intact. *She had a diagnosis of rheumatoid arthritis. *She was taking the medication methotrexate (a chemotherapy drug) for her rheumatoid arthritis. 3. Interview on 8/2/23 at 1:30 p.m. with licensed social worker C revealed: *The assistant director of nursing D (ADON) was responsible for posting transmission-based precaution (TBP) signs outside of resident's doors that were on precautions. *She was not aware that confidential medical information was written on the sign for resident -She would have removed the sign as that is not appropriate. *She was aware that resident 2 had removed the contact precaution sign with the words hazardous drug and chemo gloves from the wall outside of her room in May 2023. 4. Interview on 8/2/23 at 1:52 p.m. with certified nursing assistant (CNA) H revealed: *When a resident was on contact precautions there was a sign on the resident's door identifying precautions. *Personal protective equipment (PPE) was provided to care for that resident. *Staff were notified when a resident was on TBP through a verbal report. *She had completed training on confidentiality in May of 2023. 5. Interview at 1:57 p.m. with CNA I revealed: *Staff were notified if a resident was on TBP through a verbal report, a communication book, CNA 'cheat sheets' and signage. -The signage included what PPE was required to care for the resident and what type of precautions the resident was on. *She agreed that 'hazardous drug' and 'chemo gloves' was protected medical information and should not have been placed on those signs. 6. Interview on 8/2/23 at 1:59 p.m. with registered nurse G revealed: *Staff were notified if a resident was on precautions through a verbal report and signage placed on individual resident room doors. *She said resident 2 was still on precautions even though the signage had been removed. *She agreed that identifying information such as 'hazardous drug' and 'chemo gloves' was protected medical information and should not have been placed on those signs. 7. Interview on 8/2/23 at 2:01 p.m. with RN supervisor E revealed: *ADON H was responsible for placement of the signs for residents on TBP. *When a resident was on a chemotherapy drug that information was placed on the sign so that people would know they needed to take precautions. *She agreed, by nodding her head in an affirmative motion, that was protected medical information and should not have been placed on those signs. 8. Interview on 8/2/23 at 2:08 p.m. with ADON D revealed she: *Was responsible for placing TBP signs outside of the resident rooms. -That was to notify staff that a resident was on TBP. -Other methods used to notify staff included: emails to nursing staff, nursing communication books, resident care plans, daily staff 'lineups', and over the door hangers of PPE. *Wrote on TBP signs if a resident was on a chemotherapy drug or a hazardous drug. *Had placed signage on resident 1's and resident 2's doors indicating they were on a hazardous drug and anyone entering the room needed to use chemo gloves. *Stated that resident 2 had removed her sign some time ago. *Confirmed that information on the signs was protected medical information and should not have been on those signs. *Confirmed that all staff were provided confidentiality and resident rights training each year. 9. Interview on 8/2/23 at 3:05 p.m. with RN/staff development coordinator F revealed: *All staff were provided education on resident rights and resident's privacy policies upon hire and annually. *She confirmed all current employees had been provided additional training on resident's rights and confidentiality training in May and/or June of 2023. 10. Interview on 8/2/23 at 2:30 p.m. with director of nursing B revealed: *She had multiple meetings with their pharmacy regarding resident 2's chemotherapy medication and the result of these meetings were the following: -The processes of how they used PPE was best practice. -They should have made sure they had notified staff and visitors that resident 2 was on a chemotherapy drug. *She was unsure if placing 'hazardous drug' or 'chemo gloves' on TBP signs located in public areas was right or wrong in regard to protected medical information. *She stated, We are doing the best to protect our staff, we have several childbearing age [staff members] and a few pregnant [staff members]. *She was not sure how else to notify staff and visitors and stated, I will have to contact our pharmacy and related facilities. *She stated their pharmacy consultant might know. 11. Telephone interview on 8/2/23 at 3:06 p.m. with pharmacy consultant J revealed: *The pharmacy had not provided any signage for posting to the public regarding TBP. *He had no opinion if signage that included hazardous drug' or chemo gloves was protected medical information. 12. Interview on 8/2/23 at 4:09 p.m. with administrator A regarding the contact precaution signage outside of resident 1's room revealed: -He stated, The sign was removed this afternoon and that staff and visitors needed signs placed outside of resident's rooms if they were on TBP so they would know what to have used in order to protect themselves when a resident was on TBP. -When asked if visitors needed to know the 'why' of using precautions, he had not provided an answer. 13. Review of the provider's April, 2023 Transmission Based Precautions policy revealed: *III. Isolation Room Procedure: Once the need for transmission based precautions (isolation) has been identified, the following procedures are followed: -B. Place the proper color-coded isolation sign for the type of precaution(s) on the resident's door or designated area. --Isolation Categories ---D. Contact Precautions ----1. General: a. Door may be open. Place contact precaution sign on outer resident door. 14. Review of the provider's December, 2021 Confidential Information policy revealed: *Policy: It is the policy of the covered entities of .to respect and protect the privacy rights of patients . *Definitions and Procedures: -Confidential information discussed within this policy includes: -Patient Related Information . 15. Review of the provider's December, 2021 Resident [NAME] of Rights and Responsibilities revealed: *General Information -Residents of long term care facilities have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires long term care facilities to promote and protect the rights of each resident and stresses individual dignity and self-determination. --*Right to Privacy ---1. Regarding personal, financial, and medical affairs. ---3. During treatment and care of personal needs.

Based on observation, interview, record review, and policy review, the provider failed to: *Ensure environmental precautions were in place to prevent harm to one of one sampled resident (37) who received a burn to her left ankle from a heat register in her room after her bed had been moved. *Implement timely and appropriate bowel management interventions for one of one sampled resident (128) who had been receiving hospice services. Findings include: 1. Observation on 3/21/23 at 8:09 a.m. and again at 10:08 a.m. of resident 37 revealed: *She was lying in bed under the blankets and appeared to be sleeping soundly. *The bed was in the lowest position and a fall mat was on the floor in front of the bed. *She had a full body pillow positioned beside her on the non-wall side. *A call button was clipped to the pillow at the head of her bed. *There was a wheelchair in the corner of her room with a Pommel cushion setting in it. *At 10:08 a.m., she was lying on top of her made bed, dressed and groomed under a throw blanket and appeared to be sleeping soundly. Review of resident 37's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) score was 12 indicating her cognition was mildly impaired. *Diagnoses included Parkinson's disease, dementia, repeated falls, a burn, pain, limited range of motion, history cerebral infarction, dysphagia, weight loss, and adult failure to thrive. *On 3/3/22 the Wound/Incision -Complex assessment documented an open pink wound measuring 3.5 centimeters (cm) length x 2.5 cm width x 0.1 cm depth with an 8.75 cm wound area. An Optifoam dressing was placed over the wound/burn. *On 3/10/23 the Wound/Incision-Complex assessment documented the burn to the left ankle was 5 cm length x 5.3 cm width x 0.1 cm depth with a wound area 26.5 cm and described as redness surrounding the wound, It had a white open area inside the wound, a fluid-filled blister at the distal end of the wound and a purple area in the center of the wound. *On 3/18/23 the Wound/Incision - Complex assessment documented the burn to left ankle was 4 cm length x 2.5 width, 10 cm wound area with a dark area in center over the ankle bone and a 6 cm x 5 cm red macerated [occurs when skin is in contact with moisture for too long] area surrounding open area. *On 3/15/23 [[NAME] St. Luke's] wound care clinic orders were written as Burn L [left] foot dressing change every three days. 1.) Exoderm/Duoderm to burn site 2.) upon change clean with sterile water, dry well. 3.) Allow any necrotic tissue to peel away. 4.) f/u [follow up] 2 weeks. Ensure bottle x 1 a day. Next appointment on 3/29/23 9:30 am. *There was no documentation in the resident's medical record indicating what type or degree of burn the resident had. Review of resident 37's comprehensive care plan initiated on 10/11/23 and revised through 3/10/23 revealed: *Problem -Skin Integrity --As evidenced by: urinary incontinence, Braden reveals mild risk, requires extensive assistance with bed mobility & toileting ---3-6-23 left outer ankle as a large pink area. Optifoam gentle to left outer ankle-change every 5 days until healed. ---3-10-23 left outer ankle has clear liquid drainage on dressing, odor when taking dressing off, area is worse than on 3-6-23. (see measurements). will update MD to get wound consult. -Nutritional Status --Severely compromised nutrition status D/T [due to]: significant weight loss and needs altered diet texture and staff assistance. ---Meals at assisted table. ---Supplement with noon & supper meals and prn [as needed] Try hot chocolate Boost at breakfast. ---Black enlarged handled silverware and divided plate. -Fall risk --As evidenced by history of falls, impaired balance, Psychotropic drugs, Impaired cognition secondary to Parkinson and dementia. ---1/26/23 pommel cushion in wheelchair per safety huddle and therapy review is to continue restorative therapy and check on resident frequently. Review of the provider incident report dated 3/3/23 revealed: *Resident's injury was due to her left ankle resting against the heat register in her room. *Her room had been rearranged and the bed was moved along the wall next to the heat register. *Once the burn was identified and addressed by staff her bed was moved away from the heat register on the wall. *Education was provided to the staff that before rearranging resident's rooms they were to consult with the resident care coordinator for permission, an email was sent to the staff and the education was reinforced during the staff daily line-up meetings. *The physician and family were notified of the incident. Observation and interview on 3/22/23 at 9:22 a.m. with licensed practical nurse (LPN) Q during the wound care for resident (37) revealed: *The wound was a burn on her left ankle and was a result of her ankle resting on the heat register on the wall while she was lying in bed. *The bed was now moved away from the heat register and was placed against a different wall. *The resident required staff assistance for transfers and repositioning. *Skin assessments of identified wounds were completed on Saturdays and Sundays by staff nurses with measurements completed at that time. *The provider did not have a designated wound care nurse. *If residents wounds were not improving or worsened they were referred to the wound care clinic. *She had no formal wound care training. *The resident had been referred to the wound care clinic after her burn wound had worsened. *The old dressing was removed, the area was cleansed with normal saline, patted dry with gauze and a Exoderm dressing was placed over the residents' burn wound. *The left ankle burn was approximately 4 cm length x 2.5 width, it had a dark black area in the center over the ankle bone and had approximately a 6 cm x 5 cm red macerated area surrounding the dark area in the center of the burn. *The resident moaned, cried out and attempted to move her foot away from the nurse during the wound care process. *LPN Q agreed she was exhibiting behaviors of pain and stated that had been her usual response during the wound care for her burn. *LPN Q stated the resident was able to communicate by answering questions with a yes or no, it took her a while to respond and it was a very soft and quiet whisper when she would speak. *No resident verbal communication was observed during the observations. *The staff had received an email that there was to have been no rearranging resident's furniture in their rooms without the permission from the resident care coordinators. Interview on 3/23/23 at 8:59 a.m. with assistant director of nursing (ADON) C revealed: *Initially resident rooms were arranged per the resident's choice, their needs, and in resident 37's case she was dominant on one side so they would have looked at what was going to work best for her. *Rearranging furniture in resident's rooms was not something that happened in the facility. *Staff had historically not taken it upon themselves to rearrange furniture and that event was a total fluke. *Administrative staff had a meeting and completed the 5 why's. *Staff that had worked that shift were interviewed and two days prior to the identification of the resident's burn was when they had thought the residents bed had been moved. *No staff had come forward or admitted moving the bed and no staff had knowledge of why the bed had been moved. *The provider does not have a designated wound care nurse. *The charge nurse completed the wound care and would send a fax to the physician for communication and to obtain orders. *Nurses had not received any specialized training for burn wound care. *Resident care coordinators would have been consulted if a wound was not healing, they had assigned on line training for wound care along with each staff nurse. *The provider utilized outside referrals to consult for wound care at the hospital with a physician order. *She felt the nursing staff had the education to have known when to reach out for wound care consults with regards to wound changes or decline in the wound status. Interview on 3/23/23 at 9:49 a.m. with registered nurse (RN) P while performing another task revealed: *There was no designated wound care nurse. *The charge nurse was responsible for resident's wound care during their scheduled shift. *Nurses and CNAs completed on-line training and she had not received any specialized wound care training. *If a resident's wound was not improving or worsening the charge nurse would fax the physician and get an order to send the resident to the wound care clinic. *The staff had received an email regarding there was to have been no rearranging resident's furniture in their rooms without permission from the resident care coordinators. Interviews on 3/23/23 between 10:35 a.m. and 11:20 a.m. with CNAs S, R and J revealed: *They had all been employed from six to eight months and had received their training from the provider. *They had each received a work email regarding that there was to have been no rearranging of residents rooms or moving resident's furniture without prior approval from the nurse. *CNA S stated she would not have rearranged a resident's room or moved their furniture without talking to and getting permission from the nurse first. *CNA R stated she would have talked to the resident or a nurse and gotten permission before making any change to a resident's room. *CNA J stated she would visit with the nurse before moving a resident's furniture and also voiced she had not received any other education or shared in discussion residents' rooms and moving furniture. Interview on 3/23/23 at 10:50 a.m. with resident care coordinator (RCC) E revealed: *She had been employed for two months. *She was aware and had been educated on the newly developed protocol for staff to get permission from the resident care coordinators before re-arranging resident rooms or moving their furniture. *Staff were educated on the newly developed protocol and had received an email with continued follow up occurring at the staff's daily line up meetings. *She was not aware of staff rearranging residents' furniture prior to or since the incident occurred with resident 37. Interview on 3/23/23 at 11:41 a.m. with director of nursing (DON) B revealed: *Resident rooms were arranged for resident's choice, convenience and safety. *There had been no set policy for resident's room arrangements as residents were different and it was to have been individualized. *Conversations needed to happen before room adjustments were made to ensure resident safety. *Since the incident involving resident 37 had happened they had developed a new protocol where the standard of practice was staff must visit with the resident care coordinators first and leaders were to have discussed as a team prior to the staff rearranging resident's rooms or moving resident's furniture. *During the survey the newly developed protocol was requested. *DON B stated they had not developed a written policy or protocol, she only had the emails that had been sent to the staff and meeting notes from when meetings had taken place. *DON B stated they had completed many interviews with staff during their investigation and no one came forward during the investigation. *They had reported the incident to the South Dakota Department of Health, educated staff regarding the new protocol that had been developed, sent staff emails, followed up during staff's daily line ups and completed a sweep of the building to ensure resident's room arrangements were safe. *Since COVID nursing staff were completing on-line training's. *She was not aware if there was an on-line skin/wound training program. *Nurses communicated the resident's wound status and received physician orders for wound care by faxing a communication form to the resident's physician. *If a resident's wound was not healing or worsening a nurse would fax the physician and get an order for a wound care consult. 40788 2. Observation and interview on 3/21/23 at 8:45 a.m. with resident 128 in her room revealed she: *Was lying in bed on her side and looked thin in appearance. *Was receiving hospice services and wanted nature to take its course. *Stated her main concern was the inability to get a laxative like Milk of Magnesia which she had used at home. -Had only one bowel movement in the eleven days since her admission on 3/10/23. Review of resident 128's medical record revealed: *Her admitted was 3/10/23 and she began receiving hospice services on that same date. *Hospice registered nurse (RN) T's 3/12/23 progress note: Will plan to request prn [as needed] stool softener as patient verbalizes she has always had one in the past. She would like to try prune juice today to assist with bowels. I did update ECF [extended care facility] nurse on this request. *Medication orders signed on 3/13/23 by the resident's medical provider included the following orders: -Daily scheduled and as needed oral oxycodone-acetaminophen related to the resident's history of chronic back, neck, and coccyx pain. --That medication was an opioid with known side effects that included constipation. -Daily as needed oral senna (laxative) and daily as needed bisacodyl (laxative) suppository. *Hospice RN T's progress notes: -3/14/23: She [resident 128] shares the prune juice did help her bowels and she was able to have a bowel movement yesterday. Information was reviewed with the facility nurse. -3/17/23: Patient [resident] shares need for prn stool softener today. ECF nurse updated. Last bowel movement was 3/13/23. She continues to drink prune juice to help with bowels. *RN U's 3/19/23 faxed communication to the resident's medical provider included the following: -Resident is requesting PRN MOM [Milk of Magnesia]. States this has worked the best for her in the past for occasional constipation. She currently only has PRN bisacodyl suppositories and PRN Senna 8.6 mg BID. She has been receiving PRN Senna (once on 3/18/23 and twice on 3/19/23) with no results and she is day six of no bowel movement. She refuses the suppository when offered. *Hospice RN T progress notes: -3/21/23: Conferred with medication aide V ECF. He also updates she [resident 128] has been requesting prn stool softener for constipation. She is also requesting to have a scheduled stool softener to assist with bowels. I will plan to request this from the provider. *RN U progress notes: -3/22/23 at 9:58 a.m.: New orders were received for scheduled Senna 8.6 mg PO BID and PRN MOM. PRN milk of magnesia given this morning .in addition to her scheduled Senna to help promote bowel movement. Resident declined a PRN suppository in lieu of trying the MOM first. 12:49 p.m.: Resident was reapproached about the use of a PRN suppository which she agreed to. Hard stool present at rectum when inserted suppository. Small amount of hard stool removed with digital disimpaction. 1:31 p.m. Extra large results from suppository that was given. Interview on 3/22/23 at 3:45 p.m. with resident 128 in her room revealed: *Her bowel movement earlier that afternoon was the most painful thing and no one should have to go through that. *I just couldn't get them [staff] to understand her need to have regular bowel movements. Interview on 3/22/23 at 4:15 p.m. with resident care supervisor (RCS) D regarding resident 128 revealed: *She knew as a former hospice nurse that residents who were prescribed scheduled opioids were at increased risk for constipation without scheduled bowel management interventions. -Resident 128 should have had scheduled pharmacological and non-pharmacological bowel interventions that were initiated at the time of her admission. *She was the provider's designee and was responsible for working with hospice staff to coordinate care for residents receiving hospice care services. -She had not reviewed resident 128's hospice orders. *Nursing staff had not followed the provider's Bowel Protocol policy that included consistent administration of ordered PRN laxatives and contacting the resident's medical provider on day four if the resident had no bowel movement. *I can't even defend it referring to the reason why the resident had gone nine days without having had a bowel movement. Interview on 3/22/23 at 4:50 p.m. with RN U regarding resident 128 revealed she was aware of the provider's bowel protocol and had followed it on the days she worked by administering ordered PRN laxatives and notifying the medical provider about the resident not having had a bowel movement. Interview on 3/23/23 at 10:15 a.m. with director of nursing B revealed: *Resident 128 should have had a scheduled laxative ordered at the time of her admission. *Nursing staff had not followed the Bowel Protocol policy. *Nursing staff, RCS D, and hospice RN T were expected to collaborate on RN T's visit days to assess symptom management and address in a timely manner any barriers to symptom management to ensure the comfort and quality of life of the hospice resident. Review of the June 2022 revised Bowel Protocol revealed: *Residents at risk for constipation included those who routinely used narcotics. *For resident complaints of constipation and/or no bowel movements for two days: -5.a. Day 2=offer Prune juice. -5.b. Day 3=give ordered PRN Milk of Magnesia or Miralax. -5.c. Day 4=Listen for bowel sounds. Give ordered PRN Dulcolax Suppository. -5.d. If still no results, consider contacting the Physician.

Based on observation, interview, record review, and policy review, the provider failed to ensure ongoing and timely skin assessments were conducted and documented by a licensed nurse prior to the development of pressure ulcers for two of two sampled residents (20, and 58). Findings include: 1. Observation and interview on 3/21/23 at 10:38 a.m. with resident 20 in his room revealed he: *Was sitting in a wheelchair on a pressure relieving cushion. There was a pressure relieving cushion in his recliner and a pressure reduction mattress on his bed. *Had a colostomy, was able to empty the colostomy bag independently and the nurse changed the appliance every five days. *Received a shower with staff assistance once a week. *Had a prosthetic for his right lower leg, was able to put it on independently but was not wearing it because he had swelling in his leg and it would not fit at that time. *Had a CROW [Charcot Restraint Orthotic Walker]boot that was used to accommodate and support and keep his left foot from rolling to the outside and reduce pressure, but he was not wearing it because it caused a pressure ulcer to his left lower inner leg, that had healed. *Reported the nurses used a Betadine swab and painted a sore on his backside [buttocks], was going to wound care at the hospital for it, and the nurses had taken a picture of it weekly. *Reported the bath aide drying him off after his shower had seen the sore on his backside and reported it to the nurse. *Had no feeling or pain on his backside. *Had a sore on his backside several times before, they healed up and would come back in a different spot. *Was on a carbohydrate-controlled diet but had not always chosen to follow the diet. *Reported he exercised five days a week in the physical therapy department, but was unable to walk in the parallel bars without his prosthetic and the CROW boot. *Reported his blood sugars ran high, it was 372 when checked by nursing during the interview, his physician was aware and had given the nurses orders for how to deal with his high blood sugars. Review of resident 20's medical record revealed: *He was admitted on [DATE]. *The provider's Roster Matrix [a resident listing of pertinent care categories] indicated he had a facility acquired stage 3 pressure ulcer. *His diagnoses included insulin dependent type 2 diabetes with neuropathy, right below knee amputation, colostomy, pressure ulcer of the sacral region stage 3, limitation of activities due to disability, abnormality of gait and mobility, morbid obesity, muscle weakness, chronic kidney disease, and atherosclerotic heart disease. *The Minimum Data Set (MDS) assessments dated 11/8/23 and 2/7/23 coded him at risk for developing a pressure ulcer and he had a pressure reducing device for his bed and his chair. *His Brief Interview for Mental Status (BIMS) score was 14 on all the above MDS assessments, and indicated he was cognitively intact. *Blood sugars listed four times daily from 3/1/23 to 3/22/23 totaled 88 blood sugars ranging from 143 to 483. -19 blood sugars documented were greater than 400. -38 blood sugars documented were greater than 300. -23 blood sugars documented were greater than 200. -8 morning blood sugars documented ranged from 143 to 197. *All six Braden Scale scores (used to determine the risk of developing a pressure ulcer) completed between 2/15/22 to 2/6/23 indicated he was at mild risk for developing a pressure ulcer. *Wound/Incision - Complex assessments completed by nursing dated 12/24/22 through 3/18/23 revealed resident 20 had a stage 3 pressure ulcer and was seen at the wound clinic weekly. *The wound clinic weekly visit documentation from 9/27/23 to 3/14/23 revealed: -Resident 20's chief complaint was I have a sore on my backside -Surgical History included: coronary stents, mid foot amputation on the right - 11/2/20, right foot surgery - 9/3/2020 (9 times), decubitus surgery buttocks - 9/30/2020 (multiple), Colostomy, BKA [below knee amputation] (right). -9/27/23 Wound Assessment Wound #7 Sacral is an acute Stage 3 pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 0.5 cm length x 0.3 cm width x 0.2 cm depth, with an area of 0.15 sq [square] cm and a volume of 0.03 cubic cm. Necrotic adipose is exposed. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted. There is a moderate amount of serosanguineous [thin watery fluid that is pink in color]drainage noted which has no odor. The patient reports a wound pain level of 0/10. The wound margin is thickened. Wound bed has No epithelial, No eschar, Yes slough, Yes bright red, pink, firm granulation. -2/7/23 Wound Assessment Wound #8 Coccyx is an acute Stage 3 Pressure Injury Pressure Ulcer and has received a status of not healed. Initial wound encounter measurements are 2.5 cm length x 0.3 cm width, x 0.2 cm depth, with an area of 0.75 sq [square] cm and a volume of 0.15 cubic cm. Necrotic adipose [fat tissue] is exposed. No tunneling has been noted. No sinus tract has been noted, No undermining has been noted. There is an moderate amount of serosanguinous drainage noted which has no odor. The patient reports a pain level of 0/10 [a score of 0 meant no pain on a scale of 0 to 10, 10 indicating the worst pain ever felt]. The wound margin is unattached. Wound bed has no epithelialization, No eschar, Yes slough, Yes pink, firm granulation. *The wound care orders dated 3/14/23 read Sacrum essentially resolved, DC [discontinue] dressing. BID [twice daily] Betadine paint for 10 days then DC. DC from routine FUP [follow up] unless new wounds develop or wound persists. Review of residents 20's comprehensive care plan regarding skin integrity was initiated on 10/3/22 and revised through 2/21/23 revealed: *As evidenced by current impaired skin integrity and hx [history] of previous open area to coccyx/buttocks -2/21/23 new area - left inner calf. Resident wears CROW Boot, only wear 1-2 hours first day and slowly increase wear time monitoring skin-should not wear gripper socks-needs long sock over top of brace. -2-21-23 collagen to right coccyx wound bed. cover with Optifoam Gentle. change every 4 days. -2-21-23 to left inner calf, apply Optifoam gentle to open area on inner left calf. change every 5 days and PRN until healed. Keep long socks on when wearing boot. Review of residents 20's comprehensive care plan regarding nutritional status initiated on 10/20/22 revealed: *Moderately compromised status D/T [due to] skin concern, abnormal labs, health risks from obesity, and needs therapeutic diet. -Skin integrity - heal skin concern. Improve hgb/hct [hemoglobin and hematocrit] and A1C [a blood test that measured an average blood sugar level over the past three months] levels. -Arginaid nutritional supplement with breakfast. -'Low Concentrated Carb[carbohydrate], No Added Salt diet. Observation and interview on 3/23/23 at 10:11 a.m. with registered nurse (RN) P while performing wound care for resident 20 revealed: *Resident 20's ulcer to his coccyx was dry and scabbed over. *Orders from wound care were to paint the ulcer with Betadine through 3/24/23 and then stop the wound care. *The pressure reduction measures in place for resident 20 were a pressure reduction cushion in his wheelchair and recliner and a pressure reduction mattress on his bed. *He had an alternating air pressure reduction mattress when he had his last pressure ulcer but he had not had it since the previous pressure ulcer had healed. *Nurses completed a thorough skin assessment when a resident was admitted and then weekly for three additional weeks. *Braden scales for the identification of pressure ulcer risks were completed at admission and quarterly with the MDS. *Nurses had not completed routine skin assessments for residents other than for new admissions prior to the identification of a resident's skin concern. *Certified nursing assistants (CNA's) observed resident's skin during bathing and personal care and reported any concerns of redness, skin tears or open areas to the nurse. *She was not sure if the CNA's had received specialized training for observing resident's skin and identifying skin concerns. *There was no designated wound care nurse. *The charge nurse was responsible for the resident's wound care on their scheduled shift. *Nurses and CNAs completed on-line training's and she had not received any specialized wound care training. *If a resident's wound was not improving or was worsening the charge nurse would fax the physician and get an order to send the resident to the wound care clinic. 2. Observation and interview on 3/21/23 at 10:30 a.m. with resident 58 revealed she: *Was sitting in her wheelchair watching television and her call light was clipped to her shirt. *Had a pressure reduction cushion in her wheelchair. *Had socks and tennis shoes on her feet. *Had her bed in the lowest position. *Had heel protector boots setting on the floor next to her recliner. *Was not responding verbally when spoken to and was determined to be non-interviewable. Review of resident 58's medical record revealed: *She was admitted on [DATE]. *Her diagnoses included Alzheimer's disease, dementia, diarrhea, urinary incontinence, and pressure ulcer of the left heel. *The MDS assessments dated on 11/29/22 and 2/27/23 coded her at risk for developing a pressure ulcer and she had a pressure reducing device for her bed and chair. *Her BIMS score was 1 on all the above MDS assessments, and indicated she had severe cognitive impairment. *The provider's Roster Matrix indicated she had a facility acquired stage 3 pressure ulcer. *All Braden Scale scores completed between 11/30/22 to 1/3/23 indicated she was at mild risk for developing a pressure ulcer. *The 11/30/22 Braden Scale assessment documentation listed activity as ordered, skin care products, hygiene, specialty bed mattress and specialty cushions interventions that were in place. *The 12/20/23 Braden Scale assessment documentation listed activity as ordered, offload bony areas, elbow/heel protectors, skin care products, hygiene interventions that were in place. *Wound/Incision - Complex assessments completed by nursing started on 12/9/22 through 1/6/23 documented the left heel with a deep tissue injury [purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear], described as purple, black, dark red, and boggy. *The initial Wound/Incision - Complex assessment completed by nursing dated 12/9/22 had the wound measurements as 2.5 cm length x 4.0 cm wide and the wound area as 10 cm. *Physician communication fax dated 1/30/23 were orders for resident 58 to have been seen by podiatry at wound care at hospital. *Progress notes from the wound clinic dated 2/3/23 documented Wound Assessment - Wound #1 Left heel is chronic Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2 cm length x 4 cm width x 0.1 cm depth, with an area of 8 sq cm and a volume of 0.8 cubic cm. No tunneling has been noted. No sinus tract has been noted. No undermining had been noted. *There was no drainage noted. The patient reports a wound pain level of 0/10. Wound bed has not epithelialization, Yes eschar, No slough, No granulation. *Progress notes from the wound care clinic dated 2/3/23 documented orders for dressing as apply primary dressing - betadine gauze, dry gauze and cloth tape. Change daily. Review of residents 58's comprehensive care plan regarding skin integrity and nutrition dated 11/28/22 with a revision date of 2/20/23 revealed: *She had a pressure ulcer to her left heel. *She received Boost Breeze at breakfast and chocolate Boost Plus a supplement at the noon meal. *Nursing staff were applying topical iodine, gauze and tape daily. *No other interventions were listed on the skin integrity care plan. Observation and interview on 3/23/23 at 9:49 a.m. with registered nurse (RN) P while completing wound care for resident 58 revealed: *Resident 58 was sitting in her recliner with no pressure reduction cushion and she had heel protector boots on both feet. *Her wheelchair was next to her bed and it had a pressure reduction cushion on it. *There was a pressure reduction mattress on her bed. *Resident 58's pressure ulcer to her left heel was intact, black/brown, firm dry area, dry and scabbed over. *Orders from wound care were to apply topical Betadine, cover with gauze and tape in place daily. *The pressure reduction measures in place for resident 58 were a pressure reduction cushion to have been used in her wheelchair and her recliner, a pressure reduction mattress on her bed, and heel protector boots, *Nurses completed a thorough skin assessment when the resident was admitted and then weekly for three additional weeks. *Braden scales for the identification of pressure ulcer risks were completed at admission and quarterly with the MDS. *Nurses did not complete routine skin assessments other than for new admissions, prior to the identification of a resident's skin concern. *CNAs observed resident's skin during bathing and personal care and reported any concerns of redness or open areas to the nurse. *She was not sure if CNAs had received specialized training for observing skin and identifying skin concerns. *There was no designated wound care nurse. *The charge nurse was responsible for the resident's wound care on their scheduled shift. *Nurses and CNAs completed on-line training and she had not received any specialized wound care training. *If a resident's wound was not improving or was worsening the charge nurse would fax the physician and get an order to send the resident to the wound care clinic. Interview on 3/22/23 at 9:22 a.m. of licensed practical nurse (LPN) Q while performing another task revealed: *Braden scales were completed for residents at the time of admission and then quarterly with the MDS. *Skin assessments were completed by nursing for residents at the time of admission and then weekly for an additional three weeks. *Skin/wound assessments for the residents with identified skin wounds were completed on Saturdays and Sundays by the charge nurse working that shift and wound measurements were completed at that time. *If residents wounds were not improving or worsening they were referred to the wound care clinic. *Skin observations were done by CNAs during resident personal care and bathing and they notified the nurse if they saw any skin concerns such as redness, bruises, skin tears etc . *She denied being aware of CNAs receiving any additional skin/wound training other than what they received during their CNA course. *She denied that nursing completed routine skin assessments for residents at risk for pressure ulcers prior to the identification of a pressure ulcer. *She completed on-line training's and had not received any specialized wound care training. Interview on 3/23/23 at 8:59 a.m. with assistant director of nursing (ADON) C revealed: *Head to toe skin assessments were completed in the evening by the night shift charge nurse when a resident was admitted . *The charge nurse worked a twelve hour shift. *Braden scales were completed for residents at the time of admission and then quarterly with the MDS by the resident care coordinators. *Pressure ulcer prevention measures put into place for residents at risk for developing a pressure ulcer were repositioning schedules, specialty mattresses for pressure reduction, wheelchair/recliner cushions and some of the residents had pressure reducing boots. *CNAs completed skin observations during resident's personal care and bathing and reported any skin concerns of redness or open areas to the nurse. *She was not aware if there had been a procedure or protocol set up and in place for nurses to complete routine skin assessments for residents at risk for developing a pressure ulcer. *The charge nurse completed residents wound care and sent a fax to the resident's physician with communication of the wound status and for new orders. *The resident care coordinators were consulted if a resident's wound was not improving or was worsening. *The resident care coordinators were assigned and completed the same on-line training's as the other nurses. *The would have utilized outside referrals to consult with the wound care clinic. *She felt the nursing staff had the education and knowledge to obtain a physician order for a wound care consult for residents with wound changes, non-healing wounds or a decline in the wound status. Interviews on 3/23/23 between 10:35 a.m. and 11:20 a.m. with CNAs S, R, and J revealed: *They had all been employed from six to eight months and had received their on-line training and training from the provider. *In their roles, they were to observe residents skin during bathing and personal cares and report any skin concerns such as redness, skin tears, or open areas to the nurse. *They had not received any additional training for observing skin concerns other than what was included during their training. *They were aware pressure ulcer prevention interventions utilized for residents identified as at risk for skin breakdown were: repositioning, toileting schedules, applying barrier cream, cushions, heel boots, and pressure reducing mattresses. Interview on 3/23/23 at 10:50 a.m. with resident care coordinator (RCC) E revealed: *She had been employed for two months. *She had received training for completing admission, discharges, care conferences, the MDS assessments, and helping staff that worked with residents. *Braden Scale assessments were completed with residents at the time of admissions, and then quarterly with the MDS assessments. *Resident skin assessments were completed at the time of admission, then weekly for an additional three weeks, quarterly, and annually with the MDS assessments. *She had not received any specialized wound care training. *CNAs completed skin observations while providing residents personal cares and bathing and reported any skin concerns such as redness or open areas to the charge nurse. *She was not aware if the CNAs received any skin care education beyond the CNA certification program. Interview on 3/23/23 at 11:41 a.m. with director of nursing (DON) B revealed: *Nurses completed head to toe skin assessments for residents at the time of admission, then one time weekly for 3 additional weeks, and then quarterly and annually with the completion of MDS assessments. *Braden Scale assessments were completed at the time of admission, quarterly and annually with the MDS assessments. *Residents found to have been at risk for pressure ulcers were discussed at interdisciplinary (IDT) team meetings, therapy would have been involved and interventions were put in place such as a restorative program, repositioning, good nutrition, pressure reduction mattresses, cushions, and the family and physician were updated. *CNAs were observing resident's skin during bathing, personal care, repositioning and reporting skin concerns to the nursing staff and that was how resident skin concerns or issues were identified. *There was no process in place for nurse skin assessments to have been completed, for residents identified at risk for pressure ulcer development. *Prior to COVID they had nursing staff attend wound workshops and had wound care training events with wound care. *She was not aware if there was an on-line skin/wound training program or if CNAs had received additional training for completing skin observations outside of what they had received in their CNA certification course. Review of the provider's 6/2021 Skin Assessment policy revealed: *It is the policy of this facility that all residents will be routinely monitored for impaired skin integrity. Measures will be taken to predict residents at risk and implement individualized preventive interventions as needed. In the event impaired skin integrity unavoidably develops, individualized interventions will be implemented to promote rapid healing. -5. Weekly assessments will be completed by a licensed professional and updated on the weekly skin assessment sheet. Review of the provider's 10/2021 Pressure Ulcer Prevention Policy and Procedure revealed: *A pressure ulcer risk assessment (Braden scale) will be done on admission and repeated at defined intervals. Skin assessments will be done on admission and repeated at defined intervals. Interventions will be implemented to reduce the risk of developing pressure ulcers by managing moisture, optimizing nutrition and hydration, and minimizing pressure. all related assessments and interventions will be documented. -A. Assessment --1. Perform Braden Scale risk assessment to identify pressure ulcer risk --2. Perform skin assessment --5. Identify all individual risk factors -B. Interventions --1. Implement interventions based on Braden Scale score ---At Risk: Braden score 15 to 18 ---Moderate Risk: Braden Scale score 13 to 14 ---High Risk: Braden Scale score 10 to 12 ---Very High Risk: Braden Scale score 9 or below *This policy applies to personnel responsible for skin assessments, risk assessments and interventions to reduce the risk of developing pressure ulcers by managing moisture, optimizing nutrition and hydration, and minimizing pressure. All nursing personnel are expected to inspect and protect their patient's skin. Nursing is responsible for assessment and plan of care; the LPN and non-licensed personnel are responsible for skin inspection, implementation of plan of care and reporting any changes in skin condition to the RN. *Leadership is responsible for ensuring there is a system-wide awareness of the patient safety performance goal of providing pressure ulcer prevention measures. Leadership is responsible for making the investment in resources required to meet the goal, analyzing performance gaps, and reporting the performance gaps as indicated by metrics to corporate level. *Appropriate staff must be competent in use of the Braden Scale, skin assessment, proper repositioning techniques and proper use of related equipment.

Based on observations, interviews, cleaning checklist review, and policy review, the provider failed to: *Clean six of six hood vent covers on a regular schedule to prevent the buildup of dust. *Properly clean and delime one of one dishwasher to prevent limescale buildup. *Ensure one of one vent duct above the dishwasher remained free from dust buildup. *Maintain the following food preparation equipment in a clean and sanitary manner that was free from burnt food particles and grease buildup: -One of one fryer. -One of one flattop grill grease trap drawer. -Three of three conventional ovens. -Two of two convection ovens. *Properly label food items and discard expired foods in two of two foodservice kitchenette freezer/refrigerator units and two of two resident's communal freezer/refrigerator units. 1. Observation on [DATE] from 8:22 a.m. to 8:50 a.m. in the kitchen revealed: *The hood vent covers above the main cooking equipment were clamped into place. -The clamps and hood vent covers were coated with a layer of dust. -There was a sticker which indicated the vent ducts were last professionally cleaned on [DATE]. *The inside surfaces of the convection and conventional ovens had numerous burnt-on food particles and grease spots. *The grease trap drawer that was attached to the flattop grill was filled with grease, fat, and food particles. -The drawer was difficult to open due to the amount of debris. *The fryer was to the right of the flattop grill. -There were multiple specks of food particles and fryer oil splattered in between the gap of the fryer and the flattop grill. *The vent duct above the dishwasher was caked with clumps of dust. *The dishwasher had a crusty layer of limescale buildup on the outside seams of the dishwasher doors. 2. Interview on [DATE] at 11:01 a.m. with cook M about how often the ovens were cleaned revealed: *They tried to deep clean the ovens once a month. *If there was a major food spill, then it was cleaned right away. Interview on [DATE] at 11:18 a.m. with lead nutrition and food service worker (LNFS) I about kitchen cleaning practices revealed: *They deep cleaned the ovens once a month with an oven cleaner. *They cleaned the fridges once a week. *The dishwasher was wiped down and cleaned once a day, and delimed once a week. *The maintenance department was responsible for cleaning the vent ducts. Interview on [DATE] at 11:26 a.m. with nutrition and food service (NFS) staff N and LNFS I about cleaning the dishwasher revealed: *At the end of each day, NFS staff N would drain the dishwasher, clean out the strainer bucket, and refill the dishwasher. *They would delime the inside of the dishwasher once a week. *They both stated they had not cleaned the outside of the dishwasher very often. *They indicated that maintenance would know more information about how often the vent duct above the dishwasher was cleaned. 3. Observation on [DATE] at 2:07 p.m. of the [NAME] and Dakota freezer/refrigerator units revealed: *The resident communal freezer/refrigerator unit was black in color and was padlocked shut. *Inside the refrigerator compartment, there were: -Several containers of food that were expired: --One [NAME] jar labeled Peach with a date of [DATE]. --One container of Chobani brand yogurt with a date of Sept. 08 2022. --One container of foul-smelling cottage cheese that had turned brown in color with a Best if used by date of [DATE]. -Multiple food items that were not labeled or dated: --Two bags of sliced salami meat. --One container of an orangish-brown thick substance. --One [NAME] jar filled with a red liquid. *Inside the freezer compartment, there was a container of an unidentified purple substance that was labeled [resident's name] [DATE]. *The foodservice freezer/refrigerator unit was white in color and was padlocked shut. *In the refrigerator compartment, there was a container of what looked like pickles or cucumbers that was not labeled or dated. *In the freezer compartment, there was a bag of what looked like hamburger patties that was not labeled or dated. Observation on [DATE] at 2:22 p.m. of the Boardwalk and Cedar freezer/refrigerator units revealed: *The resident communal freezer/refrigerator unit was black in color. *Inside the refrigerator compartment, there were several items that were not labeled or dated: -One glass bowl with a plastic lid of a foul-smelling food that appeared to have been soup. -One cup of an unknown brown liquid with a date of ,d+[DATE]. -One bag of what appeared to be a pie. *The foodservice freezer/refrigerator unit was white in color and located in the Cedar dining room kitchenette. -In the refrigerator compartment, there was a bowl of blueberries with a white fuzzy growth that was dated ,d+[DATE]. -In the freezer compartment, there was an uncovered bowl of ice cream that was not labeled or dated. 4. Interview on [DATE] at 2:38 p.m. with hospitality services manager (HSM) F about the observations in finding 3 revealed: *The foodservice staff were responsible for properly labelling foods with the food item and date in the foodservice refrigerators. *It was unclear who was responsible for labelling/dating foods in the resident communal refrigerators. *She said it should have been a collaborative effort between nursing and foodservice staff. *She was not aware of the unlabeled and expired food items in the resident communal refrigerators. Continued interview on [DATE] at 3:07 p.m. with HSM F about her role and expectations in the foodservice department revealed she: *Had been in her position since [DATE]. *Was unsure when the hood vent covers were last cleaned. -She thought maintenance was in charge of cleaning the hood vent covers. -She agreed the hood vent covers and the vent duct above the dishwasher were dusty and should have been cleaned. *Stated she was unsure when the last time the food preparation equipment (conventional ovens, fryer, convection ovens) was moved away from the walls to deep clean. *Expected her staff to wipe down the ovens weekly, and deep clean the ovens with an oven cleaner monthly. -She agreed it looked like the ovens had not been deep cleaned in a long time due to the amount of burnt food on the insides of the ovens. *Expected her staff to clean the dishwasher daily, and delime the dishwasher weekly. -She was not aware that staff were not cleaning the outside of the dishwasher. -They had a difficult time with keeping the dishwasher free from limescale buildup due to the water hardness. 5. Interview on [DATE] at 4:15 p.m. with maintenance director O and HSM F about the hood vent covers revealed: *A professional duct cleaning service came every six months to clean the facility's ventilation ducts. *Maintenance director O said the kitchen staff were responsible to clean the hood vent covers monthly. -They were supposed to unclamp the hood vent covers, slide them out, and put them through the dishwasher to clean them. *HSM F indicated that her staff had not cleaned the hood vent covers, and had not completed that task since she had started working at the facility. -She was not aware that she and her staff were supposed to have been cleaning the hood vent covers monthly. 6. Review of the provider's ,d+[DATE] Sanitary Conditions policy revealed: *Policy statement: The food service will be maintained in a clean and sanitary manner in storing, preparing, distributing and serving food properly to prevent food borne illness. *Procedure section: -3. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. -4. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. 7. Review of the provider's ,d+[DATE] Foods Brought in by Family & Visitors policy revealed: *Policy statement: It is the policy of this facility that foods brought in from family and visitors, for resident consumption, will be appropriately stored, handled and consumed. *Procedure section: -D. Families will receive this safe food handling information as part of the welcome booklet received at the time [of] admission. Information on the following areas will be included . --4. Proper labeling and dating of each item --5. Leftover foods will be used within 3 days or discarded -F. Refrigerated items shall be in tightly sealed containers and marked with the resident's name, food item, and current date. These items will be stored in a designated area in the facility's refrigerator until service time. -G. Families will be encouraged to take left over food home. Uneaten portions of leftovers cannot be stored in resident's room. Leftovers cannot be returned to the facility's refrigerator. 8. Review of the provider's Dakota Cleaning List and Cedar Cleaning List for [DATE] through [DATE] revealed: *Employee initials had been marked each day for the line item Clean [Refrigerator] (check for outdates, and make sure food is all labeled) 9. Review of the provider's Cook Cleaning List for [DATE] through [DATE] revealed: *Employee initials had been marked each day for the following line items: -Clean ovens (Front or Back) -Clean fryer (as needed) 10. Review of the provider's Main Cleaning List for [DATE] through [DATE] revealed: *Employee initials had already been marked for each line item for [DATE] and [DATE], even though the survey had ended on [DATE]. *Employee initials had been marked for the line item of Delime Dish Machine Fridays for the following dates: -[DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 11. Documentation indicating when the last time the professional duct cleaning service had last cleaned the ducts was requested from maintenance director O on [DATE] at 4:15 p.m. The requested documentation had not been provided by the end of the survey on [DATE] at 1:10 p.m.

Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Routine cleaning and disinfection of high touch surfaces in the semi-private room shared by one of one COVID-19 positive resident (48) and her roommate (71). *Proper handling and disposal of mealtime utensils used by one of one COVID-19 positive resident (48). *Appropriate glove use and hand hygiene had been performed during morning personal care for one of one sampled resident (31). *Appropriate cleaning and sanitizing of the E-Z stand mechanical lift and the body sling between two of two residents (12 and 31). Findings include: 1. Observation on 3/21/23 at 8:55 a.m. outside of resident 48 and 71's semi-private room revealed: *Airborne precaution signage for COVID-19. -Personal protective equipment use: gown, gloves, eye protection, and N-95 mask inside of that room. *The start date of those precautions had begun on 3/13/23 and the end date was 3/23/23. Observation and interview on 3/21/23 at 12:30 p.m. with lead nutrition and food service worker I revealed: *A serving tray with Styrofoam plates, cups, and utensils laid uncovered on a wheeled cart outside of residents 48 and 71's room. -Scrambled egg remnants were visible on the Styrofoam plate. *With ungloved hands lead nutrition and food service worker I removed the tray, carried the tray towards the enclosed food cart down the hall, then turned back around and carried the tray back to the wheeled cart. -She pulled that wheeled cart behind her with one hand and pushed the enclosed food cart with her other hand down [NAME] Hall, through another hallway, and into the kitchen. *Lead nutrition and food service worker I confirmed: -The serving tray referred to above was resident 48's breakfast tray. -The resident had COVID-19. -The tray should not have been left uncovered and unattended outside of the resident's room. -She should not have handled the food tray without gloved hands. -The tray should have been covered prior to transporting it to the kitchen. 2. Interview on 3/21/23 at 11:40 a.m. with certified nurse assistant (CNA) G revealed: *Resident 48 was independent with her self-care and was able to use the shared sink outside of the bathroom and the toilet inside of the bathroom on her own. *Resident 48's roommate resident 71 was not positive for COVID-19. -She had a stroke history resulting in impaired use of her right side. -She required staff assistance to use the sink and the toilet she had shared with resident 48. Interview on 3/21/23 at 12:15 p.m. with resident 48 revealed she: *Was immunocompromised and that was the fifth time she had COVID-19. -Her current symptoms were sinus congestion, some coughing, popping ears, and she had been told today she had a low grade temp [temperature]. *Kept the privacy curtain around her living space enclosed. *Was able to use the shared sink and toilet on her own. Interview on 3/21/23 at 11:51 a.m. with housekeeper H regarding cleaning and disinfection of resident 48's room revealed: *She had been employed by the facility for approximately [AGE] years. *Caregivers were responsible for cleaning COVID-19 positive rooms. *Non COVID-19 resident rooms were cleaned daily using an Environmental Protection Agency (EPA) approved disinfectant. Observation on 3/21/23 at 1:00 p.m. of CNA G inside of residents 48 and 71's room revealed she: *Transported resident 71 in her wheelchair into the shared bathroom to use the toilet. -After assisting her to stand using a gaitbelt the resident was instructed to hold the wall-mounted grab bars to remain upright while CNA G lowered her undergarments. *Assisted the resident onto the toilet riser to use the toilet. *Had not used a bleach wipe or other EPA approved cleaning product to disinfect the grab bars, toilet or sink prior to or after assisting resident 71 with toileting. Interview on 3/22/23 at 9:55 a.m. with CNA G revealed: *Housekeeping staff were responsible for cleaning all resident rooms including those who had COVID-19. -That included disinfection of the bathroom and sink shared by residents 48 and 71 in their room. *She had not been given any specific instruction regarding the disinfection of the shared sink or bathroom in between use by residents 48 and 71. Interview on 3/22/23 at 5:20 p.m. assistant director of nursing/infection prevention nurse C regarding the observations referred to above revealed: *Bathroom and sink cleaning was expected to have been cleaned and disinfected with an appropriate EPA-registered disinfectant at least daily by housekeeping staff and by the caregivers between use by residents 48 and 71. *Disposable plates, cups, and utensils used by resident 48 were expected to have been discarded in the designated garbage receptacle inside of that room. Review of the undated Room Tray Procedure for Passing to COVID Positive Resident policy revealed: *All disposable products are thrown away in resident room. *All non-disposable products including tray are bagged from inside room and taken out of room and place on cart outside of room. Review of the undated Terminal Clean of Coronavirus (COVID-19) Rooms policy revealed If a patient [resident] is in droplet/airborne precautions, housekeeping will clean room on a weekly basis. Review of the revised January 2023 Housekeeping Procedure for Resident Rooms policy revealed daily cleaning expectations included using a germicidal wipe to clean the sink and a disinfection solution to clean the toilet bowl and toilet stool. 47780 3. Observation on 3/22/23 at 10:00 a.m. of a sign taped on the inside of resident 31's door stated that she should have her own E-Z stand mechanical lift body sling. Observation on 3/22/23 from 10:02 a.m. to 10:33 a.m. of CNA J performing morning personal care for resident 31 revealed she: *Entered the room without performing hand hygiene. *Left the room three times during the observation without performing hand hygiene. *During that time frame she: -Put on a clean pair of gloves without performing hand hygiene and applied lotion to the resident's legs. -Removed the soiled gloves without performing hand hygiene and proceeded to dress the resident. -Partially dressed the resident by putting her socks on, pulling a clean brief and her pants partway up her legs, and then put the resident's shoes on. -Put the E-Z stand mechanical body sling around the resident, positioned her at the side of the bed, and raised her to a standing position with the E-Z stand mechanical lift. -Without performing hand hygiene, CNA J put on clean gloves to remove the residents soiled brief. -With those same gloves, she grabbed a package of wet wipes and cleaned the resident's bottom. -With those same soiled gloves, she applied a skin protection cream to the resident's bottom. -Removed those soiled gloves and without performing hand hygiene, she: --Pulled the residents briefs and pants up. --Touched the buttons on the E-Z stand to lower the resident into her wheelchair. --Removed the sling from behind her and placed the sling onto the E-Z stand. --Wheeled the unsanitized E-Z stand with the sling on it into the hallway. -Without performing hand hygiene, she put on a clean pair of gloves and applied more lotion on the resident's skin before getting the resident fully dressed. -Removed the soiled gloves, without performing hand hygiene, and wheeled the resident out of her room. -Returned with the resident and proceeded to make the residents bed. *Had not performed hand hygiene during the entire observation. Continued observation on 3/22/23 at 10:33 a.m. of that E-Z stand mechanical lift revealed: *CNA K came and took that E-Z stand mcechanical lift and body sling as described above and went into resident 12's room. *Without cleaning or disinfecting the equipment prior to use or ensuring it had been cleaned and disinfected prior to placement in the hallway, he proceeded to use the E-Z stand mechanical lift and sling for resident 12. 4. Interview on 3/22/23 at 10:36 a.m. with CNA J about her job duties revealed she: *Had been employed for six months. *Agreed she had not performed hand hygiene when leaving or entering the resident's room. *Agreed she should have changed gloves after removing the soiled brief and performed hand hygiene. *Stated they cleaned the E-Z stand and slings between each resident use. -Had not had a chance to clean the E-Z stand and sling before another CNA took the E-Z stand and sling to use for another resident. *She was aware of the notification that resident 31 had her own sling but had not seen one in her room. 5. Interview on 3/22/23 at 1:44 p.m. with CNA K about his job duties revealed he: *Had been a CNA for [AGE] years. *Was unsure if the E-Z stand and sling he had taken had been cleaned. *Had not cleaned or sanitized the equipment before using it on resident 12. *Was aware it had to have been cleaned and sanitized between each resident use. 6. Interview on 3/23/23 at 9:21 a.m. with staff development coordinator L about CNA training and job duties revealed: *She was responsible for educating new staff regarding hand hygiene. *Agreed gloves should have been removed and hand hygiene performed after soiled briefs were removed. *Expected staff to clean and sanitize the E-Z stand mechanical lift and the body sling immediately after resident use. 7. Interview on 3/23/23 at 9:31 a.m. with assistant director of nursing/infection prevention nurse C about infection control practices revealed: *They were attempting to get every resident their own body sling. *She agreed that staff should have cleaned and sanitized the equipment between each resident use. *Staff were to follow the Disinfection of Non-Critical Patient Care Equipment policy. *Resident 31 had a history of Extended Spectrum Beta-Lactamase (ESBL) in the urine and should have had her own sling. 8. Review of resident 31's electronic medical record revealed in 2018 she had a positive culture of ESBL in her urine. 9. Review of the provider's revised October 2022 Disinfection of Non-Critical Patient Care Equipment policy revealed: *I. PURPOSE -C. For the safety and comfort of residents, all reusable (non-critical) resident care items will be cleaned, disinfected, and maintained in a safe manner between residents uses. *II. INFORMATION -1. Non-critical items are those that come into contact with intact skin but not mucous membranes. These are divided into resident care items and environmental surfaces. --Noncritical resident care items were cleaned between/after each resident use. *III. POLICY -A. Community/facility items removed from a resident's room need to be disinfected prior to use by a different resident. -D. All reusable resident care equipment removed from a resident room/procedure room is disinfected before use on another resident. -J. Disinfection Recommendations- --1. Reusable resident care equipment. ---a. Between each resident use and when soiled. ----f. lifts 10. Review of the providers revised July 2022 Hand Hygiene policy revealed: *A. HH {Hand Hygiene}, either with soap and water or with alcohol-based hand rub (ABHR): -1. Immediately before touching a resident. -5. After removing gloves.

Based on observation, interview, and record review, the provider failed to ensure: *One of one sampled resident's (10) medication had been labeled and securely stored. *Proper medication self-administration practices had been followed for one of one sampled resident (10). Findings include: 1. Observation and interview on 3/21/23 at 3:41 p.m. with resident 10 in her room revealed: *There was a clear plastic container with a screw-top lid sitting on her overbed table. -There were five or six white circular pills in the container. -The container was not labeled with any information. *When asked what the pills were for, resident 10 responded, It's for my stomach cramps. I can take one every four hours. 2. Interview on 3/22/23 at 10:01 a.m. with registered nurse (RN) U regarding resident 10's medication revealed: *The medication on her overbed table was simethicone. *Resident 10 was able to self-administer her simethicone after set-up assistance. *To set-up the medication for her, they would pop the pills out of the prescription card, put the pills in the plastic container, and place the container on her overbed table when resident 10 asked for more of the pills. 3. Interview on 3/22/23 at 10:06 a.m. with resident care supervisor (RCS) D regarding resident 10's medication revealed: *Mediation self-administration would have been documented under the activities of daily living section of the resident's care plan. *They would have reassessed the resident's ability to self-administer medications at least quarterly with each Minimum Data Set (MDS) assessment. *Resident 10's care plan did not include a description of the medication that was self-administered. *Resident 10 had been living at the facility for several years, and the medication self-administration physician's order was from her admission in 2017. 4. Interview on 3/22/23 at 4:33 p.m. with assistant director of nursing (ADON) C about resident 10's medication revealed: *Resident 10 was visually impaired. *She liked to keep things in the same spot so she could find them. *She had increased anxiety when she was first admitted in 2017 because she could not have her medications at her bedside. -At that time, they assessed her for medication self-administration. *She indicated her staff probably should have labeled the medication. *She confirmed: -To set-up the medication for resident 10, staff would pop the pills out of the prescription card and put them in the clear plastic container. -They did not have a secure location to keep her medication due to her vision impairment. *There could have been a risk of a resident wandering into her room and mistakenly taking the medication. At that time, policies for medication self-administration, medication labeling, and medication storage were requested. The requested information had not been provided by the end of the survey on 3/23/23 at 1:10 p.m. 5. Interview on 3/22/23 at 5:05 p.m. with RCS D and RCS E regarding resident 10's medication revealed: *They had physician orders to set-up her medication to self-administer. *They would give her six simethicone pills at a time, and she took them on an as-needed (PRN) basis. *The PRN medication was not labeled once placed in the clear plastic container. *They confirmed there could have been a risk of a resident wandering into her room and mistakenly taking the medication. At that time, policies for medication self-administration, medication labeling, and medication storage were requested again. The requested information had not been provided by the end of the survey on 3/23/23 at 1:10 p.m. 6. Review of resident 10's list of active medications revealed: *There was a physician's order for Simethicone 80 Mg [milligrams] Chew. -The medication route was PO [by mouth]. -The frequency was Q4H PRN [every four hours as needed]. -The reason was Flatulence. -The physician order started on 8/1/22. -The order had not indicated that she could self-administer the medication after set-up assistance. 7. Review of resident 10's care plan revealed that there was no documentation of her medication self-administration status. 8. Review of resident 10's 3/7/23 quarterly MDS assessment revealed she had a Brief Interview for Mental Status score of 12, indicative of moderate cognitive impairment. 9. Review of resident 10's physician's admission order sheet from 10/9/17 revealed: *The primary medical diagnosis was dementia - [history] of brain tumor - seizure activity. *The secondary medical diagnoses were: [hypertension] - anemia - [chronic kidney disease] - [extended-spectrum beta-lactamases] in urine - macular degeneration - [carbapenem-resistant Enterobacterales]. *Under the Basic Treatments section, the line item May self administer meds after set up by the nurse, was checked. 10. Review of resident 10's Self Administration LTC assessment from 10/17/17 revealed: *Under the Approval Not Granted section: -Resident does have poor vision . She will have her . Gas X Chew [simethicone] at bedside in her room per [provider's order] on 10/17/17. This will be reviewed with her [primary care provider] on 10/19/17 on rounds. Resident has situational distress with changes in her living arrangements and inability to have these medications at bedside upon admission. Will monitor use and safety and [discontinue] if she is unsafe with it. *The physician was notified and approved the resident self-administering her medication. 11. Review of resident 10's Self Administration LTC assessment from 6/29/20 revealed: *At the time of the assessment, she was able to: -State the reason for the medication. -Read label or identify medication. -State the time medications should have been taken. -Correctly state and demonstrate the proper dosage for each medication. -Open and close the medication containers. -Demonstrate secure storage for medication in room. -Correctly request medication. -Understand and will not leave medication unattended. -Recognize the quantity of medication to take at a given time. *Under the Approval Not Granted section: -Resident continues to be able to identify her bedside meds when staff ask her. She does have poor vision, but has adapted to the feel of her medication containers and is able to see well enough to identify them and use them correctly. 12. Policies for policies for medication self-administration, medication labeling, and medication storage were requested on 3/22/23 at 4:33 p.m. from ADON C, and again on 3/22/23 at 5:05 p.m. from RCS D and RCS E. The requested information had not been provided by the end of the survey on 3/23/23 at 1:10 p.m.

Based on observation, interview, record review, and policy review, the provider failed to ensure an integrated plan of care had been developed for one of one sampled resident (128) receiving hospice services. Findings include: 1. Observation and interview on 3/21/23 at 8:45 a.m. with resident 128 in her room revealed she: *Was lying in bed on her side and looked thin in appearance. *Had fallen prior to her admission but had not had a fall since she het admission. *Was receiving hospice services and wanted nature to take its course. *Stated her main concern was the inability to get a laxative like Milk of Magnesia which she used at home. -Had only one bowel movement since her admission on 3/10/23. *Attended Catholic mass and had a supportive family. *Ate her meals in the dining room. Review of resident 128's medical record revealed: *Her admitted was 3/10/23 and on that same date she was started on hospice services. *Hospice nurse T's 3/10/23 through 3/21/23 progress notes revealed the resident had: -A terminal diagnosis of severe anemia. -Accepted the following hospice services: nurse, nurse aide, social worker, and chaplain visits. -A history of chronic neck, back, and coccyx pain. -Expressed a fear of falling and not wanting to become addicted to the pain medication she was receiving. -Voiced the need for a stool softener like the one she was accustomed to using at home. Review of resident 128's comprehensive care plan last revised on 3/18/23 revealed: *A Hospice Care Problem included the following Interventions: -The first name of hospice nurse T was identified as the primary nurse and there was a hospice aide for bathing -See visit schedule [for hospice staff] in communication book -Contact hospice team with any physical/emotional changes --There was no indication of how often these disciplines were to have been in the facility to assess the resident or what type of supportive care they were expected to provide during their visits. --There was no documentation regarding a social work or chaplain visits. --There was no mention of the resident's terminal diagnosis. --There was no mention of her choices such as rehospitalization , what care she wanted in the event of an acute illness or injury or any goals she had related to her terminal diagnosis. -Do not push food/fluids as it may cause adverse effects --That intervention had not been re-evaluated for appropriateness based on the resident's history of and current issues with constipation. *Bowel and Bladder Problem Interventions: -Failed to identify the resident's history of constipation, her increased risk for constipation based on her narcotic use, pharmacological or non-pharmacological constipation management interventions. *Pain Problem Interventions: -Included the use of a daily pain assessment but had not identified pharmacological or non-pharmacological pain management interventions, or what the resident had identified as an acceptable level of pain for her. Interview and review of resident 128's comprehensive care plan with resident care supervisor D on 3/22/23 at 3:45 p.m. revealed: *She was the designee responsible for working with hospice to coordinate care for residents receiving hospice care services. *All interdisciplinary team members were responsible for care plan development, review, and revision but she was responsible for accountability of the overall care plan process *Staff used information contained in the resident's care plan for guidance on how to direct a resident's care. *Resident 128's hospice care plan had not reflected coordinated care and services between the provider and the hospice provider or the resident's individualized hospice care needs and choices. Interview on 3/23/23 at 10:15 a.m. with director of nursing B regarding resident 128's hospice care plan revealed it had not reflected a collaborative effort between the provider and the hospice provider regarding the hospice services and interventions expected to have been provided to that resident. Review of the last revised July 2013 Hospice Services policy revealed: *4. Hospice and facility will at this first meeting review and integrate the current plan of care with Hospice. *5. The integrated plan of care will be updated and revised as necessary to reflect the resident's current status. *7. The plan of care will include directives for managing pain and other uncomfortable symptoms.

Based on observation, interview, record review, and policy review, the provider failed to ensure safety assessments were completed and documented for 6 of 18 sampled residents (4, 11, 16, 31, 44 and 57) who had side rails on their beds. Findings include: 1. Observation on 10/27/21 at 9:43 a.m. of resident 11's bed revealed bilateral side rails near the head of the bed. *The side rail by the wall was in the upright position and the other side rail was down. Interview on 10/27/21 at 9:45 a.m. with resident 11 revealed: *She had used the side rails for positioning herself in bed. *The side rails had been on her bed since her admission. *She could not remember education being provided for risks of the bed rails or signing a consent form for their use. Review of resident 11's medical record revealed: *She had been admitted on [DATE]. *Her brief interview for mental status (BIMS) was 15 and indicated her cognition was intact. *A 2/15/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her last revised care plan stated she used side rails for bed mobility. 2. Observation and interview on 10/26/21 at 7:55 a.m. with resident 16 revealed she: *Had been lying in her bed with bilateral side rails near the head of the bed and both side rails were up. *Used the side rails to hold herself up when staff assisted her with care and to reposition. *Thought the side rails had been on her bed since her admission. *Could not recall education being provided regarding risks of the bed rails or if she had signed a consent for their use. Observation on 10/27/21 at 9:31 a.m. of resident 16 in bed with her eyes closed with both side rails in the upright position. Review of resident 16's medical record revealed: *She had been admitted on [DATE]. *She had been on hospice since May 2021. *Her BIMS score was 10 indicating she had a moderate cognitive impairment. *A 12/13/20 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her last revised care plan stated she used side rails for bed mobility. 3. Observation on 10/26/21 at 8:05 a.m. and 10/27/21 at 9:22 a.m. with resident 31 in a bed with bilateral side rails, her eyes closed and both side rails up. Review of resident 31's medical record revealed: *She had been admitted on [DATE]. *Her BIMS score was three indicating severe cognitive impairment. *A 6/9/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her last revised care plan stated she used side rails for bed mobility. 4. Observation on 10/26/21 at 7:40 a.m. of resident 57's bed with bilateral side rails near the head of the bed, and the bed rail next to the wall had been in the upright position. Interview on 10/28/21 at 10:31 a.m. with certified nursing assistant (CNA) E revealed: *They put the side rails up for all the residents if they are in bed for safety so they did not fall. *For more information they looked at the care plans for specific instructions such as if there should be one or both side rails up or down for the resident. Interview on 10/28/21 at 10:44 a.m. with resident 57 revealed: *She used the side rails every day to get into bed. *The bed rails assist her to be able to turn over and change position. *They do not bother her. *The staff put the bed rails up before she goes to bed each night. Review of resident 57's medical record revealed: *She had been admitted on [DATE]. *Her BIMS score was 15 indicating she was cognitively intact. *A 1/6/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her last revised care plan stated she used side rails for bed mobility and transfers. Review of the above care plans revealed no specific information about placement of the side rails for the residents. -There was no mention of whether one side rail or both was to be used. -There was no mention of what diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical records of the above residents revealed: *Side rail safety assessments had not been completed to ensure: -The risks and benefits had been reviewed with the resident or their representative. -The provider received signed consent for side rails before their use. *Appropriate alternative interventions had been attempted prior to side rails being used. 5. Observation and interview with resident 44, on 10/26/21 at 10:45 a.m. revealed: *Bilateral side rails towards the head of her bed. *She has side rails so I don't fall out and uses them to turn over when in bed. *She does not recall staff discussing the risks and benefits of using the side rails. Review of resident 44's medical record revealed: *She had been admitted on [DATE]. *Her BIMS of 15 indicated her cognition was intact. *A 12/30/20 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her last revised care plan on 9/30/21 stated she used partial side rails to enable bed mobility and transfers. 6. Observation on 10/27/21 at 8:10 a.m. of resident 4 in her bed revealed raised bilateral side rails towards the head of her bed. Review of resident 4's medical record revealed: *She had been admitted on [DATE]. *Her MDS revealed a BIMS score of 3 indicating severe cognitive impairment. Her BIMS of 3 indicated her cognition was severely impaired. *A 5/13/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her last revised care plan on 8/5/21 stated she used partial side rails to enable bed mobility and transfers. Review of residents 4 and 44's medical records further revealed: *No assessment was completed before side rails were used. *No consent form was signed. *No education on the risks associated with side rails were documented. *No quarterly assessment was completed regarding side rail usage. *Use of the side rails was not reviewed quarterly at the care conference. Interview on 10/26/21 at 4:49 p.m. with resident care supervisor (RCS) B revealed the following regarding provider's side rails: *The bed controls for their electric beds were a part of the side rail. *The current practice was to leave the side rails on the beds. *She stated the side rails help residents maintain their bed mobility. *She stated there was no real side rail assessment in Meditech, the provider's electronic medical record (EMR). Interview on 10/27/21 at 8:34 a.m. with housekeeper D when asked about how many of the beds have side rails, he replied I don't think there is a bed that doesn't have them. Interview with RCS B and RCS C on 10/28/21 at 9:21 a.m. revealed: *RCS B stated: -No assessments were completed to address the side rails. -She did not view side rails as a restraint but felt that they were used to maintain independence. -The resident and or family member do not sign a consent for the use of the side rail. -She could not show documentation where the resident and family were educated on the risk. Medical record review and interview with RCS B on 10/28/21 at 9:30 a.m. regarding the provider's EMR revealed and confirmed: *She was aware of the provider's August 2020 Restraint Policy. *There was a pre-restraint assessment available in the provider's EMR. *This assessment included: -Device type (side rails were one of the fifteen devices listed on the checklist). -Consent/orders, where staff could indicate a consent was signed -Education provided to resident and family. *There was a restraint assessment available in the provider's EMR. *This assessment included the following statements where staff could indicate yes or no and add a comment: -Currently using side rail. -Are devices used considered a restraint. *Neither of these assessments were currently being used to assess side rails. *RCS B stated the pre-restraint assessment could be added to the admission set. *RCS B stated they are not completing a quarterly assessment of the side rails. *RCS B confirmed the use of these assessments were the policy for side rails. *The care conference summary was completed by the resident care coordinators. -Included a section for safety device or restraint review. *RCS B stated that the topic of side rails was not currently discussed at the care conference. *RCS B confirmed she was not following the provider's August 2020 Restraint Policy regarding side rails. Interview with director of nursing A on 10/28/21 at 9:58 a.m. confirmed: *Side rails were on most of the beds in the facility. *Admission process included side rails on the standing orders obtained from the physician. *She was aware of the requirement to complete assessments when using side rails. *Confirmed side rail assessments had not been completed. Review of the provider's August 2020 Restraint Policy regarding side rails revealed: *Side rails will not be offered as part of routine care. *Before utilizing side rails a pre-restraint assessment will be completed to ensure the resident's safety of the device. *If the resident is determined to be able to use the device safely the interdisciplinary team will educate the resident on the risk associated with side rail use and alternatives available such as a repositioning or assist bar. *A quarterly assessment will be documented in the restraint assessment. *Use of the device will be reviewed quarterly by the interdisciplinary team, resident, and family at the care conferences.

Based on observations, staff interviews, and record review, the facility failed to ensure staff performed adequate hand hygiene while serving room trays to prevent the spread of infection, including COVID-19 in one of four wings. This failure had the potential to affect the 18 residents living on the Boardwalk wing, who were all COVID-19 negative or recovered. Findings include: On 12/14/20 at 12:20 PM, Dietary Aide (DA) 1 was observed serving room trays from a wheeled cart on the Boardwalk wing. DA1 entered room B3 without sanitizing her hands and delivered the tray to the resident on the left side of the room. DA1 assisted the resident in opening the beverages and setting up the utensils. DA1 then exited the room without performing any hand hygiene. DA1 pushed the meal cart down the hall and entered room B9 without sanitizing her hands and set up the resident's meal. DA1 then left the room without sanitizing her hands, then entered room B8 without performing hand hygiene. DA1 delivered the tray and picked up a used clothing protector that was on the resident's table with her bare hands. DA1 placed the used clothing protector on the meal cart next to another meal tray and continued on without performing hand hygiene. DA1 entered room B14 without sanitizing her hands and delivered the meal tray to the resident on the left. She assisted in opening the beverages, soup, and applesauce containers and set up the utensils for the resident. DA 1 then exited the room without performing hand hygiene and began to push the empty cart with the used clothing protector down the hall. During an interview on 12/14/20 at 12:35 PM, DA1 stated she was new to the position and this was her fourth day on the job. She stated hand sanitizer was available at the entrance to each resident room. DA1 added, I try to sanitize between every room, but I get caught up and don't always, so I try to do it between carts at least. During an interview on 12/15/20 at 11:00 AM, the Infection Preventionist (IP) stated staff were expected to perform hand hygiene between serving each meal tray. He stated it would be appropriate to use hand sanitizer between residents, unless their hands were visibly soiled. On 12/15/20 at 11:44 AM, DA1 was observed serving room trays from a wheeled cart on the Boardwalk wing. She entered room B1 without sanitizing her hands and delivered the tray to the resident on the right side of the room. She moved items off the resident's bedside table, then assisted in opening the milk container and can of soda and putting butter on the potatoes. DA1 then retrieved the next tray from the hall without first sanitizing her hands and proceeded to re-enter room B1 and serve the resident on the left side of the room. DA1 opened the beverage containers, then left the room without performing hand hygiene. DA1 then moved to Room B3 and served a resident's food tray without sanitizing her hands. During an interview on 12/15/20 at 12:25 PM, the Director of Nursing (DON) stated the dietary staff were responsible for serving room trays, and she expected the staff to perform hand hygiene between serving each tray. On 12/15/20 at 12:40 PM, the DON provided a 2019 ServSafe flier titled, Hand Washing 101. She stated this flier was provided to DA1 at orientation. The DON stated DA1 had not yet completed the written test on infection control that was part of the dietary orientation. The 2019 ServSafe Hand Washing 101 flier documented, You should always wash your hands BEFORE you handle food or begin any food-related task, but it's also very important that you wash your hands AFTER these activities: -Handling raw meat, poultry, and seafood. -Using the restroom. -Touching your hair, face, body, clothes, or apron. -Sneezing, coughing, or using a tissue. -Smoking, eating, drinking, or chewing gum. -Using chemicals that might affect the safety of food. -Emptying or taking out the garbage. -Clearing tables or washing dirty dishes. -Handling money and making change. The flier did not address hand hygiene when serving residents their meals. During an interview on 12/15/20 at 12:55 PM, the IP stated DA1 also viewed a video on hand hygiene and infection control during her orientation.