Every finding on record at Avera Oahe Manor

Based on record review, interview, and policy review, the provider failed to ensure the advanced directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) for three of twelve sampled residents (1, 20, and 28) was documented in the residents' electronic medical records (EMR) to inform staff members what the resident wanted in the situation that they stopped breathing or if their heart stopped beating. Findings included: 1. Review of resident 1's EMR revealed she admitted to the facility on [DATE]. Her [DATE] Brief Interview for Mental Status (BIMS) assessment score was 3, which indicated her cognition was severely impaired. There was no documentation indicating that any advance directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) paperwork was completed upon admission informing the resident or residents representatives about the advance directives. A copy of her Durable Power of Attorney (someone designated on a legal document to act on behalf of a resident) (POA) document was scanned into the her EMR, but it did not address her code status wishes. A [DATE] physician's order indicated her code status was DNR/DNI (do not resuscitate (do not preform cardiopulmonary resuscitation (CPR)/do not intubate (do no place a breathing tube or use a mechanical ventilator if they stop breathing). There was no physician documentation supporting that code status order or indicating that her wishes were discussed informing the resident or the resident's representative. Her banner on her EMR indicated her code status was DNR/DNI. 2. Review of resident 20's EMR revealed she admitted to the facility on [DATE]. Her [DATE] BIMS assessment score was 11, which indicated her cognition was moderately impaired. There was no documentation indicating that any advance directive paperwork was completed upon admission. A copy of her Durable POA document was scanned into her EMR, but it did not address her code status. A [DATE] physician's order indicated her code status was DNR/DNI. There was no physician documentation supporting that code status order or indicating that her wishes were discussed with the resident or the resident's representative. Her banner on her EMR indicated her code status was DNR/DNI 3. Review of resident 28's EMR revealed she admitted to the facility on [DATE]. Her [DATE] BIMS assessment score was 3, which indicated her cognition was severely impaired. There was no documentation indicating that any advance directive paperwork was completed upon admission. A copy of her Durable POA was scanned into her EMR, but it did not address her code status. A [DATE] physician's order indicated that her code status was DNR/DNI. There was no physician documentation supporting that code status order or indicating that her wishes were discussed with the resident or the resident's representative. 4. Interview on [DATE] at 10:35 a.m. with director of nursing (DON) B revealed that she confirmed the staff would not know if they were to perform CPR (cardiopulmonary resuscitation) for a resident or not based on the resident's POA information alone. She stated that the resident's code status wishes for staff to perform or not perform CPR should be confirmed with a resident before an event could occur where their heart stops beating or they stop breathing. She stated that calling the resident's POA in the event the resident's heart stopped beating or they stopped breathing would delay life-saving care for that resident. DON B stated that confirming the resident's advance directive upon admission had not been consistently documented. 5. Review of the provider's [DATE] Long Term Care Advance Directives Policy revealed that initial discussion about the resident's health status, treatment options, and expected outcomes would occur during the resident's initial comprehensive assessment and care plan meeting. The resident had the right to refuse care and treatment, and the resident may not be treated against his/her expressed wishes.

Based on observation, interview, record review, and policy review the provider failed to ensure infection control practices were followed for the cleaning of a nebulizer (a device that converts liquid medication into an inhalable mist) for one of one sampled resident (25) and the cleaning of a continuous positive airway pressure (CPAP) machine for one of one sampled resident (23). Findings include:1.Observation and interview on 8/18/26 at 8:56 a.m. with resident 25's in her room revealed there was a nebulizer machine on top of her nightstand that had the tubing and mouthpiece connected to it, and the medication reservoir (the clear container that holds the liquid medication) appeared wet. The mouthpiece was positioned upright between the handle and the nebulizer machine.She stated she received three nebulizer treatments a day and an additional rescue treatment PRN (as needed) when she had difficulty breathing. She stated the staff disconnected the nebulizer only at night to clean it. 2. Review of resident 25's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), history of pneumonia, (a lung infection that fills the air sacs with fluid, causing cough, fever and trouble breathing), and pulmonary hypertension (high blood pressure in the arteries that carry blood from your heart to your lungs). Her 6/11/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact.She had a 5/30/26 physician order for arformoterol (Brovana) (a long-acting bronchodilator used to relax airway muscles) 15 mcg (micrograms) to be administered via nebulizer two times daily at morning and bedtime. A 5/30/26 physician's order for levalbuterol (Xopenex) (rescue solution used to treat or prevent sudden shortness of breath, wheezing, and chest tightness) 1.25 milligrams to be administered via nebulizer every six hours PRN for wheezing A 8/11/26 physician's order for revefenacin (Yupelri) (a once-daily, long-acting bronchodilator used to relax airway muscles) 175 mcg to be administered via nebulizer in the mornings. 3. Observation and interview on 8/18/26 at 9:19 a.m. with resident 23's in his room revealed his CPAP machine was on top of his nightstand. The water chamber remained connected to the CPAP machine and contained water. Resident 23 stated he was unsure if the staff cleaned and emptied the water from the water chamber of the CPAP machine. 4. Review of resident 23's EMR revealed he admitted to the facility on [DATE]. His diagnosis was sleep apnea (a medical condition where breathing stops and starts repeatedly during sleep, preventing deep rest). His 7/23/26 BIMS assessment score was a 7, which indicated his cognition was severely cognitively impaired.His 8/19/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated on 5/30/26, DAILY-Hand wash the [CPAP] mask, cushion, frame, elbow, and tubing quick release with warm, mild soap and [a] washcloth. Allow to dry.- Empty humidifier container and place on clean cloth upside down to dry.The BRAIN (staffs daily task checklist) indicated, CPAP Cleaning, Comment: DAILY-Hand wash the mask, cushion, frame, elbow, and tubing quick release with warm water, mild soap and [a] washcloth. Allow to dry.- Empty humidifier container and place on clean cloth upside down to dry. 5. Observation on 8/18/26 from 1:30 p.m. through 4:00 p.m. revealed the nebulizer machine in resident 25's room remained on her nightstand with the tubing and mouthpiece still connected. The CPAP machine in resident 23's room continued to have water present in its water chamber. 6. Observation on 8/19/26 at 9:00 a.m. in resident 23's room revealed his CPAP machine was on top of his nightstand. The water chamber remained connected to the CPAP machine and contained water. 7. Interview on 8/19/26 at 9:23 a.m. with licensed practical nurse (LPN) D revealed that the CPAP machine was cleaned daily, and the cleaning was completed by either a certified nursing assistant (CNA) or a nurse. She indicated it was checked off in the Brain when the task was completed by the staff. 8. Interview on 8/19/26 at 1:45 p.m. with registered nurse (RN)/nurse coordinator C revealed that either a nurse or a CNA after the CNAs had completed the CPAP education competency, they can clean the CPAP machines. The CNAs clean the nebulizer machine. The staff did not receive education when they were hired regarding the policy for cleaning the CPAP or nebulizer machines, and she was responsible for providing education on cleaning both types of equipment. 9. Interview on 8/19/26 at 2:25 p.m. with CNA E revealed she was aware CNAs were responsible for cleaning the nebulizer machine; however, she believed this was done once a day at the end of the day. She was not aware the nebulizer machines were to be cleaned between each nebulizer treatment. 10. Interview on 8/19/26 at 2:35 p.m. with director of nursing (DON) B revealed she expected the staff to rinse out the nebulizer after each treatment and to rinse and clean the CPAP water chamber after every use. 11. Review of the provider's revised June 2026 Respirator Equipment Care policy revealed, Daily-wipe out the mask with clean wash clothe [cloth] and empty water chamber. 12. Review of the provider's revised November 2019 Nebulizer Cleaning policy revealed, Rinse nebulizer mask components with tap water following EVERY nebulizer treatment. Place on a new paper towel and allow mask and medication components to air dry until next scheduled treatment or until component [components] are fully dried. 13. Review of the CPAP manufacturer's user guide revealed Daily: Empty the humidifier tub [water chamber] and wipe it thoroughly with a clean disposable cloth. Allow it to dry out of direct sunlight. 14. Review of the nebulizer manufacturer's user guide revealed, After each use: Wash the medicine cup and mouthpiece with warm running water. Let them air dry on clean paper towels.

Based on observation, record review, interview, and policy review, the provider failed to ensure PRN (as needed) psychotropic (drugs that affect brain activities associated with mental processes and behavior) medication orders had a usage stop date or a documented reason for continuing the medication beyond fourteen days for one of one sampled resident (5) who had a physician's order to receive haloperidol lactate, an antipsychotic medication (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions), as needed, without a usage order stop date or documented reasoning for continuation beyond fourteen days. Findings include:1. Observation on 8/18/26 at 12:01 p.m. in the dining room during the noon meal service revealed resident 5 walked between two dining tables with his walker. He made loud noises and looked around the room in different directions. When a staff member asked him what was wrong, resident 5 did not reply. The staff member assisted resident 5 into his chair at a dining room table. When the staff member started to cut resident 5's meal into pieces, he repeatedly hit her hand. He did not talk during the meal service and attempted to get up from his chair four times. 2. Review of resident 5's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 7/20/26 Brief Interview for Mental Status (BIMS) assessment score was 00, which indicated that his cognition was severely impaired. His diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, behaves, often causing a loss of contact with reality), insomnia (a sleep disorder characterized by persistent difficulty sleeping), mood disorder (a mental health condition that causes persistent and extreme shifts in a person's emotional state, disrupting their daily life), and severe cognitive impairment (a profound loss of intellectual capacity that makes a person unable to live independently). He had a 7/2/26 physician's order to recieve haloperidol lactate 5 milligrams (mg) by injection once daily as needed for major depressive disorder (a serious mood disorder that causes ongoing sadness, hopelessness, and loss of interest in activities) with severe psychotic symptoms. That physician's order did not include an end date. He last received a haloperidol injection on 7/26/26. Resident 5's 7/15/26 consultant pharmacist monthly medication review indicated that the haloperidol orders would require extended use documentation for use beyond fourteen days due to CMS [Centers for Medicare and Medicaid Services] rules on PRN [as needed] psychoactives. If not already done, please follow-up on planned duration for this order. 3. Interview on 8/19/26 at 4:18 p.m. with licensed practical nurse (LPN) D revealed that she was responsible for viewing the pharmacists' monthly resident medication reviews and then sending those to the physician for review for appropriateness of medication use. 4. Interview on 8/20/26 at 8:04 a.m. with director of nursing (DON) B revealed that resident 5's physician did not respond to the pharmacist's 7/15/26 monthly medication review request regarding the duration of resident 5's PRN haloperidol medication order. 5. Interview on 8/20/26 at 10:17 a.m. with registered nurse G revealed that she believed resident 5 had not received the haloperidol injection for a long time. She stated that his medications had been adjusted so that he did not need use of his PRN (as-needed) medications recently. 6. Interview on 8/20/26 at 10:24 a.m. with LPN D revealed that she remembered sending the pharmacists' monthly medication review to resident 5's physician. She did not received a response from resident 5's physician regarding resident 5's haloperidol medication. 7. Interview on 8/20/26 at 10:35 a.m. with DON B revealed there was no process for what staff should do if the physician did not respond to the pharmacist's monthly medication review recommendations. She was aware that antipsychotic medications required a 14 day stop date or documented physicians's evaluation of the resident and rationale for the appropriateness for extending that resident's PRN medication orders beyond 14 days. She stated that without a stop date, the medication could be considered a chemical restraint (the use of medication to control a person's behavior, restrict their freedom of movement, or sedate them). 8. Review of the provider's April 2026 Psychotropic Medication Use Policy revealed that the provider would monitor psychotropic medications for proper dose, duration, evidence of adequate monitoring, and efficacy. PRN anti-psychotic drugs will be limited to [fourteen] days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication.

Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, record review, interview, and policy review, the provider failed to ensure the staff followed professional standards regarding unwitnessed falls after one of one sampled resident (28) was found on her bedroom floor by certified nursing assistant (CNA) (I), had a bruise on her face, and the staff did not follow the provider's unwitnessed fall protocol. Findings include:1. Review of the provider's 6/21/26 FRI revealed that registered nurse (RN) H reported to director of nursing (DON) B on 6/20/26 at 6:27 p.m. that resident 28 had a bruise on her forehead. DON B initiated an investigation after resident 28 reported that she was not sure where the bruise on her forehead came from. RN H performed a full head-to-toe assessment on resident 28 and did not find any further skin injuries. DON B interviewed certified nursing assistant (CNA) I on 6/23/26 regarding resident 28's facial bruise. CNA I stated that around midnight on 6/18/26, he observed resident 28 on her bedroom floor, and her head was near a cabinet. Resident 28 needed help with her shoes, so CNA I helped her stand up from the floor, remove her shoes, then assisted her into her bed. Later that night, he observed her kneeling on her bedroom floor, tied her shoes, and then she stood up independently. CNA I had reported resident 28 being on the floor to LPN J, who was the charge nurse that night. He stated that resident 28 had told him that she had gotten to the floor herself to put on her shoes, so CNA I did not consider finding resident 28 laying on the floor to be an unwitnessed fall. DON B interviewed licensed practical nurse (LPN) J on 6/24/26 regarding resident 28's facial bruise. LPN J understood CNA I's report of the incident as resident 28 was getting up and down independently instead of being found on the floor. LPN J stated that if she had understood that the resident was found on the floor, she would have started the facility's fall protocol. CNA I and LPN J were individually educated on unwitnessed falls, the requirement to initiate the post-fall protocol (including vital signs [measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate] and neurological assessments [assessment of nerve function, reflexes, coordination, motor skills, sensation, and mental status]), and reporting the fall to management. All staff were required to perform that same education by 7/6/26. The resident's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was updated on 6/26/26 to include an alarm that would sound in the hallway if the resident got up without staff assistance. 2. Observation on 8/18/26 at 9:57 a.m. revealed resident 28 walked with a staff member at her side, with no mobility aids (a tool or piece of equipment to improve functional capabilities such as a walker, cane, or wheelchair). Further observation on 8/18/26 at 12:26 p.m. revealed resident 28 independently walked into the dining room for the lunch meal service with her family member. 3. Review of resident 28's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. Her 6/15/26 Brief Interview for Mental Status (BIMS) assessment score was 3, which indicated that her cognition was severely impaired. She had diagnoses of dementia (a group of symptoms affecting memory, thinking, and social abilities) with anxiety, restless leg syndrome (a neurological condition that causes an irresistible urge to move the legs), and macular degeneration (an eye disease that damages part of the back of the eye and can cause gradual vision loss). She had a care plan with a 5/30/25 care area for staff to provide assistance assuring all activities of daily living (ADL) needs are met, with the intervention to let staff know that she was independent with ambulation (walking) but needed assistance with bathing and setup for meals. On 5/30/26 the staff added fall precautions to her care plan. The staff was to keep her floor clear of clutter, use a bed alarm to alert the staff that the resident was up and may need assistance, and to provide non-skid footwear as the resident ambulated independently. 4. Interview on 8/20/26 at 10:35 a.m. with DON B revealed that she expected the staff to follow the provider's post-fall policies and procedures if they were uncertain whether a resident received an injury from a fall. She confirmed that would have included a neurological evaluation. She expected a post-fall worksheet to have been filled out. She stated that she spoke with LPN J, who would have reported the 6/18/26 incident as an unwitnessed fall if she had understood that the resident had potentially fallen to the ground. DON B stated that a post-fall worksheet and a neurological assessments were not completed by LPN J after resident 28's facial bruising was noticed by the staff. 5. Review of the provider's September 2025 Fall Evaluation and Injury Prevention Policy revealed that If a resident hit their head or if the fall was unwitnessed and the resident is not able to communicate if they hit their head, staff will complete the Neuro Checks [neurological assessment] intervention. After the staff completed the neurological checks, staff was expected to complete a post fall huddle, notify family, notify the residents provider, perform a skin assessment, and review/update the care plan. 6. Review of the provider's April 2026 Falls and Accidents Policy revealed that If the resident hit their head, or the fall is unwitnessed, neurological assessment should be completed every [four] hours for seven assessments. 7. Review of an undated blank copy of the provider's Post Fall Worksheet form included a place for the staff to document that the resident's vital signs and neurological checks were completed, the staff members involved in the incident, a fall scene investigation report, a root cause of the fall, and a checklist that was to be completed by the staff members who filled out the form.

Based on observation, interview, and review of the posted daily nursing staffing information review, the provider failed to ensure the daily nursing staffing information, including the actual hours worked by registered nurses, licensed practical nurses, licensed vocational nurses, and certified nursing assistants per shift, was posted for residents, staff, and visitors for two of the three survey days.Findings include: 1. Interview on 8/18/26 at 8:35 a.m. during the entrance conference with director of nursing (DON) B revealed the current resident census was 37.2. Observation on 8/18/26 at 8:45 a.m. of the daily nursing staffing posted on the wall across from the nurses' station revealed the form was dated 8/16/26, the resident census was recorded as 36, and the nurse staffing hours were not totaled. 3. Observation on 8/19/26 at 8:02 a.m. of the daily nursing staffing posted on the wall across from the nurses' station revealed the form was dated 8/19/26, the census was recorded as 36, and the nurse staffing hours were not totaled.4. Interview and review of the daily nursing staffing posted forms on 8/19/26 at 9:47 a.m. with DON B revealed the forms used did not include the total number of nurse staffing hours worked. She was not aware that the daily nursing staffing form for 8/17/26 and 8/18/26 was not posted on those days. She confirmed the resident census on the 8/19/26 form was inaccurate at 36, and the census should have been 37. DON B stated that the night shift charge nurse and the day shift charge nurse were responsible for completing the daily nursing staffing form and posting it each day.5. A daily nursing staffing posting policy was requested and was not received by the end of the survey time.

Based on record review, interview, and policy review, the provider failed to ensure pharmacist recommendations from the resident's monthly medication reviews were addressed by the physician for one of one sampled resident (5) and physician orders were entered into the resident's electronic medical record (EMR) for one of one sampled residents (6) regarding psychotropic medications (drugs that affect brain activities associated with mental processes and behavior). Findings include:1. Review of resident 5's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 7/20/26 Brief Interview for Mental Status (BIMS) assessment score was 00, which indicated that his cognition was severely impaired. His diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, behaves, often causing a loss of contact with reality), insomnia (a sleep disorder characterized by persistent difficulty sleeping), mood disorder (a mental health condition that causes persistent and extreme shifts in a person's emotional state, disrupting their daily life), and severe cognitive impairment (a profound loss of intellectual capacity that makes a person unable to live independently). He had a 7/2/26 physician's order to recieve haloperidol lactate 5 milligrams (mg) by injection once daily as needed for major depressive disorder (a serious mood disorder that causes ongoing sadness, hopelessness, and loss of interest in activities) with severe psychotic symptoms. That physician's order did not include an end date. He last received a haloperidol injection on 7/26/26. Resident 5's 7/15/26 consultant pharmacist monthly medication review indicated that the haloperidol orders would require extended use documentation for use beyond fourteen days due to CMS [Centers for Medicare and Medicaid Services] rules on PRN [as needed] psychoactives. If not already done, please follow-up on planned duration for this order. 2. Review of resident 6's EMR revealed she admitted to the facility on [DATE]. Her 6/29/26 BIMS assessment score was 8, which indicated that her cognition was moderately impaired. Her diagnoses included insomnia (a sleep disorder characterized by persistent difficulty sleeping), and anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). She had a 6/17/26 physician's order for lorazepam (a psychotropic medication used for the short-term relief of anxiety, panic, and seizures) 0.5 milligrams (mg) to be administered by mouth every four hours PRN (as needed) for anxiety. Resident 6's 7/3/26 consultant pharmacist monthly medication review indicated that [resident 6] has an order for lorazepam.CMS [Centers for Medicare and Medicaid Services] rules require that PRN orders for psychotropic medications be limited to 14 days. The order may be extended beyond the 14 days if the provider believes it is appropriate. There was a 7/5/26 response from the provider that stated the patient was currently on hospice (care that focuses on comfort, dignity, and quality of life for people who are terminally ill and expected to live six months or less), so please keep order active for six months. The physician's order for lorazepam did not have a stop date. 3. Interview on 8/19/26 at 4:18 p.m. with licensed practical nurse (LPN) D revealed that she was responsible for reviewing the pharmacists' monthly resident medication reviews and then sending those to the physician for review for appropriateness of medication use. 4. Interview on 8/20/26 at 8:04 a.m. with director of nursing (DON) B revealed that resident 5's physician did not respond to the pharmacist's 7/15/26 monthly medication review request regarding the duration of resident 5's PRN haloperidol medication order. 5. Interview on 8/20/26 at 10:24 a.m. with LPN D revealed that she remembered sending the pharmacists' monthly medication review to resident 5's physician. She did not receive a response from resident 5's physician regarding resident 5's haloperidol medication. 6. Interview on 8/20/26 at 10:35 a.m. with DON B revealed that she was aware that antipsychotic medications required a fourteen-day stop date per CMS regulations, and psychotropics could only be continued with a rationale from a physician. She stated the facility did not have a process for what the staff should do if the physician did not respond to a pharmacist's monthly medication review. She acknowledged that the stop date for resident 6's lorazepam should have been confirmed and changed by a nurse if resident 6's physician did not change the lorazepam order themselves. DON B stated that without a stop date, a psychotropic medication could be considered a chemical restraint (the use of medication to control a person's behavior, restrict their freedom of movement, or sedate them). 7. Review of the provider's April 2026 Psychotropic Medication Use Policy revealed that the provider would monitor psychotropic medications for proper dose, duration, evidence of adequate monitoring, and efficacy. PRN anti-psychotic drugs will be limited to [fourteen] days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication. PRN psychotropic medications will be limited to [fourteen] days unless the physician identifies the rationale to extend the medications beyond [fourteen] days. 8. A Monthly Medication Review policy was requested on 8/20/26 at 10:24 a.m. and was not received by the end of the survey.

Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to follow nursing professional standards to ensure one of one sampled resident (1) had consistent neurological checks completed and documented after the resident fell and hit her head, according to the provider's policies.Findings include:1. Review of the 8/3/25 SD DOH FRI regarding resident 1 revealed:*On 8/3/25 at 12:00 p.m. resident 1 was walking with certified nursing assistant (CNA) E to the bathroom.*CNA E let go of resident 1's gait belt (a waist strap gripped as support for safe mobility and transfers) to turn on the bathroom light.*Resident 1 lost her balance, fell to the floor, and hit her head on the floor.*Resident 1 was assessed by licensed practical nurse (LPN) F, who did not identify any injuries at that time.*Resident 1 was taken to the emergency room by her husband, who was present at the time of the fall.*While in the emergency department resident 1's husband declined a CT scan (imaging test that uses x-rays of cross sections of the body) of resident 1's head.2. Review of resident 1's electronic medical record (EMR) revealed:*She was admitted on [DATE].*Her 8/7/25 Brief Interview of Mental Status (BIMS) assessment score was 13, which indicated her cognition was intact.*Her diagnoses included Parkinson's (a disorder of the central nervous system that affects movement, often including tremors), weakness, dizziness on standing, and loss of balance.*Review of her admission care plan revealed on 8/1/25 an intervention was added to her care plan that indicated resident 1, transfers and ambulates with staff assistance x1 [times one], a walker and [the use of a] gait belt.*Resident 1's 8/1/25 fall risk assessment, had a score of 2 which indicated she required Standard fall precautions.*Resident 1 was admitted to the emergency room on 8/3/25 at 1:30 p.m. and discharged from the emergency department on 8/3/25 at 2:29 p.m.*She returned to the facility on 8/3/25 at 2:30 p.m. with a diagnosis of mild dehydration (loss of body fluid caused by illness, sweating, or inadequate intake), and was advised to increase her fluid intake.3. Review of resident 1's post-fall neurological assessments (assessment of nerve function, reflexes, coordination, motor skills, sensation, and mental status) (neuros) revealed:*There were identified areas for assessment on the Neuro Check Care Assessment in resident 1's EMR which included:- Neurological--Orientation--Behavior--Speech Patter- Glasgow Coma Scale [a neurological assessment tool used to evaluate the level of consciousness after a brain injury]--Eye opening--Verbal response--Motor response--Glasgow coma scale total score- Pupil Assessment--bilateral eyes--Pupil size (mm) [millimeters]--Pupil reaction--Pupil shape- Ocular [eye] Assessment--Eye movement--Tracking on horizontal plane--Tracking on vertical plane--Able to independently open and close eyelids- Visual Acuity--Peripheral visual fields intact--Blurry Vision- Neurological Symptoms-Dizziness/vertigo-Nausea/vomiting-Headache- Movement/Strength/Sensation--bilateral lower--Movement description--Strength description--Sensation description--bilateral upper--Movement description--Strength description--Sensation description.*Resident 1's 8/3/25 12:00 p.m. neuro assessment taken immediately after the resident's fall did not have the Pupil Assessment or the Movement/Strengths/Sensation portions of the assessment completed.*Resident 1's 8/3/25 12:30 p.m. neuro assessment did not have the Glasgow Coma Scale, Pupil Assessment, Ocular Assessment, Visual Acuity, Neurological Symptoms, or the Movement/Strength/Sensation portions of the assessment completed.*Resident 1's 8/3/25 1:00 p.m. neuro assessment did not have the Glasgow Coma Scale, Pupil Assessment, or the Movement/Strength/Sensation portions of the assessment completed.*Resident 1's next neuro assessment was completed on 8/3/25 at 5:00 p.m. and did not have the Glasgow Coma Scale, Pupil Assessment, Ocular Assessment, Visual Acuity, Neurological Symptoms, or the Movement/Strength/Sensation portions of the assessment completed.*Resident 1's 8/3/25 9:00 p.m. neuro assessment did not have the Glasgow Coma Scale completed.*Resident 1's 8/4/25 1:04 a.m. neuro assessment did not have resident 1's orientation, the Glasgow Coma Scale, bilateral lower sensation description, or bilateral upper sensation description.*Resident 1's 8/4/25 5:00 a.m. neuro assessment did not have the Glasgow Coma Scale completed.*Resident 1's 8/5/25 9:00 a.m. neuro assessment did not have the Glasgow Coma Scale completed.*Resident 1's 8/6/25 9:00 a.m. neuro assessment had every field in the neuro assessment completed.*Resident 1's 8/7/25 9:00 a.m. neuro assessment did not have the Ocular Assessment, Visual Acuity, Neurological Symptoms, or the Movement/Strength/Sensation portions of the assessment completed.*Resident 1's 8/8/25 9:00 a.m. neuro assessment did not have the Glasgow Coma Scale completed.*Resident 1's 8/9/25 9:00 a.m. neuro assessment did not have the Glasgow Coma Scale, Pupil Assessment, Ocular Assessment, Visual Acuity, Neurological Symptoms, or the Movement/Strength/Sensation portions of the assessment completed.*Resident 1's 8/10/25 9:00 a.m. neuro assessment did not have the pupil size, Ocular Assessment, Visual Acuity, Neurological Symptoms, or the Movement/Strength/Sensation portions of the assessment completed.*Resident 1's 8/11/25 9:00 a.m. neuro assessment did not have the Glasgow Coma Scale, or the pupil size completed.4. Interview on 9/3/25 at 2:15 p.m. with LPN D revealed:*Neuro assessments were to be completed anytime a resident fell and hit their head.*She would check the resident's pupils, make sure the resident could follow commands, and check their strength in their upper and lower extremities.*There was a post-fall worksheet that the nursing staff followed so they would know what needed to be done after a resident fell and how often the resident's vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) needed to be taken and when the neuro assessments were to be completed.5. Interview on 9/3/25 at 2:56 p.m. with registered nurse (RN)/infections preventionist (IP) B revealed:*Each of the areas identified on the Neuro Check Care Assessment form was visible to the nurse who was completing the resident's neuro assessments.*RN/IP B verified resident 1's documented neuro assessments completed after she fell, had areas that were completed were blank or not completed.6. Interview on 9/3/25 at 3:10 p.m. with RN/IP B and LPN C revealed:*They felt the expectations were not clear regarding what needed to be charted related to in the residents' neuro assessments because when one identified area on the Neuro Check Care Assessment was completed, the neuro assessment task was able to be documented as completed in the EMR system.*RN/IP B's expected that the residents' Neuro Check Care Assessments were to be completed as thoroughly as possible.*They stated that it would not be possible to identify if there was a change in a resident's neurological status if the neuro assessments and documentation of those assessments were not complete.7. Interview on 9/4/25 at 11:10 a.m. with administrator A revealed:*She expected the documentation on the Neuro Check Care Assessment form would be completed consistently.*She verified the documentation in resident 1's post-fall Neuro Check Care Assessments were not completed consistantly.8. Review of the provider's undated Post Fall Worksheet revealed: *If [a] resident hit [their] head, or if [a] fall is not witnessed and [the] resident is unable to tell you if they hit their head, Neuro checks need to be completed as below, in addition to vital signs.-Initially after the fall, every 30 minutes times two, every four hours times four, and daily times seven.Review of the provider's February 2024 Fall Evaluation and Injury Prevention policy revealed:* Resident fall.-c. Assessment of the resident will continue at least every shift for the next 72 hours.--a. Reassessments should include vital signs, neurological assessments, review of systems as well as worsening or improving symptoms as well as any treatment provided.-d. If the resident hit their head or the fall was unwitnessed and the resident is not able to communicate if they hit their head, staff will complete the Neurological Assessment-LTC [long-term care] at least every 4 hours x [times] 4 then daily x 72 hours.

Based on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the provider failed to ensure a safe environment by not having checked the coffee temperature to ensure it was within a safe temperature range before serving it to one of one sampled residents (9) who spilled her coffee and sustained a burn to her upper anterior (front) thighs.Findings include: Review of the provider's 5/21/25 SD DOH FRI report revealed that resident 9 had spilled her coffee in her lap at a meal on 5/16/25. Findings include:1. Resident 9 had picked up her cup from the table and it caught on her meal container, tipping the coffee into her lap. She wheeled herself out of the dining room. One of her tablemates notified the activities director (who is also a CNA) who had been in the dining room, and found resident 9 attempting to enter the lobby restroom and immediately assisted her in getting the wet clothing away from her skin. The resident suffered burning and blistering to her upper anterior (front) thighs. 2. Review of DON B's notes regarding the incident revealed that the coffee maker tank was set to a temp of 180 degrees and the staff had checked the coffee temperature and it was 168 degrees. 3. Interview on 7/29/25 at 8:37 a.m. with food service worker II (FSW II) R revealed that his position held the primary responsibility for filling the coffee carafes. He had not been instructed to take the temperatures of hot beverages or on what a safe serving temperature would be. He stated that after the 5/16/25 burn from hot coffee, they left the coffee carafe open in the kitchen for a few minutes in order to cool the coffee, and then they got a new coffee machine. They did not check the temperature of the coffee carafe after leaving it open. *Interview on 7/29/25 at 10:21 a.m. with resident 9 revealed that she burned her legs when she spilled her coffee in her lap. She said it was painful at the time but it healed up quickly. She stated that it was an accident, and anyone could spill their coffee. She thought there had been too much fussing about it and she had been embarrassed by it. *Interview on 7/29/25 at 12:00 p.m. with FSW II Q revealed her FSW II position was responsible for delivering meals to residents in the dining room but was not responsible for serving hot beverages. She had never checked the temperature of the hot beverages and did not think it was a part of the provider's regular food temperature monitoring and recording process. *Interview on 7/29/25 at 2:40 p.m. with certified dietary manager (CDM) P revealed that they had not taken the temperatures of hot beverages (coffee, hot water, hot chocolate) before serving them to the residents. The coffee machine supplier had installed a low temp kit on the coffee maker on 5/20/25 that was to limit the coffee temperature. They checked and recorded the temperature of the coffee from 5/17/25 to 6/7/25. Those temperatures ranged from temperature ranging from 145 to 156 degrees Fahrenheit (F). A new coffeemaker was installed on 6/24/25 with software-controlled temperatures that was to ensure that coffee and hot water could not dispense out of the machine if it was over 160 degrees F. They had not taken any temperatures of the coffee since that new machine was installed. *Interview on 7/31/25 at 1:30 p.m. with CDM P revealed that she was not aware that director of nursing (DON) B's notes of the above incident's investigation stated that the coffee dispenser tank was set at 180 degrees F and that dietary staff had temped the coffee at 168 degrees F. She did not know who might have provided those temperatures to the DON. She stated that she had instructed the staff to check the coffee temperature to ensure it had cooled to 150 degrees F before serving. She thought a safe temperature for serving hot beverages was be 160 degrees F. *Interview on 7/31/25 at 2:00 pm. with DON B revealed she thought the 180 degrees F coffee temperature in her notes had come from the coffee machine supplier. She could not identify who had temped the coffee at 168 degrees F. *Review of resident 9's electronic medical record (EMR) revealed that she was admitted on [DATE] with a primary diagnosis of dementia. Her Brief Interview for Mental Status (BIMS) assessment score was 7 which indicated she had severe cognitive impairment. *Her 3/13/25 hot liquid risk screening indicated no safety risk factors related to hot liquids. On 5/16/25, nurse practitioner (NP) A ordered Silvadene cream and dressings to the burn site. Resident 9's family member was notified of the incident and requested that she have a burn wound consultation. An e-care wound consultation (visit with a medical provider through the use of live video) was completed with no changes to treatment recommended. Wound inspection of resident 9 on 5/23/25 indicated that skin area remained red, measured 8.5 cm x 3.5 cm, and was dry. It required no further treatment. *Review of the provider's 10/31/24 LTC Falls and Accidents Policy revealed that staff will ongoingly assess the physical environment with regard to potential hazards, including access to.hot liquids and any deficiencies in the safety of the physical environment will be immediately addressed. *Review of the provider's 5/22/24 LTC Food Safety and Sanitation Policy revealed the serving temperature of hot beverages (coffee, tea, water) should be adjusted based on assessment of risk in order to decrease risk of resident burn.

Based on Payroll Based Journal (PBJ) reports review, interview, posted nurse schedule review, and staff timecard review, the provider failed to ensure a registered nurse (RN) had been scheduled for eight consecutive hours of coverage for ten days in quarter four (Q4) (July 1 through September 30) of fiscal year 2024, and for seven days in quarter one (Q1) (October 1 through December 31) of fiscal year 2025.Findings include: 1.Interview on 7/29/25 at 8:48 a.m. with director of nursing (DON) B during the entrance conference revealed she thought the provider had a registered nurse (RN) staffing waiver in place that exempted them from the requirement of having an RN in the facility for eight consecutive hours seven days a week.2. Review of the provider's RN waiver application revealed:*The provider had an RN waiver in place that required to have been reapproved by 7/10/24.*The provider sent an email to the South Dakota Department of Health (SD DOH) to reapply for the RN waiver on 5/16/25.*On 6/5/25 the SD DOH replied to the provider's application with direction from the Center for Medicare and Medicaid Services (CMS) to, wait on the waiver review and approval until after the facility's next recertification survey.3. Review of the provider's nurse staffing schedule for 7/20/25 through 8/9/25 revealed there was no RN scheduled on 7/26/25.4. Review of the RN staff timecards for Q4 fiscal year 2024 and Q1 fiscal year 2025 revealed:*RN coverage for eight consecutive hours could not be verified for 7/19/24, 7/20/24, 7/21/24, 7/27/24, 8/16/24, 8/17/24, 9/7/24, 9/8/24, 9/28/24, and 9/29/24 in Q4 of fiscal year 2024.*RN coverage for eight consecutive hours could not be verified for 10/19/24, 10/27/25, 11/10/25, 11/28/25, 12/21/25, 12/22/25, and 12/23/25 in Q1 of fiscal year 2025.5. Interview on 7/30/25 at 8:11 a.m. with DON B revealed the provider did not have a staffing policy.6. Interview on 7/31/25 at 9:00 a.m. with administrator A and DON B revealed:*Administrator A was responsible for submitting the application to the SD DOH for the RN staffing waiver request.*Administrator A was not aware the RN staffing waiver had been due for renewal on 7/10/24.*Administrator A realized there was a lapse in the RN staffing waiver in May 2025, when she submitted the letter to renew the waiver.*Even after the lapse in the waiver was identified Administrator A, DON B stated she was not aware an RN needed to be in the facility for eight consecutive hours seven days per week.*DON B verified there were days in Q4 fiscal year 2024, and Q1 fiscal year 2025, that there was no RN in the facility for eight consecutive hours.*She stated there were days in the provider's current schedule that did not have an RN scheduled for eight consecutive hours.

Based on observation, record review, interview, and policy review the provider failed to ensure, the care plans were updated for one of one sampled resident (5) to reflect her current care needs, and one of one sampled resident (38) who no longer had a urinary catheter. Findings include: 1. Observation on 7/29/25 at 2:50 p.m. of resident 5 revealed: *She was sitting in a recliner with her feet elevated in the common area. *She began sitting forward and attempted to scoot forward in the recliner. *Certified nursing assistant (CNA) J asked resident 5 to wait a moment until she got resident 5’s wheelchair. *CNA J then assisted resident 5 in transferring to her wheelchair. Observation and interview on 7/30/25 at 11:28 a.m. with registered nurse (RN) G revealed: *She pushed resident 5 in her wheelchair into her room. *RN G stated resident 5 was able to walk, but she was unsteady and had a high risk for falling. *RN G assisted resident 5 to a standing position, held her hands, and provided cues for resident 5 to walk into the bathroom. *RN G stated resident 5 would attempt to stand and walk independently at times, but staff would watch her closely and walk with her. *RN G stated resident 5 was usually continent of urine but wore a liner in her underwear at night. *Resident 5 was not wearing an incontinence product at that time. Review of resident 5’s 7/30/25 care plan revealed: *The ADLs (activities of daily living) focus area indicated, -She was incontinent two or more times a week and wore a large pull-up. -She transferred and walked in her room independently. -She used the toilet independently. *The intervention area of bowel and bladder indicated she, -Used a panty liner for bladder leakage. Review of the 7/31/25 care sheet revealed: *Resident 5 used a wheelchair. *Staff were to walk with her in the hallway when she was restless. *She did not require any incontinence products. Interview on 7/31/25 at 10:04 a.m. with CNA M revealed: *Each staff member received a resident care sheet at the beginning of their shift that included, general care needs information for each resident. *In addition to the care sheets, she referenced the residents' care plans in the computer system to determine the care assistance she needed to provide to each resident. *Resident 5 spent most of the time in her wheelchair. *She would get up and attempt to walk independently at times, but staff would monitor her closely, and would walk with her for her safety when she stood up. 2. Observation and interview on 7/29/25 at 2:52 p.m. with resident 38 revealed: *He did not have a urinary catheter. Record review of resident 38's electronic medical record revealed: *His medical orders from 6/1/25 through 7/30/25 indicated he did not have a urinary catheter order and it was discontinued on 6/12/25. *His care plan indicated he had a urinary catheter from an outside facility related to urinary incontinence. Interview on 7/30/25 at 8:53 a.m. with CNA S regarding resident 38 revealed he did not have a urinary catheter as noted on his care plan dated 6/20/25. 3. Interview on 7/31/25 at 10:04 a.m. with DON B regarding resident 38’s urinary catheter revealed: *Resident 38’s care plan did not get updated after his urinary catheter was discontinued on 6/12/25. *She stated the nurse should have updated his care plan after they had received the order to discontinue it. Interview on 7/31/25 at 2:10 p.m. with director of nursing (DON) B regarding resident care plans revealed: *She expected resident care plans to be updated anytime there was a change in a resident’s care or condition. *The nurses were able to update care plans in addition to all the management staff. *No one was currently completing audits of the care plans to ensure they were accurate. *She was aware the care plans were not up to date and some of the information in them were not up to date. *She verified there was conflicting information in resident 5’s care plan which included, -Within the bowel and bladder focus area it indicated resident 5 was to wear a pull-up for incontinence and a panty liner for urinary leakage. -Within the ADL focus the care plan indicated resident 5 had the tendency to walk without a wheelchair or walker and she was independent with ambulation in her room. -Within the bowel and bladder focus area it indicated resident 5 needed assistance with toileting, and within the ADL focus area the care plan indicated she was independent with toileting. -The care sheet indicated she did not wear any incontinence product, and staff should walk with her in the hallway when she was restless. -The care sheet did not that she primarily used a wheelchair for locomotion. 4. Interview on 7/31/25 at 10:28 a.m. with licensed practical nurse (LPN) H revealed she did not know how to update resident care plans, and she did not know how to update care plans. 5. Review of the provider’s care plan policy dated 11/2024 revealed: *” It is the philosophy of [NAME] [long term care] LTC to communicate effectively with all staff providing care for our residents. By ensuring a standardized careplan [care plan] process we are ensuring staff is getting the needed information for [the] resident’s care.” *”Policy Implementation: 5. iii. Only licensed professionals and designated ancillary department leaders will have access to make any changes to a resident’s plan of care. This includes but is not limited to adding or deleting interventions from the worklist and adding or editing or frequencies on said interventions.”

Number of residents sampled:Number of residents cited:Based on observation, interview, and policy review the provider failed to follow infection control practices to ensure:*Enhanced barrier precautions (EBP) (glove and gown use when providing contact care) and contact precautions (gown and gloves must be worn when entering a resident's room to prevent the spread of an identified organism) were properly followed for two of two sampled residents (3 and 26).*The sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) slings were not shared or properly disinfected between residents (4 and 17) use.Findings include: 1. Observation on 7/29/25 at 9:38 a.m. of resident 3's room revealed:*A sign on the outside of his door indicated the need for contact precautions.*Personal Protective Equipment (PPE) was hanging on the door across the hall from resident 3's room.Review of resident 3's electronic medical record (EMR) revealed:*He had a left knee abscess that was drained on 1/27/25.-The culture obtained during the abscess being drained was positive for methicillin-resistant staphylococcus aureus (MRSA) (a contagious antibiotic-resistant infection).*He had a 4/3/25 physician order for a dressing change to an open wound on his left knee.*His 7/30/25 care plan indicated he was on contact precautions due to an open wound on his left knee that had been cultured positive for MRSA on 1/27/25.Observation and interview on 7/29/25 at 10:38 a.m. outside resident 3's with certified nursing assistant (CNA) J revealed:*CNA J exited resident 3's room with the sit-to-stand lift and placed the lift in the hallway without disinfecting the lift.*She had a gown and gloves on when she exited the room.*She walked across the hallway to the tub room and removed and discarded her gown and gloves.*She applied another pair of gloves without performing hand hygiene (handwashing).*She pushed resident 3's wheelchair into the hallway from the tub room.*CNA J then cleaned the sit-to-stand lift with a disinfectant wipe.*Resident 3 was seated in his recliner in his room.*CNA J stated resident 3 was on contact precautions because he had a wound on his knee that had previously tested positive for MRSA.Observation on 7/29/25 at 11:08 a.m. of housekeeper N in resident 3's room revealed:*She was mopping resident 3's room floor.*She was not wearing a gown or gloves, which would have been required for a resident who was on contact precautions when she entered the resident room.Interview on 7/31/25 at 1:30 p.m. with housekeeper N revealed:*The cleaning of a resident's room consisted of wiping down all the surfaces in the room, cleaning the toilet, and mopping the floor daily.*A deep cleaning of each resident's room, which included dusting and cleaning the registers was completed weekly.2. Observation on 7/29/25 at 9:38 a.m. of resident 26's room revealed, there was a green square posted on the door frame at the entrance to her room, and PPE was hanging on the back of her room door.Interview on 7/29/25 at 10:44 a.m. with CNA J revealed:*The green square on the door frame indicated the resident was on enhanced barrier precautions (EBP).*Resident 26 was on EBP for a history of MRSA.*Resident 26 did not have an open wound.3. Observation on 7/29/25 at 9:44 a.m. in the Haven secured dementia unit's common area revealed, several wheelchairs were lined up against the wall. Four of those wheelchairs had a sit-to-stand lift sling draped over the back of the wheelchair.Observation on 7/30/25 at 11:42 a.m. in the Haven common area revealed:*There was a sling draped over the sit-to-stand mechanical lift.*Registered nurse (RN) G and CNA K used a second sit-to-stand lift sling to assist resident 17 from the recliner to his wheelchair.*CNA K then placed that sit-to-stand sling on top of the other sling that was draped over the mechanical lift.*She wiped the bars on the sit-to-stand that the resident holds on to and the arms that support the lift sling with a disinfectant wipe but did not clean any other surfaces of the lift or change the lift sling.*The sit-to-stand sling was made of cloth material, which would not maintain the wet contact time required with the use of disinfectant wipes to ensure the sling was disinfected between each resident use.*CNA K then used the lift sling used for resident 17 for assisting resident 4 from a recliner to his wheelchair with the sit-to-stand lift.*CNA K then draped the sit-to-stand lift sling back over the lift.*CNA K wiped the bars on the sit-to-stand that the resident holds on to and the arms that support the lift sling with a disinfectant wipe but did not clean any other surfaces of the lift or change the lift sling.*No hand hygiene was completed before, during, or after the above residents' transfers. 4. Interview on 7/31/15 at 10:04 a.m. with CNA M revealed:*All residents were to have their own sit-to-stand sling.*The slings were to be cleaned weekly and as needed by laundry.*The sit-to-stand lifts were to be wiped down after each resident use.*She was not aware of any resident in the Haven area who was on EBP.*She wore PPE when providing any close contact cares with resident 26.*She wore PPE when she assisted resident 3 to the bathroom or changed his clothing.5. Interview on 7/31/25 at 10:18 a.m. with RN F revealed:*All residents were to have their own sit-to-stand slings.*The sit-to-stand lift was to be wiped down after each resident use.*EBPs were to be implemented with any resident who had a urinary catheter, a wound, or a history of an MDRO (multidrug resistant organism).*Residents 3 and 26 were on EBP due to having a history of MRSA.*Staff were to wear a gown and gloves with resident 26 anytime she was in the bathroom or with bedding changes because she was often incontinent of urine.*PPE was to be worn when the staff completed dressing changes for resident 3.6. Interview on 7/31/25 at 12:20 p.m. with RN/infection preventionist C revealed:*Each resident was to have their own sit-to stand lift sling.*The sit-to-stand lift was to be wiped down with a disinfectant after each resident use.*PPE should be worn when providing most resident cares, such as toileting, changing clothes, changing bedding, bathing, and transferring residents on EBP.*PPE should be worn anytime a staff member entered the room of a resident on contact precautions.*She expected housekeeping to wear PPE when cleaning a room of a resident on contact precautions if their clothing could come in contact with any of the room surfaces.*PPE should be removed prior to exiting a resident's room who is on contact precautions.7. Interview on 7/31/25 at 2:10 p.m. with director of nursing (DON) B revealed:*PPE should be worn with residents on EBP anytime staff would come into contact with the resident.*PPE should be worn with residents on contact precautions anytime staff come in contact with the resident.*PPE should be removed prior to the staff member exiting the resident's room.*She expected the housekeeping staff to wear PPE when cleaning a resident's room who was on contact precautions.*Each resident should have had their own sit-to-stand sling.*The sit-to-stand lift should have been cleaned after each resident use.Review of the provider's 11/13/24 Transmission Based Precautions and Enhanced Barrier Precautions policy revealed:*Purpose:- A means of transmission for the organism.--Interruption of this link in the chain of infection is achieved primarily by separating an individual physically (Transmission Based Precautions) or using a barrier (Enhanced Barrier Precautions).* Enhanced Barrier Precautions are used during high contact resident care activities for the following residents and should be implemented as facilities are able:-a. Infection of colonization with an MDRO when contact precautions do not otherwise apply. -d. if a, b, or c apply, gown and gloves must be used during high contact resident care activities including (but not limited to)--i. dressing--ii. bathing--iii. transferring --iv. providing hygiene--v. changing linen--vi. changing briefs or assisting with toileting--vii. device care or use (Central lines, urinary catheters, feeding tube, trach [tracheostomy] adjustment/care--viii. wound care (any wound requiring a dressing)--ix. Therapy requiring resident contact with uniform* Remove PPE appropriately and complete hand hygiene before leaving the room.* Contact Precautions will be used for residents with known or suspected infections due to certain organisms. Examples are:.-Active infection with MDRO.* Gowns:-a. Wear whenever anticipating that clothing will have direct contact with the resident or potentially contaminated environmental surfaces or equipment in close proximity to the resident. [NAME] gown upon entry into the room if need is anticipated.* Gloves:-a. Wear whenever touching the resident's intact skin or surfaces and articles in close proximity to the patient (e.g. medical equipment, bed rails). [NAME] gloves upon entry into the room if need is anticipated.-c. Remove before leaving the room.- Hand Hygiene upon entering and leaving the room and after removal of PPE.Review of the provider's October 2024 LTC [long term care] IC [infection control] Policy & Procedures policy revealed:* Handwashing: Good hand hygiene techniques will be used before, during and after the care of each resident.* CLEANING DISINFECTION AND STERILIZATION OF EQUIPMENT-A. Non-Disposable Items:. --5. All other equipment will be cleaned between use of each resident.

Based on observation, interview, record review, the provider failed to have a physician order for two of two sampled residents' (12 and 38) use of continuous positive airway pressure (CPAP) devices, which deliver pressurized air through a mask to keep a person's airways open. Findings include: 1. Observation and interview on 7/29/25 at 10:22 a.m. with resident 38 revealed: *He had a CPAP machine that he cleaned himself. He stated, “I am going to as them [the staff] to do it because I think it could use a women’s touch.” 2. Interview on 7/30/25 at 8:10 a.m. with director of nursing (DON) B revealed they did not have a CPAP policy. She stated they did not have a current CPAP cleaning process but they were working on one. *She stated the current CPAP machines in the facility were newer and were cleaned in self-cleaning devices. *She stated the certified nursing assistants (CNAs) had been trained on the CPAPs by the family of a previous resident, but a newly contracted travel CNA had not been trained. 3. Interview and observation on 7/30/25 at 8:49 a.m. with CNA L revealed: *She demonstrated how resident 38’s CPAP mask went into the “SoClean” automated CPAP cleaning and sanitizing machine's tank in his room after it was removed from his face. *She stated, I just hit the “on” button and it cleans and sanitizes his mask. She was not sure how often or when his CPAP device was to be cleaned. She stated the nurses cleaned the CPAPs. She stated there was one other resident with a CPAP machine. 4. Review of resident’s 12s EMR revealed her care plan indicated she used a CPAP device but there was not a medical order for that CPAP device. 5. Review of resident 38s EMR revealed his care plan indicated he used a CPAP device but there was not a medical order for the CPAP device. 6. Interview on 7/31/25 at 11:35 a.m. with certified medication aide (CMA) I revealed she had been trained how to use the CPAP devices automated cleaning system but she did not remember who trained her or when. She thought that CPAP training was part of her new staff orientation process and yearly competency reviews. 7. Interview on 7/31/25 at 11:38 a.m. with LPN H revealed she had been trained how to use the CPAP devices but could not remember who trained her or when. She thought it had been trained probably more than a year ago since she had received any CPAP training. 8. Interview on 7/31/25 at 10:04 a.m. with DON B regarding what professional standard reference she used revealed: *She stated she would have used the manufacturing guidelines for new equipment or for the current CPAP devices. *She stated she she did not have a physician order policy but had a checklist process for physician orders that the nurses followed. *There were 3 lists the nurse could use for new order, admission, or return from hospital. *She agreed that CPAP was not on any of the 3 lists for a nurse to check off that a resident had that device or that the nurse had obtained a physicians order for that devices use for a resident.

Based on electronic medical record (EMR) review, interview, and policy review, the provider failed to ensure documentation in the EMR had indicated that three of three sampled residents (332, 182, and 82) had received their baseline care plan. Findings include: 1. Review of resident 82, 182, and 332's EMR confirmed no documentation they had received a copy of their baseline care plan. Interview on 1/24/24 at 3:20 p.m. with director of resident care J regarding documentation of resident's receiving a copy of their baseline care plan revealed: *She agreed that their was no documentation that resident 82, 182, and 332 had received a copy of her baseline care plan. *Licensed practical nurse (LPN) H should have provided the copy of the baseline care plan to the resident and documented that it was given. Interview on 1/25/24 at 2:40 p.m. with LPN H regarding documentation of resident 182 and 82 had received a copy of their baseline care plan revealed: *She did not have documentation that a copy of the baseline care plan had been provided to the residents and representatives. *They would have printed a copy of the baseline care plan and provided it to the resident or representative, but they do not document that it had been given. Review of the provider's October 2023 Care Plan Procedure revealed: *The plan of care is initiated within 48 hours after admission and fully developed within seven days following the comprehensive assessment, by the interdisciplinary team.

Based on observation, interview, electronic medical record (EMR) review, and policy review the provider failed to ensure two of two sampled resident's (332 and 27) had a physician's order, assessment, consent, care planned, and inspection of the side rails they had been using. Findings include: 1. Observation and interview on 1/23/24 at 10:43 a.m. with resident 332's regarding the use of her side rail that was raised at the head of her bed revealed she used the side rail for bed mobility. Review of resident 332's EMR revealed: *On 1/8/24 a device evaluation was completed and was marked no for currently using a device to assist with mobility/positioning/safety. *No physician's order, consent, or care plan had indicated the use of the side rail. 2. Observation and interview on 1/23/24 during the initial tour revealed resident 27: *Had one side rail in the up position near the head of the bed, on the left side. *Resident stated she uses it to move herself around in bed. Interview on 1/24/24 at 3:44 p.m. with LPN H regarding request for resident 27's side rail revealed she: *Had not been aware of resident 27's side rail. *Stated there was not an assessment, order or consent for resident 27's side rail. Review of resident 27's EMR revealed there was no physician's order, assessment, consent, or care plan for the use of a side rail. Interview on 1/25/24 at 10:30 a.m. with maintenance technician I regarding the inspection of the side rail when attached to a resident's bed revealed: *All but four of the beds with side rail had been in use upon his employment in 2019. *He had not been inspecting the bed with side rails annually. Review of the provider's April 2023 Siderail Policy revealed: *If side rails are in use, the resident will have a dated, timed order from the provider with the rational for the side rail use. The resident will be assessed and care planned for the side rail and the family will sign a consent for the side rail use. *Use of side rails will be reevaluated at every provider visit and quarterly with care plans. Review of the provider's April 2023 Restraint Policy revealed: *Staff will fill out the side rail/grab bar intervention and ADL intervention prior to side rail utilization to assess bed mobility. *Results of resident's bed mobility needs will be reviewed by interdisciplinary team, resident/family, and resident's physician. Designated interdisciplinary team members will assist in evaluation the resident's cognitive status as the interdisciplinary team determines the resident's full ability to make a safe decision regarding the side rail usage. *Prior to utilizing side rails a pre-retraining assessment will be completed to ensure resident's safety of the device. *A physician's order must be obtained for the use of the side rails. *Use of device will be care planned accordingly and quarterly assessment will be documented in the restraint assessment. *Staff will document on side rail usage every shift. This information will be charted on the Side/Rail Grab Bar intervention in the EHR. *Use of the device will be reviewed quarterly by Interdisciplinary team, resident, and family at the care conference. 35121

Based on observation, interview, record review, and policy review, the provider failed to offer or provide dignified positioning for one sampled vulnerable resident (82) while in the activity room. Findings include: 1. Observation on 1/24/24 at 9:40 a.m. of the front activity room revealed: *Resident 27 was seated in a chair at the table across from resident 82. *Resident 82 was positioned approximately 3 feet from the activity table in her wheelchair, slumped forward with her head hung over her knees, her arms hung down in front of her, and her hands resting on her ankles/feet by the front wheelchair pedals. *Activities assistant E was placing bingo cards on the activity table. *Activities coordinator F had then entered the room. *Shortly after, activities assistant G had entered the room. *All three staff sat at the opposite end of the table from the residents and had what appeared to be a meeting. *Resident 82 was noted to be in the same position, with her head at her knee level, moving her left hand and lifting her head periodically. *None of these staff were observed to have acknowledged resident 82 or offer/request assistance for her to be repositioned in an upright position. 2. Observation on 1/24/24 at 9:49 a.m. revealed: *All three activities staff (E, F and G) exited the activities room. *Resident 82 remained in the same position, moving both of her hands, touching her feet, ankles and wheelchair legs and pedals, and attempting to lift her head. 3. Observation and interview on 1/24/24 at 9:53 a.m. revealed: *Resident 27 was sitting across from resident 82. She shook her head and stated she had to ask them [staff] to help her [resident 82]. *Resident 27 stated she was worried she [resident 82] was going to fall out of her chair. *Resident 82 was in her wheelchair positioned at the bingo table, slumped over with her right hand and head resting on the table. 4. Observation on 1/24/24 at 9:56 a.m. revealed activities coordinator F entered and exited the activity room, leaving resident 82 in the same position. 5. Observation on 1/24/24 at 10:02 a.m. revealed: *Activities coordinator F had returned with two other staff. *Those two staff assisted resident 82 from her wheelchair in the activities room to a recliner in the dining room with her feet elevated. *The resident closed her eyes and appeared to have fallen asleep. 6. Record review revealed resident 82: *Was admitted on [DATE]. *Was admitted to hospice services on 1/19/24. *Had diagnoses of: -Parkinson's disease with dyskinesia, with fluctuations. -Dementia in other diseases classified elsewhere, severe, with psychotic disturbance. -Idiopathic scoliosis [curved spine]. -Weakness. -Anxiety disorder, unspecified. -Moderate persistent asthma. 7. Interview on 1/25/24 at 9:58 a.m. with administrator A and director of nursing B regarding vulnerable residents, including resident 82, revealed: *Staff should have approached the resident and assisted if they were appropriate to do so. *Staff should get nursing staff or use the radio to call for assistance. *All residents should get help in a dignified and timely manner. 8. Interview on 1/25/24 at 11:01 a.m. with activities coordinator F regarding the observations of resident 82 revealed she stated: *She should have checked to see if the resident was ok or needed assistance. *All staff should check on any resident who is seen in poor or unsafe positioning and assistance should be given or requested right away. 9. Review of the provider's last approved February 2023 Patient/Resident Rights and Responsibilities policy revealed: *The patient/resident has the right to be treated with dignity, compassion and respect. The patient/resident has the right to care that takes into account the social, spiritual and cultural matters that have an effect on his or her illness. Race, ethnicity, sex, culture, language, sexual orientation, gender identity, physical/mental disabilities, religion or ability to pay will not affect the care delivered. 10. Review of the provider's last approved April 2023 Resident Quality of Life policy revealed: *The provider will promote care of each resident in a manner and in an environment that maintains and enhances each resident's dignity and respect while enhancing the resident's individuality. *Staff provides care that maintains and enhances each resident's self-esteem and self-worth. This is carried out with each interaction staff have with each resident. *While providing care to residents and/or during staff interaction(s), staff will promote resident dignity. *Staff will provide care to residents in the above referenced areas (others as indicated) in a manner that recognizes the self-worth, dignity and respect of each resident.

Based on observation, interview, record review, job description review, and policy review, the provider failed to fully implement an activity program based on resident assessment and preference for two of two sampled residents (3 and 21) in the memory care unit (MCU). Findings include: 1. Observation on 7/13/21 between 2:40 p.m. and 5:05 p.m. of residents 3 and 21 revealed: *The dining area and television lounge were a combined space. *Resident 3 sat in a recliner in the television lounge area with the television on. -Her eyes remained closed until 3:22 p.m. when she awoke. *Resident 21 had been in a recliner in that same television lounge. -His recliner was positioned so that he was unable to see the television screen. *He remained in that recliner with his eyes closed. *Both residents were assisted out of their recliners and into their wheelchairs for the evening meal about 5:00 p.m. Interview on 7/13/21 at 5:10 p.m. with medication aide F regarding the MCU activity schedule for that date revealed: *One of eight residents had attended church outside of the MCU at 10:00 a.m. *No one had attended the table time activity scheduled at 11:00 a.m. *Water painting scheduled for 2:00 p.m. had not occurred. *Ice cream cup activity scheduled for 2:30 p.m. had not occurred. *Activities assistant O tried to take a few MCU residents off the unit for daily activities otherwise MCU staff tried to entertain them. Observation on 7/14/21 between 9:15 a.m. and 10:45 a.m. revealed: *Resident 3 was in a recliner in the television lounge area with the television on. -Her eyes were closed. *Resident 21 sat in his wheelchair at the dining table, finished breakfast then was moved to a recliner in the television lounge area. Interview on 7/14/21 at 5:40 p.m. with licensed practical nurse M regarding the MCU activity schedule for that date revealed: *Activities assistant O had not worked that day. *The polish nails activity scheduled for 10:00 a.m., table time activity at 11:00 a.m., and ball toss scheduled for 2:30 p.m. had not occurred. *Activities coordinator P had delivered popcorn for the 2:30 p.m. popcorn/pop activity. Observation on 7/15/21 at 9:37 a.m. of residents 3 and 21 revealed: *Resident 3 was at the dining table with a ball in her lap and manipulative items in front of her. -She had not interacted with any of those items. *Certified nurse aide (CNA) Q sat next to resident 3 and worked on a laptop computer. *Resident 21 sat in a recliner in a corner of the television lounge unable to see the television that was on. Interview on 7/15/21 at 9:45 a.m. with CNA Q and LPN G regarding residents 3 and 21 revealed: *It was typical for residents 3 and 21 to sit in recliners after breakfast until lunch then return to those recliners for the afternoon until the evening meal. *Resident 21's wife visited weekly or every other week. -Staff assisted him to call her when he requested. *Neither resident had participated in the Music and Memory program but other residents had. Observation on 7/15/21 at 12:50 p.m. in the MCU dining area revealed: a counter top with multiple plastic containers filled with activity items such as a gadget board, colored pencils, crayons, paper, flash cards, puzzles, assembly type items similar to Legos, and a plastic ball. Review of resident 3's activity care plan last revised on 3/25/21 revealed the following activity preferences: *Spending most of her time in the dining room/activity area. *CD player in her room. *Has a permission slip to use Music and Memory as an activity. *Nails polished and hair combed. *Attend church services off unit two times per week. *Beauty shop weekly. *Will encourage more involvement by next evaluation. Review of resident 21's care plan last revised on 6/14/21 revealed the following activity preferences: *Looking at local newspapers, farm magazines, and daily news sheets. *Visits and phone calls with his spouse. *Church activities two times weekly off the MCU. *Watching westerns. *Manipulating a gadget board or other sorting activity. *Wearing his baseball hat and attending daily coffee time. *Any kind of action game. *Encourage activities out of the MCU. Review of the 7/1/21 through 7/15/21 Activity One-on-Ones documentation revealed: *There was a list of twenty-one one on one activity ideas for residents that had not attended activities on a regular basis. *Helping resident 3 with a meal had been documented as a one on one activity six times. -Looking at pictures had been documented once. *Resident 21 had not been identified as a resident meeting one on one activity criteria. Interview on 7/15/21 between 1:15 p.m. and 2:00 p.m. with activities coordinator P regarding the monthly MCU activity schedule revealed: *The only regularly scheduled activities on the calendar that occurred off the MCU unit were inspiration time every Tuesday and Thursday and scripture time every Tuesday. -It was the responsibility of nursing staff to have residents up and in their wheelchairs so activities staff could transport them to those church activities. -She had not prepared a list of residents she had expected nursing staff to have ready to be taken to activities off the MCU. *She confirmed that between 6/1/21 and 7/15/21 documentation showed residents 3 and 21 had each been offered the opportunity to attend church off the MCU two times. *She confirmed documented one on one activities for resident 3 referred to above had not been acceptable. *Activities assistant O led the weekday table time activity on the MCU. -That occurred prior to lunch and might include activities such as ball rolling, reading or a craft. *Nursing staff had been expected to carry out the table time activity if activity assistant O was absent as well as all other activities on that activity schedule unless otherwise indicated. -Some nursing staff were better than others about ensuring those activities had occurred as scheduled. -She helped as she was able to. *She was not sure how to raise the expectations and accountability for implementation of the MCU activity calendar and not spoken to her immediate supervisor about that dilemma. Review of the undated Activity Calendar/Schedule policy revealed: *Activities: -Activities are individualized to increase participation according to hobbies, habits and life roles. If resident is able, they may participate in activities in both sections (memory care unit and general population unit) of the nursing home. *Staffing: -Staff is equipped with the knowledge needed to care for people with dementia. All staff working in the Haven (memory care unit) attend yearly education. Review of the undated Activity Coordinator job description revealed: *Job Summary: -Plan, develop and implement activities programs that assist in maintaining each resident's highest functioning level dealing with physical, social, spiritual and mental well-being aspects. -Assess each resident for activity abilities and interest and develop an individual care plan as indicated from the assessment. -Contact different departments for consultation to meet the resident's needs. -Communicate concerns and/or progress to those departments.

Based on record review and interview, the provider failed to have a system in place to ensure complete and accurate resident medical records for one of one sampled residents (23) who received hospice services through one of one hospice agency. Findings include: 1. Review of resident 23's medical record revealed: *She had been admitted to hospice on 2/17/21. *Her care plan had not been updated to include her hospice admission until 3/5/21. *Her care plan included: -Problems -1) Spiritual [name of resident] and her family will be given the opportunity to express their faith and feelings within context of their faith tradition. -2) [Resident's name] pain will be minimized within the limits of the disease. -3) Symptoms problematic to [resident's name] will be addressed to maintain optimal quality of life. *No interventions had identified what hospice services were provided, how often hospice services were to have been in the facility, or how hospice care was used. 1. a. Refer to F849.

Based on record review and interview, the provider failed to ensure an integrated plan of care had been developed for one of one resident (23) receiving hospice services. Findings include: Review of resident 23's medical record revealed:*She had been admitted to hospice on 2/17/21. *Her care plan had not been updated to include her hospice admission until 3/5/21. *Her care plan included: -Problems-1) Spiritual [name of resident] and her family will be given the opportunity to express their faith and feelings within context of their faith tradition.-2) [Resident's name] pain will be minimized within the limits of the disease. -3) Symptoms problematic to [resident's name] will be addressed to maintain optimal quality of life. *No interventions had identified what hospice services were provided, how often hospice services were to have been in the facility, or how hospice care was used. Interview on 7/15/21 at 8:15 a.m. with director of nursing (DON) B regarding hospice revealed: *DON B confirmed she had been designated as the point of contact between the provider and the hospice agency.*There were no hospice binders for residents receiving hospice care. *Hospice care plans were to have been faxed to the facility and those care plans should have been placed into the facilities care plan binder.-That had not been done.*She stated they did not have a procedure in place to ensure information was being received by hospice services.*All hospice information had been received verbally from the hospice nurse when she visited.*DON B had been unable to locate the resident's hospice care plan or any documentation from hospice for any visits hospice had completed for resident 23.*DON B was unaware of how often the hospice nurse or aide visited resident 23. -She stated it was dependent on the phase the hospice resident was in.--She also stated she could find out the days hospice visited resident 23 if I wanted her to. *DON B confirmed resident 23's plan of care had not been developed a collaborative plan of care but should have been.

Based on observation, interview, record review, and policy review, the provider failed to:*Implement a repositioning schedule for one of one sampled resident (23) at risk for skin breakdown. *Ensure one of one sampled resident's (8) injury of unknown origin was reported, assessed and investigated. Findings include:1. Random observations on 7/13/21 from 8:15 a.m. through 6:45 p.m., on 7/14/21 from 7:45 a.m. through 6:00 p.m., and on 7/15/21 from 7:30 a.m. through 10:50 a.m. of resident 23 revealed:*She had been in her room sitting upright or partially reclined in her Broda chair.*She had not been repositioned from side to side while sitting in the her Broda chair or moved out of the chair to relieve pressure to her back, buttocks, back of her arms, or back of her thighs. Record review revealed resident 23 was at moderate risk for skin breakdown. Interview on 7/14/21 at 4:33 p.m. with registered nurse (RN) coordinator J regarding resident 23 revealed:*While she worked night shift she observed resident 23 not being repositioned. *She entered a scheduled repositioning time for two times at night.-Midnight and 3:00 a.m.*She had not entered any other scheduled repositioning times. Interview on 7/14/21 at 5:18 p.m. with medication aide L regarding repositioning of resident 23 revealed:*They repositioned her by reclining the Broda chair back into a semi laying position.*She did not know of any other way of repositioning her. Interview on 7/14/21 at 5:18 p.m. with RN D regarding repositioning of residents revealed all residents should be repositioned at least every two hours. Interview on 7/15/21 at 9:08 a.m. with director of nursing (DON) B regarding resident 23 revealed:*She agreed resident 23 was unable to reposition herself.*Her expectation was that resident's unable to reposition themselves would have been repositioned at least every two hours.*She stated RN coordinator J had noticed resident 23 was not being repositioned at night.*On 6/27/21 RN coordinator J added a repositioning task in the electronic medical record.*That repositioning task was only scheduled for two times in a 24 hour period.-It had been scheduled for midnight and three a.m.-There were no other scheduled repositioning times.*DON B agreed leaning a resident back in their Broda chair into a reclining position was not considered repositioning.*She agreed the repositioning task should be update for repositioning every two hours. Review of the 9/2019 last reviewed Pressure Ulcer Prevention Policy/Procedure revealed:*VII. Related documents.*iii. Repositioning.-Turn patient every two hours; use a facility-defined reminder.*Seated patient.-Limit the time to two hours for patients in seated position.*b. Moderate Risk: Braden Scale score 13 to 14.-ii. Repositioning.-Reposition patient every two hours according to facility-defined turning reminders. Evaluate for increased turning/small shifts (every one hour, every 30 minutes). 2. Observation and interview on 7/13/21 at 3:02 p.m. with resident 8 revealed she had: *A bruise measuring approximately two inches by one inch just above the inside of her elbow which had been green and purple in color. *Not been responsive to attempts at conversation. Review of resident 8's medical record and care plan revealed: *Her brief interview of mental status indicated she had severe cognitive impairment. *Her care plan reflected she should have had weekly skin assessments. *Skin assessments completed on 7/6/21 and 7/13/21 had not identified she had a bruise. Interview on 7/14/21 at 4:10 p.m. with director of nursing B regarding a bruise of resident 8 revealed she: *Had not been aware of any bruising. *Thought licensed practical nurse (LPN) G might know something as she had been in charge of skin conditions of residents. Interview and observation on 7/14/21 at 4:52 p.m. with LPN G regarding bruising of resident 8 revealed: *Skin assessments were completed on a weekly basis. *She had not been aware of a bruise. *She had then assessed resident 8 and measured the bruise to be 2.1 centimeters (cm) x 4.7 cm on her left arm. *The process for injury of unknown origin was to have been: -A nurse would be notified upon finding by a certified nursing assistant (CNA). -The nurse would have measured and completed a skin assessment. -Any injury would have been reported to the DON for investigation. *The bruise should have been reported to someone and investigated. *Resident 8 was unable to say what had happened. *She would notify the DON for an investigation to be completed. Interview on 7/14/21 at 5:15 p.m. with CNA H regarding bruising of resident 8 revealed she: *Had assisted her on 7/13/21 to the restroom and had not seen any bruising. *Would have reported to a nurse the bruise if she had seen it. Interview on 7/15/21 at 12:44 p.m. with medication aide F regarding the bruising of resident 8 revealed she: *Had seen the bruise on 7/10/21. *Had not reported it to anyone. *Knew she should have reported the bruise to a nurse. *Assumed someone else would have reported it. Interview on 7/15/21 at 12:44 p.m. with DON B regarding the bruise on resident 8 revealed: *She agreed the bruise should have been reported to her when it was first noticed. *Employees sometime assume someone else reported an injury. -Knew they should report any injures to a nurse. *Had provided education to staff regarding reporting injuries on 2/21/20 and 5/20/20. Interview with 7/15/21 1:30 p.m. with DON B revealed: *They did not have a skin assessment policy. *They had been developing a skin care program. *Skin assessments had been done the day a resident received a bath. Review of providers' October 2017 Abuse, Neglect, Mistreatment and Misappropriation of Resident Property revealed: *g. Injuries of Unknown Origin: An injury should be classified as an injury of unknown source when both of the following conditions are met: i. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. ii. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.

Based on observation, interview, and record review, the provider failed to ensure: *The appropriateness for dining assistance had been documented in three of three observed residents' (3, 9, and 27) care plans who had received dining assistance. *One of three observed dining assistants (M) had not fed one of three observed residents (9) who was at risk for aspiration. Findings include: 1. Observation on 7/13/21 at 5:15 p.m. in the memory care unit (MCU) revealed residents 3 and 27 had received dining assistance. 2. Observation and interview on 7/14/21 at 5:20 p.m. in the MCU dining room with dining assistant M feeding resident 9 revealed she: *Received dining assistant training and worked in that capacity about two years. -Was not a certified nurse aide. *Nursing staff had told her if there were any residents she was unable to feed. -There were no residents currently in the MCU she was restricted from feeding. *Confirmed the water she helped resident 9 drink was thickened because he sometimes coughed when he drank water. Interview on 7/14/21 at 4:45 p.m. with registered nurse D regarding the dining assistance program revealed: *She was responsible for the dining assistant education program. *Residents not eligible for dining assistance included those with swallowing difficulties, feeding tubes, residents at risk for aspiration and those who required thickened liquids. Interview on 7/14/21 at 5:30 p.m. with licensed practical nurse N regarding the dining assistant program revealed she: *Was responsible for the oversight of the dining assistants and determined whether a resident was appropriate to be fed by a dining assistant. *Stated there were no residents in the MCU who were ineligible for dining assistance. Review of resident 9's care record revealed: *A physician's order dated 5/18/21 for nectar thick liquids. *A speech language pathologist progress note dated 6/30/21 indicated resident 9's diet had been changed to nectar thick water because he coughed drinking water. Review of resident 9's care plan last reviewed on 4/29/21 revealed: *His diet was regular with small servings. *A history of recurrent upper respiratory infections. *A need for extensive assistance of one staff for eating. Interview on 7/15/21 at 10:15 a.m. and 11:05 a.m. with director of nursing (DON) B regarding the dining assistant program revealed: *Residents excluded from this program included those who required thickened liquids or had a modified diet texture such as puree. *She was not aware resident 9 had orders for thickened water. -Dining assistant M should not have been allowed to feed him. *Dining assistants relied on nursing staff to advise them of those residents they should not feed. *She confirmed resident 9's care plan had not been updated to reflect current diet orders. *The appropriateness of residents 3, 9, and 27 for dining assistance had not been identified in their care plans. A dining assistance program policy was requested of administrator A on 7/15/21 at 8:10 a.m. On that same date at 11:45 a.m. DON B stated they had no policy.

Based on record review, interview, and policy review, the provider failed to ensure an effective quality assurance (QA) program had been maintained to identify concerns and to develop and implement corrective action for residents with falls. Findings include: 1. Review of the provider's QA meeting notes from 7/2/14 through 6/30/15 revealed falls had been discussed in two of the five meetings. The number of falls had been monitored. There had been no fall monitoring documented in 2015. There had been no documentation that falls had been investigated. There had not been corrective measures put in place by the provider to help minimize falls in the facility. Any current corrective measures in place for preventing falls had not been monitored by the provider for effectiveness. Interview on 9/2/15 at 3:50 p.m. with the director of nursing revealed: *She was responsible for the provider's QA program. *She was aware the facility had a lot of falls. *She believed there had been less falls with major injury since the 2014 QA studies about falls. *She thought what they had done in 2014 had been enough but agreed there could be more monitoring done. *Falls were discussed in nursing meetings, but monitoring and corrective actions had not been done. Review of the provider's October 2012 Plan-Do-Check-Act-Cycle (PDCA) quality management approach policy revealed the following steps to take to solve problems: *Plan, identify and analyze a problem and get to the root cause. *Do, find best solutions and test those solutions. *Check, measure how effective a test solution had been and look for ways to improve. Measure results. *Act, fully implement the most effective solution. *Repeat the above cycle for continuous improvement. Review of the undated Quality Improvement (QI) plan revealed the methodology (procedure) of the quality improvement program had included: *Problem identification, data examined. *Problem assessment, assessment findings. *Problem resolution, action and follow up. *One of the goals of the QI plan was to establish priorities for investigation and correction of problems that impacted direct or indirect resident care and to protect residents from adverse outcomes. Refer to F323, findings 1, 2, 3, and 4A.

(Surveyor: A. Based on observation, interview, record review, and policy review, the provider failed to implement appropriate interventions to prevent future falls for three of nine sampled residents (1, 7, and 9) who had multiple falls. Findings include: 1. Review of resident 9's medical record revealed: *She had been admitted on [DATE]. *She was alert with memory problems and forgetfulness. *She had a Brief Interview for Memory Scale (BIMS) (memory test) score of nine that indicated moderate memory issues. *She required extensive assistance of one staff member for moving in bed, walking, dressing, personal hygiene, and using the toilet. *She required supervision and set-up assistance with eating. *Her [DIAGNOSES REDACTED]. Random observations from 9/1/15 through 9/2/15 revealed resident 9: *Used a walker and one staff person for assistance to walk. *Spent a lot of time in the recliner in the dining room by the bird cage. *Did not have a falling star sticker (used to identify residents as fall risk) by her door or on her walker. Interview on 9/2/15 at 10:50 a.m. with medication aides/certified nursing assistants (CNA) D and E regarding resident 9 revealed: *She was supposed to walk with a walker and staff assistance. *She attempted to walk on her own at times. *She had not fallen for a few months but had a history of [REDACTED]. *She should have had a falling star sticker on her door or walker. *The falling star sticker indicated the resident was a high fall risk. *The Minimum Data Set (MDS) coordinator usually put the stickers on the residents' doors. Review of resident 9's Fall Follow-Up progress notes by nursing revealed falls and the prevention methods regarding future falls on the following dates: *12/5/14, fell in her room with a head injury. -She had attempted to transfer herself. -She had a short term memory problem. -Prevention: Reminded to ask for assistance. Staff to anticipate needs as much as possible. She is very independent with most things and sometimes does not allow staff to assist her. *12/15/14, had a witnessed fall in the hallway and hit her head. -She had a short term memory problem. -She was sent to the hospital for evaluation. -Prevention: TABS (type of monitor that alerts staff when a resident moves) alarm placed on bed, and will be applied to wheelchair and recliner when in those. To use wheelchair more than walker, with staff assist. *12/31/14, fell in the dining room with no injury. -She had been turning with staff assistance and fell backward. -Prevention: Continue to assist with ambulating (walking). *1/30/15 , fell in her room and hit her head. -She had removed her TABS alarm and gotten up by herself. -Prevention: Use tabs monitor already, it was in place and she ripped it off and proceeded to try and get herself out of bed. she had already been toileted as well X (times) 3 since she was put to bed after lunch. *3/9/15, fell within the dining room and hit her head. -She was witnessed falling and had been told to wait for assistance prior to that. -Prevention: Always ambulate with resident. Use a gait belt. Use a walker. Tabs alarm. *3/20/15, fell in the dining room and hit her head. -She was witnessed attempting to transfer herself. -Prevention: Anticipate (resident's name) needs and assist with leaving the table. *4/4/15, fell in the dining room with no injury. -She was lowered to the floor by nursing staff. -The right side of the dining chair broke when it tipped with her. -Prevention: Seek new chair that slides when she pushes self back. *6/8/15, fell in the dining room and struck her left elbow. -She had a hematoma (swelling with bruise) on her left shoulder. -She had a broken left humerus (arm). -Prevention: Staff to not take her to the table until meal is to be served as will not wait for assist. Review of resident 9's 7/22/15 care plan revealed: *She had short and long term memory problems and impaired decision making. *She required extensive assistance of one staff person with moving in bed, walking, dressing, personal hygiene, and using the toilet. *She was at high risk for falls, and she had a history of [REDACTED]. *Interventions for falls included: -Assess for acute med (medical) conditions. -Assess for environment. -Keep area properly lighted. -Keep obstacles out of the way. -Keep area calm and try to prevent distractions. -To sit in regular dining room chair not high back chair at the table as she pushes chair back at times and regular chairs are stronger. -Anticipate needs. -Take to recliner chair in dining room as soon as done eating so she does not attempt to go by herself. -Use TABS monitor when in bed. -Be aware that she does not use call light but calls out for nurse when she wants something. *Those interventions had been initiated on 2/25/14. 2. Review of resident 1's medical record revealed: *She had been admitted on [DATE]. *She was alert but forgetful. *Her [DIAGNOSES REDACTED]. Observation and interview on 9/1/15 at 9:25 a.m. of resident 1 revealed: *She was sitting in her recliner in her room with her feet up. *She was alert, pleasant, and oriented to person and place. *There was a TABS alarm sitting on the foot of her bed that was not attached to her clothing. *She stated she did not get up on her own; she would use the call light to get the staff to help her if she needed something. -The call light was within reach. Observation during the medication administration for another resident on 9/1/15 at 10:30 a.m. with RN C revealed: *Resident 1 was walking in the hallway by herself. *RN A stated Oh I don't like that. She's not supposed to be up by herself. *After she finished preparing the other resident's medication she closed the medication cart. *She went into that other resident's room across the hall and administered the medication. *When she came back out of that room approximately thirty seconds later, resident 1 was lying on the floor on her left side. *Resident 1 had hit her head and was bleeding from lacerations by her left eyebrow and left elbow. *RN C assessed the resident. *RN C, with the help of medication aides/CNAs D and E, and the resident care coordinator nurse assisted the resident into a wheelchair and back to her room. *Once resident 1 was in her room nursing staff continued their assessment. Interview with medication aide E at the time resident 1 was brought back into her room after the fall revealed: *She should have had the TABS alarm put on her when she was in her recliner. *She was unsure who had put her into the recliner after breakfast. *Anyone who had seen the resident walking by herself should have stopped to help her right away to prevent her from falling. *She could have walked with staff assistance but not by herself. Interview on 9/1/15 at 10:45 a.m. with the director of nursing (DON) confirmed resident 1 should not have been walking by herself if she had a TABS alarm. Interview on 9/1/15 at 10:46 a.m. with the Minimum Data Set (MDS) assessment nurse regarding resident 1 revealed: *She had been the one who had brought her back to her room after breakfast around 9:00 a.m. *She had assisted her into the recliner, had put the TABS alarm on the back of the chair, and had clipped it to the resident's shawl. *She thought the resident probably had removed the TABS alarm on her own. *She had been removing the TABS monitor on her own and had recently cut the strings with a scissors in her room. *They had removed the scissors. *She agreed they should have probably tried something different than the TABS alarm since she was removing it and cutting the strings. *She confirmed if a staff member had seen the resident walking by herself they should have helped her right away. *She agreed the resident needed assistance with walking. Further interview on 9/1/15 at 11:45 a.m. with the MDS nurse revealed she: *Had taken the resident's scissors away the day before. *Had not documented that the resident had cut the strings of the TABS alarms, or the scissors were taken from her room. Interview on 9/1/15 at 11:45 a.m. with RN C confirmed: *She should have taken resident 1 back to her room right away when she had seen her walking by herself. *She might have prevented resident 1's fall that morning. Review of resident 1's Fall Follow-Up progress notes by nursing revealed falls and the prevention methods regarding future falls on the following dates: *6/11/15, fell in her room and obtained a bruise on her right elbow. -She had attempted to transfer herself. -She had a short term memory problem. -Prevention: Remind resident to use call system for help. *7/1/15, fell in her room and obtained a skin tear on her left elbow. -She had a short term memory problem. -Prevention: Making sure bed is in proper position and call light within reach. *8/9/15, fell in her room and obtained skin tears on both arms and a bruise on her left knee. -Prevention: Call for assist. *8/10/15, fell in her room with no injury. -She had a short term memory problem. -Prevention: Keep encouraging her to use call light and check her often. *8/17/15, fell in her room with no injury. -She had a short term memory problem. -Prevention: Continue to use tabs monitor, toilet on rounds, anticipate needs. *9/1/15, fell in the hallway and hit her head. She obtained skin tears to her left eyebrow and left elbow. -She was witnessed attempting to transfer herself. -She had a short term memory problem. -Prevention: When standing in hallway take to room immediately. Review of resident 1's 7/1/15 care plan revealed: *She had mild cognitive (memory, thinking) loss. *She required extensive assistance of one staff person with dressing, personal hygiene, and using the toilet. *She required assistance of one staff person with walking in her room and the hallways. *She was at high risk for falls. *The last fall was written in as 8/17/15. *The interventions for falls included: -Medication Review by provider with each visit. -Pharmacy consultant review monthly. -Monitor for side effects of medications. -Seek dose reduction when appropriate of medications. -Monitor for mood and behavior. *Handwritten entries of: -Call for assist - call light in reach. -TABS monitor to bed and wheelchair. *There were not specific interventions for all the falls. Surveyor 3. Review of resident 7's complete medical record revealed: *She had sixteen falls total 7/23/14 through 9/2/15. *She had hit her head twice. *She had been trying to use the restroom herself on several occasions when she had fallen. *She had been left alone on a lift in the bathroom and had fallen out of it on 3/12/15. Review of resident 7's fall reports revealed the following fall information and interventions to prevent future falls: *7/23/14, found sitting on the floor in her room. -Interventions: monitor closer, can not use tabs alarm because the resident removes it, and she does not understand to use the call light. *8/31/14 at 9:00 p.m., found sitting on the floor in her room. -Interventions: offer assistance to bathroom and remind her to call for help. *9/30/14 at 4:10 p.m., fell on her back when an aide left her to get her wheelchair (w/c). -Interventions: monitor closer and call for assist and not leave her to get w/c. *10/5/14 at 1:58 p.m., found incontinent (loss of bladder or bowel control) on the floor in her room, so suspected she had been trying to go to the bathroom. -Intervention: resident had been educated to wait for assistance and she needed reinforcement for understanding. *10/14/14 at 5:05 p.m., found on the floor by her bed with a small mark on her back. -Intervention: resident educated to wait for assistance, and needed reinforcement for understanding. *12/21/14 at 8:18 p.m., found sitting on the floor in her room facing the bathroom. -Intervention: tabs alarm on while in her w/c. *1/21/15 at 12:59 p.m., walking herself with her walker and fell backwards on her back and buttock resulting in thigh and hip pain. -Intervention: educated to wait for assistance, and needed reinforcement for understanding. *1/22/15 at 2:55 p.m., trying to go to the bathroom by herself and fell . -Interventions: anticipate resident's needs and take her to the bathroom around 2:30 p.m. or so. *3/12/15 at 10:58 a.m., tried to get up in the dining room, slid down to the floor without injury, and was taken to the bathroom. -Interventions: give her a magazine to occupy her time, allow her to sit on the toilet longer before getting up, and to monitor her bowel movements (BM). *3/15/15 at 11:20 a.m., had been hooked into a lift in the bathroom over the toilet. The certified nursing assistant had left her on the lift, and when she returned the resident had been on the floor in the sling of the lift. -Interventions: follow current plan of care and to not leave her alone on the lift. *3/16/15 at 7:00 p.m., found on the floor between her w/c and bed. -Interventions: reinforce the need to get assistance from staff and to not allow her in her room until staff were ready to place her in bed. *3/22/15 at 2:23 p.m., found on the floor in her room with the tabs alarm sounding. -Interventions: continue care as outlined in care plan. *5/21/15 at 8:09 p.m., witnessed sliding out of her w/c. -Intervention: remind resident not to try to stand alone. *5/24/15 at 2:12 p.m., was witnessed slipping out of her w/c and hit her head. -Interventions: monitor closely and remind her to sit up straight in her w/c. *7/15/15 at 1:30 p.m., found on her back, in her room with the tabs alarm going off. She had a large bump on her forehead. -Intervention: continue to monitor, and try to keep her out of her room so staff could monitor her better. Review of resident 7's 6/15/15 Minimum Data Set (MDS) assessment revealed: *A brief interview for mental status score of five, indicating she was severely cognitively (ability to understand) impaired. *She was occasionally incontinent of bladder and frequently incontinent of bowel. -She was not on a toileting plan. Review of resident 7's current care plan revealed she was at high risk for falls. *In the fall section: -On 7/15/15 had fallen and hit her head. -A 7/15/15 goal, tabs alarm (device used to help prevent falls) at all times. -An intervention, remind her to wait for assistance. -An intervention, give her reading material, so she will stay in the dining room. *No other falls had been noted on her careplan. *No other interventions had been listed on her careplan. *In the continence section she had urinary incontinence and received assistance to go to the bathroom. -A 3/25/14 goal, would accept assistance to toilet to prevent falls. -Intervention, toilet on rounds. -Intervention, staff to toilet her during the night and in the morning to prevent falls. Interview on 9/2/15 at 10:40 a.m. with nurse F revealed: *Staff did not document every time they toileted a resident. *Resident 7 was toileted every day. *Toileting was only documented during quarterly care planning. *There were no specific toileting programs in the facility. *She said staff had left resident 7 alone on the lift on 3/15/15, because they had been trying to prevent another resident fall. Surveyor 4. Review of the Nurse's Staff Meeting notes from August 2014 through August 2015 revealed falls had been discussed in: *September 2014: -They mentioned the number of falls from August, and one resident who was at high risk. *December 2014: -They mentioned the process for neurological (nervous system) checks if a resident hit their head during a fall and the number of falls from November. -There were hand outs for 10 Questions at the Time a Resident Falls, Risk Factors/Contributing Factors for Falls, and Fall Risk for Injury - ABCs attached. *January 2015: -They mentioned the number of falls from December 2014 and three residents who had two falls each. *February 2015: -They mentioned the number of falls from January and two residents who had two and three falls each. -There were notes for possible fall prevention ideas for one of those two residents. *March 2015: -They mentioned the number of falls from February and one resident who had three falls. *May 2015: -They mentioned the number of falls from April and two residents who had two and three falls each. -There were notes for possible fall prevention ideas for those residents. *June 2015: -They mentioned the number of falls from May and one resident who had two falls. -There were notes for possible fall prevention for that resident. *July 2015: -There was a note that stated Number of falls in June decreased to 6. Mostly due to deaths of specific residents. *Falls were not mentioned in August, October, or November 2014, or April and August 2015. *Only specific residents had been discussed for prevention ideas in the above months not all residents. Interview on 9/2/15 at 9:15 a.m. with the DON regarding falls revealed: *They were talked about at the quarterly risk management meetings. *They did not discuss them at the quarterly quality assurance performance improvement (QAPI) meetings. *There was no fall committee. *They would follow their fall prevention policy. Interview on 9/2/15 at 3:50 p.m. with the DON, interim administrator, and new administrator regarding falls revealed: *The DON was aware the facility flagged high for falls on their quality measures reports. *There was no fall committee; she felt they maybe needed to have one. *Falls would have been discussed sometimes during MDS or care plan meetings and at the monthly nursing meetings. -They would have identified the number of falls, but not what had happened to cause those falls. *Last year they had worked on falls as part of QAPI, but it was not on the 2015 goals. *The DON felt the facility had fewer falls with major injury but still a high number of total falls. *They agreed they needed to do more education with the staff related to falls. *There were no residents on individualized toileting programs in the facility. -Residents were taken to the toilet per the facility standard times (before and after meals, at bedtime, night rounds, and as needed). *Fall interventions to prevent future falls were decided by the nurse at the time of the fall. -No one reviewed those interventions to make sure they were appropriate. *Care plan updates/revisions should have been done by the nurse after a fall. -There should have been interventions on the care plan for each fall, not just the date of the fall listed. *They agreed: -Fall interventions should have been individualized for each resident. -There were a lot of different interventions that could have been tried to prevent falls. -Encouraging or reminding a resident with cognitive impairment to use the call light was not an appropriate intervention. -There was a problem with the system related to falls in the facility. *The DON stated they were still using the falling stars (sticker to alert staff of resident's at risk for falls) program per their policy. -Residents 1 and 9 should have had falling star stickers by their doors. -The MDS nurse usually put the stickers on the doors of those residents identified at high risk for falls. Review of the provider's February 2007 Fall Prevention policy revealed: *The purpose was to identify residents and patients who are at risk for falling by educating employees and families. To institute preventative interventions, outlining communication and documentation. *The Director of Nurses, Nursing Coordinators and Coordinator of Maintenance are responsible for assuring implementation of this policy, for providing a safe environment, and for maintaining appropriate equipment to aide in fall prevention. Registered Nurses are responsible for implementation and oversight of individualized resident fall prevention care including assessing fall risk upon admission, using the Morse Fall Scale in the hospital, reassessing residents for change in fall risks when a change in condition occurs and collaborating with the interdisciplinary team in the prevention of falls. *Notation should be made in the nurse's notes, including those factors which have placed the resident at risk for falls, patient response to event, evidence of injury, location, provider notification and actions taken. If history of more than 3 falls in 3 months or the resident/patient is considered intermediate or high risk according to assessment, place a falling star at the room door, on the headboard, on the walker or w/c and on the care plans and reassess quarterly. The Falling Star Prevention Plan continues for the resident until the risk assessment falls below 5. *Contributing factors will be documented in the nurses' notes and in the communication book .Keep the room free of clutter. Chair, bed and room alarms are to be instituted at the discretion of the care plan team, physical therapy or the nurse. All staff will implement interventions to create a safe environment conducting environmental rounds. *The interdisciplinary care plan team will assess all factors contributing to a fall, such as the environment, equipment and medications. Changes to plan of care will be recommended. *Facility fall review is completed monthly and reported to staff for identification of high risk residents. B. Based on observation, interview, and manufacturer review, the provider failed to ensure two of four randomly observed EZ Way Stands (mechanical lift used for transferring residents) had safety tabs per manufacturer's guidelines. Findings include: 1. Random observations on 9/1/15 from 8:00 a.m. through 3:30 p.m. of two EZ Way Stand mechanical lifts revealed they had no safety tabs attached to the harness attachment area. Those tabs were to ensure the residents would not have fallen from the mechanical lift. Interview on 9/2/15 at 7:50 a.m. with the maintenance supervisor revealed: *He had not been aware the mechanical lifts required safety tabs. *He did not have the mechanical lifts on a preventative maintenance program to ensure they were in proper working condition. *The provider had an outside contract with a company who came to the facility on ce a year to inspect and check on various items in the building. The mechanical lifts had been one of those items. *He was not sure what items the company checked on the mechanical lifts. Review of the provider's December 2014 Maintenance/Engineering of Existing procedures confirmed the mechanical lifts had not been listed as an item to be routinely inspected and checked to ensure proper working condition. Review of the surveyor's copy of the 6/17/14 EZ Way Smart Stand Operator's Instructions Manual revealed: *It is important that certain basic checks be periodically made by maintenance staff to ensure on-going safety throughout the life of the device. *Recommendations were suggested to inspect the mechanical lifts every month. *Any detected deficiency must be rectified before the stand is put back into service. *Safety tabs need to checked to make sure they are in place. The provider did not have the above operator's instructions manual to follow. C. Based on observation and interview, the provider failed to ensure all staff were educated on the paging system to be used during an emergency situation for one of one secured unit (Haven). Findings include: 1. Random observations on 9/1/15 from 7:30 a.m. through 5:30 p.m. of the Haven unit revealed were two staff members working in the unit except when they took their individual breaks. Interview on 9/1/15 at 10:00 a.m. with registered nurse (RN) A revealed: *There were two staff members working in the unit from 7:00 a.m. to 6:30 p.m. *During the evening and through the night time hours one staff member worked in the unit. *There would have been only one staff member working in the unit during break times. Interview on 9/1/15 at 10:40 a.m. with certified nursing assistant (CNA) B revealed: *The other staff member had left the unit for her break. *CNA B had been working in the unit by herself. *She would have pulled the call light cord located in the residents' rooms should an emergency have occurred. The call light would have sounded out at the main nurses' station. The call light would have alerted the staff members located at the nurses' station that assistance was needed in that room. *She had not been aware of any other paging or calling system in place to alert the other staff members when assistance was needed in the unit. *She could not guarantee there was always someone located at the nurses' station during times of an emergency to ensure assistance would have occurred. Interview on 9/2/15 at 10:50 a.m. with RN A revealed: *The unit had walkie talkies handheld radio device) located in the kitchen. *The staff in the unit should have used those walkie talkies to communicate with the staff out on the main unit. *The walkie talkies did not always work and required the batteries to be re-charged every two hours. *There had been no back-up walkie talkies for the staff members to use while the others were re-charging. *She had informed the director of nursing (DON) the walkie talkies did not always work. *She could not guarantee the staff in the unit and out on the main floor used the walkie talkies for communication as directed to by the provider. Observation on 9/2/15 at 10:55 a.m. of the walkie talkies with RN A revealed: *They had been located in the unit kitchen and were laying on the counter. *They had not been working and required re-charging. *She had not been able to confirm how long they had been uncharged. *She and the other staff member in the unit had not used them during their individual break times. Interview on 9/2/15 at 1:45 p.m. with the DON regarding the paging system for the safety of the residents and staff when working in the secured unit revealed: *There had been two sets of walkie talkies. One set had been located in the unit kitchen and the other at the nurses' station on the main unit. *The nursing staff were to have used those walkie talkies to communicate with each other. *She had not been aware: -The nursing staff were not using them at all times. -They were not always working correctly. *She would have expected the staff to be using the walkie talkies as directed by the provider. The provider was not able to provide a policy and procedure regarding the paging system required to be used in the secured unit during emergency situations.

Based on observation, record and policy review, and interview, the provider failed to ensure a pressure ulcer did not develop for one of one sampled resident (6) identified as being at risk for pressure ulcers. Findings include: 1. Observation on 3/20/12 at 9:15 a.m. revealed resident 6 had a dried blistered area on his right heel. Interview with certified nurse aide A at that time revealed the blister was dry now, and it looked better than last week when it was noted. Further observation at that time of resident 6's buttock area revealed no red or open areas. Random observation throughout the survey from 3/19/12 to 3/21/12 revealed resident 6 had a heel-protector on his right heel. Review of residents 6's most recent Minimum Data Set ((MDS) dated [DATE] revealed: *He was at risk for developing pressure ulcers. *He did not have any pressure ulcers. Review of the annual Care Area Assessment (CAA) dated 5/9/11 revealed resident 6 had triggered for pressure ulcers. The findings had indicated he was at risk for skin problems due to a Braden score of 15 and because of his physical limitations. Review of the Braden Scale score range revealed a score of 15 to 18 meant the residen was at risk for developing pressure ulcers. Further review of the CAA revealed to proceed to care planning and to follow the ulcer prevention protocol. Review of resident 6's treatment notes revealed: *On 2/22/12 a 3 x 1/2 centimeter (cm) open sore and 1 x 1 cm open sore had been noted on the buttock area. *On 2/24/12 there had been a blister, and the resident was to have been positioned off his bottom when in bed. *On 3/5/12 "healed" with further documentation indicating there was a light crusted layer without redness or drainage. *On 3/15/12 documentation noted that morning a 4 cm clear blister was discovered on his right heel. *On 3/17/12 it was noted there was no fluid in the blister. The skin was intact. *On 3/20/12 a note indicating the blister was intact. The resident's heel was kept on a pillow, and a heel-protector was in place. Review of resident 6's skin integrity event reporting documentation dated 2/22/12 revealed two pressure ulcers on his left buttock. It revealed the first was 3 cm x 1/2 cm, and it was red with no drainage. Below that area was a 1 cm x 1 cm open ulcer that was red and had no drainage. Review of resident 6's current care plan with the last care conference date of 1/31/12 revealed: *The problem of being at risk for pressure ulcers was not addressed. *The problem was not identified, no goals were developed, and no approaches were presented to prevent the development of a pressure ulcer or to follow the ulcer prevention protocol. *The only entry related to the pressure ulcer on the care plan was a later entry on 3/18/12 related to the blister on the right heel with approaches included. Interview on 3/21/12 at 8:45 a.m. with the MDS coordinator B regarding resident 6 revealed: *The problem of at risk for pressure ulcers should have been included on the care plan with the approach of following the ulcer prevention protocol. *The problem should have been included since the annual review of 5/9/11. *She confirmed the only approches on the care plan currently for pressure ulcers was the right heel with those approaches. *She confirmed even though some of the pressure ulcer prevention guidelines were being implemented there was nothing on the care plan about following the guidelines. *She stated it had just gotten missed on the care plan, and she did not know why. Interview on 3/21/12 at 9:30 a.m. with the director of nursing confirmed: *The care plan for resident 6 should have included the resident was at risk for pressure ulcers. *The protocol guideline should have been addressed and followed. Review of the undated pressure ulcer policy revealed "Each resident is assessed on admit (admission), quarterly, and when a change in condition occurs for the potential development of p. (pressure) ulcers due to medical, functional, or nutritional factors." Review of the undated care planning policy revealed the purpose was: *"To develop individualized care plans for each resident acccording to their needs, behaviors, and diversions which work for them." *"To provide consistent day to day care."