Every finding on record at Avera Rosebud Country Care Center

Based on record review, interview, and policy review, the provider failed to ensure that a current copy of the advance directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) was included in the medical record for one of one sampled resident (14) after being admitted to the facility.Findings include:1. Review of resident 14's electronic medical record (EMR) revealed that he was admitted to the facility on [DATE]. There was no documentation indicating that any advance directive paperwork expressing his wishes regarding his code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) was completed upon admission. A copy of his living will was scanned into the EMR, but it did not address his resuscitation status. The banner area where the resident's code status was typically displayed read Resuscitation status not ordered. There was no physician order addressing his code status. 2. Interview on 5/20/26 at 2:47 p.m. with registered nurse (RN) C revealed that she identified a resident's code status by referring to a paper sheet posted at the nurses' station that listed the residents' code status. There were also color-coded stickers on the residents' paper charts, which indicated their code status, and that information was available in the residents' EMR. 3. Interview on 5/20/26 at 2:58 p.m. with certified nursing assistant (CNA) G revealed that she located a resident's code status by referring to a paper sheet posted at the nurses' station, and that the residents' code status was also listed in the CNA care plan (personalized plan that addresses a resident's care needs, goals, and interventions) book. 4. Review of the paper sheet posted at the nurses' station revealed that resident 14's code status was documented as do not resuscitate/do not intubate (DNR/DNI) (no life-sustaining measures if one's heart or breathing stops). 5. Review of resident 14's paper chart revealed there was a red sticker on the outside which indicated DNR/DNI. Inside his chart, there was a form titled Patient Evacuation Form, To go with patient, which included a box labeled Other Information or Directives. In that box Code Status Full Code was written. 6. Interview on 5/21/26 at 11:20 a.m. with DPCS B revealed that resident 14 was a full code because his medical power of attorney (POA, someone designated on a legal document to act on behalf of a resident) did not decide what they wanted the resident's code status to be. She acknowledged that his living will did not address his resuscitation status and that there was no physician order specifying his code status. She expected there to be a code status order for all the residents. She acknowledged that the paper sheet posted at the nurses' station and the form in resident 14's paper chart contained conflicting information, and that the discrepancy would be confusing for the staff if resident 14 needed life-saving measures. 7. Review of the provider's August 2024 Advance Directive Policy revealed When an advance directive is received, it will be incorporated into the patient's plan of care. Caregivers need to know the status of each patient's advance directive to communicate and advocate for the patient's wishes and rights concerning life-prolonging health care decisions. At the time of admission, all patients, age [AGE] or older. will be assessed regarding advance directives as set forth in this policy. During the admission assessment, admitting personnel will ask patients whether they have an advanced directive. The patient's response is to be documented on the assessment form.

Based on record review and interview, the provider failed to ensure the Notice of Medicare Non-Coverage (NOMNC) was provided for two of two sampled residents (19 and 21) who's Medicare-covered services were ending, still had remaining Medicare benefit days, and remained in the facility.Findings included:1.Review of resident 19's Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Beneficiary Notification Review form provided by social worker designee (SWD) J revealed that resident 19's Medicare Part A Skilled Services Episode start date was 10/28/25. Resident 19's last covered day of Part A was 12/31/25. He was not given the NOMNC (notice that informs residents that their Medicare-covered services are ending on a specific date and explains their right to request an appeal)and he remained in the facility. 2. Review of resident 21's CMS SNF Beneficiary Notification Review form provided by SWD J revealed that resident 21's Medicare Part A Skilled Services Episode start day was 12/9/25. Resident 20's last covered day of Part A was 1/15/26. She was not given the NOMNC and she remained in the facility. 3. Interview on 5/20/26 at 11:06 a.m. with SWD J regarding Medicare non-coverage notices revealed he was unaware that resident 19 and 21 should have been provided a NOMNC form. SWD J was hired on 9/11/23. 4. Interview on 5/20/26 at 3:40 pm. with social worker consultant (SWC) K revealed that she met with SWD J quarterly to review resident items. SWC K's focus was on resident discharge planning when residents would leave the facility. She did not discuss with SWD J when to provide the NOMNC forms to the residents.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed for the cleaning of nebulizers (a device that converts liquid medication into an inhalable mist) for two of two sampled residents (8 and 21). 1. Observation and interview on 5/19/26 at 1:32 p.m. of resident 21 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 lying directly on the nightstand, uncovered. She stated she received three nebulizer treatments a day and that the staff sometimes disconnected her nebulizer to clean it. When the staff came to administer her treatment, they usually took the medication reservoir to the bathroom and rinsed it out before giving her the treatment. 2. Review of resident 21's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her diagnoses included shortness of breath, wheezing, and obstructive sleep apnea. Her 3/9/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. She had a 2/24/26 physician order for Ventolin (a fast-acting bronchodilator used to relax airway muscles) 2.5 milligrams to be administered via nebulizer at 7:00 a.m., 2:00 p.m., and 7:00 p.m. 3. Interview on 5/20/26 at 2:47 p.m. with registered nurse (RN) C revealed that her nebulizer cleaning process was to disassemble the resident's nebulizer after each treatment, clean the components, and leave them to dry on a barrier. She confirmed that the mouthpiece and medication reservoir should be cleaned and left to dry after each nebulizer treatment. 4. Observation and interview on 5/19/26 at 1:49 p.m. with resident 8 in his room revealed was a nebulizer machine with an attached mouthpiece lying on his bedside table. The medication reservoir appeared to have multiple small wet spots on the inside of the reservoir. Resident 8 stated he received two nebulizer treatments a day. The staff would clean the nebulizer components but he was unsure how often they cleaned it during the day. 5. Review of resident 8's EMR revealed he admitted to the facility on [DATE]. His 8/12/25 BIMS assessment score was 9, which indicated his cognition was moderately impaired. His diagnosis included chronic obstructive pulmonary disease (COPD). He had a 8/14/25 physicians order, arformoterol neb [nebulizer] [Brovana] 15 mcg [microgram]. There was no documentation that the staff had cleaned his nebulizer after each treatment. 6. Observation on 5/20/26 at 10:35 a.m. in resident 8's room revealed that the nebulizer with the attached mouthpiece was lying on resident 8's bedside table. The medication reservoir had appeared to have multiple small wet spots and a mist film on the inside portion of the reservoir. 7. Interview on 5/20/26 with RN C in resident 8's room regarding the cleaning of the nebulizer components revealed that she had forgotten to come back to resident 8's room and clean the nebulizer components after his treatment that morning. After each use the mouthpiece, extender and the medication reservoir should be cleaned. The nebulizers components should be cleaned with soap and water once a day. 8. Interview on 5/20/26 with director-patient care services (DPCS) B regarding cleaning of resident 8's nebulizer components revealed she expected the staff to follow the provider's policy and to wash the nebulizer components after each treatment. After the last nebulizer treatment of the day the nebulizer components should be cleaned with soap and water. 9. Review of the provider's updated May 2026 Nebulizers policy revealed: a. Nebulizers components (mask, mouthpiece, and reservoir) will be rinsed in clean running tap water. Do not let components touch the sink. Place components on a clean towel and cover with a clean paper towel after each treatment. Change towels after each treatment. Once every 24 hours wash all components with dish soap and water, rinse, and allow to air dry on and under clean paper towels.

Based on observation, interview, record review, and policy review, the provider failed to ensure urinary catheter (flexible tubing inserted into the bladder to drain urine) bags were cleaned and stored in a manner to prevent contamination and potential infection to one of one sampled resident (31) whose urinary catheter bag was stored in his bathroom shower without the catheter tubing connector (that attaches to the resident's indwelling catheter) capped. Findings include:1. Observation on 5/19/26 at 1:58 p.m. in resident 31's bathroom revealed there was a toilet without a lid next to a shower stall with a half-opened plastic shower curtain. Inside the shower stall, there was a bench attached to the shower wall that had a towel with a urinary catheter bag placed on it. The shower stall had a handrail attached to the wall with another urinary catheter bag hanging on that handrail. Neither of the catheter bags were labeled with the date that they were last used, or had a cover over the catheter tubing connector. There was a plastic container with a plastic syringe in it next to the urinary catheter bag on the bench. That syringe had a date of 1/19/26 written on it. 2. Observation on 5/20/26 at 11:06 a.m. in resident 31's bathroom revealed the same two urinary catheter bags in the same position; one was on the handrail, and one was on the shower bench. 3. Review of resident 31's electronic medical record (EMR) revealed that he admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15, indicating that his cognition was intact. His diagnoses included a kidney transplant (replacing a failed kidney with a healthy one), chronic kidney disease (a long-term, progressive loss of kidney function), and urinary retention (the inability to empty the bladder) requiring a urinary catheter. His care plan had a focus area of [urinary] catheter use with interventions for the staff to change that urinary catheter monthly and to clean his urinary catheter and measuring devices per facility policy. 4. Interview on 5/20/26 at 1:36 p.m. with certified nursing assistants (CNA) E and G revealed that the CNAs were expected to clean the urinary catheter bags using a syringe filled with a vinegar mixture. They were expected to change the syringes once per week and label those syringes with the date, and the resident's name and room number. After the CNAs cleaned the bags, they were expected to place a cap over the open end of the tubing and store it in a clean area. They only had to clean the urinary catheter bags after it was used by the residents. 5. Interview on 5/20/26 at 4:49 p.m. with CNA D revealed that none of the current residents with urinary catheters regularly switched between day and night urinary catheter bags. She indicated that resident 31 only switched from his regular catheter bag to a larger catheter bag when he left the facility for medical appointments. 6. Interview and policy review on 5/21/26 at 9:55 a.m. with registered nurse (RN) F revealed that she was the infection preventionist for the facility. She expected urinary catheter bags to be cleansed, drained, and for the staff to place a cap over the end of the tubing of the urinary catheter bag to keep that bag clean. She agreed that if a urinary catheter bag did not have a cap over the tubing, and the bag was hanging next to a toilet, then that bag would be considered contaminated. RN F expected the syringe that was used to clean the urinary catheter bags to be changed weekly, and acknowledged this expectation was not clearly stated in the facility's policies. She indicated that resident 31 only changed his urinary catheter bags when he left the facility for a medical appointment. 7. Interview and policy review on 5/21/26 at 11:11 a.m. with director of patient care services (DPCS) B revealed that she considered a urinary catheter bag without a tubing cap that was stored next to a resident's toilet to be contaminated. She acknowledged that the policy regarding cleaning urinary catheter equipment did not identify when the syringe used to clean the urinary catheter tubing or the urinary catheter bag should be changed to a new one, and who was expected to perform those tasks. 8. Interview and EMR review on 5/21/26 at 11:28 p.m. with support specialist H regarding resident 31 confirmed that the last time he left the facility was on 5/19/26 for an appointment with his primary care physician. 9. Review of the provider's April 2023 Care of Indwelling Urinary Catheters and Drainage Systems policy revealed that if a resident switched from a overnight urinary catheter bag to a urinary catheter leg bag during the day, the staff were expected to ensure both of the urinary catheter bags were cleansed once every 24 hours. After cleansing the bag, the staff were to hang the bag to dry and do not allow the outlet valve to touch anything including your hands as it could become infected.

Based on observation, interview, record review, and policy review, the provider failed to ensure the resident's medication self-administration assessment was completed and a physician's order was obtained for one of one sampled resident (21) who was not assessed to determine her ability to safely self-administer her medications or had a physician's order to self-administer those medications.Findings include:1. Observation and interview on 5/19/26 at 1:32 p.m. in resident 21's room revealed she had a nebulizer machine (a device that converts liquid medication into an inhalable mist) on top of her nightstand. She stated she received three nebulizer treatments per day.2. Observation on 5/20/26 at 2:40 p.m. in resident 21's room revealed that she was sitting in her recliner holding the nebulizer mouthpiece in her mouth, and the nebulizer machine was running. No staff members were in her room or the hallway to monitor her nebulizer medication administration.3. Interview on 5/20/26 at 2:47 p.m. with registered nurse (RN) C regarding resident 21's self-administration of her nebulizer treatment revealed RN C stated, She's okay to give it to herself.4. Review of resident 21's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her diagnoses included shortness of breath, wheezing, and obstructive sleep apnea. Her 3/9/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. She had a 2/24/26 physician order for Ventolin (a fast-acting bronchodilator used to relax airway muscles) 2.5 milligrams to be administered via nebulizer at 7:00 a.m., 2:00 p.m., and 7:00 p.m.There was no medication self-administration assessment completed to determine whether she could safely self-administer her medications. There was no physician order that indicated resident 21 was able to self-administer the nebulizer medication.A copy of resident 21's medication self-administration assessment was requested, but none was provided during the survey.5. Interview on 5/21/26 at 11:20 a.m. with director of patient care services (DPCS) B revealed she expected a medication self-administration assessment and a physician order for resident 21 to be documented in the EMR. She expected the nursing staff to follow the provider's medication self-administration policy, and acknowledged that the policy was not followed.6. Review of the provider's October 2023 Medication Policy revealed that Nursing personnel will administer medications until the nurse completes the Self Administration intervention in the work list AND a provider order is obtained. Self-administration of medications or storage of medications will be allowed if the resident is physically and/or cognitively able to do so. The physician must write an order for each medication to be self-administered or stored bedside: right resident, right medication, right amount, right time, and right route.

Based on observation, record review, interview, and policy review, the provider failed to ensure one of two mechanical dishwashers that used high temperature sanitizing met the required minimum wash and rinse temperatures. Findings include: 1. Observation on 2/11/25 at 8:36 a.m. of the long-term care (LTC) kitchenette revealed: *The mechanical dishwashing machine had a label that revealed HOT WATER SANITIZING: -WASH TEMPERATURE 150 [degrees] F [Fahrenheit] MIN [minimum]. -RINSE TEMPERATURE 180 F MIN. *Posted on the door of the reach-in refrigerator was the February 2025 Dishmachine Temperature Record that included: -Columns to record the Start Wash/rinse and Finish Wash/rinse for each of the three mealtimes Breakfast, Lunch, and Supper. -Each column had two recorded temperatures. The wash temperature was separated by a dash from the rinse temperature. -The wash temperatures recorded ranged from 142 to 160 degrees F. --Twelve of those recorded wash temperatures were not at the minimum wash temperature of 150 degrees F. -The rinse temperatures recorded ranged from 172 to 184 degrees F. --Twenty-eight of those recorded rinse temperatures were not at the minimum rinse temperature of 180 degrees F. 2. Interview on 2/11/25 at 8:56 a.m. with food service manager (FSM) F in the main kitchen revealed: *She had worked at the facility for [AGE] years. *The LTC kitchenette's mechanical dishwasher was used to clean and sanitize the dishes used to serve meals to the residents of the nursing home. *The LTC kitchenette's mechanical dishwasher was a high temperature dishwasher that used heat for sanitization. 3. Observation and interview on 2/11/25 at 1:50 p.m. in the LTC kitchenette with food service worker (FSW) J and FSW K revealed: *FSW J rinsed dishes under hot running water and placed those dishes in a rack which she then pushed into the mechanical dishwasher to be cleaned and sanitized. *FSW K removed the rack from the dishwasher and placed the clean dishes on the shelves in the kitchenette. *FSW K stated she had let the dishwasher run three or four cycles before she documented the wash and the rinse cycle temperatures before she sent the loads of dishes through the dishwasher. *The 2/11/25 dinner start wash/rinse temperatures on the Dishmachine Temperature Record posted on the door of the reach-in refrigerator were documented as: -A wash cycle temperature of 154 degrees F. -A rinse cycle temperature of 180 degrees F. *FSW K stated the wash cycle temperature should have been at the minimum 160 degrees F or above and the rinse cycle temperature was at the minimum 180 degrees F. *FSW K stated if the dishwasher readings were not reaching the minimum temperatures she would notify FSM F or maintenance. *The following random observations on 2/11/25 were made of the above mechanical high temperature dishwasher: -At 1:52 p.m. the wash cycle reached 149 degrees F and the rinse cycle reached 178 degrees F. -At 1:54 p.m. the wash cycle reached 145 degrees F and the rinse cycle reached 178 degrees F. -At 2:00 p.m. the wash cycle reached 144 degrees F and the rinse cycle reached 178 degrees F. -At 2:02 p.m. the wash cycle reached 145 degrees F and the rinse cycle reached 178 degrees F. -At 2:11 p.m. the wash cycle reached 145 degrees F and the rinse cycle reached 176 degrees F. -At 2:14 p.m. the wash cycle reached 147 degrees F and the rinse cycle reached 178 degrees F. -During those observations: --FSW J had the hot water running and was rinsing dishes under that hot running water. --The wash cycle ran between 30 to 33 seconds. --The rinse cycle ran for approximately 10 seconds. *On 2/11/25 at 2:16 p.m. FSW K recorded the dinner finish wash/rinse temperatures on the Dishmachine Temperature Record as: -A wash cycle temperature of 147 degrees F. -A rinse cycle temperature of 178 degrees F. -FSW K agreed those temperatures did not meet the minimum temperatures for hot water sanitizing. -FSW K reported to FSM F on 2/11/24 that the LTC kitchenette's mechanical dishwasher had not reached the minimum temperatures required. Interview on 2/11/25 at 2:24 p.m. with FSM F regarding the observations above of the LTC kitchenette's high temperature mechanical dishwasher's temperatures revealed: *She stated Why hasn't anyone said anything. *The following were requested: -The Dishwasher Temperature Records for November 2024, December 2024, and January 2025. -The LTC kitchenette's mechanical dishwasher's manufacturer's manual. 4. Observation and interview on 2/12/25 at 9:35 a.m. in the LTC kitchenette revealed: *The Supper Start Wash/rinse temperatures for 2/11/25 were documented as: --A wash cycle temperature of 151 degrees F. --A rinse cycle temperature of 178 degrees F. --The rinse cycle temperature did not meet the minimum temperature of 180 degrees F required for hot water sanitizing. -The Supper Finish Wash/rinse temperatures for 2/11/25 were documented as: --A wash cycle temperature of 147 degrees F. --The wash cycle temperature did not meet the minimum temperature of 150 degrees F required for hot water sanitizing. --A rinse cycle temperature of 178 degrees F. --The rinse cycle temperature did not meet the minimum temperature of 180 degrees F required for hot water sanitizing. -The documented 2/12/25 breakfast start wash/rinse temperatures met the required temperatures for sanitizing. *On 2/12/25 at 9:35 a.m. FSW J and FSW K were in LTC kitchenette area and preparing to wash and sanitize the breakfast dishes through the mechanical dishwasher. *FSW K stated maintenance tech E had been in and out of the LTC kitchenette working on the mechanical dishwasher that morning, 2/12/25. *The following random observations on 2/12/25 were made of the mechanical high temperature dishwasher: -At 9:37 a.m. the wash cycle reached 158 degrees F and the rinse cycle reached 176 degrees F. -At 9:40 a.m. the wash cycle reached 144 degrees F and the rinse cycle reached 176 degrees F. -At 9:43 a.m. the wash cycle reached 144 degrees F and the rinse cycle reached 180 degrees F. -At 9:50 a.m. the wash cycle reached 144 degrees F and the rinse cycle reached 176 degrees F. *At 9:50 a.m. FSW J stated she thought that running the hot water to rinse the dishes prior to placing them in the dishwasher may have affected the hot water temperature. 5. Observation on 2/12/25 at 10:05 a.m. of the main kitchen revealed: *The mechanical dishwashing machine had a label that revealed HOT WATER SANITIZING: -WASH TEMPERATURE 160 F MIN. -RINSE TEMPERATURE 180 F MIN. *At 10:13 a.m. the mechanical dishwasher reached: -A wash cycle temperature of 167 degrees F. -A rinse cycle temperature of 195 degrees F. -Those temperatures were above the minimum temperatures required for hot water sanitizing. 6. Interview on 2/12/25 at 10:20 a.m. with FSM F regarding the observations made above of the LTC kitchenette mechanical dishwasher's temperatures revealed she stated they could transport, wash, and sanitize the nursing home dishes in the main kitchen's mechanical dishwasher. 7. Interview on 2/12/25 at 1:44 p.m. with FSW K revealed she and FSW J had brought the dishes used to serve the dinner meal in the nursing home to the main kitchen to be washed in that mechanical dishwasher. 8. Interview and observation on 2/12/25 at 2:09 p.m. in the LTC kitchenette with maintenance tech E revealed: *He thought the incoming water temperature for the mechanical dishwasher should be between 55 and 60 degrees F. *He turned on the water faucet, placed a digital thermometer in the running water coming out of the faucet and noted the temperature of the incoming water was at 47 degrees F. -He stated that was ten degrees colder than what it should be. *He had called the mechanical dishwasher's servicing dealer and had discussed what needed to be done to ensure the mechanical dishwasher met the minimum temperatures required for hot water sanitizing. -He stated the dishwasher had been set at Cycle 1 which was a one-minute cycle. *At 2:12 p.m. he changed the dishwasher to Cycle 4 and stated that was a four-minute cycle: -The wash cycle then reached 156 degrees F which was above the required minimum temperature of 150 degrees F. -The rinse cycle then reached 180 degrees F which was the minimum temperature required. *At 2:18 p.m. he changed the dishwasher to Cycle 2 and stated that was a two-minute cycle: -The wash cycle then reached 156 degrees F. -The rinse cycle then reached 181 degrees F. -Both of these temperatures were above the minimum temperatures required for hot water sanitizing. -Maintenance tech E confirmed the mechanical dishwasher used hot water sanitization. 9. Interview on 2/12/25 at 2:49 p.m. with FSM F regarding the requested policy on the mechanical dishwasher revealed she: *Provided a February 2025 Dishwasher Temperature policy. *Had revised the policy that day, 2/12/25. *Stated the previous policy was very vague and did not contain the mechanical dishwasher's minimum temperatures. -She had not kept a copy of that previous policy. 10. Observation and interview on 2/13/25 at 8:44 a.m. with FSW K in the LTC Kitchenette revealed: *The current Dishmachine Temperature Record had recorded: -The 2/12/25 Dinner Start Wash/rinse area had noted dishes at Hosp [hospital main kitchen]. -The 2/12/25 Dinner Finish Wash/rinse area had noted done dishes @ [at] H [hospital main kitchen]. *The documented 2/12/25 supper start and finish wash/rinse temperatures met the required temperatures for sanitizing. -No wash or rinse cycle temperatures for 2/13/25 had been recorded. *At 8:50 a.m. FSW K stated: -The mechanical dishwasher temperatures for the 2/13/25 breakfast start were: --The wash cycle had reached 153 degrees F. --The rinse cycle had reached 180 degrees F. -She confirmed both of those temperatures met the minimum temperatures required for hot water sanitizing and recorded those temperatures. 11. Interview on 2/13/25 at 9:04 a.m. with FSM F revealed FSW K had reported to her on 2/11/24 and 2/12/24 that the LTC kitchenette's mechanical dishwasher had not reached the minimum temperatures required. 12. Observation on 2/13/25 at 9:33 a.m. in the LTC Kitchenette with FSW J and FSW K while operating the mechanical dishwasher revealed: *The mechanical dishwasher was set at Cycle 2. *At 9:34 a.m. the wash cycle reached 151 degrees F which was above the required minimum temperature of 150 degrees F. -The rinse cycle reached 180 degrees F which was the minimum temperature required. *At 9:37 a.m. FSW J turned on the hot water to rinse the dishes: -The wash cycle reached 149 degrees F. -The rinse cycle reached 180 degrees F. -The wash cycle temperature did not meet the minimum temperature of 150 degrees F required for hot water sanitizing. *At 9:40 a.m. FSW J shut off the hot water she had been running to rinse dishes. *At 9:44 a.m. the wash cycle reached 151 degrees F and the rinse cycle reached 180 degrees F. *At 9:47 a.m. FSW J turned on the hot water to rinse the dishes: -The wash cycle reached 149 degrees F. -The rinse cycle reached 180 degrees F. -The wash cycle temperature did not meet the minimum temperature of 150 degrees F required for hot water sanitizing. 13. Interview on 2/13/25 at 9:55 a.m. with FSM F regarding the above observations and the mechanical dishwasher's temperatures revealed she: *Confirmed some of the dishwasher temperatures were under the minimum temperature required. -Stated she would discuss with maintenance tech E what needed to be done to raise the hot water temperature. 14. Review of the provider's November 2024 Dishmachine Temperature Record for the LTC kitchenette's mechanical dishwasher revealed: *There were 31 out of 180 recorded wash temperatures that did not meet the minimum required wash temperature of 150 degrees F which was 18 percent of the recorded temperatures. *There were 36 out of 180 recorded rinse temperatures that did not meet the minimum required rinse temperature of 180 degrees F which was 20 percent of the recorded temperatures. 15. The provider's December 2024 Dishmachine Temperature Record for the LTC kitchenette's mechanical dishwasher was requested on 2/11/25 at 2:24 p.m. from FSM F but was not received by the end of the survey. 16. Review of the provider's January 2025 Dishmachine Temperature Record for the LTC kitchenette's mechanical dishwasher revealed: *There were 40 out of 180 recorded wash temperatures that did not meet the minimum required wash temperature of 150 degrees F which was 23 percent of the recorded temperatures. -Six wash temperatures were not recorded on the form. *There were 69 out of 180 recorded rinse temperatures that did not meet the minimum required rinse temperature of 180 degrees F which was 39 percent of the recorded temperatures. -Six rinse temperatures were not recorded on the form. Review of the provider's February 2025 Dishwasher Temperature Policy revealed: *Purpose: To assure that temperatures in the dishwasher remains at the proper temperatures to clean and sanitize the dishes. *The Information and Procedure section included; -1.NURSING HOME wash temperatures should remain at a MINIMUM of 150 degrees and rinse temperatures at a MINIMUM of 180 degrees. --The policy did not indicate if the minimum temperature readings were Fahrenheit (F) or Celsius (C). -2. After turning on dishwasher and filling, it should be run through three cycles to assure [sic] that the water reaches the highest possible temperature before inserting dirty dishes. -3. At the time that the dishes are washing, the temperature should be recorded. -4. At the final rinse the temperature should also be recorded. -5. This should be done with BREAKFAST, LUNCH AND DINNER dishes each day. -6. If a temperature does not reach the designated numbers, the problem should be reported to the supervisor or the maintenance person so it can be monitored/addressed and adjusted. -7. If maintenance is unable to fix immediately, the dishwasher company will be called to repair, and dishes transported to alternative kitchen to be washed or disposable [dishes] will be utilized. *The policy did not indicate it had been approved. Review of the provider's June 2021 AM16 Dishwasher's instructions manual revealed: *The model AM16VL-[NAME] was circled indicating that was the model number of the LTC kitchenette's mechanical dishwasher. *The Water Supply Requirements for Model AM16VL-[NAME] Hot Water Sanitizing indicated: -The recommended cold water temperature was 65 degrees F. -The minimum cold water temperature was 55 degrees F. *Operating temperatures for all models are as follows: -Sanitizing Mode: Hot Water. --Wash Temperature Minimum Wash indicated 150 F (66 C [Celsius]). --Rinse Temperature Minimum Rinse indicated 180 F (82 C). Review of the provider's 12/31/24 job description for a Food Service Worker revealed the essential job functions included: *Cleans and sanitizes equipment, utensils, dishes, pot/pans, floor mats, floors, and work areas following proper procedure. *Operates dish machine and kitchen equipment safely and efficiently. Review of the provider's 11/22/24 job description for a Food Service Manager revealed: *The Job Summary included Ensures that all standards and regulations concerning dietary services are met and maintained. *The Essential Job Functions included: -Ensures that all standards of cleanliness and quality are maintained in the dietary department. -Directs activities and collects data to demonstrate a safe and sanitary food service operation to meet state health department, and federal regulations.

Based on record review, interview, policy review, the provider failed to ensure seven of twelve sampled residents (1, 22, 23, 26, 80, 81, and 130) or their representatives had received a summary of their baseline care plan within 48 hours. Findings include: 1. Record review of resident 22's paper medical record (PMR) revealed: *She had been admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) assessment score of 12 which indicated moderate cognitive impairment. *There was no documentation in her PMR that indicated a baseline care plan summary had been provided to the resident or the resident's representative. -Her current medication list was provided to her on 10/29/24. *Her representative was her son. 2. Record review of resident 130's PMR revealed: *She had been admitted on [DATE]. *She had a BIMS score of 10 which indicated moderate cognitive impairment. *There was no documentation in her PMR that indicated a baseline care plan summary had been provided to the resident or the resident's representative. -Her current medication list was provided to her on 2/7/25. *Her interdisciplinary team members (IDT) did not sign her baseline care plan. 50916 3. Review of resident 1's PMR revealed: *She had been admitted on [DATE]. *She had a BIMS assessment score of 6 which indicated she had significant cognitive impairment. *She had a designated durable power of attorney (POA). *There was no indication resident 1 or her POA had been provided the summary of the baseline care plan. 4. Review of resident 26's PMR revealed: *She had been admitted on [DATE]. *She had a BIMS assessment score of 10 which indicated she had moderate cognitive impairment. *Her representative/person to contact was her granddaughter. *There was no indication resident 26 or her representative had been provided the summary of the baseline care plan. 43021 5. Record review of resident 23's PMR revealed: *She had been admitted on [DATE]. *She had a BIMS assessment score of 7 which indicated severe cognitive impairment. *Her representative was her daughter. *A partially completed five-page baseline care plan form indicated: -Her admitted was 7/10/24. -Her current medication list had been provided to her daughter on 7/10/24. -Page five, which included a signature area for the team members who contributed to the baseline care plan was blank. -Page six, which included areas to document the baseline completion date, the date is was reviewed with the resident/representative, and the resident/representative signatures, was missing. -No documentation that indicated the baseline care plan summary had been provided to the resident or her daughter. *A Care Plan Signature Page indicated her daughter had signed and received resident 23's comprehensive care plan on the following dates: -On 7/23/24. -On 9/10/24. -On 12/10/24. 6. Interview on 2/11/25 at 9:43 a.m. with resident 80 revealed he could not recall his care plan having been discussed with him the first or second day when he was admitted to the facility about a week ago. Record review of resident 80's PMR revealed: *He had been admitted on [DATE]. *He had a BIMS assessment score of 13 which indicated he was cognitively intact. *A partially completed five-page baseline care plan form indicated: -His admitted was 2/3/25. -His current medication list had been provided to the resident on 2/3/25. --Page five, which included a signature area for the team members who contributed to the baseline care plan was blank. -Page six, which included areas to document the baseline completion date, the date is was reviewed with the resident/representative, and the resident/representative signatures, was missing. -No documentation that indicated the baseline care plan summary had been provided to the resident or his representative. 7. Record review of resident 81's PMR revealed: *She had been admitted on [DATE]. *She had a BIMS assessment score of 6 which indicated she had severe cognitive impairment. *A partially completed five-page baseline care plan form indicated: -Her admitted was 2/3/25. -Her current medication list had been provided to her spouse, resident 80, with no date indicated. -Page five, which included a signature area for the team members who contributed to the baseline care plan had an illegible signature. -Page six, which included areas to document the baseline completion date, the date is was reviewed with the resident/representative, and the resident/representative signatures, was missing. -No documentation that indicated the baseline care plan summary had been provided to the resident or her representative. 8. Review of the 2017 American Association of Nurse Assessment Coordination (AANAC)/American Association of Directors of Nursing Services (AADNS) baseline care plan form and interview on 2/12/25 at 10:55 a.m. with Minimum Data Set (MDS) Coordinator C revealed: *She had started working at the facility on 4/28/24. *She had not had much training regarding the baseline care plan and stated I'm self-taught. *On the first day of a resident's admission, the admitting nurse would take the five-page AANAC/AADNS Baseline Care Plan form into the new resident's room and interview the resident and family to answer questions and fill out the form. -The completed form was to be kept in a Short Term Care Plan binder which were kept at each nurses station. *She stated they had not been providing a copy of the baseline care plan to the resident and/or the resident's family. *She was not aware of the form's sixth page which had sections to document completion dates and signatures. *She agreed the resident and representative, if applicable, were not receiving a written summary or a copy of the baseline care plan within 48 hours of a resident's admission. *She stated she was not aware of the requirements that the baseline care plan needed to be: -Developed within 48 hours of a resident's admission. -Provided to the resident and their representative that included: --The initial goals of the resident. --A summary of the resident's medications and dietary instructions. --Services and treatments to be provided by the facility. *She stated a copy of the comprehensive care plan was provided to the resident and family after the MDS assessment was completed at the resident's care plan conference which was from 14 to 21 days following the admitted . *She confirmed a copy of the baseline care plan was not provided to the resident and/or family prior to receiving that comprehensive care plan. Interview on 2/12/25 at 12:02 p.m. with director of nursing (DON) B revealed: *The admitting nurse would use the five-page AANAC/AADNS Baseline Care Plan form to interview the resident and family. *She confirmed a copy of the baseline care plan was not provided to the resident and/or family. *She agreed they were not meeting the requirement to provide a written summary of the resident's baseline care plan to the resident and/or the resident's representative, if applicable. 9. Review of the provider's June 2023 LTC Baseline/Comprehensive Care Plans policy revealed: *Policy: The interdisciplinary team will develop a baseline and comprehensive care plan for each resident . *Procedure: -1. A baseline care plan will be developed within 48 hours of a resident's admission to promote continuity of care and communication amount nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. -2. Information for the baseline care plan will be based upon admission orders, information from the transferring provider and discussion with the resident and resident representative if applicable and the resident so chooses. -3. The baseline care plan will include the minimum health care information necessary to properly care for a resident including, but not limited to: a. Initial goals based on admission orders, b. physician orders, c. dietary orders, d. therapy services, e. Social services, f. PASRR [Pre-Admission Screening and Resident Review] recommendations, if applicable, g. instructions needed to provide effective person-centered care that meets professional standards of quality of care, h. address resident and safety concerns to prevent decline or injury, i. identify needs for supervision, behavioral interventions and assistance with ADL's [Activities of Daily Living] as necessary. -4. There will be documentation in the clinical record that the baseline care plan was given to the resident and/or representative . 10. Review of the provider's September 2011 job description for MDS Specialist revealed: *Essential functions included: -Completes initial admission care plan on each resident. *Responsibilities, expectations, and standards included Comply with safety principles, laws, regulations and standards associated with, but not limited to CMS [Centers for Medicare and Medicaid Services], .

Based on observation, interview, and policy review, the provider failed to ensure proper medication preparation for three of three residents (13, 19, and 21) by one of one licensed practical nurse (LPN) (I) who prepared their medications and stored them to administer to the residents later. Findings include: 1. Observation and interview on 2/12/25 at 11:27 a.m. with LPN I at a medication (med) cart revealed: *He had dispensed resident 13, 19, and 21's medications into white paper medication cups and did not label them to identify which resident's meds were in each cup. *He left resident 13's medications on top of the med cart and then placed resident 19 and 21's medications in the top drawer of the cart and shut the drawer. *He confirmed he did not dispense and prepare residents' medications individually. *He stated he had a system and that's the way I do it. *He stated he did not get confused when he administered residents' medications that he placed in unlabeled cups to be given later. 2. Interview on 2/12/25 at 3:26 p.m. with LPN I about the provider's medication policy revealed: *He knew it mentioned the five rights of medication administration. *He could not clarify any other information in the policy. 3. Interview on 2/13/25 at 8:31 a.m. with director of nursing (DON) B revealed: *She had previously spoken to LPN I about setting up (placing meds in cups to be given later) resident medications and he knew he was not supposed to do that. *She was not aware that he did not label the paper medication cups to identify which resident's meds were in the cups. *She agreed setting up and storing meds to administer to residents later was not an acceptable practice for medication administration. *She had provided education regarding correct medication administration processes in the past. 4. Review of the provider's revised 10/2023 Medication Policy revealed: *Once the resident is identified, the medication needs to be delivered to the resident. Once the medication is administered, the nurse will document as appropriate in the Mar. *All medications will be given according to the 5 rights: right medication, right resident, right time, right dose/amount, and right route. *Medications are not allowed to be routinely set up in cups and stored to give later. If a resident wants their medications later than when prepared, the med cup must be dated and timed with the resident's name on the med cup, another med cup placed on top to prevent contamination and stored in the med cart.

Based on observation, interview, record review, and policy review, the provider failed to assess grab bars for safety for four of four sampled residents (8, 26, 1, and 15) who had grab bars on their beds. Findings include: 1. Observation on 2/11/25 at 8:53 a.m. of resident 8's room revealed grab bars were on both sides of the bed. Review of resident 8's electronic medical record (EMR) revealed: *She had a Brief Interview for Mental Status (BIMS) assessment score of 5 which indicated she had severe cognitive impairment. *A device evaluation for her use of grab bars was last completed on 8/1/2024. -She utilized the right and left grab bars for turning and repositioning while in bed. *There was no documentation that an assessment on the grab bars had been completed to determine safe use or measurment of the grab bars. 2. Observation and interview on 2/11/25 at 10:04 a.m. of resident 26 in her room revealed: *She used a walker for ambulation. *Grab bars were on both sides of her bed. *She stated the grab bars had been there since she arrived at the facility. *She used the grab bars to get up and out of bed. Review of resident 26's EMR revealed: *She was admitted on [DATE]. *She had a BIMS assessment score of 10 which indicated she had moderate cognitive impairment. *A device evaluation for her use of grab bars was last completed on 12/8/24 which indicated she was safe to use them. *There was no documentation that an assessment on the grab bars had been completed to determine safe use or measurement of the grab bars. 3. Observation and interview on 2/11/25 at 1:31 p.m. with resident 1 in her room revealed: *She had grab bars on both sides of her bed. *She stated she used them to help her reposition. Review of resident 1's EMR revealed: *She had a BIMS assessment score of 6 which indicated she had severe cognitive impairment. *A device evaluation for her use of grab bars was last completed on 1/17/25. -She utilized the grab bars to assist her in sitting up, sitting down, rolling side to side, and repositioning in bed. *There was no documentation that an assessment on the grab bars had been completed to determine safe use or measurement of the grab bars. 4. Observation and interview on 2/11/25 at 1:49 p.m. with resident 15 in her room revealed: *Grab bars were on both sides of her bed. *She stated she did not turn in bed due to her right arm immobility, but she would grab one of them to hold onto occasionally. Review of resident 15's EMR revealed: *She had a BIMS assessment score of 12 which indicated she had moderate cognitive impairment. *A device evaluation for her use of grab bars was completed on 2/11/25. -She utilized the right and left grab bar for bed mobility and positioning. *There was no documentation that an assessment on the grab bars had been completed to determine safe use or measurement of the grab bars. 5. Interview on 2/12/25 at 1:52 p.m. with director of nursing (DON) B and registered nurse (RN) G revealed: *They were to complete the device evaluation for the residents' safe use of grab bars every 90 days. *They had not completed measuring assessments to ensure safety requirements for the use of the grab bars had been met. 6. Interview on 2/13/25 at 9:21 a.m. with administrator A revealed maintenance had not completed measurement assessments for the safe use of the grab bars for any resident. 7. Observation on 2/13/25 at 10 a.m. revealed 27 out of 30 observed resident beds had grab bars in the up position on their beds. 8. Review of the provider's revised 7/2015 Restraints and Entrapment policy revealed: *The term entrapment describes an event in which a resident is caught, trapped, or entangled in the open space of side rails, grab bars, or in gaps around mattresses. 9. Review of the provider's revised 6/2016 Preventative Maintenance policy revealed: *All equipment and building service is to be in satisfactory working condition for the safety and wellbeing of patients, residents, visitors, employees, and volunteers.

Based on record review and interview the provider failed to ensure appropriate and timely Medicare notices had been provided for one of two sampled resident (20) who was discharged from skilled services. Findings include: 1. Review of resident 20's Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Beneficiary Notification Review form provided by social services designee D revealed: *His Medicare Part A Skilled Services Episode start date was 9/2/24. *His last covered day of Part A Service was 11/13/24. *He had not been given a SNF Advance Beneficiary Notice of Non-coverage (ABN) form and had remained in the facility. 2. Interview on 2/12/25 at 4:40 a.m. with social services designee D regarding Medicare non-coverage notices revealed: *He had been hired on 9/11/23. *He was not aware resident 20 should have been provided a SNF ABN form. *He believed he had completed the Notice of Medicare Non-coverage form for resident 20. 3. Interview on 2/13/25 at 9:13 a.m. with licensed social service consultant L revealed: *She met with social services designee D once a quarter to review items. *Her focus is on discharge planning when residents leave the facility. *She agreed the SNF ABN form was not provided to resident 20 and it should have been.

Based on review of the South Dakota Department of Health (SD DOH) online report, interview, and policy review, the provider failed to ensure an allegation of sexual abuse made by one of one sampled resident (20) against a certified nursing assistant (CNA) (D) was thoroughly investigated. Findings include: 1. Review of the SD DOH online report revealed the following: *On 1/11/24 at approximately 7:45 p.m. resident 20 reported an allegation to certified nursing assistant (CNA) E that CNA D had sexually abused her. -CNA E had reported the allegation to registered nurse (RN) F. *The provider submitted that allegation to the SD DOH online reporting system on 1/12/24 at 2:15 p.m. Interview on 1/23/24 at 1:27 p.m. with RN B regarding the above revealed she: *Had thought the sheriff's office was completing the investigation. *Was not sure if anyone had interviewed CNA D. *Confirmed the provider had not completed a thorough investigation. Interview on 1/23/24 at 1:38 p.m. with administrator A regarding the SD DOH online report revealed he: *Had first become aware of the above-referenced allegation on 1/12/24 at approximately 1:00 p.m. by RN B. *Suspended CNA D at around 2:30 on the 12th [1/12/24]. *Had notified the local sheriff's office to complete an investigation on 1/12/24. -Stated he thought that the sheriff's investigation would have been sufficient. -The sheriff's office had requested the Department of Criminal Investigations (DCI) complete an interview with CNA D. --As of 1/23/24, the DCI had not interviewed CNA D. *Stated he had interviewed CNA D regarding the alleged sexual abuse, with one question being asked, Did you, do it? -The employee response has been No, I did not. *Allowed CNA D to return to work on 1/17/24, in the facility, without completing a thorough investigation. *Confirmed other staff or residents that might have had relevant information were not interviewed. *Confirmed the allegation had not been thoroughly investigated. Interview on 1/23/24 at 2:55 p.m. with RN F via telephone conference revealed the following: *On 1/11/24 CNA E reported to her that resident 20 had made the allegation referenced above. *She had reported the allegation by facsimile and telephone conference to director of nursing (DON) G on the evening of 1/11/24, she could not recall the time of the notification. -DON G stated to RN F there was nothing to corroborate that the incident had happened, and that she would take care of it tomorrow. --DON G was not in the facility the evening of 1/11/24. *RN F allowed CNA D to continue working his shift that evening. -She did not initiate an investigation regarding the alleged sexual abuse. -She had 5not notified CNA D of the allegation against him. DON G was not available for an interview during the survey period. Review of the provider's April 2016 Abuse Prohibition Policy and Procedure revealed: *Reporting suspected abuse and neglect -All staff is expected to report suspected abuse, neglect, exploitation, misappropriation of property immediately upon forming a suspicion; failure to report will result in corrective action in addition to notification to Board of Nursing of negligence if nursing staff had knowledge but did not report concern. -Mandatory reportable (as outlined in state regulation) need to be reported to the Dept. [Department] of Health within 24 hours of forming suspicions of abuse or neglect and must include follow up investigation and report within 5 days; if the suspected abuse or neglect resulted in serious bodily injury the report will be made within two hours of forming suspicion of abuse or neglect.

Based on review of the South Dakota Department of Health (SD DOH) online report, interview, and policy review, the provider failed to ensure an allegation of sexual abuse made by one of one sampled resident (20), was reported within the required time frame of two hours from the time that the provider was made aware of the allegation. Findings include: 1. Review of SD DOH online report revealed the following: *On 1/11/24 at 7:52 p.m. resident 20 reported an allegation to certified nursing assistant (CNA) E that CNA D had sexually abused her. -CNA E reported the allegation to registered nurse (RN) F. *On 1/12/24 at 2:15 p.m. RN B submitted the allegation to the SD DOH online reporting system. Interview on 1/23/24 at 1:38 p.m. with administrator A regarding the above allegation revealed the following, he: *First became aware of the above-referenced allegation on 1/12/24 at approximately 1:00 p.m. *He was not aware that an allegation that would have been considered a serious bodily injury was to have been reported to the SD DOH within two hours after becoming aware of the allegation. Interview on 1/23/24 at 2:55 p.m. with RN F via telephone conference revealed the following: *On 1/11/24 CNA E had reported to her that resident 20 had made the allegation referenced above. *She had reported that allegation by facsimile and telephone conference to director of nursing (DON) G on the evening of 1/11/24, she could not recall the time of the notification. -DON G had stated to her there was nothing to corroborate that the incident had happened, and that she would follow up the next day. DON G was not available for an interview during the survey period. Review of the provider's April 2016 Abuse Prohibition Policy and Procedure revealed: *Reporting suspected abuse and neglect -All staff is expected to report suspected abuse, neglect, exploitation, misappropriation of property immediately upon forming a suspicion; failure to report will result in corrective action in addition to notification to Board of Nursing of negligence if nursing staff had knowledge but did not report concern. -Mandatory reportable (as outlined in state regulation) need to be reported to the Dept. [Department] of Health within 24 hours of forming suspicions of abuse or neglect and must include follow up investigation and report within 5 days; if the suspected abuse or neglect resulted in serious bodily in jury the report will be made within two hours of forming suspicion of abuse or neglect.

Based on observation, interview, record review, and policy review, the provider failed to implement Pull-Tab alarm assessments, reassessments of those alarm devices, update resident care plans to reflect the current use of those alarms, and notify the resident's family when the Pull-Tab Alarms were implemented for three of three sampled residents (10, 15, and 20). Findings include: 1. Observation and interview on 10/24/23 at 10:41 a.m. with resident 10 revealed: *He was lying in bed watching television. *A Pull-Tab alarm was attached to the bed and a garment clip was attached to his shirt. *He had a wheelchair and a walker in the corner of his room. *His feet were elevated, and he had heel protectors on both feet. *He stated that he had gone to the hospital after a fall for a broken hip, he had done some therapy afterwards and he had sores on his heels that were healing. Observation on 10/24/23 at 11:46 a.m. of resident 10 in the dining room during the lunch meal revealed: *The resident was sitting in a wheelchair at the dining room table eating lunch. *A Pull-Tab alarm was attached to the back of his wheelchair with a garment clip attached to the back of his shirt. Observation on 10/26/23 at 12:51 p.m. of resident 10 propelling his wheelchair back to his room from the dining room revealed: *He had a Pull-Tab alarm attached to the back of his wheelchair with a garment clip attached to the back of his shirt. Review of resident 10's medical record revealed: *He was admitted on [DATE]. *Diagnoses included dementia and physical deconditioning. *He had a Brief Interview for Mental Status (BIMS) score of seven indicating severe impaired cognition. *He had a history of falls. *He had a fall with an injury on November 2022 that was listed on the provider's Matrix. *A 10/21/22 02:25 a.m. nurse note stated: Resident continues to be weak and unsteady with treatment for hyponatremia, has had a recent fall, resident found transferring and ambulating independently but due to unsteady gait, tab alarm has been placed for resident safety as he is not using call light for assist. *A 4/14/23 physician signed and dated facsimile (fax) requesting an order for a Pull-Tab alarm. *A 9/15/23 fall risk assessment revealed he was at high risk for falls and listed a Pull-Tab alarm as a fall prevention intervention. *No documentation was found regarding family or the resident's representative had been notified that the Pull-Tab alarm had been implemented. *A review of the care plan revealed there was no documentation of the Pull-Tab alarm documented on the care plan. Interview on 10/26/23 at 10:37 a.m. with the Minimum Data Set (MDS) Coordinator C regarding Pull-Tab alarms revealed: *The process to initiate a Pull-Tab alarm would have been completed due to falls and the fall risk assessment. *Pull-Tab alarms were often implemented by the nurses and at night. *The family member or representative had to have been notified when those Pull-Tab alarms were placed on the residents. *She was unable to locate any documentation in the resident's medical record that his family was notified about the placement of a Pull-Tab alarm. *She was unable to confirm that she had added the Pull-Tab alarm to the resident care plan. *The fall risk assessment dated [DATE], had the Pull-Tab alarm listed as an intervention but they had no Pull-Tab alarm-specific assessments that were completed. *There was no process to reassess the effectiveness of Pull-Tab alarms once they were implemented, they had no process in place to reassess if the Pull-Tab alarm was effective or ineffective for the resident. Interview on 10/26/23 at 11:57 a.m. with registered nurse (RN) D regarding Pull-Tab alarms revealed: *The nurse placed Pull-Tab alarms on residents when the nurse felt the resident was at high risk for falls and was unsafe. *She was unsure if a physician's order for the Pull-Tab alarms were needed but the physician was usually notified by a fax to let them know about the Pull-Tab alarms. *Generally, the family was notified by a phone call to let them know a Pull-Tab alarm was placed, which should have been documented in the residents medical record. *There was a section in the medical record to document when the family member or their representatives were notified, and documentation of those phone calls were probably missed. *Maybe it was not the policy to call, but she would have called them, so they were aware. *They would let the MDS nurse know in the report and may have written it in the care plan books when a Pull-Tab alarm was placed on a resident. *She was not sure if a re-evaluation was needed or if it had been completed to continue the use of a Pull-Tab alarm. *Once the Pull-Tab alarm was placed, they stayed. *She had not been in a situation when once the Pull-Tab alarm was placed it had ever been removed. *She believed that the Pull-Tab alarms resulted in fewer falls for residents. *She stated when she heard a Pull-Tab alarm go off, she was up and on the move. Interview on 10/26/23 at 1:02 p.m. certified nursing assistant (CNA) F regarding Pull-Tab alarms revealed: *CNAs notified the nurses if they felt a resident needed a Pull-Tab alarm, if they were at risk of falling, or if there was a safety concern. *The nurse might explain to the CNA to place the alarm, but the alarm would not have been placed unless the nurse directed it to have been placed. *Most of the residents that had Pull-Tab alarms would not have been able to have been asked for their permission as they were confused. *The nurse called the family to let them know the Pull-Tab alarm had been put on. *They were told at the stand-up meetings when a new Pull-Tab alarm was placed for a resident. *She was not aware when a Pull-Tab alarm had been re-evaluated, once a resident had a Pull-Tab alarm, they continued with it. Interview on 10/26/23 at 1:21 p.m. with director of patient care B regarding Pull-Tab alarms revealed: *There was no resident or resident representative signature for the informed consent with the placement of Pull-Tab alarms for residents. *She knew the Pull-Tab alarms could have been a mental restraint, but the policy was old-school thinking and had not addressed those Pull-Tab alarms as a resident restraint. *Pull-Tab alarms were placed mostly at night because residents were restless, had dementia, and had gotten their days and nights mixed up, or because residents had a lot of falls, despite providing other interventions such as distractions, having residents in a common area, and activities. *They had no Pull-Tab alarm policy, but the [NAME] Hospital had one she would get for the surveyor's request for a Pull-Tab alarm policy. *They had no Pull-Tab alarm assessments, and had not performed any formal assessments for those alarms. *Her expectation was the use of an alternate method should have been attempted and documented prior to the placement of a Pull-Tab alarm. *She expected family and physicians to have been notified when a Pull-Tab alarm was placed, and that should have been documented in the resident's medical record. *She expected that Pull-Tab alarms would have been reassessed for continued use with the completion of the MDS, documented on the care plan, and reviewed with the family at the care plan meetings. 45683 2. Observation and interview on 10/24/23 at 3:03 p.m. with resident 15 in her room revealed: *She was seated in her wheelchair. *She enjoyed living at the facility. *She was not sure how long she had lived there. *Her family came to visit when they could. *She had a Pull-Tab alarm attached to the back of her wheelchair and one placed on her bed. *Her plan was to return home. Review of resident 15's medical record revealed: *She was admitted on [DATE] and her diagnoses included the following: -Vascular dementia with behavioral disturbance. -Paranoid type delusional disorder. -Major neurocognitive disorder. *Her BIMS score was 4 which indicated severe cognitive impairment. *She had a history of falls. *Her care plan goal was to have no injuries from falls. *Her discharge goal was to remain at the facility long-term. *The care plan documented Tab alarm to bed and wheelchair. *No documentation was found regarding family or family representative notification that those alarms were implemented. 3. Observation and interview on 10/25/23 at 9:43 a.m. with resident 20 in her room revealed she: *Was seated in her wheelchair. *Really enjoyed living here. *Thought she had lived there for a few months. *Had a Pull-Tab alarm attached to the back of her wheelchair. *Was not sure what the alarm was used for. Review of resident 20's medical record revealed: *She was admitted on [DATE] and her diagnoses included: -Alzheimer's. -Dementia without behaviors. -Anemia. -Depression. *Her BIMS score was 3 which indicated severe cognitive impairment. *She had fallen on 8/22/23 and again on 9/17/23. *She had a Fall Risk Assessment completed on 8/16/23 with a score of 4 indicating she was a high fall risk. *Her care plan goal was to have no injuries from falls. *No documentation was found regarding family or family representative notification that the bed/chair Pull-Tab alarm had been implemented. Review of the [Name of the provider] 3/2022 Patient Restraints policy revealed: * B. Alternatives to Restraints: Alternatives to restraints should be considered before restraint application. Some examples are: Frequent verbal instruction, bed alarm implementation, frequent observation, diversional activity, call light use re-explained, patient moved closer to the nurse's station, family at bedside, patient placed on fall risk precautions, sitter, reality orientation, mobility monitor implementation, one to one staffing, and rooms with video monitoring.

Based on observation, interview, record review, and policy review, the provider failed to: *Provide timely notification to one of one sampled resident's (8) primary care provider as the initial burn injury evolved. *Follow their policies and procedures regarding wound assessments. *Provide timely investigation of and notification of resident injury to South Dakota Department of Health. Findings include: 1. Observation and interview on 8/24/22 at 11:20 a.m. with registered nurses (RN) G and H during a wound dressing change for resident 8 revealed: *She had a burn wound on the outside of her left mid-thigh. *The burn wound edges were raised and white in color, with depression noted in the middle of the burn wound. The surrounding burn wound area was splotched red. *RNs G and H explained: -Resident 8 had spilled hot chocolate on herself on 8/2/22, which resulted in the burn wound. -When the accident occurred, the burn wound area was not open nor blistered. -[MEDICATION(S)] cream had been applied twice a day with dressing changes. Interview on 8/24/22 at 5:17 p.m. with director of nursing (DON) B and RN/minimum data set (MDS) coordinator C regarding the burn wound incident revealed: *Resident 8 was not able to feed herself and required extensive assistance of one staff with meals. *On 8/2/22 at 5:10 p.m. resident 8 had been served hot chocolate. -Certified nursing assistant (CNA) I had been present at the dining table with resident 8. -Resident 8 had grabbed the mug of hot chocolate and CNA I attempted to take the drink away from her which resulted in the hot chocolate spilling on resident 8's left hand and left thigh. *On 8/2/22 at 5:40 p.m. the on-call provider had been notified. -The on-call provider did not visually assess the burn wound. -Telephone orders from the on-call provider were received to start [MEDICATION(S)] cream [twice per day] for a week or until healed to affected burn area. *The wound care team had not been following resident 8's burn wound because the wound care team only followed pressure ulcers. A follow-up interview on 8/24/22 at 6:06 p.m. with administrator A and DON B regarding resident 8's burn wound revealed: *The wound care team followed pressure ulcers and the wound care team had not been following resident 8's burn wound. *Resident 8's primary care provider (PCP) had not assessed the burn wound until 8/16/22 which was two weeks after the burn wound occurred, and the on-call provider had given provisional orders. *When asked why a medical provider had not been involved sooner when the electronic medical chart documentation showed the burn wound worsening, DON B did not have an answer. *Administrator A agreed the wound care team should have been following the burn wound, and the burn wound should have been assessed by her PCP sooner than 8/16/22. An attempt was made on 8/25/22 to call CNA I who had been with resident 8 at the time of the incident. A voicemail was left, and she had not called back prior to the survey exit. Interview on 8/25/22 at 2:50 p.m. with RN/minimum data set (MDS) coordinator C regarding wound care team assessments revealed there was no documentation of any wound care team assessment in resident 8's paper chart or electronic medical record. Review of resident 8's paper chart and electronic medical record revealed: *She sustained the burn wound on 8/2/22. *The on-call provider had ordered for [MEDICATION(S)] cream to be applied twice per day on 8/2/22. *The burn wound had started to blister on 8/3/22. *The blisters on the burn wound had opened on 8/9/22. *Her PCP visually assessed the burn wound on 8/16/22 during his routine rounding. *The South Dakota Department of Health had not been notified of the incident until 8/17/22 at 11:54 a.m. *There was no documented assessment by the wound care team of the burn wound injury to determine if the wound team should follow the concern through the healing process. *There was no documentation by nursing service of notification to primary care or on-call provider as the burn wound evolved. Review of provider's February 2020 Wound Assessment policy revealed: *Wound refers to all open areas, ulcers, lacerations, skin tears, or other skin issue. *The wound care team was to assess wounds weekly. *The MDS coordinator was responsible for documentation of the wound care team assessment in the [electronic medical record] for each wound on a weekly basis. *In the Procedure section of the policy, procedure number two stated, A wound referral does not mean the wound team will follow every skin issue thru the healing process. Wound Team will make the determination to follow skin concerns thru the healing process based on their assessment.

Based on observation, interview, record review, and policy review, the provider failed to ensure proper infection control techniques were followed during nursing procedures for: *One of one sampled resident (11) during one of three observed dressing changes performed by two of two registered nurses (RN) (D and E). *Two of two randomly observed nebulizer (neb) cleanings for resident 33 cleaned by two of two RNs (B and F). Findings include: 1. Observation on 1/29/20 at 10:30 a.m. of RNs D and [NAME] during a dressing change for resident 11 revealed RN D: *Applied hand gel then lifted a cloth covering from a wound kit that was placed on a cart outside resident 11's door. *With ungloved hands she: -Opened a plastic bag, removed several unpackaged gauze sponges from the package, and placed them in her opposite ungloved hand. -Reached into the wound kit to remove a packaged dressing, packaged wound barrier wipes, and an unpackaged paper wound measuring tool. -Brought those wound supplies into the resident's room. -Placed them on the resident's bedside table directly on top of a pile of mail without placing a barrier between the wound supplies and the mail. *Washed her hands and put on gloves. With those gloves on she: *Removed the soiled dressing. *Picked up the paper measuring tool and placed it on the wound to measure it. *Cleansed the wound using the gauze pads. *Opened the barrier cream and applied it to the wound area. *Removed her gloves and applied hand gel. She then put on clean gloves and with those gloves she: *Picked up the dressing package from on top of the mail. *Opened the package and applied the dressing to the buttocks. *Removed the gloves and washed her hands. Interview at that time with RNs D and [NAME] regarding the above dressing change confirmed: *Gloves should have been worn to remove unpackaged supplies from the wound kit. *A barrier should have been placed between the clean wound supplies and the mail on the table. *Packaged dressing supplies should have been opened prior to putting on clean gloves to prevent cross-contamination of the clean wound supplies. *RN [NAME] stated her expectation was that gloves were to have been changed between soiled items and clean items. Interview on 1/29/20 at 11:00 a.m. with the director of nursing (DON) C confirmed a barrier should have been used between clean and soiled items, and gloves should have been changed between clean and soiled areas. Review of the provider's (MONTH) 2019 Proper Wound Care Technique policy revealed:*Hands were to have been washed and clean gloves were to have been applied before touching the wound or wound dressings. *Sterile dressings will be used. Nonsterile gloves may be used, but care should be used to avoid touching the surface of the dressing that will contact the wound bed. 2a. Observation on 1/28/20 at 10:00 a.m. of RN B cleaning a neb mask and chamber after a neb treatment for [REDACTED]. *Removed the mask and chamber from the tubing. *Separated the mask from the chamber. *Set the mask in the bottom of the sink as she rinsed out the chamber with water. *Picked up the mask and rinsed it under the water spigot. Surveyor b. Observation on 1/28/20 at 10:35 a.m. of RN F cleaning a neb after completing a treatment for [REDACTED]. *She took the nebulizer to the sink in the room and rinsed the pieces off under the running water. *She turned off the faucet with her bare hands. *She then obtained a paper towel from the dispenser above the sink and used it to dry off the neb device. *She placed the pieces she had rinsed and dried off in a drawer with the neb machine. -She did not change the paper towel that was already in the drawer prior to putting the cleaned pieces on it. He was observed touching and moving items around in his drawer including the paper towel and machine. c. Interview on 1/28/20 at 5:30 p.m. with the director of nursing (DON) confirmed RN F did not follow the appropriate processes for cleaning the neb machine. Surveyor d Interview on 1/29/20 at 11:00 a.m. with DON C confirmed RN B should not have placed the mask in the sink while she rinsed the chamber. Review of the provider's (MONTH) 2014 Concentrator and Nebulizers policy revealed:*Nebulizer components (mask, mouthpiece, and tubing) will be rinsed in clean water and allowed to air dry after each treatment. *Nebulizer masks, cups, and tubing were to have been discarded when discontinued, contaminated, defective, or as deemed by the nurse and after a respiratory infection.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (37) had appropriate bowel management. Findings include: 1. Observation on 12/19/18 at 7:05 a.m. of certified nurse aide (CNA) A performing morning care with resident 37 revealed: *She was able to answer yes and no questions related to her daily activities. *She had been able to state no when asked if she needed to have a bowel movement. Review of resident 37's medical record revealed: *She was admitted on [DATE]. *She had [DIAGNOSES REDACTED]. and history of urinary tract infection [MEDICAL CONDITION]. *Her 11/26/18 admission Minimum Data Set (MDS) assessment revealed: -A Brief Interview of Mental Status score had been three indicating severe cognitive impairment. -She --Was an extensive assistance of one staff member with toileting and personal hygiene needs. --Had been able to indicate toileting needs. --Had always been continent of bowel. *She had a recent short stay hospitalization related to rule out [MEDICAL CONDITION], UTI, and constipation from 12/7/18 to 12/11/18. *She had not had a bowel movement (BM) for seven days. Interview on 12/19/18 at 7:30 a.m. with CNA A regarding resident 37's toileting habits revealed: *She was able to tell staff when she needed to have a BM. *She preferred to use the toilet and not go in her brief. Interview on 12/19/18 at 9:01 a.m. with CNA B regarding bowel management revealed: *Resident 37 was able to ask to use the toilet. *Every morning in report CNAs were given a list of residents who had not had a BM in three days. -The night nurse printed the report for day shift. *The nurse would inform the CNAs if a resident were to receive a suppository or medication to assist with a BM. -CNAs would be aware of who would need immediate assistance with toileting. *When the resident had results the CNA charted in the computer under Bowel Record. Interview on 12/19/18 at 10:30 a.m. with the director of nursing regarding resident 37 and the bowel management program revealed: *She was unclear why the resident did not flag on the BM report. *There must have been a glitch in the computer system. *They had started keeping the daily BM report to monitor patterns and chronic issues. -Hoped it would prevent a resident from going seven days or more without a BM. *Was unclear what else could be done to prevent the issue from happening again. Interview on 12/19/18 at 11:56 a.m. with the MDS coordinator revealed: *The physician had been contacted regarding resident 37's chronic constipation issue. *The computer system only had one report for no BM in three days. -Had been saving the report. -Unsure of what other measures could have been taken to prevent that from happening again. *When they had a new admission they would run a BM report to make sure the new resident flagged on the report. *Needed to develop a better plan to manage the bowel program. Review of the provider's (MONTH) (YEAR) Bowel and Bladder policy revealed it did not address a bowel management program or system for a resident with constipation.

Based on record review, interview, and policy review, the provider failed to ensure appropriate stop orders and clinical needs were in place for the use of as needed (PRN) [MEDICAL CONDITION] medication for two of five sampled residents (21 and 26) receiving psychoactive medication. Findings include: 1. Review of resident 21's medical record revealed physician's orders [REDACTED].>*[MEDICATION NAME] 100 milligram (mg) by mouth at HS (bedtime) for dementia. *On 11/16/18 via fax for [MEDICATION NAME] 2.5 mg PO (by mouth) q (every) 8 hours prn agitation. *There had not been: -A stop date for the 11/16/18 order. -Documentation by the physician indicating rationale for the PRN antipsychotic medication to be extended beyond fourteen days. Review of the (MONTH) (YEAR) Gradual Dose Reduction-Psychopharmacological Medication form regarding the [MEDICATION NAME] for resident 21 revealed: *Pharmacy recommended a dose decrease. *The physician response indicated no change. -That action required the physician to provide clinical contraindication or exempt condition. -No information had been provided. 2. Review of resident 26's medical record revealed physician's orders [REDACTED]. *Signed and dated on 12/3/18 for [MEDICATION NAME] 0.5 mg p.o. PRN every six hours for agitation. *There had not been: -A stop date for the order of 12/3/18. -Documentation by the physician that had rationale for the PRN antipsychotic medication to be extended beyond fourteen days. Interview on 12/19/18 at 8:50 a.m. with the director of nursing revealed she: *Agreed there was not an effective procedure in place for management of PRN antipsychotic medication orders. *Had educated the physicians on antipsychotic PRN orders but had not kept any documentation of that education. *Had been trying to educate the nurses to enter a fourteen day stop date for all PRN antipsychotic medications ordered. *Agreed the physicians should have been ordering the stop dates for the PRN antipsychotic medications not the nurses. *Agreed the provider had not always been contacted to examine the residents and document the need for continued use of antipsychotic medications. Review of the provider's last reviewed (MONTH) (YEAR) Antipsychotic Medication policy revealed: *Antipsychotic medications will be supervised by the physician for appropriateness of use. *The physician was to have reviewed antipsychotic medications and make recommendations for continuation. *PRN antipsychotic medication orders, and PRN [MEDICAL CONDITION] medication orders, including [MEDICATION NAME], are limited to 14 days. At that time the provider will be contacted to physically examine the resident and document rationale for keeping the PRN order, or, the order will automatically discontinue per date entered in the EMAR (electronic medication administration record).

Based on observation, record review, interview, and policy review, the provider failed to review and revise care plans to address residents' current needs for 2 of 12 sampled residents (26 and 37). Findings include: 1. Review of resident 26's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He had a history of [REDACTED]. *His 11/14/18 quarterly Minimum Data Set (MDS) assessment Brief Interview of Mental Status (BIMS) cognitive score had been zero indicating severe cognitive impairment. *His current care plan had interventions that included turning and repositioning every two hours. -That included toileting transfers. Observations of resident 26: *On 12/17/18 from 7:45 a.m. through 11:10 a.m. and 2:00 p.m. through 5:30 p.m. revealed he had been sitting in his chair. He had not changed position or off-loaded his coccyx area. *On 12/17/18 from 3:30 p.m. through 6:30 p.m. in the hallway and dining room revealed he had been sitting in his chair. He had not changed position or off-loaded his coccyx area during that time. Interview on 12/19/18 at 8:50 a.m. with the director of nurses revealed she agreed: *Resident 26 had not be repositioned and off-loaded from his coccyx area during the above time frames. *The care plans needed to be updated. 2. Review of resident 37's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. Review of resident 37's 11/26/18 admission MDS assessment revealed: *Her BIMS score had been three indicating severe cognitive impairment. *She was an extensive assistance of one staff member with toileting and personal hygiene needs. -She had been able to indicate toileting needs. -She was always continent of bowel. *She had a recent short stay hospitalization related to rule out [MEDICAL CONDITION], UTI, and constipation from 12/7/18 to 12/11/18. *Her 11/26/18 care plan did not have a problem area, goal, or interventions related to her constipation. Interview on 12/19/18 at 11:56 a.m. with the MDS nurse regarding resident 37's care plan revealed: *She had chronic issues with constipation. *There was no explanation why the care plan did not have a problem area related to constipation. Surveyor 3. Review of the provider's effective (MONTH) (YEAR) Care Plan Procedure policy revealed: *It contained details for staff to implement a care plan per Meditech Care Plans. *Each discipline had been responsible for following that policy for care planning in the facility. *The care plan was to have obtained measurable objectives for the highest level of functioning for each resident. *The care plan was to have been structured with a resident centered approach. *Care plans were to have been updated by designated staff.

Based on observation, interview, and policy review, the provider failed to maintain the security of medical records for one of two storage areas (back hallway). Findings include: 1. Random observations beginning 5/24/16 from 4:30 p.m. until exiting at 6:00 p.m. and on 5/25/16 from 7:00 a.m. until 3:30 p.m. revealed an unmarked door in the back hallway across from an employee bathroom and beside the maintenance room. The door was unlocked. Inside the room residents' medical records were stacked against all walls and were also stacked in the middle of the room leaving little room for movement. The door had remained open each time it was checked. Interview on 5/25/16 at 3:30 p.m. with the maintenance supervisor revealed she: *Was not aware medical records were being stored in the room. *Was not aware the room had been unlocked. Interview on 5/26/16 at 7:30 a.m. with health information manager A revealed:*Medical records were stored in the basement and in the room located in the back hallway. *Staff requiring access to medical records in the basement had to sign out a key from her. *The last time a key had been requested was 8/11/15. *The health unit coordinator (HUC) had a key to access the records in the room located in the back hallway. *She would not have known when the door had been unlocked. Interview on 5/26/16 at 8:00 a.m. with the director of nursing revealed:*She had called HUC B and was told that she did not have a key to access the medical records. *She would have had to obtain a key from the health information manager's office. *HUC B told her the last time she needed to access that room was approximately one year ago. *The medical records areas were to have remained locked and secured at all times. Review of the provider's 3/1/05 Safeguarding Protected Health Information policy revealed: *The purpose was to comply with the Health Insurance Portability and Accountability Act (HIPPA). *The provider would at all times have in place appropriate administrative, technical, and physical safeguards to protect the privacy of protected health information.

Based on observation, interview, record review, and policy review, the provider failed to ensure side rails had been assessed for safety and entrapment (getting caught in) risk for three of three sampled residents (6, 8, and 9) reviewed. Findings include: 1. Observation on 7/15/15 at 8:00 a.m. of resident 9's bed revealed a quarter side rail up on the top half of his bed. Review of resident 9's medical record revealed the side rail/grab bar assessment had been completed on 6/17/15. The assessment had not included safety and entrapment risk of the side rail/grab bar. 2. Observation on 7/15/15 at 10:00 a.m. of resident 6's bed revealed one side rail up on the top half of her bed. Review of resident 6's medical record revealed the side rail/grab bar assessment had been completed on 4/29/15. The assessment had not included safety and entrapment risk of the side rail. 3. Observation on 7/15/15 at 10:05 a.m. of resident 8's bed revealed one side rail up on the top half of her bed. Review of resident 8's medical record revealed the side rail/grab bar assessment had been completed on 5/20/15. The assessment had not included safety and entrapment risk of the side rail. 4. Interview on 7/15/15 at 10:10 a.m. with the director of nursing revealed: *The residents were assessed for appropriateness of and ability to use the side rails/grab bars prior to use and with each Minimum Data Set assessment and as needed. *There were approximately twenty-two beds with attached side rails. *Not all of those side rails were being utilized. *Those beds with side rails had open areas between the rails measuring no larger than nine inches and no smaller than five and three-quarter inches. *Residents with those side rails including residents 6, 8, and 9 had not been assessed for possible entrapment hazard. Review of the provider's revised May 2014 Restraints policy had not included the need to monitor the residents for potential of entrapment by side rails or grab bars.

Surveyor preceptor. Based on observation, interview, record review, and policy review, the provider failed to prevent pressure ulcers from developing for one of one sampled resident (1). Findings include: 1. Observation and interview on 2/28/11 at 5:30 p.m. of resident 1 in her room revealed: *She was sitting in her recliner with the foot rest up. She was noted to have heel lift boots on both feet. *She stated her heels were numb. *She resident denied pain. *When asked by this surveyor how long she had the pressure ulcers, she stated a few weeks. Observation and interview on 2/28/11 at 5:50 p.m. with registered nurse A regarding resident 1 revealed: *Her right heel had an area that was dark in color, and about the size of a dime. *Her left heel had an area that was dark in color with some peeling skin noted over that area. It was noted to be approximately the size of a nickle. *The heel pressure ulcers were first noted approximately 3 weeks ago. *The pressure ulcers on both heels were being treated with [MEDICATION NAME] ointment. *She had not had a pressure relieving mattress prior to the development of the pressure ulcers to both heels. Interview on 3/1/11 at 10:00 a.m. with director of nursing B regarding resident 1 revealed: *The only pressure relieving devices/equipment the resident had prior to the occurrence of the heel pressure ulcers was a wheelchair seat cushion. *She stated she suspected the resident had obtained the heel pressure ulcers from sitting in the recliner with her feet resting directly on the footrest. Review of resident's 1 entire medical record revealed: *Her care plan had not been reviewed and revised to reflect the current pressure ulcer status. Refer to F280, finding 1. *She had multiple medical [DIAGNOSES REDACTED]. *The 1/5/11 Minimum Data Set (MDS) documented the resident was at risk for developing pressure ulcers. There was no active pressure ulcers indicated in MDS. *The 1/11/11 Braden Scale documented she was at moderate risk for developing pressure ulcers. *She had not been eating well for the past two months as evidenced by the review of her food intake log. *The dietician had not assessed her since 7/19/10. Refer to F325, finding 1. *Nursing had documented the pressure ulcers were first noted on both heels on 2/13/11. They were noted to be at stage I on both heels at that time. *The nursing pressure ulcer assessment dated [DATE] revealed: -The right heel pressure ulcer measured 1.6 centimeters (cm) by 1.0 cm. -The left heel pressure ulcer measured 2.1 cm. by 1.1 cm. -The right and left heel pressure ulcers had dried blisters. -Both the right and left heel pressure ulcers were stage 1. *Nursing documentation of both the right and left heel pressure ulcers sizes were completed on 2/13/11 and 2/25/11. Size documentation was not noted in any other areas. Review of resident 1's reposition log revealed during February 2011 she was documented as not having been repositioned for periods up to fourteen hours in a day. Interview on 3/2/11 at 9:00 a.m. with MDS coordinator C revealed: *She agreed according to the repositioning log documentation resident 1 had periods up to fourteen hours without being repositioned. *The wound team did not regularly report stage I pressure ulcers to the dietary team. *She agreed the dietician should have assessed resident 1 as soon as the pressure ulcers were noted. Refer to F325, finding 1. Interview on 3/2/11 at 9:00 a.m. with director of physical therapy I revealed: *There was no one person who had oversight of the wound care team. *There were no written protocols for the wound team to follow. *The nurse with the primary responsibility of the wound care team had left employment with the provider approximately three weeks ago. *She had been on vacation for two weeks and had not seen resident 1 until 3/1/11. *When she evaluated resident 1's heels she found the pressure ulcers on both heels to be stage I. *She agreed according to the repositioning log documentation resident 1 had periods up to fourteen hours without being repositioned. *She agreed the resident was at risk for development of pressure ulcers prior to the time of onset. *She agreed pressure relieving devices should have been implemented prior to the occurrence of the pressure ulcers on both heels. Review of the provider's 1/1/09 pressure ulcer prevention policy revealed: *The purpose of the policy was to ensure proper pressure ulcer interventions were identified for each resident. *Residents should have been repositioned every fifteen minutes to two hours depending on the resident's needs. *Resident's heels should be elevated to prevent direct contact and pressure. *Resident's found to be at moderate risk per the Braden Scale should have had appropriate nursing interventions and pressure relieving devices implemented prior to the development of pressure ulcers.