Every finding on record at Avera Sister James Care Center

Based on record review, interview and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, the provider failed to ensure four of six sampled residents' (3, 34, 107, and 151) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop and individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas of diagnosis, Pre-admission Screening and Resident Review (PASRR) or dialysis. Findings include:1. Review of resident 34's EMR revealed he was admitted to the facility on [DATE]. His 2/24/26 BIMS assessment score was 15 which indicated his cognition was intact. He had a diagnosis of Chronic Bipolar Affective Disorder (a mental health condition that causes extreme, cyclical shifts in mood, energy and activity levels) dated 2/2/15. Resident 34 had a 11/20/23 Maximus notice of PASRR Level 1 screen outcome that indicated if a resident was currently in a Medicaid-certified nursing facility, the facility would need to document your PASRR condition in important Medicaid nursing facility paperwork. The facility should mark yes for question A1500 on the MDS assessment. Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? Also, your specific PASRR condition(s) should be checked in question A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Resident 34's 2/24/26 annual MDS Assessment, Level II PASRR at question A1500 was marked no. There was no ability to answer A1510 and list the resident's diagnosis. 2. Interview and EMR review on 5/13/26 at 4:26 p.m. with SSD E confirmed she completed resident 34's 2/24/26 annual MDS section A on 2/24/26. She agreed based on the PASRR level I Screen Outcome question A1500 should have been marked yes. That would have made question A1510 available to put in resident 34's current diagnosis. She used CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 to complete the resident's MDS assessments. She refers to the resident's PASRR level Maximus letters to complete section A, the resident's diagnoses, and admission orders. 3. Review of resident 107's EMR revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar II (mental condition causing extreme shifts in mood, energy, and activity levels), depression, and anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). Interview and EMR review on 5/14/26 at 1:37 p.m. with SSD P regarding resident 107's PASRR form and her MDS admission assessment coding at A1500 revealed that resident 107's Level I PASRR was completed by the hospital staff, where she was a patient before she was admitted to the nursing home. The hospital did not indicate on her Level I PASRR that she had a diagnosis of Bipolar II, and she was not referred for a Level II PASRR review. Resident 107's 3/25/25 psychiatric provider's note indicated she had the diagnosis of Bipolar II since 1/14/13. SSD P indicated she should have reviewed resident 107's diagnoses when she admitted to the nursing home, identified that she had a diagnosis of Bipolar II, completed a new Level I PASRR, and referred resident 107 for a Level II PASRR review for that diagnosis. 4. Interview on 5/12/26 at 1:51 p.m. with resident 151 in his room revealed he just returned from his dialysis treatment at a dialysis facility. His dialysis treatments were completed on Tuesdays, Thursdays, and Saturdays, and he received them for quite a while. 5. Review of resident 151's EMR revealed he was admitted to the facility on [DATE]. His admission 5/1/26 MDS assessment did not indicate that resident 151 received dialysis treatments. 6. Interview on 5/14/26 at 2:20 p.m. with RN supervisor D revealed resident 151 was receiving dialysis treatments. She acknowledged she did not document on his 5/1/26 admission MDS that he was receiving dialysis treatments. She indicated dialysis should have been documented. She was responsible for completing the nursing components of resident 151's MDS, which included the resident's dialysis treatments. 7. Review of resident 3's EMR revealed he was admitted to the facility on [DATE]. His diagnoses included paranoid delusional disorder (a mental illness where a person holds strong, false beliefs despite evidence to the contrary). A 4/3/25 Level I PASRR screen was completed, and he was referred to a Level II PASRR review. The Level II PASRR review indicated he had a mental health diagnosis. His comprehensive 3/11/26 MDS assessment was coded as no at question A1500 for having a mental health diagnosis. Interview on 5/14/26 at 2:05 p.m. with SSD P revealed she was responsible for completing the resident's MDS assessments, question A1500, for all residents in the Cabin neighborhood. Resident 3's 3/11/26 MDS assessment at question A1500 should have been coded as yes for resident 3 having a Level II PASRR. 8. Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed review of the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed section A, item A1500 indicated to Code 1, yes if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition. Section I, Page I1 and I2, Steps for Assessment: 1. Indicate the resident's primary medical condition category that best describes the primary reason for the Medicare Part A stay. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available. Section N, Page N6 and N7, Steps for Assessment: -1. Review the resident's medical record for documentation that any of these medications were received by the residents and for the indication of their use during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care settings where the resident may have received any of these medications while a resident of the nursing home (e.g., valium given in the emergency room).

Based on observation, interview, and document review, the provider failed to follow food safety standards to ensure that equipment in food service and preparation areas was maintained in a sanitary condition for two of six pantry dishwashers, one of five wall-mounted fans, and one of fifteen handwashing sinks. This deficient practice had the potential to affect the safety of food served to residents. Findings include:1. Observation on 5/14/26 at 7:58 a.m. in the Country neighborhood pantry revealed that there was a thick layer of biofilm (a sticky film with germs) and food particle buildup on the inner surface of the dishwasher doors, which could result in dishes not being properly cleaned and sanitized, which could place residents at risk for foodborne illness.Across the room from the dishwasher, a fan was mounted to the wall. A layer of visible dust buildup was on the fan blades and the fan cage. The fan was blowing air across the room to where the hot-holding steam tables used to serve residents' food was located. That had the potential to blow contaminants onto food-contact surfaces and the food itself, which created potential for foodborne illness risk.2. Observation on 5/14/26 at 11:39 a.m. in the Chalkstone neighborhood pantry revealed there was an unidentified layer of grayish buildup in one of the handwashing sinks. The dishwasher had a thick layer of biofilm and food particle buildup on the inner surface of the dishwasher doors.3. Interview on 5/14/26 at 11:51 a.m. with food service worker-feeding assistant (FSW-FA) M and certified dietary manager (CDM) I revealed that the staff were supposed to clean the sinks and dishwasher daily. To clean the dishwasher, she would turn the machine off, drain all the water, spray down the inside parts and wash arms with plain water, and remove the catch screens to spray them off in the sink. Neither FSW-FA M or CDM I was aware of the buildup on the inner surface of the dishwasher doors in the Chalkstone pantry.5. Interview on 5/14/26 at 3:42 p.m. with director of support services (DSS) L revealed that the staff had standard kitchen and neighborhood pantry cleaning task lists, but there were no checklists to show when those tasks were last completed. He expected the staff to inspect and clean the wall-mounted fans regularly. He was not aware of the buildup on the inner surface of the dishwasher doors in both observed pantries.6. Review of the provider's August 2022 revised Cleaning Schedule for the main kitchen adapted from the 2005 [NAME] & Associates, Inc. Policy and Procedure Manual revealed that kitchen appliances, sinks, and faucets should be cleaned daily. The walls, sinks, floors, and shelves in the Pot & Pan Room should be cleaned weekly. Dust Back of Appliances should be cleaned monthly.7. Review of the provider's undated Pantry Cleaning Lists revealed that there were columns for daily, weekly, and monthly cleaning.For the dishwashers, the daily cleaning included clean drain screens/remove food particles and wipe off front & sides of cabinet. The weekly cleaning included wipe off tops. The monthly cleaning included deep clean (edges, gaskets, etc.). There was a note on the second page that read, Wall Fan!!!!!!! (Check daily).The Pantry Cleaning Lists did not include the handwashing sinks.

Based on observation, record review, interview, and policy review the provider failed to ensure infection control practices were followed for one of two sampled residents (22) who used a nebulizer (a device that converts liquid medication into an inhalable mist) machine that was not cleaned after each use by the nursing staff and according to the provider's policy.Findings include:1. Observation on 5/12/26 at 10:35 a.m. of resident 22 in his room revealed, he placed his handheld nebulizer tube in the holder on the nebulizer machine after completing his treatment tubing was dated 4/2/26.2. Observation on 5/12/26 at 1:45 p.m. in resident 22's room revealed the handheld nebulizer tube was in the holder on the nebulizer machine, the nebulizer tube is dated 4/2/26 and had a small amount of clear liquid remaining in the chamber.3. Observation on 5/13/26 at 9:48 a.m. in resident 22's room revealed his handheld nebulizer tube was in the holder on the nebulizer machine with a clear liquid half-filled the medication chamber.4. Observation on 5/13/26 at 11:17 a.m. of resident 22's room revealed that the medication chamber on the handheld nebulizer tube had residual clear liquid in the bottom of the medication chamber.5. Observation on 5/14/26 at 9:04 a.m. of resident 22's room revealed the handheld nebulizer tube was in the holder on the nebulizer machine, which had a clear liquid that half-filled the medication chamber.6. Observation and interview on 5/14/26 at 11:11 a.m. of resident 22's room revealed, he completed his nebulizer treatment and placed the nebulizer tube on the holder on the nebulizer machine. He stated, It's been more than a week since the staff changed his nebulizer tube.7. Review of resident 22's electronic medical record (EMR) revealed his 3/24/26 Brief Interview for Mental Status (BIMS) assessment score was 14 indicated he was cognitively intact. He had a 1/22/25 physician's order for Albuterol (a prescribed medication used to treat wheezing, shortness of breath) 0.083 % (percent) 2.5 milligrams (mg) inhaled every four hours as needed (PRN) by nebulizer. He had a 4/1/25 physician's order for Albuterol/Ipratropium (a prescription medication used to treat airway narrowing in the lungs) 3 milliliters (mL) every six hours PRN by nebulizer. He had a 5/14/25 physician's order for Albuterol/Ipratropium 3 milliliters (mL) inhaled twice daily (BID) by nebulizer. He had a 2/25/25 physician's order to self-administer his nebulizer treatments after set-up assistance was provided by the staff.He had a 1/21/25 physician's order for his nebulizer tubing to be changed (replaced) weekly on Wednesdays at 7:00 p.m. with an intervention note that stated, Do not chart if you did not do.8. Interview on 5/14/26 at 11:17 a.m. with licensed practical nurse (LPN) G revealed that nebulizer tubing was to be changed weekly on the night shift. Tubing was to be dated when it was changed. If the tube was dated 4/2/26, then it was not changed since that date. It was the nurse's responsibility to rinse the nebulizer tube and attachments after the residents used them. She did not rinse resident 22's nebulizer tube and attachments on 5/12/26, or 5/14/26 when she completed the set-up of resident 22's nebulizer medications.9. Interview on 5/14/26 at 11:25 a.m. with registered nurse (RN) supervisor C revealed that nebulizer tube and attachments were to be changed daily and that the nebulizer oxygen tubing was to be changed weekly on Wednesday night. If a nebulizer medication chamber was labeled 4/02/26, she would assume that it was not changed since April 2, 2026. She expected the nurse to rinse the nebulizer medication chamber after each use and leave it to air-dry for the next use. She confirmed there was no task in the medication administration record (MAR) to remind nurses to go back and rinse them after the residents completed their nebulizer treatment.10. Review of the provider's February 2026 Respiratory Equipment Care policy revealed Clean according to [the] manufacturer's instructions for use (MIFU) if available. If no MIFU is available: a. After every treatment: Empty excess fluid. Rinse [the] nebulizer with sterile (preferred) or distilled water. Shake off excess moisture. Store: place on a clean, dry paper towel (change the paper towel after each treatment) and store in a clean, dry location in the resident's room to air dry for the next treatment or in a designated vented respiratory bag that is changed weekly. Weekly: replace nebulizer.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the staff used assistive safety devices for one of one resident (1) who fell, suffered a broken nose, and required emergency room treatment, while ambulating to a meal when one of one certified medication aide (E) failed to use a gait belt (a waist strap gripped as support for safe mobility and transfers) while assisting resident 1 with ambulating (walking).Findings include: 1. Review of the 1/28/26 SD DOH FRI regarding resident 1 revealed:*He was ambulating to the dining room.*He tripped over his feet and fell forward hitting his head on a table and landed on the floor.*CMA E was walking with the resident, but did not use a gait belt.*He was sent to the emergency room for evaluation.*He had a nasal bone fracture (broken nose) and multiple skin tears on his face and arms. 2. Observation and interview on 2/4/26 at 9:10 a.m. with resident 1 in his room revealed:*He had multiple cuts and bruises on his face and arms from a recent fall.*He used his walker to help keep his balance when he walked.*He stated he got ahead of himself and was going too fast when he tripped and fell on his way to the dining room.*A staff member was walking with him when he fell. 3. Interview on 2/4/26 at 2:25 p.m. with CMA F revealed:*A gait belt was used when transferring or walking with a resident unless they were independent.*The therapy department would evaluate the residents to determine the level of supervision for transfers and walking.*Resident 1 was an assist of one (needed one staff member to assist him with walking) according to his care plan (personalized plan that addresses a resident's care needs, goals, and interventions) so he would use a gait belt when walking with him. 4. Interview on 2/4/26 at 2:35 p.m. with CMA E revealed:*She was walking with resident 1 to the dining room when he fell.*She knew he was an assist of one with ambulation.*He started walking too fast and his walker was too far out in front of him.*She asked him to slow down.*She did not use a gait belt while walking with resident 1.*He tripped over his own feet and fell into the table and hit his head.*She was educated on gait belt use after that incident. 5. Review of resident 1's electronic medical record (EMR) revealed:*He was admitted on [DATE].*His Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated he was cognitively intact.*His admitting diagnosis included congestive heart failure (CHF), weakness, and hyponatremia (low blood sodium levels).*His care plan indicated:-I am at risk for falls due to [use of] high-risk meds, morbid obesity, impaired mobility, [and] need for assistance.-I will have no falls in the next 90 days.-Ensure [my] call light [is] in reach [while I am] in [my] room.-Fall safety rounds (staff checking on residents on a routine basis).-Walker with gait belt [and] 1 assist.-W/C [wheelchair] with foot pedals on for distance.-Cue resident to slow down when ambulating*His fall risk assessments completed on 12/1/25, 12/4/25, 12/21/25, 12/31/25, 1/22/26, and 1/28/26 indicated that resident 1 was at a high risk for falling. 6. Interview on 2/4/26 at 3:45 p.m. with physical therapist D revealed:*She assisted resident 1 with therapy and his therapy services ended on 1/22/26.*He was discharged from therapy with instructions for contact guard assist of one with a gait belt (a staff member would walk with him, and he would have a gait belt on).*He was on a walk to dine program (staff would walk with him to and from meals).*She expected that the staff would use a gait belt when resident 1 was walking. 7. Interview and review of resident 1's care plan on 2/6/26 at 8:30 a.m. with registered nurse (RN) C revealed:*She confirmed resident 1 had a walker, a gait belt, and was a one assist on his care plan.*That care plan information was transferred to the staff daily sheets (printed information with resident care needs).*She expected the staff to use a gait belt when resident 1 was ambulating.*Education was provided to the staff after his 1/28/26 falling incident. 8. Interview on 2/6/26 at 10:30 a.m. with administrator A and director of nursing (DON) B revealed:*They expected staff to follow the resident's care plan.*They agreed CMA E should have used a gait belt when walking with resident 1.*Education was provided to the staff regarding gait belt use and following the care plan.*Gait belt audits were being completed. Review of the provider's February 2026 SJCC [Sister [NAME] Care Center] Gait Belt- LTC [Long Term Care] policy revealed Gait belts will be used for any resident who requires assistance with transfers and/or ambulation. Review of the provider's revised October 2024 LTC Falls and Accidents-System Standard policy revealed:*C. Review of individualized, resident-centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment must occur. The plan of care must be updated/modified accordingly.

Based on observation, interview, record review, and policy review, the provider failed to implement their tobaco free campus policy for three of three sampled residents (66, 115, and 144) who smoked on the provider's property. Findings include: 1. Observation on 1/7/24 at 8:29 a.m. of resident 144 revealed: *She was seated in a wheelchair with a coat on. *She used the side exit door on the Chalkstone Drive neighborhood to go out to smoke. *The exit door had been propped open and a staff member stood there and monitored her while she smoked a cigarette. 2. Observation and interview on 1/7/25 at 9:56 a.m. with resident 66 in his room revealed: *He smoked and kept his smoking supplies in his room. *The staff would let him out when he wanted to go smoke. 3. Observation on 1/8/25 at 1:01 p.m. of resident 115 revealed: *She had been outside smoking on the facility property. *She discarded her cigarette in the landscaping in the facility parking lot. 4. Interview on 1/8/25 at 8:42 a.m. with registered nurse (RN) supervisor G regarding resident 66's smoking revealed: *He did not keep any supplies in his room and would ask other residents for cigarettes when he wanted to smoke. *He had a smoking assessment completed and was determined to be safe to smoke independently. *He only smoked at night. *She confirmed residents had been smoking all over, even though they were a tobacco-free campus. *Director of nursing (DON) B had been working on a notice to provide to residents who smoked informing them that smoking would not be allowed on campus. 5. Interview on 1/8/25 at 10:43 a.m. with RN supervisor F regarding residents' smoking revealed: *The facility had allowed residents who smoked to use the exit door at the end of the hallway by the fireplaces in each of their neighborhoods. *The side exit doors were unlocked and had a bucket sitting outside for cigarette butts to be extinguished in. *DON B had planned on sending out individual letters to residents who smoked informing them that there would be a ban on smoking. 6. Interview on 1/8/24 at 1:55 p.m. with DON B regarding residents smoking revealed: *Residents were originally supposed to smoke at the end of the driveway of the facility. *Since there had been a lot of noncompliance with that by residents who smoked, the facility allowed them to smoke outside of the exit door of their assigned neighborhood. *She planned on sending a notice to residents who smoked that there would be no smoking allowed on campus. *Residents had sat out in the courtyard and in front of the building to smoke. *Smoking assessments were to be completed for residents who wished to go outside and smoke. *If residents were determined unsafe to smoke independently, staff were to assist them outside and monitor them. *Residents' smoking supplies were to be kept in their locked medication drawer in their room or in the nurses station. *Residents were allowed to smoke anytime they wanted. 7. Review of resident 144's electronic medical record (EMR) revealed: *She had a Brief Interview of Mental Status (BIMS) assessment score of 15 which indicated she was cognitively intact. *She was admitted on [DATE]. *Her diagnoses included bipolar disorder, risk of malnutrition, spinal stenosis (spinal narrowing), and nicotine dependence. *On 10/13/23 her care plan indicated she smoked. *Her smoking evaluation had been completed on 10/18/24 which determined her safe to smoke independently. 8. Review of resident 66's EMR revealed: *He had a BIMS assessment score of 15 which indicated he was cognitively intact. *He was admitted on [DATE]. *His diagnoses included chronic end stage kidney disease, pulmonary vascular disease (chronic circulatory condition), and type II diabetes mellites. *On 4/5/23 his care plan indicated he smoked. *His smoking evaluation had been completed on 2/13/24 which determined him safe to smoke independently. 9. Review of resident 115's EMR revealed: *She had a BIMS assessment score of 15 which indicated she was cognitively intact. *Her diagnoses included type II diabetes mellitus, chronic kidney disease stage three, bipolar affective disorder, and schizophrenia. *She was admitted on [DATE]. *On 5/30/24 her care plan indicated she smoked. *Her smoking evaluation had been completed on 5/30/24 which determined her safe to smoke independently. 10. Review of the provider's welcome booklet dated 9/30/19 given at time of admission revealed: *Smoking is not permitted in the care center or on campus by anyone. 11. Review of the provider's Tobacco Free Campus Policy dated 6/13/23 revealed: *This policy supports a tobacco free campus to benefit the health, safety, and well-being of all who visit and work at our facilities. *This includes buildings, walkways, parking lots/ramps, and any public sidewalk or street that falls within campus boundaries. *This policy applies to employees, physicians, contractors, vendors, visitors, and patients. *Tobacco-Free signs are posted in appropriate places to inform medical staff, patients, and visitors of this policy. *Anyone who uses tobacco or smoking type products must leave the property. * .tobacco waste will not be left on the properties.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Two of two sampled residents' (80 and 330) had been assessed to determine their ability to have safely self-administered those medications and a physician's order to self-administer those medications. *One of one sampled resident (330) who stored a self-administered medication at his bedside had a physician's order to have stored that medication at his bedside. Findings included: 1. Observation and interview on 1/7/25 at 9:32 a.m. with resident 330 revealed: *Resident 330 was seated on the edge of the bed with a face oxygen mask on. *He was on 6 liters of oxygen. *Stated he had a bloody nose that morning. -Stated his nose would often get dry from the oxygen, and would bleed. *There was a prescription nasal spray on the bedside table. *Resident 330 stated he used that nasal spray every morning for his dry nose. Review of resident 330's electronic medical records (EMR) revealed: *He was admitted to the facility on [DATE]. *His diagnoses included: acute congestive heart failure, acute respiratory failure, chronic obstructive pulmonary disease, oxygen use, and hypertension. *A request was sent to the physician for an order for the nasal spray on 11/20/24. *There was no documented assessment completed for the resident to determine his abililty to safely self-administer the nasal spray. *There was no physician's order for the resident to self-administer the nasal spray or to have it kept at his bedside. Interview on 1/8/25 at 7:54 a.m. with registered nurse (RN) supervisor C revealed: *She was unaware resident 330 was self-administering the nasal spray. *She was responsible for the completion of a medication self-administration assessment for resident 330. 40788 2. Observation and interview on 1/6/25 at 4:39 p.m. in resident 80's room revealed: *A nebulizer machine (a medical device that delivers liquid medication that forms a fine mist for inhalation) sat on her bedside table. -She used that machine daily to administer her breathing treatments. Review of resident 80's EMR revealed: *Her diagnoses included chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues). *Her physician's orders included nebulizer treatments that were scheduled three times a day and as needed every four hours. -There was no physician's order for her to have self-administered her nebulizer treatment. Observation on 1/7/25 at 2:45 p.m. outside of resident 80's room revealed: *She was self-administering a breathing treatment using her nebulizer machine. *RN E entered the resident's room, turned off the nebulizer machine, cleaned and properly stored the nebulizer equipment, and then exited the room. Interview on 1/8/24 at 9:30 a.m. with RN E regarding the observation above revealed: *It was her practice to set up the resident's nebulizer machine with the physician-ordered medication, turn the machine on, and allow the resident to self-administer her breathing treatment. *Residents who self-administered a medication were expected to have been assessed to ensure they were safely able to perform that task. -She did not know if a medication self-administration assessment was completed for resident 80. Interview and EMR review on 1/8/25 at 9:35 a.m. with RN supervisor D regarding resident 80's self-administration of her nebulizer treatment revealed: *There was no medication self-administration assessment or physician's order supporting the resident's ability to have safely self-administered her nebulizer treatments but there should have been. Review of the provider's revised September 2023 Self-Administration of Medications policy revealed: Policy: A resident may only self-administer medications after the IDT [interdisciplinary team] has determined which medications may be safely self-administered. Procedure: C. Determination of the residents' ability to self-administer medication by the IDT will be documented in the resident's medical record and on the care plan. The documentation will also include the participation of the resident and resident representative, if applicable, in the assessment and care plan process. F. A physician's order will be obtained and recorded in the chart. The order also will include which specific medications can be kept at the bedside. This order is placed on the Resident Status Board.

Based on a complaint, record review, observation, and interview, the provider failed to ensure six of eight sampled residents (1, 2, 3, 4, 5, and 6) had received regular scheduled bathing. Findings include: 1. Review of the South Dakota online report received on 1/10/24 revealed: *The complainant reported that on Sunday 1/7/24, the overnight shift was short-staffed and they had a concern about the residents safety. *The complainant was concerned that the day shift had also been short-staffed and often residents were not getting their scheduled baths, stating residents are going 8 or 9 days without a bath. *The provider had been short-staffed on and off for a while. *The complainant had addressed her concerns regarding staffing and bathing with the director of nursing but stated nothing has changed. *At the time of the report, the complainant had not thought any resident had a negative outcome from being short-staffed. 2. Observation and interview on 1/23/24 at 4:00 p.m. with resident 1 revealed: *He was sitting in his electric wheelchair at the end of the hall. *His hair was matted down. *He stated he is happy with his care. *He indicated that he does not get a bath as often as he would like. *He had not gotten a bath for 15 days. *He stated that it bothered him not to get a bath regularly. *He would have preferred to have a bath at least weekly. Review of resident 1's electronic medical record (EMR) and interview with registered nurse (RN) clinical care coordinator K revealed: *He received baths on the following days: -12/10/23. -12/19/23. -01/01/24. -01/18/24. *The care plan included his personal care that he would need assistance with part of his weekly bath. 3. Observation and interview on 1/23/24 at 4:30 p.m. with resident 2 in her room revealed: *She was sitting in her recliner. *She used a walker to get around her room. *She stated it had been a couple of weeks since she had a bath and she was red under her stomach folds. Review of resident 2's EMR and interview with RN clinical care coordinator G revealed: *She received baths on the following days: -12/06/23. -12/18/23. -12/30/23. -01/11/23 no other baths were documented after this date. 4. Interview on 1/24/24 at 7:49 a.m. with resident life coordinator E revealed: *She had reviewed the staff schedule and stated that there was no bath aide scheduled today but that there would have been more staff coming in later in the morning to assist with bathing. *She stated that they had been short-staffed the last two weeks and that had contributed to the residents not receiving regular bathing. *She stated that staff do their best to ensure residents get their baths. 5. Interview on 1/24/24 at 7:55 a.m. with registered nurse (RN) clinical care coordinator G regarding resident bathing revealed: *A bath schedule was printed every morning. *They attempted to follow the bathing schedule. *A bath aide was not schedule for today. *Staff completed the resident's baths when there was no bath aide. *She had done two resident baths that morning. *The resident life coordinator would also do baths when available. 6. Interview on 1/24/24 at 8:00 a.m. with resident life coordinator H revealed:*She normally would have had a busy schedule with scheduled activities for the residents. *She was a certified nursing assistant (C.N.A.) *She would assist with resident bathing when necessary. *Tried to squeeze in baths between activities. 7. Interview on 1/24/24 at 8:10 a.m. with medication aide F revealed: *The staff used a weekly bathing schedule sheet to determine which resident would need a bath. *The bath schedule sheet had the resident's room numbers listed with some that had been highlighted with a number beside the room number. When asked what those highlighted room numbers meant and the number beside them, she stated that those were the priority showers and the number by the room number meant the number of days it had been since the resident's last bath. *When asked about the residents that had gone more than 10 days, she stated it was due to being short-staffed. *She stated that she would give every resident a bed bath when completing morning care. 8. Interview on 1/24/24 at 8:30 a.m. with RN clinical care coordinator D revealed: *Unit supervisors would discuss the resident bathing needs and schedules during the morning huddle. *The staff would identify those residents who had gone the longest without a bath and would make those residents the priority for that day. *She would attempt to schedule the most efficient staff to work as the bath aide to attempt to get more residents' baths completed during the day. *She stated that staffing had been a challenge due to the recent weather and a couple of staff that were out on medical leave. *Residents in the Dakota neighborhood received a bed bath with their morning care. *She had been utilizing a couple of part-time staff to assist with resident baths. They would call mid-morning to see if they were needed and would come in to assist with resident baths. 9. Observation and interview on 1/24/24 at 8:45 a.m. with resident 3 in his room revealed: *He was sitting in his wheelchair. *He stated that he had a shower yesterday. *He stated he had gone at least two weeks without a shower before that, the staff that were here did a good job there just was not enough of them. Review of resident 3's EMR and and interview with RN clinical care coordinator G revealed: *He had received showers on the following dates: -12/21/23. -01/04/23. -01/23/24. *His care plan revealedhe would have received bathing every Tuesday. 10. Interview on 1/24/24 at 9:00 a.m. with medication aide I regarding the bath schedule revealed: *A bath schedule was available every morning. *They had fallen behind on baths recently. *She stated they try to catch up with the baths for those resident's who had gone the longest time without bathing. 11. Interview on 1/24/24 at 9:13 a.m. with licensed practical nurse (LPN) J and RN clinical care coordinator K regarding resident bathing revealed: *They were behind on baths due to a recent snowstorm and some residents with influenza. *The bath assignments were printed and the schedule was in the whirlpool room. *If a bath had been missed the goal was to follow up with a bath the next day. 49395 11. Review of the 1/22/24 Dakota Neighborhood Bath Schedule sheet revealed: *Resident 4 had not received a bath in 15 days. *Resident 6 had not received a bath in 13 days. *Resident 5 had not received a bath in 13 days. 12. Review of resident 4's EMR revealed: *The resident received baths on the following dates: -12/21/23 -01/03/24 -01/06/24 -01/22/24 *The care plan indicated that the resident should have received a whirlpool bath weekly and as needed. 13. Review of resident 5's EMR revealed: *The resident had received baths on the following dates: -12/20/23 -01/03/24 -01/10/24 -01/22/24 14. Review of resident 6's EMR revealed: *The resident had received baths on the following dates: -12/20/23 -01/03/24 -01/10/24 (the resident had not received a bath as of the review by the surveyor on 1/24/23). 15. Interview on 1/24/24 at 11:00 a.m. with RN clinical care coordinator D revealed: *When asked about bathing frequency for residents 4, 5, and 6, she stated they should have been receiving baths weekly. *Resident 6 would refuse her baths because she preferred her baths early in the morning. That could not always be accommodated if staff came to work later in the morning to assist with baths. 16. Interview on 1/24/24 at 11:30 a.m. with director of nursing services (DNS) B and director of quality C revealed: *DNS B stated that the expectation was that residents would have received a bath/shower weekly. Some residents with dementia would have received a bed bath. Bed baths would include washing the resident's faces and peri care (cleaning the private areas) was completed with every resident at bedtime. *She stated that she would have liked to have each neighborhood be consistent with how they were tracking resident baths/showers. *The unit care coordinators for each neighborhood would collaborate daily to ensure bathing was getting completed for each resident. *When asked what the provider was doing currently to solve the issue of bathing, DNS B and director of quality C both stated that they were attempting to hire staff but finding staff was difficult. *They do not currently have a policy regarding bathing preferences and frequency. Bathing preferences and frequency were discussed during the resident's admission conference.

Based on record review, interview, and policy review, the provider failed to ensure two of two sampled residents (17 and 71) on the 200 Cabin unit had received a proper notification of bed hold notice option upon their transfer out of the facility. Findings include: 1. Review of resident 17's electronic medical record (EMR) revealed: *She had a fall on 7/4/23 and was transferred to the emergency room . *Resident 17 was hospitalized for a left hip fracture on 7/4/23 and was discharged from the hospital on 7/7/23. *Her emergency contact had been notified on 7/4/23 of the fall and the need for an emergency room evaluation. *There had not been any documentation found regarding notification of the resident's bed hold. 2. Review of resident 71's EMR revealed: *He required an emergency room evaluation on 5/30/23. *Resident 71 was hospitalized for pneumonia on 5/30/23 and was discharged from the hospital on 6/2/23. *There was no documentation in the EMR that the resident's emergency contact had been notified of the necessity for an emergency room visit or bed hold notification. 3. Interview on 9/14/23 at 12:45 p.m. with director of nursing (DON) B, registered nurse (RN) C, and social services regarding the bed hold for residents the required hospitalization revealed: *Residents who had been sent to the emergency room and required hospitalization should have received a bed hold notice. *They thought that resident 17 and or the POA had received a bed hold notice but agreed they were unable to locate on in her EMR. *They had known that resident 71 had a POA and were unsure why they had not been contacted. *They agreed that there had not been a bed hold notice given to resident 71. *Social services D stated that she would have received a notification for any resident that was on a leave of absence. *She would have followed up on the residents with a leave of absence to ensure they had a received a bed hold notice. *Social services D thought that the nurse had already contacted resident 71's POA to inform them about the bed hold. 4. Review of the provider's December 2021 Bed Hold Policy revealed: *It is the policy of this facility that residents who are transferred to the hospital are provided with written information about the State's bed hold duration and payment amount before being transferred. *Residents and their representative will be provided with bed hold and return information at admission and before a hospital transfer. *Nursing and social work staff are educated about the resident's bed hold and information is provided at the time the resident leaves the facility.

Based on observation, interview, record review, and policy review, the provider failed to ensure three of ten sampled residents (68, 77 and 155) were assessed for ability the to safely self-administer medications that had been prepared by one of one registered nurse (RN) BB and one of one licensed practical nurse (LPN) E prior to allowing those residents to self-administer medications. Findings include: 1. Observation and interview on 9/13/23 at 1:36 p.m. with RN BB preparing medication for administration for resident 68 reveled: *RN BB prepared gabapentin 300 milligrams (mg) oral capsule in a medication cup and placed it on the resident 68's bedside table. *RN BB stated that resident had a physician's order to self-administer her oral medication. *She had not stayed and observed the resident take their medication. Review of resident 68's electronic medical record (EMR) revealed: *There was no assessment completed for self-administration of that medication. *There was no physician's order to self-administer her medication. 2. Observation and interview on 9/14/23 at 7:00 a.m. with LPN E preparing oral medication and administering insulin for resident 77 revealed: *LPN E had prepared the following medications: -Magnesium Oxide 400 mg oral table. -Tamsulosin 0.4 mg oral capsule. -Aspirin 81 mg chewable tablet. -Pantoprazole 40 mg oral capsule. -Levothyroxine 75 micrograms (mcg) oral tablet. -Topiramate 50 mg oral tablet. -Furosemide 40 mg oral tablet. -Sertraline 25 mg oral tablet. *She placed all the above medication in a medication cup and placed them on the resident's bedside table. *She had not stayed in the room and observed the resident take those medications. *LPN E stated that resident 77 was cognitively intact and was able to self-administer his oral medication. Review of resident 77's EMR revealed: *He had not been assessed to safely self-administer his oral medications. *There was no physician's order for the resident to self-administer his medications. 3. Observation and interview on 9/14/23 at 7:30 a.m. with LPN E preparing oral medication and administering insulin for resident 155 revealed: *LPN E had prepared the following oral medication: -Atorvastatin 40 mg oral tablet. -Cholecalciferol 2000 units oral tablet. -Guaifenesin ER 600 mg oral tablet. -Apixaban 5 mg oral tablet. -Calcium carbonate 500 mg oral tablet. -Docusate sodium 100 mg oral capsule. -Dapagliflozin 10 mg oral tablet. -Sacubitril/valsartan 49/51 mg oral tablet. -Potassium chloride CR 20 milliequivalents (mEq) oral tablet. -Acetaminophen 500 mg two oral tablets. -Metoprolol succinate XL 100 mg oral tablet. -Tramadol 50 mg two oral tablets. -Amiodarone 200 mg oral tablet. *LPN E had handed the cup of medications to the resident to take. *She had not stayed in the room and observed the resident taking those medications. Review of resident 155's EMR revealed: *He had not been assessed to safely self-administer his oral medications. *There was no physician's order for the resident to self-administer his medications. Interview on 9/14/23 at 12:30 p.m. with DON B, RN C and social services D regarding the above observations of residents self-administering their medications revealed: *DON B stated that residents should have been assessed to ensure the resident could safely self-administer medications. *Once an assessment was completed the physician should have been contacted for an order to self-administer their medication. *They agreed that the above resident had not been assessed nor had an order to self-administer medications. Review of the provider's October 2022 Self-Administration of Medication policy revealed: *An assessment of the resident's ability to self-administer medication will be performed by the IDT every three months, based on changes in the residents' medical and decision-making status, and as needed *A physician's order will be obtained and recorded in the EMR. The order also will include which specific medication can be kept at the bedside. *The order is placed on the Resident Status Bar.

Based on observation, interview, and policy review, the provider failed to ensure proper sanitation practices for: *One of one oven had a large amount of grease and dust covering the top. *Natural gas lines behind one of one oven had a large amount of grease and lint covering the pipes. *Backsplash behind one of one oven had grease on it. *Range hood had a thin layer of dust and lint build up. Findings include: 1. Observation on 8/9/22 at 8:59 a.m. in the main kitchen with nutrition and food service - head cook A revealed: *Two large oven racks were on top of a [NAME] oven. *The racks and the top of the oven had a thin layer of food particles, grease, and dust built up on them. *The natural gas lines behind the stove and ovens were covered with grease and lint. *There were splatters of grease on the stainless steel backsplash behind the Vulcan steam ovens. *The range hood had lint and dust built up on the edges and the vent louvers. *A sticker on the range hood showed: -It had been cleaned by Tri-State Cleaning Service in November 2021. -The schedule included the next cleaning for November 2022. Interview and document review on 8/10/22 at 4:15 p.m. with manager-nutrition and food B regarding the kitchen cleaning list revealed he: *Shared the monthly deep cleaning list with the surveyor. *Expected the staff to follow the cleaning list. *Thought the gas lines and range hood were on the monthly kitchen cleaning list but were not listed. *Agreed the top of the oven, gas lines, and stainless steel backsplash needed to be cleaned monthly and the range hood needed to be cleaned quarterly. Review of the providers September 1985 Infection Control in Food Safety/Sanitation Program for Nutrition Services policy revealed: *Environmental Services: -Nutritional service staff will dispose of garbage from the kitchen at a minimum of daily and more often if needed . -Nutritional staff does regular cleaning of walk-in freezers and refrigerators, with quarterly deep cleaning of walk-ins with removal of carts and shelving and cleaning walls, ceilings, and floors. *Equipment: -All equipment used by Nutritional Services meets standards of your State Department of Health . -Vent hoods are cleaned quarterly per preventive maintenance schedule. A full hood cleaning is done annually. -Ovens and oven racks in the kitchen are cleaned thoroughly once a month, and/or after spills occur.

Based on observation, interview, record review, policy review, and manufacturer's recommendations review, the provider failed to ensure infection control and technique was maintained for: *Hand hygiene and glove use by two of two observed certified nursing assistants (CNA)(A and B) for one of one sampled resident (369) with [MEDICAL CONDITIONS] during personal care. *Cleaning of a glucometer for three of three randomly observed residents (44, 133, and 270) by two of two observed registered nurses (RN) (F and G). *Hand hygiene and glove use during blood sugar monitoring for three of three randomly observed residents (44, 133, and 270) by two of two observed RNs (F and G). Findings include: 1. Review of resident 369's medical record revealed he was on contact isolation for [MEDICAL CONDITION]. Observation and interview on 12/2/19 from 4:50 p.m. through 5:10 p.m. in resident 369's room with CNAs A and B revealed: *Without performing hand hygiene they both put on gloves and a yellow isolation gown. -Pushed the full lift into his room. -Removed his boot protectors. *CNA B: -Emptied urine from his catheter into a clear container. -Handed the container to CNA A who emptied it into the toilet *With the same gloves on they: -Assisted him to turn over to his left side in bed. -Unfastened his brief. *CNA A pushed the brief that contained a small bowel movement under his buttock. -Removed wet wipes from a container and cleaned his buttock area. -Discarded the soiled brief and wipes into a garbage can. -Removed the glove on her right hand, discarded it into the garbage can, and without performing hand hygiene put on a new glove. *CNAs A and B attached the brief, and then pulled his shorts up. *CNA A pushed the full lift over beside him. *CNAs A and B attached the shower sling to the full lift. *CNA A began to lift him up with the full lift. -They decided the shower sling was not appropriate. -Lowered him to the bed and removed the shower sling. *CNA A removed her gloves and gown and discarded them into the garbage. -Left the room and used hand gel outside his door. -Returned to his room and without performing hand hygiene or putting on a gown, put on gloves. *Both CNAs positioned the sling under him. *CNA A ran the controls on the full lift and guided him towards the wheelchair (w/c). *CNA B stood behind the w/c as they lowered him into it. *CNA A removed her gloves and went out into the hallway. -Put on new gloves, removed two wipes from a Clorox Bleach Germicidal Wipes container located on the front of his room door, and quickly wiped the handles of the full lift excluding the control panel. -Left the full lift to air dry without keeping the surface wet. -Pushed the full lift into the hallway. -Washed her hands with soap and water. -Confirmed they used the full lift on other residents on his neighborhood. Interview on 12/3/19 at 3:04 p.m. with the director of nursing (DON) regarding resident 369 during the above observation revealed: *They should have done hand hygiene before entering his room. *There were several missed hand hygiene opportunities. *They should have used soap and water not hand gel for someone with [MEDICAL CONDITION]. *The total lift was used for other residents on his neighborhood. *The contact time for the Clorox Bleach Germicidal Wipes was three minutes. *The CNA had not cleaned the full lift correctly due to not wiping down the control panel. *She could not confirm if the CNA had left the full lift wet for the entire contact time as she was not there. Review of the Clorox Bleach Germicidal Wipes manufacturer's recommendation label on the container revealed:*To clean and disinfect nonporous surfaces: -Wipe surface to be disinfected. -Use enough wipes for treated surface to remain visibly wet for the contact time listed below. -Let air dry. Review of the disinfectants and Contact Time information sheet for the Clorox Bleach Germicidal Wipes manufacturer's recommendations revealed three minutes. Review of the provider's (MONTH) 2019 Long-Term Care - Isolation for Airborne-Droplet-Contact-[NAME] Contact Precautions policy revealed: *D. [NAME] Contact Precautions will be used for residents with known or suspected infections due to [MEDICAL CONDITIONS]. -2. Hand Hygiene: --a. Perform hand hygiene before donning PPE (personal protective equipment). --B. Use soap and water per policy. Alcohol hand sanitizer should not be used. -3. Gowns: --a. Worn when entering the room. --B. Remove before leaving the room. -4. Gloves: --a. Worn when entering the room. --b. During the course of providing care for resident, change gloves after having contact with infective material, and when going from a dirty to a clean body site. --c. Remove before leaving the room. 2. Observation and interview on 12/4/19 at 11:01 a.m. in resident 44's room with RN F revealed: *RN F: -Entered the resident's room with a wheeled cart. --There was a glucometer on top of that cart. -Performed hand hygiene and put on gloves. -Placed the glucometer on the night stand without first laying down a barrier. -Cleaned the resident's finger with a wet cotton ball. -Performed the finger stick and wiped the first drop of blood off. -Applied the blood drop on the test strip, read the test strip, and disposed of it in the Sharps container. -Placed the soiled glucometer on the wheeled cart without laying down a barrier. -Wiped the glucometer off with the Super Sani-Cloth but did not leave it wet for two to three minutes. -- She stated she leaves it to air dry for two to three minutes. -The glucometer remained on the soiled work station. -She confirmed the glucometer and the wheeled cart were used for everyone in that neighborhood. 3. Observation on 12/4/19 at 11:23 a.m. in resident 133's room with RN G revealed: *RN G: -Sanitized his hands and entered the resident's room with a wheeled cart. --There was a glucometer on top of that wheeled cart. -Took a cotton ball, test strip, and lancet, and then went to the sink to wet the cotton ball. -Washed his hands for approximately three seconds and dried them. -Washed the resident's finger with wet cotton ball. -Performed the finger stick without gloves on. -Placed the soiled glucometer with the test strip on top of the wheeled cart without laying down a barrier. -Typed on the computer keyboard and without performing hand hygiene left the room. -Returned to the resident's room and without performing hand hygiene he continued to type on the computer keyboard looking for a physician's orders [REDACTED].>-Found an order and administered two pills to the resident. -Removed the used test strip from the glucometer without the use of gloves. -Placed the test strip in the Sharps container. -Left the room and performed hand hygiene. -Had not cleaned or disinfected the glucometer or wheeled cart. -Went to another resident's room to do a blood sugar check with that same glucometer and wheeled cart. 4. Observation and interview on 12/4/19 at 11:37 a.m. in resident 270's room with RN G revealed: *RN G: -Entered the resident's room with the same unclean glucometer and wheeled cart. -Obtained a test strip, cotton ball, and lancet. -Washed his hands approximately three seconds under running water. -Obtained a dry paper towel and placed it on the wheeled cart. -Washed the resident's finger with a wet cotton ball. -Without gloves on performed the finger stick. -Placed the soiled glucometer with the test strip on the wheeled cart on half of the paper towel. -Took an insulin pen, set it to twelve units, and administered it. -Removed the used test strip from the glucometer and placed it in the Sharps container. -Performed hand hygiene outside of the room. *Interview at that time with RN G revealed: -He was done. -He cleaned the glucometer at the end when he was done. -When asked how he cleaned the glucometer he did the following: --He took a Super Sani-Cloth and wiped the glucometer off. --It did not stay wet for two minutes. --Laid the glucometer on the soiled wheeled cart to air dry. --He confirmed the glucometer was used with other residents. 5. Interview on 12/4/19 at 2:09 p.m. with the DON regarding the above observations revealed: *Her expectations would have been: -For the glucometer to have been cleaned and disinfected between each resident use. -Gloves should have been worn while performing blood sugar checks. -To have followed the glucometer manufacturer's recommendations for cleaning and disinfecting it. -She agreed there were several missed hand hygiene opportunities. Review of the provider's (MONTH) 2019 Disinfection of Non-Critical Patient (resident) Care Equipment policy revealed: *K. Disinfection Recommendations- -1. Reusable resident care equipment: All applicable label instructions on EPA-registered disinfectant products must be followed . -a. Between each resident use and when soiled. -e. Glucometer or re-useable point of care testing labeled for multiple resident. Review of the Talking Points for Nova StatStrip Blood Glucose Monitor revealed: *Wash your hands and don gloves. -Wash the patient finger with soap and water. Dry the finger. -Lance finger with one time use BD Microtainer contact-activated lancet. -Wipe away the first drop of blood. Use the second drop of blood for testing. -Dispose of lancet in sharps. -Remove strip by pulling it out of meter or using the sliding strip remove button on back of the meter. -Remove contaminated gloves, clean hands with gel(if hands are soiled with visible blood, use soap and water). -Don a clean set of gloves. -Place clean paper towel on sink. -Disinfect the outside of the meter. Do not get fluid into the electronics. -Set meter on clean paper towel. -Remove gloves and wash hands. -Pick up meter and dispose of paper towel. -Return meter to docking station. Review of the 2019 Super Sani-Cloth General Guidelines for use revealed: *3a. If present, remove heavy soil loads prior to disinfecting. -3b. Unfold a clean wipe and thoroughly wet surface. -4. Allow treated surface to remain wet for two (2) min. Let air dry. Surveyor Review of the provider's (MONTH) (YEAR) Standard Precautions policy revealed: *Standard Precautions include the following: -1. Hand washing: --Hands are to be washed after touching blood, body fluids, secretions, excretions or other contaminated items, whether or not gloves have been worn. --Hands must be washed immediately after removal of gloves, between any patient (resident) contact and when otherwise indicated. --To prevent cross contamination of different body sites on the same patient, it may be necessary to wash hands between tasks and procedures. -2. Gloves: --Gloves are to be worn when touching blood, body fluids, secretions, excretions and other contaminated items. --Gloves shall be changed between tasks and procedures on the same patient, after contact with material that may contain a high concentration of microorganisms. -4. Gowns: --When performing procedures that may be likely to generate splashes or sprays of blood, body fluids, secretions or excretions, wear a gown to protect the skin and to prevent soiling of clothing. --Always remove the soiled gown as soon as possible and wash hands. -5. Patient Care Equipment: --All patient care equipment that is soiled with blood, body fluids, secretions or excretions shall be handled in a manner that will prevent skin and mucous membrane exposure.

Based on Healthcare Online Self Reporting submitted to the South Dakota Department of Health (SD DOH), closed record review, interview, personal training record review, and policy review, the provider failed to ensure: *One of one closed sampled record for resident (1) had received appropriate emergency response procedures by one of one licensed practical nurse (LPN) (A). *Seven of eighteen sampled overnight nursing assistants (B, H, I, J, K, L, and M) had been trained in cardiopulmonary resuscitation (CPR). *Physician had been notified of a change in condition of one of one sampled resident (1) who had coded. *LPN (A) had pronounced a resident (1) death. *One of one LPN (A) had completed documentation for one of one sampled resident (1) with a change in condition in the resident's medical record. Findings include: 1. Review of the Healthcare Online Self Reporting initial report submitted to the SD DOH received on [DATE] at 4:42 p.m. regarding resident 1 revealed: *The resident had been a full code status for CPR. *On [DATE] the resident had coded. *LPN A: -Had performed CPR on the resident. -Had not called an ambulance. -Had faxed the primary doctor to notify of the resident's death. *The incident had occurred on [DATE] at 11:45 p.m. *Type of event being reported was: -Suspicion/allegation of abuse/neglect. *Allegation type: Neglect. *Suspicion/Allegation of Abuse/Neglect: Facility personnel. Review of resident 1's closed medical record revealed: *A [DATE] admitted . *[DIAGNOSES REDACTED]. *On the undated admission assessment cheat sheet the code was documented as needs clarified. *The [DATE] signed physician's orders [REDACTED].>-Code status was marked for DNR (do not resuscitate.) *A [DATE] signed fax by the physician: -3. Resident would like her code status changed to a Full Code and does not wish at this time to be a DNR. (MONTH) we change code status to Full code? --Physician had documented Yes. *A signed Power of Attorney for Health Care executed by resident 1 on [DATE] stated she: -Appoints my nieces as co-agents to serve as my attorneys in fact for health care. Review of the following nurses notes regarding resident 1 revealed on: *[DATE] at 6:35 p.m. documented by registered nurse (RN)/nurse manager E: -Family wanted code status as well as (resident) to be Full Code. Did write for orders for code status and did put into the computer to get signature on code status. Did request a palliative care consult and did discuss this with family. *[DATE] at 3:09 p.m. nurses note documented by LPN A revealed: -She had performed CPR on resident 1. -Informed the staff the resident had expired. -Long term care document had been faxed to her primary physician. Review of the following faxes to resident 1's primary physician revealed on: *[DATE] at 11:45 p.m.: Unresponsive, no palpable pulse. *[DATE] at 12:21 a.m.: -Next of kin had been notified. -Funeral home had been notified. 2. Observation and interview on [DATE] at 10:30 a.m. on Dakota neighborhood with RN/nurse manager E revealed: *The crash cart: -Was located in a locked store room with a key pad. -Had an ambu bag and CPR board. *The designated automatic external defibrillator (AED) for Dakota neighborhood was located on a wall outside the neighborhood by the therapy room. *There were several oxygen tanks and supplies located in a locked store room with a key pad. *The licensed staff and CNAs had access to the crash cart and oxygen supplies. Interview on [DATE] at 11:30 a.m. with nursing assistant (NA) B and the director of nursing (DON) regarding resident 1 revealed: *She: -Had worked at the facility for three years as a temporary employee. -Had been hired on [DATE] as a full time nursing assistant. -Was not CPR certified. -Only worked on the Dakota neighborhood. -Worked the evening/overnight shift in twelve hour shifts. -Was full time and worked three shifts a week. *On [DATE] at 11:45 p.m. there was one certified nursing assistant (CNA), one nurse, and herself working on Dakota neighborhood. *There could be up to thirty-eight residents on Dakota neighborhood. *Her job duties included answering call lights, doing rounds, checking and changing incontinent residents, laundry, and cleaning up the neighborhood. *She knew: -The crash cart was kept in a supply room with a key pad. -The code for the key pad. -Where the oxygen was kept -Where the AED was kept. *On [DATE] around 11:30 p.m. she answered resident 1's call light and assisted her to the toilet. *Resident 1 had: -Been ambulating with one staff for assistance. -Been very anxious. -Used her call light a lot that evening. *After she had assisted the resident to the toilet she left the room to give her privacy. *The resident put on the call light, and she went back into her bathroom. -Used stand by assistance to get her off the toilet. -The resident used the walker and ambulated to the point in the room where the bathroom door and room met. *Resident 1: -Stated I don't feel well. -Started to go down. *She: -Grabbed the back of the resident's pants and placed her knee behind her to anchor her. -Used the walkie-talkie to request assistance in resident 1's room: -Hurry fast. *CNA C came into the room. *At that point the resident had slid down her pant leg, down on her knees, and onto the floor. *There was not a gait belt in the room, so CNA C left the room to get one. -She tried to assist the resident to a standing position but could not get her up *The resident stated she felt dizzy. *CNA C went and got the Hoyer lift. *LPN A had been coming down the hall. -She walked into the room and around the resident, kicked the walker out of the way, and helped the resident roll on to the floor. -At that time the resident was not responding and had shallow breathing. *Once on the floor she was not breathing. *LPN A turned up the oxygen for her. *LPN A and CNA C began doing sternal rubs on the resident's chest. -They transferred the resident into bed with the Hoyer lift. *LPN A initiated CPR. *CPR had been done while the resident was on the mattress without a back board under her. *LPN A asked CNA C to get an oxygen mask. *CNA C was unable to locate an oxygen mask. *NA B went to find the oximeter. *CNA C went to get the stethoscope. *During that time all three staff discussed if the resident was a code or a no code status. -No one knew for sure. -No one went to check. *CNA C checked the resident's blood pressure but could not hear anything. *LPN A listened with the stethoscope. -She told them there was not a reading on the oximeter, blood pressure, nor stethoscope sounds. *LPN A said She's gone. -She had no idea how long CPR had been done. -She had not directed NA B or CNA C to call 911, get the crash cart, get the AED, or contact other nurses on the other neighborhoods. *After LPN A discontinued CPR on the resident CNA C and she left the room to answer call lights. *LPN A had gone to call the family. *CNA C and NA B assisted with post-mortem clean-up. *She knew if a resident was a full code or a no code the information could be found in the computer. *Everyone had access to the computer information. *That was the only way to tell what code status a resident was. *She had not been involved in any other resident incidents dealing with a code status. Further interview per telephone on [DATE] at 1:15 p.m. with NA B revealed she: *Did not know where the crash cart was located on Dakota neighborhood at the time of the incident with resident 1 on [DATE]. *Had been informed after the incident at a conference where to find the crash cart. Telephone interview on [DATE] at 1:00 p.m. with CNA/medication aide (MA) C regarding resident 1 revealed: *She usually worked on Dakota neighborhood. *Usually worked the 5:00 p.m. to 9:00 p.m. shift or the 10:00 p.m. to 6:00 a.m. shift. *Sometimes she would work a twelve hour overnight shift. *There were usually two CNAs on Dakota for the overnight shift. *She had worked one time as a team leader in the two and half years she had been employed. *At the time of the incident she did not know where the crash cart was. -A few days after the [DATE] incident they had a care conference meeting and showed her where the crash cart was located. *On [DATE]: -She had been assigned to work the other side of the hallway on Dakota. -She knew NA B had gone into resident 1's room. -She heard NA B ask for assistance over the walkie-talkie. -When she walked into resident 1's room she: --Saw the resident on her knees with the walker in front of her with both hands holding onto the walker. -NA B told her what had happened. -They both tried to get her up but were not able too. -She left the room to get the Hoyer lift. -On the way she met LPN A and told her there was a fall in resident 1's room. -LPN A and she her went into resident 1's room. -At that time the resident was laying on her back on the floor. -They rolled her from side-to-side and placed the lift sling under her. -She could tell the resident was unresponsive at that time. -They took the nasal cannula from her nose and placed it into her mouth. -LPN A turned the oxygen up. -LPN A instructed her to begin sternal rubs on her. -They placed her on her back on the bed. -LPN A checked for a pulse and could not find one. -LPN A began CPR. -LPN A instructed her to get the vital sign (VS) machine and oximeter. -She thought LPN A had meant the oxygen mask not the CPR mask. -She could not find the oximeter. -NA B brought the VS machine into the room. -She ran back to the room with a different mask and stethoscope. -LPN A continued to perform CPR on the resident. -LPN A checked for a heart beat and was unable to hear one. -LPN A discontinued performing CPR. -NA B and her left the room to answer call lights. -NA B and her assisted with the normal post mortem care of a resident. *LPN A did not direct NA B or her to call 911, get the crash cart, the AED, or contact any other nurse in the building. Telephone call on [DATE] at 1:40 p.m. was placed to LPN A with a message to contact the surveyor. Interview on [DATE] at 3:05 p.m. with registered nurse (RN) N regarding a resident code status revealed: *She worked the day shift on Dakota neighborhood. *To find out a resident's code status she would look on the computer. *The person who found a resident requiring CPR should be responsible to initiate CPR. Interview on [DATE] at 3:15 p.m. with CNA D regarding her job revealed: *She: -Had been employed almost a year. -Usually worked on Dakota neighborhood. -Usually worked the twelve hour overnight shift. -Had not been offered CPR training. -Knew the resident code status could be found on their sheet in a binder, or in a chart, or a piece of paper. -Was not able to find the code status information when asked. -Was not sure what an AED was or where the AED designated for Dakota neighborhood was located. -Would ask a nurse if she needed to know where to find the AED. *Prior to the [DATE] incident with resident 1 she did not know where the Dakota crash cart was. -Following the [DATE] incident with resident 1 she asked where the crash cart was located. Telephone interview on [DATE] at 6:05 p.m. with physician/medical director F regarding resident 1 revealed: *He had been notified of the resident's death by a fax on [DATE]. *He saw the fax at 8:15 a.m. on [DATE]. *He was not on call and would not have been contacted regarding the death. *The on-call physician should have been contacted. *He had not given an order to release the body. -That was usually done by the on call physician. *His expectations of a resident who was a full code would have been to follow the protocol and the ACLS (advanced cardiac life support) guidelines for code status. *Resident 1 should not have been a full code due to her disease process. -He had encouraged her to not be a full code. *Typically the physician made the decision when to discontinue CPR. *They had a private quality meeting on [DATE] with the administrator, director of nursing (DON), and himself to review the events from [DATE] regarding resident 1. *As the medical director he had concerns regarding the above event. -Appropriate protocols were not followed. *The outcome for resident 1 would have been the same. *He saw that as an opportunity for them to review policies and work with new employees. *He thought it would improve their processes. Telephone interview on [DATE] at 8:40 a.m. with LPN A regarding resident 1 revealed: *She: -Had been hired in (MONTH) (YEAR). -Primarily worked on the Dakota neighborhood, but had worked on other neighborhoods. -Worked the twelve hour overnight shift. -Had worked four, twelve hour shifts and the night of [DATE] was her fifth twelve hour overnight shift. -Had been scheduled for four, twelve hour overnight shifts but had traded to help out a co-worker making that her fifth, twelve overnight shift. -Was trained in CPR and had her CPR renewed in (MONTH) 2019. -Had been trained to call E-long term care for the ambulance. -Was not told to call 911 first. *An order was needed to get an ambulance. *If a resident was a full code you could call 911. Continued interview with LPN A revealed: *On the night of [DATE]: -Resident 1's condition had changed. -The resident 1 was experiencing high anxiety over the weekend. -She had requested the day shift visit with the physician to see if they could get something for her increased anxiety. -When she reported for her shift on [DATE] at 6:00 p.m. she found out nothing had been done for the resident's increased anxiety. *On [DATE] around 11:30 p.m. she knew an aide had gone into the resident's room to assist her with toileting. -She heard NA B request assistance from another aide in the resident's room. -She had not been called to the resident's room. -She had been walking down the hallway, and saw the resident on the floor. -They began sternum rubs to her. -Transferred her with the Hoyer lift to the bed. -She started CPR on the resident. -She told NA B to take over CPR, so she could call for assistance. -NA B said she was not CPR trained. --She thought everyone had been CPR trained. -CNA C was getting the oxygen mask, vital signs (VS) machine, and oximeter. -She kept performing CPR on the resident. -She checked the residents VS and could not hear any. --She said the resident was gone. --They had done everything they could. -She made the decision to stop CPR. -She called the family. -She did not notify the physician on call. -She sent a fax to the resident's primary physician. -The family told her to call the funeral home. -She had not reached out to other nurses for assistance during the code. -She did not direct NA B and CNA C to get the crash cart. -She had not faxed nor called the on-call physician regarding the resident. -She called the funeral home and released the body without calling a physician for an order. -She probably should have called the on-call physician instead of faxing the primary physician. -She did not know why she did what she had done during the [DATE] event with the resident. -She did not know how long she had done CPR on the resident. -She had self-reported herself to the South Dakota Board of Nursing. Interview on [DATE] at 9:07 a.m. with RN/nurse manager revealed: *She was one of the nurse managers. *She primarily worked on the Dakota neighborhood. *She worked the day shift. *She had been a nurse manager for six years. *She was not aware the night CNAs were to be trained in CPR. *During the [DATE] resident 1 event she would have : -Had a CNA call the ambulance. -Had another nurse from the building assist her with the code. *A nurse can not pronounce death. *Her expectations of any resident with a full code status during a nonresponsive episode would be to call the ambulance, continue with CPR until the ambulance arrived, and then the ambulance personnel would take over. *LPN A should have notified the physician on call after resident 1 had died . Interview on [DATE] at 11:00 a.m. with RN/quality and service excellence G regarding the quality assurance (QA) program revealed: *She was the QA coordinator. *They tracked and trended the reportable state reports. *They had not discussed code status of residents recently. *They did have a quality meeting on [DATE] where they discussed the general aspect of the situation and CPR event from [DATE]. *They had not discussed night CNAs being CPR trained. Interview on [DATE] with the DON at the following times revealed at: *1:30 p.m. -CNA C was CPR certified. -NA B was not CPR certified. --She should have been since her start date was [DATE]. --She had been assigned to do the CPR training. *She agreed the CPR policy stated The following positions will receive training in CPR. Night shift CNAs. *She was aware NA B and CNA C had not known where the crash cart was located on Dakota neighborhood prior to the [DATE] incident. *2:45 p.m.: -Multiple night aides were not CPR trained. -They had identified that on [DATE]. -Human resources (HR) had been working on getting the night aides CPR trained. -On the night of [DATE] there were three RNs and one LPN in the building besides LPN A. Interview on [DATE] with the DON at the following times revealed at: *9:40 a.m. -The resident code status was found on the status board on the computer. -All nurses, CNAs, MAs, health unit coordinators, and social workers had access to that information. -The primary responsibility for CPR was with the nurse, but they could direct the staff on what to do. -They followed the South Dakota Board of Nursing guidelines for their professional standards. -All night CNAs should have been trained in CPR. -When they identified the problem with the event from [DATE] they had not followed their policy for night CNAs being trained in CPR. -They had never had an incident where the nurse had not called 911. -The orientation check list showed the buddy assigned to a new employee showed them where the crash cart was. -She was unaware NA B and CNAs C and D did not know where the crash cart was. *Her expectations for nurses performing CPR were: -If the resident was not breathing on the floor they should have initiated CPR on the floor. -The nurse should have delegated someone to check the status board for code status and called 911. -You needed a hard surface to perform CPR on. -LPN A should have initiated CPR and called for help. -Anyone could have grabbed the computer and checked resident 1's code status. -LPN A should have called for help; there were four other nurses in the building. --Professional back up helped. -LPN A should have notified the on-call physician making it known resident 1 did not have a pulse, respiration, or blood pressure, the skin color, and other symptoms. -Nurses could not pronounce death. -When the nurse informed the physician of the above the physician would have said yes to call the funeral home. -A fax was not appropriate to let a physician know when a death had occurred, a call should have been placed to the physician. -LPN A had not followed any physician orders. -She had seen an alert on [DATE] on her computer/email in the morning informing her of resident 1's incident. -She had found out later in the day from RN/nurse manager E that the information had come through in morning report. *1:13 p.m.:-They noticed LPN A had not documented in resident 1's chart the incident from [DATE]. -They had LPN A do a late entry when she had come back to the facility to visit with them regarding the [DATE] resident 1 incident. *1:24 p.m.: -LPN A should have documented the event on [DATE]. -She confirmed LPN A :--Was working her fifth, twelve hour night shift in a row. --They were usually scheduled for three, twelve hour shifts over their scheduled weekends. --LPN A had made the decision to trade hours and ended up with the five, twelve hour night shifts in a row. Review of the nursing schedule from [DATE] through [DATE] of the five neighborhoods for the overnight shift revealed the following CNAs were not CPR trained: *Dakota on: -[DATE] one of three CNAs. -[DATE] two of two CNAs. --[DATE] one of two CNAs. *Country Retreat on: -[DATE] one of two CNAs. *Cabin Retreat on: -[DATE] one of two CNAs. *Riverfront Retreat on: -[DATE] two of two CNAs. -[DATE] one of one CNA. -[DATE] two of two CNAs. *Chalkstone on: -[DATE] one of one CNA. -[DATE] one of two CNAs. Review of an email dated [DATE] at 4:30 p.m. from HR partner O revealed: *Asking who the CNAs that are on the night shift. *Checking to see if the correct people have CPR assigned to them. Review of employee information on [DATE] at 1:24 p.m. with the DON regarding the nursing assistants hired dates and CPR trained revealed the following had not been CPR trained: *NA B hired date was [DATE]. *CNA H hired date was [DATE]. *CNA I hired date was [DATE]. *CNA J hired date was [DATE]. *CNA K hired date was [DATE]. *CNA L hired date was [DATE]. *CNA M: -Hired date was [DATE]. -Had changed to the overnight shift in (MONTH) 2019. Interview on [DATE] at 11:10 a.m. with human resources partner O regarding staff personnel revealed: *When a new person was hired they were assigned training to do on the Avera Training for CPR. *She confirmed all the licensed nurses were CPR certified with the exception of two newly hired ones. Further interview and Student Management Assigned Learning document review on [DATE] at 11:20 a.m. with HR partner O regarding newly hired staff revealed: *Long term care new hire mandatory education to be completed within the first thirty and sixty days of employment did not have CPR listed. *Each staff member would be assigned CPR training depending on their positions. Interview on [DATE] at 2:45 p.m. with the DON regarding overnight CNAs not trained in CPR revealed: *Multiple night aides were not trained in CPR. *They had identified the above issue on [DATE]. *Human resources had been working on getting the CPR training assigned to the nursing assistants not trained in CPR. *They should have been CPR trained. Review of the provider's (MONTH) 2019 Nursing Services: Building Competency Evaluations policy revealed: *Nursing services: -The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. *Sufficient Staff: -The facility must provide services by sufficient numbers including RN's, LP's and, CAN's. -These employees will provide nursing care to all residents in accordance with resident care plans which includes assessing, evaluating, planning implementing and responding to a resident's needs. Review of the provider's [DATE] Education/Development policy revealed: *Purpose:-Education/development is essential to gain knowledge regarding new concepts and skills. -Each employee with his/her leader is responsible to identify areas for growth and to develop and implement a plan to achieve identified education goals. *Mandatory Education Requirements:-Are required for all employees. -It is an expectation that all employees complete new hire education, annual mandatory education, and ongoing designated mandatory education as a mechanism to ensure competency. -Mandatory education requirements will be scheduled to allow employees flexibility for completion. Review of the provider's [DATE] CPR (Cardiopulmonary Resuscitation) policy revealed: *Policy: -CPR (Cardiopulmonary Resuscitation) will be provided to residents/patients experiencing a respiratory or [MEDICAL CONDITION], unless they have indicated their choice of DNR (Do Not Resuscitate) with valid MD order. *Procedure: -1. CPR (Cardiopulmonary Resuscitation) will be initiated, by a staff member that is CPR certified, on any resident that is Full Code, that is validated by review of the chart for order, in the event of respiratory or [MEDICAL CONDITION]. If in doubt, initiate CPR. -2. Staff Assignments: --a. Call ,[DATE] or delegate someone to call ,[DATE]. --b. If two rescuers are present, one will provide CPR while the other calls ,[DATE] and gets the crash cart, AED and vital signs monitor. (Both a. and b. may be delegated to additional persons). ---i. Equipment on the crash cart will include the following: CPR mask, oxygen, oxygen tubing, stethoscope, suction machine with suction tubing, PPE (Personal Protective Equipment) and CPR board. --c. If resident or other is a full code, initiate CPR steps immediately by opening AED and following directions from AED machine per AED/BLS (basic life support) instructions. --d. Someone must document accurate timing of events. (This task may be delegated to an employee). --e. If an AED is not available, initiate CPR per BLS (2 minute cycles) until AED or emergency help arrive. -3. Continue CPR until emergency medical help arrives and take over or until the resident or individual regains a pulse or begins to breathe on their own. (Continue CPR unless physically unable to continue). --a. In the event that the resident or individual regains a pulse, but is not breathing effectively, continue rescue breaths without chest compressions. Again, continue to follow direction of AED. -4. The family of the resident as well as the physician should be notified following a code. *Staff Required CPR Training -To meet the needs of our elders and clients, the following positions will receive training in CPR: --All Nurses. --Night Shift C.N.A.s: --Resident Assistant Aides. Review of the provider's [DATE] AED policy revealed: *The AED is indicated for use on victims of sudden [MEDICAL CONDITION] on whom an apparent lack of circulation is indicated by all the following: -Unconsciousness. -Absence of breathing. -Absence of detectable pulse. -CPR has been initiated. *Training Requirements: -1. Persons trained to use the Automatic External Defibrillator (AED) must be currently certified in CPR. *Procedures: -1. Response: When a Code Blue is called, a designated staff person will bring the AED to the site of the code. Review of the provider's (MONTH) (YEAR) Death/Death Pronouncement policy revealed: *A. The charge nurse was to notify the appropriate people following a resident's death: -1. Attending physician or designee. *B. A physician is required to pronounce death. Pronouncing death is not within the scope of Registered/Licensed Practical Nursing Practice in the State of South Dakota. The Registered Nurse/Licensed Practical may act as a Physician Agent in pronouncing death using the following approved criteria and procedure. -The charge nurse will assess resident and determine expiration based on the following criteria. --No auscultated apical heart tones x 2 minutes. --No auscultated breath sounds x 2 minutes. --Fixed, dilated pupils and, --Unresponsive to painful stimuli. --When criteria is met, the charge nurse will act as a Physician Agent in pronouncing death by contacting the Attending Physician or designee for an order to pronounce death. --Charge nurse will document the above criteria as a nurses' note in the residents chart. --Charge nurse will write the verbal/telephone order received from the Attending Physician or designee on the telephone order sheet of the residents chart, including date and time of death. Review of the provider's (MONTH) 2011 Inter-Facility Transfer policy revealed: *Guidelines: -2. In case of critical, serious emergency, facility staff directly call 911 for support. Review of the provider's [DATE] Emergency Cart policy revealed: *Purpose: -In the event of a life threatening situation, an emergency crash cart room will be located in an accessible location with anticipated supplies stocked to enhanced staff response time and preparedness. *Procedure: -1. An emergency crash cart will be located in the clean utility room, easily accessible to staff. -2. The care will contain at a minimum: Sphygmomanometer, stethoscope, Flash light, oxygen supplies and e-tank regulator, AED machine, CPR supplies, ambu bag, hypoglycemic supplies,, supplies to control bleeding. -3. CPR board will be located behind the emergency cart. Review of the provider's (MONTH) (YEAR) Documentation policy revealed: *Policy: -To give the facility and /or resident and resident's family a record of the quality of care given to the resident, guides the physician in his/her treatment, use and effects of drugs and plan for care. -Provides documentation of a resident's stay in the facility should the need arise for legal review. -The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. -It is also necessary to include data needed for identification and communication with family and friends. -Complete history of resident and present illness is required at the time of admission and throughout residents stay. *Procedure: -B. Notes are to be written on all long term residents as health status deems necessary, frequency is determined by the individual nursing service. -C. Notes are required on all residents as the necessity arises. --1. Record significant information. --2. Observations should be a specific and objective as possible. --7. Record all accidents and incidents. --8. e. Blood pressure or any significant vital sign changes. Review of the provider's undated Quality Resident Care policy revealed:*Quality resident care is evidenced by: -2. Evaluation of assessment data, identification of the resident's needs/problems, and development of individual plan of care consistent with the resident's medical, nursing, mental, and psychosocial needs. -4. Providing adequate, competent staff to respond to resident's care requirements. Review of the provider's (MONTH) (YEAR) LPN/Team Leader job description revealed: *A. Leadership Functions: -7. Monitors nursing care given to the residents by others. *Technical/Professional Competencies: -4. Demonstrates ability to assess residents, identify concerns, and follow-up with practitioners in a timely, professional manner. -5. Demonstrates ability to use appropriate delegation of tasks. -9. Demonstrates versatility and flexibility in meeting needs and [MEDICATION NAME] routines bases on the resident wants and desires. -16. Ensures appropriate and complete documentation. *E. Personal Care Functions: -All care is provided according to each individual residents care plan and wishes. -Uses nursing assistant skills in response to resident needs and requests for care. -Demonstrates flexibility to readily readjustment priorities in response to residents needs. -Responds and reports promptly all

Based on closed record review, nursing schedule review, in-service training review, interview, and policy review, the provider failed to ensure: *One of one closed sampled resident record (1) had received emergency services. *Seven of eighteen night nursing assistants (B, H, I, J, K, L, and M) had received training in cardio-pulmonary resuscitation (CPR). Findings include: 1. Review of resident 1's closed medical record revealed: *A [DATE] admitted . *[DIAGNOSES REDACTED]. *On the undated admission assessment cheat sheet the code was documented as needs clarified. *The [DATE] signed physician's orders [REDACTED].>-Code status was marked for DNR (do not resuscitate.) *A [DATE] signed fax by the physician: -3. Resident would like her code status changed to a Full Code and does not wish at this time to be a DNR. (MONTH) we change code status to Full code? --Physician documented Yes. *A signed Power of Attorney for Health Care executed by resident 1 on [DATE] stated she: -Appoints my nieces as co-agents to serve as my attorneys in fact for health care. Review of the following nurses notes regarding resident 1 revealed on: *[DATE] at 6:35 p.m. documented by registered nurse (RN)/nurse manager E: -Family wanted code status as well as (resident) to be Full Code. Did write for orders for code status and did put into the computer to get signature on code status. Did request a palliative care consult and did discuss this with family. *[DATE] at 3:09 p.m. nurses note documented by LPN A revealed: -She had performed CPR on the resident. -Informed the staff the resident had expired. -Long term care document had been faxed to her primary care physician. Refer to F658. :

Based on record review, interview, and policy review, the provider failed to ensure the South Dakota Department of Health (SD DOH) had been notified in designated timeframe of a reportable incident for one of one closed resident record (1). Findings include: 1. Review of the Healthcare Online Self Reporting initial report submitted to the SD DOH regarding resident 1 received on [DATE] at 4:42 p.m. revealed: *The resident had been a full code status for cardiopulmonary resuscitation (CPR). *On [DATE] the resident had coded. *Licensed practical nurse (LPN) A had performed CPR on the resident. *LPN A had: -Not called an ambulance. -Faxed the physician to notify him of resident 1's death. *The incident had occurred on [DATE] at 11:45 p.m. *Type of event being reported was: -Suspicion/allegation of abuse/neglect. *Allegation type: Neglect. *Suspicion/Allegation of Abuse/Neglect: Facility personnel. Interview on [DATE] at 1:30 p.m. with the director of nursing regarding resident 1 revealed they: *Had not submitted an initial report to the SD DOH within twenty-four hours. *Did not think of it as an abuse investigation. *Knew the [DATE] incident had not gone right. *Should have submitted an initial report to the SD DOH within twenty-four hours. *The report should have been submitted on [DATE]. *Nurses could have submitted the initial report for [DATE]. Review of the provider's (MONTH) (YEAR) Abuse Prohibition policy revealed: *4. Mandatory reporting of alleged abuse, neglect, or misappropriation of resident property will be reported to the Department of Health Chief Complaint officer and the local ombudsman within ,[DATE] hours of the incident. -The 24 hour time frame begins when any employee first knows about the event. -The results of all investigations must be reported to the Department of Health and the Ombudsman within 5 calendar days of the incident.

Based on observation, interview, record review, and guideline review, the provider failed to ensure for three of five sampled residents (73, 75, and 83) with cognitive impairment: *Individualized and meaningful activities had been provided. *Appropriate documentation to support the delivery of activities had been completed. Findings include: 1. Observation on 10/15/18 at 4:30 p.m. of resident 73 revealed she was sleeping in bed. Interview on 10/16/18 at 8:36 a.m. with registered nurse (RN) clinical coordinator B revealed resident 73 was bedfast. She only got up into her wheelchair for meals. Sometimes it was just for breakfast. She was in her wheelchair at this time. Observation on 10/16/18 at 10:13 a.m., 11:30 a.m. and 11:49 a.m. of resident 73 revealed she was lying in bed. Observations on 10/17/18 at 10:00 a.m. and 10:41 a.m. of resident 73 revealed she was lying in bed. Review of resident 73's 8/23/18 Minimum Data Set (MDS) assessment revealed: *She had short and long term memory problems. *She was totally dependent on staff for bed mobility, transferring, locomotion on the unit, dressing, eating, using the bathroom, and personal hygiene. Review of resident 73's 10/18/17 care plan revealed for routine and activities: *I watch mass and rosary frequently on my TV. *I enjoy holding my stuffed animals. *I enjoy listening to music in my room. *I need staff to help me to and from activities. *I need assistance if it is a hands on activity. *I use to play piano and so I love listening to piano. *I am religious and so I enjoy attending rosary and mass occasionally when my family visits. There was no activity participation documentation to review. 2. Observation on 10/15/18 at 5:44 p.m. of resident 83 revealed he was sitting in his wheelchair in the back hallway of the Country neighborhood. Observation on 10/16/18 from 10:13 a.m. through 10:49 a.m. of resident 83 revealed: *At 10:13 a.m.: -He had been sitting in the back area of the hall at a table close to the social service designees (SSD) desk. -There had been a nursing student with him. -She was not talking to him. -He was staring at the wall. -At the table next to him there where two ladies getting their nails painted. *At 10:21 a.m. there was no one sitting at the table with him. *At 10:26 a.m. he was still sitting alone with nothing in front of him. *At 10:35 a.m. a student sat down with him but was watching the other table. *At 10:46 a.m. he was still sitting at that table with no staff with him. *There had been no music or TV on in the area. *At 10:49 a.m. clinical coordinator B came and took him to his room. Observation on 10/17/18 from 8:15 a.m. through 9:00 a.m. of resident 83 revealed: *He was self-propelling himself down the 119 through 137 hallway. -It was very slow going for him, and he got stuck next to the wall at a doorway. *At 8:34 a.m. he had gotten to the desk and was trying to pull himself along. *At 8:54 a.m. he turned himself around and self-propelled himself back down the hall along the wall. *There had been no staff that offered him assistance. Observation on 10/17/18 at 10:00 a.m. of resident 83 revealed he had been sitting in his wheelchair in the back part of the hallway. His eyes were closed. Observation on 10/17/18 at 10:41 a.m. of resident 83 revealed he was in his room with the TV on. Review of resident 83's 8/29/18 MDS assessment revealed: *He was unable to complete the resident interview to determine his cognition level. *Staff indicated he had long and short term memory problems. *He required extensive assistance from one staff member for bed mobility, transferring, locomotion on the unit, dressing, eating, using the bathroom, and personal hygiene. Review of resident 83's 10/24/17 care plan revealed for routine and activities: *My son (name) is very involved in my care and is a significant source of support for me. *He visits and calls often. I experience some memory loss and will at times forget where I was going or how to get there. *Please assist me to and from activities, church, and groups. *I like to visit and reminisce about my wife or time in the Army. *Please allow me time to voice my feelings and stories as they are an important part of who I am. There was no activity participation documentation to review. 3. Random observations of resident 75 on 10/15/18 from 4:00 pm through 6:30 pm, on 10/16/18 from 8:00 am through 4:00 pm, and 10/17/18 from 8:00 am through 2:00 pm revealed: *She spent much of her day alone in her room, laying on her bed. -Soft music was playing at times. *Staff were in her room to provide care that she was completely dependent on. *She was out of her room only at meal times. *She was not observed to attend any of the scheduled group activities. *She was unable to communicate verbally, although she was noted to make a continuous whimpering sound. Review of resident 75's 10/17/18 care plan with a start date of 10/25/17 revealed: *Problem: Psychosocial/Activities I have started getting very nervous about new situations. I have not had much interest in doing things that I used to like to do. I don't understand many of them any longer. -I am catholic and my faith is important to me, but often don't attend Mass as large groups make me nervous. *Interventions included: -Turning on TV to channel 18, Mass or music. -Turning on the radio to country western music. -One to one (1:1) visits one to three times a week. -Touch can irritate me - so being calm presence is what I need at times. --Sitting with her, apply oils, rosary. Interview on 10/17/18 at 9:07 a.m. with Dakota's resident life coordinator C and review of resident 75's activity participation records revealed: *She did not attend any activities. -She was up only for meals. *1:1 activities were offered weekly for her. *1:1 activities included hand massages with essential oils and praying of the rosary. -She denied the hand massages bothered the resident. *She also turned on music and the rosary daily. -No indication other staff were engaging in 1:1 activities for her. -There was no documentation to support activities being provided other than a hand written note. -- The hand written note was full of abbreviations that were not able to be understood. *A request for the activity policy was made at this time. Interview on 10/17/18 at 12:15 p.m. with clinical coordinator A revealed resident 75 was on hospice. Interview on 10/17/18 at 1:22 p.m. with the activities coordinator revealed there was no activity policy, and she provided an activity guideline for resident 1:1's. Surveyor: 4. Interview on 10/17/18 at 8:53 a.m. with SSD E regarding activities revealed: *She assisted with activities. *They did not document individual activities. *They had no one currently on a one-to-one program. *Residents could go to main activities that were in the gathering space outside of the neighborhood. *Review of the calendars revealed some were in the main gathering space and some were on the neighborhood. *Today at 9:45 a.m. they were supposed to have a volunteer read the newspaper, but she had called in sick. So the SSD took it off the board up front and had not replaced it with anything else. *They also had voting on the calendar, but that was not going to happen until tomorrow. -That activity had not been replaced with anything. *They had not updated the calendar to reflect those changes. *There was no documentation of what other activities had been canceled. Interview on 10/17/18 at 1:06 p.m. with the director of nursing and clinical coordinator B revealed: *They did not document on activities and had not for a very long time. *They had stated two staff members one from Country and one from Riverfront neighborhoods were attending the activity training going on this week. *Activities should still have been going on when they were not around. *The SSD should not have canceled an activity without replacing it with something. Review of the provider's undated resident 1:1 guideline revealed: *What characteristics qualify for a 1:1: -Does not come out of room -Isolated/no engaged -Score high on phq9 (as written) -Depression -Needs are not being met -Behaviors -Alzheimer's/Dementia -No Visitors/phone calls *What does not qualify them: -Goes out for meals -Family/friend visit and or phone calls -In room activities-looks out window, watches birds, animals, change in scenery/seasons, watches TV, word finds/puzzles -goes to activities and is participating to their capacity *Who decides if needs a 1:1: -Resident life coordinator, HHG -Always good to include nurse coordinator -Can discuss at self led teams *Frequency and duration of 1:1: -2-4 times a week -10-15 minutes *Where and when to chart 1:1's: -chart under resident/activity assessment -chart after you complete 1:1 *Care plan a 1:1 -Plan: I enjoy my 1:1 visits; I need my 1:1 visits as I isolate myself, am depressed, I have no visitors. During my visits I like to have my hands rubbed with lotions, listen to music, reminisce, what the squirrels outside, etc. -Goal: I will respond to 1:1's by talking facial responds, foot tap, relaxed body language etc -Intervention: Put what type of 1:1's activities the resident like how many time and duration.

Based on observation, interview, record review, and policy review, the provider failed to implement the appropriate interventions and treatments for three of six sampled residents (2, 5, and 17) to prevent pressure ulcers from developing or worsening while receiving care in the facility: Findings include: 1. Observation on 9/5/17 at 4:05 p.m. of resident 5 revealed: *She had: -Been laying on her bed sleeping. -Heelift pressure reduction boots on both of her feet. -Her legs elevated off the mattress by a pillow. *There had been an air mattress overlay covering her mattress. Interview on 9/5/17 at 4:20 p.m. with registered nurse (RN) and unit clinical coordinator D regarding resident 5 revealed: *She had: -[MEDICAL CONDITION] and was not interviewable. -Required staff assistance with all activities of daily living (ADL). -An unstageable pressure ulcer to her left heel. -That pressure ulcer had been acquired while receiving care in the facility. Observation on 9/6/17 at 1:42 p.m. with RNs E and D with resident 5 revealed: *They had prepared to change the dressing to her left heel. *Removal of the dressing revealed a wound to the inner aspect of her left heel. -That wound bed was dry and covered with a brown colored scab. Review of resident 5's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She currently had required the staff to: -Assist her with all of her mobility needs for transferring from place-to-place, moving in bed, and ADLs. -Implement any preventative interventions to ensure skin breakdown would not have occurred. *Her capabilities with assisting the staff to meet her daily needs had started to decline since July 2017. *Her Braden pressure ulcer risk assessment scores from 10/20/16 through 7/21/17 ranged from thirteen to nine. -Those scores had supported a decline in her capabilities, and she was at high risk for skin breakdown. *On 11/20/16 she had acquired a stage two pressure ulcer that had been: -Located on her left heel and was documented as an intact blister. -The size of that blister had been 1.5 centimeters (cm) by (x) 1.5 cm. -Covered with a fluff dressing for protection. *On 11/23/16: -That pressure ulcer was dark red/purple in color and was documented as unstageable. -The size of the pressure ulcer had increased to 4.5 cm in length and was 5.0 cm wide. -The pressure ulcer continued to be covered with a fluff dressing for protection. *On 11/29/16 she had acquired a stage two pressure ulcer to her right heel. *[MEDICATION NAME] was applied to those pressure ulcers after they both had opened. *On 2/14/17 the physician had referred the resident to the general surgeon for that left heel pressure ulcer with the following documentation: -That wound had: --Been red with a necrotic area. --A foul and rotten smell to it. *No documentation to support: -Preventative measures had been put in place prior to the skin breakdown. -The dietician had reviewed the chart prior to 4/11/17, five months after the staff had identified the left heel pressure ulcer. -Her current nutritional status was sufficient enough to support healing of an opened wound. Review of resident 5's 7/25/17 comprehensive care plan revealed: *A focus area: -Potential for skin breakdown due to limited mobility and incont (incontinent) of B&B (bowel and bladder). -I am wheelchair bound and poor appetite. -I do have [MEDICAL CONDITION]. *Goal under that focus area: -Skin Integrity - improve. Heel ulcer will be (there) healed by the end of the quarter. -That goal had not identified where the heel ulcer(s) had been located. *Interventions under that focus area had not identified: -How often she should have been repositioned. -What had been put in place for the staff to follow to ensure no further skin breakdown occurred. *A focus area: -I am on a no added salt diet with pureed textures due to chewing problems. I am totally dependent on staff to feed me all meals. -That focus area had not supported any pressure ulcers to her left or right heels. *The goal and interventions for the above focus area had not identified any current or past skin concerns. Review of resident 5's undated Elder Care Plan inside the clothes closet in her room revealed: *Cognitive status Confused-can't make needs known. *Needs assist with all ADLs. *Heel protectors. *Float heels. *No documentation to support: -When the above interventions had been initiated. -She had required nutritional interventions to promote the healing of her wounds. Review of resident 5's following physician's orders [REDACTED].>*On 11/20/16 had been informed of the blister identified on the resident's left heel. The staff were to cover it with a protective dressing after it had been cleaned with a wound cleanser. *On 11/29/16 paint the left heel with [MEDICATION NAME] prior to covering with a fluff dressing twice a day. *On 2/9/17 the following was requested from the physician: -We have been using [MEDICATION NAME] on ulcer on heels but Lt heel is not improving. Can we have order to apply silver antimicrobial wound dressing to Lt heel, cover with non-adhesive [MEDICATION NAME] and kerlix, change every 3 days. *No documentation to support when the [MEDICATION NAME] treatment had been initiated for the right heel prior to 2/9/17. -The physician had supported that treatment request 2/9/17. *On 2/14/17 the physician had referred the resident to have a general surgeon assess the wound with the following documentation noted: -That wound had: --Been red with a necrotic area. --A foul and rotten odor. *On 2/22/17 the general surgeon had debrided the left heel until an increase in pain had occurred. -Had ordered wet-to-dry dressing changes to be done on that wound twice a day. *On 3/20/17 she had been referred to have a wound specialist assess the wound. -It continued to have a foul odor and was not healing. -That specialist ordered the entire wound to be painted with [MEDICATION NAME]. Review of resident 5's foot care assessments from 11/1/16 through 11/30/16 revealed: *On 11/22/16 the staff had started applying protective boots to the feet and elevating her legs. -Those preventive measures had not been put into place until two days after an area of concern had been identified to her left heel. Review of resident 5's consultant dietitian referral form from November 2016 through April 2017 revealed the resident had not been referred to the registered dietician (RD) until April 2017. Review of resident 5's registered dietician's (RD) progress notes from 11/1/17 through 5/1/17 revealed: *No documentation to support she had reviewed the resident's medical record for wound concerns until 4/11/17. *On 4/11/17 the RD documented: -Increased protein-need related to compromised skin integrity as evidenced by open state three left heel ulcer and Braden score of 11. -She now has an open stage three ulcer on the left heel but no [MEDICAL CONDITION] noted. -Dietary to provide 4 oz (ounces) Ensure 1-2 times per day to meet increased protein needs. -Nutrtional goal: improve skin integrity. Interview on 9/7/17 at 9:15 a.m. with RN unit clinical coordinator D regarding resident 5 revealed: *The resident had: -Acquired stage two pressure ulcers to both her left and right heels. -Acquired those pressure ulcers while under the care of the facility. -Shuffled her feet and heels against the mattress and recliner when the staff provided care for her. *The staff had: -Elevated her legs with the use of a pillow but had not used the Heelift boots until after she acquired an open wound. -Not considered the shuffling movement she made with her feet as a potential for creating skin breakdown. *The resident had experienced a decline in condition and required increased staff assistance. -That decline had placed her at a higher risk for skin breakdown. *She confirmed the dietary department should have been notified in a more timely manner to ensure she had adequate nutritional support and interventions to promote healing of those opened wounds. *The interdisciplinary team would have met weekly to discuss any concerns regarding all of the residents on their specific unit. -Those area of concerns would have included opened wounds and those at high risk for skin breakdown. -The certified dietary manger (CDM) for that specific unit would have attended all of those weekly meetings. -The CDM would have informed the RD of any nutritional concerns regarding the residents. -There was no documentation to support the resident's wounds had been reviewed with the dietary department prior to 4/11/17. *The unit managers were responsible for updating the residents' care plans. *The care plan was not updated, reviewed, and revised to ensure she had received the necessary care and services she required. *The elder care plan: -Should have been dated to support when any interventions were put into place. -Was considered a worksheet for the CNAs to follow to ensure the residents had received the appropriate care. *She agreed they had failed to be proactive with preventative interventions in a timely manner to ensure no skin breakdown had occurred for the resident. Interview on 9/7/17 at 10:15 a.m. with the director of nursing (DON) regarding resident 5 confirmed the above interview with RN unit clinical coordinator D. Interview on 9/7/17 at 10:42 a.m. with the dietary manager (DM), CDM, and RD regarding resident 5 revealed: *They confirmed the above dietary documentation for the resident. *The RD had: -Been in the facility weekly to review residents' charts. -Relied upon the staff to ensure she had been notified of any wound concerns. *They confirmed: -There were weekly meetings with the interdisciplinary team to discuss any and all concerns regarding the residents for that specific unit. -The CDM: --Attended those weekly meetings and would have relied upon the nursing staff to have informed her of any wound/skin concerns. --Would have been responsible to ensure the RD was notified of those concerns discussed in the weekly meetings. --Was on maternity leave during the time-frame when the resident had acquired those pressure ulcers. --Would have been supported by another CDM from another unit in her absence. -The dietary department should have been notified of those wounds in a more timely manner to ensure she had received adequate nutritional support for those opened wounds. *The care plan should have been updated to support those opened wounds and to ensure proper healing of those wounds had occurred. 2. Review of resident 17's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He currently had required the staff to: -Assist him with transferring from place-to-place and ADLs. -Implement any preventative interventions to ensure skin breakdown would not have occurred. *Braden pressure ulcer risk assessment scores from 6/20/17 through 8/31/17 ranged from fifteen to eighteen indicating he was at risk for skin breakdown. *He had returned from an overnight hospital stay with an abductor brace in place on 6/30/17. -A skin assessment for that day was requested from household coordinator H on 9/7/17 at 2:05 p.m. and from the DON on 9/7/17 at 2:55 p.m. It was not provided by the end of the survey. *A stage II pressure ulcer on his back under the abductor brace was discovered on 7/16/17 that measured 1.2 cm x 1.5 cm x 0.0 cm. *A bed sore/fluid-filled blister at left heel was reported to his physician on 7/19/17. -There was no documentation it was measured on 7/19/17. -On 8/10/17 it measured 5.0 cm x 3.0 cm. Observation and interview on 9/7/17 at 7:46 a.m. of resident 1 during the dressing change by licensed practical nurse (LPN) M revealed: *Two opened areas on his mid back. -The previously discovered ulcer measured 3.0 cm by .1 cm by 0.0 cm. -The new ulcer measured 1.0 by 1.5 by 0.0 cm. -That was the first time LPN M had seen a second opened area on his back. *The heel ulcer measured 3.0 cm by 4.5 cm by 0.2 cm. *TED hose were applied to both legs. -A physician's orders [REDACTED]. Review of resident 17's 9/6/17 care plan revealed: *A problem area of skin integrity updated on 8/29/17. -I have developed stage 2 ulcer on mid back and left heal (heel). -I wear an immobilizer brace at all times. -I have wool skin surrounding as I have very fragile skin. *A goal to Improve my skin integrity in the next 90 days. *Interventions for skin integrity were High risk for skin breakdown, monitor skin with cares/dressing. *Interventions for pressure reducing devices were: -Air mattress on bed, be sure working. -Horn cushion in W/C (wheelchair) per PT (physical therapy) to help keep hip abducted. *Interventions for cast/splint were: -8/3/17 Continue abductor brace until surgery, can use abductor pillow at night. -Abductor brace at all times (ok to have abductor brace off during shower but use hip precautions). *Interventions for skin care protection were: -Wear protective boots any time in bed. -Float heals. -Put moisture cream on arms q (every) shift - Rub lightly as is tender. *There was no documentation found to support the above interventions were initiated prior to the development of the pressure ulcer. Review of his undated current Elder care plan revealed: *It did not mention he had pressure ulcers. *Float heels and heel protectors were not circled. *Wool skin to abductor brace was not listed. *Ted Hose OFF @ (at) HS (bed time). Review of his undated current communication sheet revealed it did not mention he had pressure ulcers or to use protective boots. Interview on 9/7/17 at 2:05 p.m. with household coordinator H regarding interventions for resident 17 revealed she: *Was responsible for updating his care plan. *Confirmed his Elder Care plan and the communication sheet did not mention he had two pressure ulcers nor had they included all of the specific interventions staff were to do. *Was not able to find documentation to support when the above interventions were initiated. *Stated the use of an air mattress was the only intervention in place prior to the development of either pressure ulcer. *Had initiated a note to staff of things they were to do for resident 17. -The note was attached to a clipboard and presented to the surveyor. -There was no documentation to support when the note was initiated or updated. -It instructed to: -Do not put (TED hose) on left leg if not having swelling, irritates heal (heel) more. -In bed must have booties protectors on and lower legs on pillows to float heals. -Make sure sheep skin is tucked between his back ulcer and brace. Interview on 9/7/17 at 2:55 p.m. with the DON regarding resident 17's care plans and communication sheet revealed she: *Agreed those documents were not complete and did not reflect his current needs. *Would have expected more specific interventions for residents who were at risk for skin issues. *Stated the resident would have been at a high risk for developing skin issues. *Confirmed the use of an air mattress was the only intervention in place prior to the development of his pressure ulcers. 3. Review of resident 2's 6/8/17 quarterly MDS assessment revealed: *She required extensive assistance with bed mobility. *Her Brief Interview for Mental for Mental Status (BIMS) was 7 that score indicated severe cognitive impairment. *She was at risk for pressure ulcers. *Had a stage one pressure area identified. *Skin and ulcer treatment had included: -Pressure reducing devices to her chair and bed. -Pressure ulcer care. *The pressure ulcer treatments had not included a turning/repositioning program. Review of resident 2's medical record revealed: *Falls on 5/17/17, 6/7/17, 7/1/17, 7/2/17, and 7/17/17. *On 5/2/17 RN N had documented a hardened area to her left buttocks and the color was Skin appropriate color for race. *Documentation on 5/10/17 and 5/30/17 indicated the area was unchanged. *There had been no further documenation from 5/10/17 through 5/30/17. *On 6/12/17 a Braden skin assessment indicated a score of sixteen indicating mild risk for breakdown. That had been forty-one days since the initial identification of the hardened area to the residents left buttock. Skin interventions included: -A Panacea mattress to help reduce pressure. -A ROHO air-filled cushion in her wheelchair. *On 6/13/17 she was seen by eLTC (an urgent care telehealth encounter) for a left hip bulge and a discolored lump on her upper left buttock. -At that time the physician had documented the area was a dark reddened area and intact. -Does not resemble ulcerated area, skin intact over area. -Reported by nursing staff that patient (resident) has had several falls recently. *On 6/23/17 RN O documented the area to the buttocks had a fluid-filled blister and was a stage 2 opened area. Dressings were applied. A pressure reducing air bed was initiated. *On 7/24/17 a Braden skin assessment score was sixteen indicating mild risk of skin breakdown. That was 10 days after the resident had been evaluated by eLTC. Skin interventions included: -air mattress is now on the bed; -roho cushion in wheelchair; -heel protectors when lying in bed. *The documented area had continued to worsen, and on 7/25/17 had required surgical debridement.That was one day after the above interventions had been put in place. *The surgeon who performed the debridement on 7/25/17 left orders for the resident to be moved every hour. *On 8/2/17 the surgeon left orders to Keep pressure off area & change position frequently. *On 8/9/17 the surgeon left orders to Make sure pt. (patient) is being repositioned at least every two hours. *There was no documentation in the medical record to indicate the staff had followed the physician orders [REDACTED]. Review of resident 2's 8/10/14 impaired skin integrity care plan revealed: *The resident had a potential for skin breakdown related to: -Impaired mobility. -Incontinence of bladder and some bowel incontinence. -[MEDICAL CONDITION]. *The goal was she would be free from skin breakdown. *A 7/22/17 updated intervention of a dressing change twice daily to her wound. *Other interventions had included: -Preventative skin care. -Lotion skin as needed. -Creams to her private area as needed. -A Panacea mattress on her bed. -A cushion in her chair. *The 8/10/14 Impaired activities of daily living (ADL) functioning for bed mobility care plan indicated: -I do need extensive assist of one. -I do have turn rails on my bed that help me repo (reposition) myself and to sit myself up. -An addition of an 8/5/15 intervention indicated: Has grab bar on both sides of the bed to assist in getting in and out of bed; moving from lying and sitting position and to go from side to side. *The interventions had not included how often or when the staff were to have assisted her with repositioning. Review of the undated Elder care plan used by the direct care staff to provide care to resident 2 regarding repositioning revealed: *A mechanical stand lift was used for transfers. *Leans forward. *Need to lie down (after) noon. Will refuse. Please educate. *Night routine rounds indicated: 2 with no other explanation. *There was no further documentation the resident was to have been repositioned routinely by staff. Observation and interview with CNA I on 9/7/17 at 8:00 a.m. with resident 2 during morning care revealed CNA I stated: *Resident 2 was supposed to have been repositioned at night by the staff, but she was not sure if that was done. *She was supposed to have been repositioned by day staff, but she refused to lay down during the day. *She told staff she would lay down after they went home, but CNA I was not sure if she layed down after they left for the day. *The resident could speak and understand, but she did not always make sense or follow direction from staff. *The staff entered the resident's room at least every two hours to be sure she was not bending forward in her chair. *The staff also toileted her during the day and at night when she needed to use the toilet. Interview on 9/7/17 at 2:00 p.m. with RN unit clinical coordinator D regarding resident 2's pressure area and interventions to prevent pressure revealed: *The resident often refused to reposition or to lay down. *She was offered a recliner on 6/12/17, but she refused to move out of her wheelchair. *She provided documentation regarding education she had provided to the resident on 7/22/17, 7/25/17, and 8/5/17 regarding repositioning and use of heel protectors and pillow positioning. The education provided was started forty-two days after the hip buldge was identified. There was documentation of the resident's refusal to follow nursing direction for repositioning at those times. *The occupational therapist had also documented on 6/28/17, 7/27/17, 7/31/17, and 8/14/17 regarding the resident's refusal of laying down during the day or pillow positioning. The education provided started fifty-seven days after the initial identification of the left hip buldging on 5/2/17. *The direct care staff did not document when they repositioned her. Repositioning documentation was not an expectation of the caregivers. *The direct care staff did not document refusals of repositioning. *She was aware of the physician's orders [REDACTED]. *She confirmed she had not added a repositioning plan to the care plan or the elder care plan. *She was also responsible for conducting MDS assessments. *She had not proceeded with a significant change in status of the Minimum Data Set (MDS). She had not considered the changes had required an MDS assessment at the time. Interview on 9/7/17 at 2:30 p.m. with the director of nursing revealed: *Her expectation was the resident would have had a repositioning plan on her care plan. *She confirmed the resident had areas of significant change that would have required a significant change in status MDS. Phone calls were made with message left on 9/7/17 at 2:15 p.m. to resident 2's primary provider and secondary provider to review her pressure ulcer care. As of 9/11/17 at 8:00 a.m. the physicians had not responded to those messages left. 4. Review of the provider's August 2014 Skin/Wound Care Guidelines policy revealed: *The objective was to: -Assess all elders for risk of pressure ulcers using a standard risk assessment. -Implement appropriate measures on admission or with a change of condition to prevent/reduce heal pressure ulcers. *A skin risk/Braden assessment was completed on admission, and on a regular basis, or with a change in condition, or with the plan of care. *Protocol with possible interventions included: -Reposition minimum every 2 hours. -Intervention for Braden Protocol. -Gel cushion in chair. -Float heels. -Draw sheet for repositioning. -If no PT, OT and RT set up program. -Evaluate need for skin moisture barrier and incontinent products. *Documentation was to have included: -The CNAs would screen the elder's skin daily during care and report any skin related issues. -Wound and skin impairments were to have been checked once per shift and assessed with [REDACTED]. -The nurse could complete a thorough skin/wound intervention into the electronic medical record. -Treatment plans for wounds were to be re-evaluated every one to two weeks to determine the need for a change in the treatment plan. -If an elder and/or family refuses or is resistant to staff interventions to reduce risk, treat ulcer or there (their)wounds, they will receive education of potential consequences and this will be documented in the medical record. Review of Bergstrom, N; Braden, B et al., Nursing Research 1987, Volume 36, PP 206 to 210 revealed regarding The Braden Scale of Predicting Pressure Sore Risk: *For mild to moderate score of thirteen to eighteen protocol included: -Reposition weight-shifting and skin inspection. -Promote activity. -Manage risk factors including incontinence, nutrition, and friction shearing. -Evaluate on a change of condition. *For high to severe score of six to twelve protocol included: -Supplement with small positional shifts. -Seating/posture assessment. -Nutritional assessment. -Educate. -Evaluate on change of condition.

Based on record review, interview, and Resident Assessment Instrument (RAI) review, the provider failed to ensure a significant change in status assessment had been completed for three of three sampled residents (2, 5, and 14) who had a Minimum Data Set (MDS) assessment completed and had reflected either a decline or improvement in their overall health status. Findings include: 1. Review of resident 5's medical record revealed MDS assessments had been completed on the following dates: *4/20/17, an annual assessment. *7/20/17, a quarterly assessment. Review of the above MDS assessments for resident 5 revealed status declines in the following areas: *Section G, Functional Status for 4/20/17: -Bed mobility: required extensive assistance of one person to move to and from a lying position, turn side-to-side, and position her body while in bed. -Transfers: required extensive assistance of one person to move to and from surfaces such as a bed to a chair. -Dressing: required extensive assistance of one person to assist with putting her clothes on or taking them off. -Hygiene/Bathing: required extensive assistance of one person to assist her with personal hygiene and taking a bath. -Toileting: required extensive assistance of one person to assist her with going to the bathroom. *Section G, Functional Status for 7/20/17: -Bed mobility: required two or more staff members to move her to and from a lying position, turn side-to-side, and position her body while in bed. -Transfers: required two or more staff members to move her to and from surfaces, such as a bed to a chair. -Dressing: required two or more staff members to assist her with putting her clothe on or taking them off. -Hygiene/Bathing: required to or more staff members to assist her with personal hygiene and taking a bath. -Toileting: required two or more staff members to assist her with going to the bathroom. *Section H, Bowel and Bladder for 4/20/17: -Bowel incontinence: frequently incontinent. -Urinary incontinence: frequently incontinent. *Section H, Bowel and Bladder for 7/20/17: -Bowel incontinence: always incontinent. -Urinary incontinence: always incontinent. Interview on 9/7/17 at 9:15 a.m. with registered nurse (RN) unit clinical coordinator D regarding significant changes in resident 5's overall health status at the time of the 7/20/17 MDS assessment revealed: *She confirmed: -There were declines in her abilities with bed mobility, transfers, hygiene/bathing, and toileting. -The resident had been able to use a stand-aide mechanical lift to assist the staff members with her transfers prior to that MDS assessment. -The resident was requiring a mechanical lift to move from her bed to her chair by the end of the MDS look back period. -Declines in her bowel and bladder incontinence. -She should have completed a Significant Change in Status Assessment. 2. Review of resident 14's medical record revealed MDS assessments had been completed on the following dates: *2/8/17, an admission assessment. *7/27/17, a quarterly assessment. Review of the above MDS assessments for resident 14 revealed status improvements in the following areas: *Section D, Resident Mood Interview: -2/8/17: total mood severity score was seven out of thirty indicating mild depression. -7/27/17: total mood severity score was two out of thirty indicating minimal depression. *Section G, Functional Status for 2/8/17: -Bed mobility: required extensive assistance of one person to move to and from lying position, turn side-to-side, and position her body while in bed. -Transfers: required extensive assistance of one person to move to and from surfaces such as a bed to a chair. -Ambulation: required extensive assistance of one person with walking. -Hygiene/Bathing: required extensive assistance of one person to assist her with personal hygiene and taking a bath. -Toileting: required extensive assistance of one person to assist her with going to the bathroom. *Section G, Functional Status for 7/27/17: -Bed mobility: required no staff assistance with moving to and from a lying position, turning side-to-side, and positioning her body while in bed. -Transfers: required no staff assistance with moving to and from surfaces, such as a bed to a chair. -Ambulation: required no staff assistance with walking. -Hygiene/Bathing: required limited assistance of one person to assist her with personal hygiene and taking a bath. -Toileting: required no staff assistance with going to the bathroom. *Section H, Bowel and Bladder for 2/8/17: -Urinary incontinence: was continent. *Section H, Bowel and Bladder for 7/27/17: -Urinary incontinence: occasionally incontinent. Interview on 9/7/17 at 8:10 a.m. with RN unit clinical coordinator F regarding significant changes in resident 14's overall health status at the time of the 7/27/17 MDS assessment revealed: *She confirmed: -There had been an improvement with her mood and behaviors. -There were improvements in her abilities with bed mobility, transfers, hygiene/bathing, and toileting. -The resident had relied upon the staff to assist her with the above activity of daily living (ADL) functions prior to that MDS assessment. -The resident was not requiring the staff to assist with the ADL functions by the end of the MDS look back period. -She should have completed a Significant Change in Status Assessment. 3. Interview on 9/7/17 at 10:10 a.m. with the director of nursing (DON) regarding the above significant changes for residents 5 and 14 revealed: *She had confirmed a Significant Change in Status Assessment should have been completed on their most recent MDS assessments. *The MDS assessments would have been completed according to the RAI manual directions. 4. Review of resident 2's medical record revealed she was admitted on [DATE]. Review of the 3/9/17 quarterly MDS revealed: *No behaviors were observed. *A weight of 160 pounds (lb). *She was at risk for pressure ulcers. *There were no current pressure ulcers. Review of the 6/8/17 quarterly MDS revealed: *No behaviors were observed. *A weight of 159 lb. *She was at risk for pressure ulcers. *A stage one pressure area was identified. *Skin and ulcer treatment had included: -Pressure reducing devices to her chair and bed. -Pressure ulcer care. *The pressure ulcer treatments had not included a turning/repositioning program. Review of the medical record revealed: *On 5/2/17 RN N had documented a hardened area to her left buttocks on 5/2/17. The color was documented as Skin appropriate color for race. *Documentation of the area on 5/10/17 and on 5/30/17 was unchanged. *On 6/13/17 she was seen by eLTC (an urgent care telehealth encounter) for a left hip bulge and a discolored lump on her upper left buttock. At that time the physician documented the area was a dark reddened area and intact. Does not resemble ulcerated area, skin intact over area. Reported by nursing staff that patient has had several falls recently. *On 6/23/17 RN O had documented the area to the buttocks had a fluid-filled blister and was a stage 2 opened area. Dressings were applied. A pressure reducing air bed was initiated. *The documented area had continued to worsen, and on 7/25/17 had required surgical debridement. Review of the registered dietitian's documentation for resident 2 revealed:*On 7/25/17 her weight was 156.5 lb indicating a one lb loss in thirty days. *On 8/15/17 her weight was 150.5 lb indicating a significant weight loss of five percent in one month. *The dietitian had planned to: -Keep her on a feeding record and encourage snacks. -Increase her protein. -Continue use of dietary supplements to provide calories to prevent further weight loss and protein for healing. Interview on 9/7/17 at 2:00 p.m. with RN unit clinical coordinator D regarding resident 2 revealed: *She was also in charge of completing MDS assessments. *She was aware of the resident's pressure ulcer and a significant weight change. *The resident was due for a quarterly MDS assessment in the next week. *She confirmed the resident had qualified for a Significant Change in Status assessment. *She had not considered completing a significant change MDS when those concerns had been identified, but it should have been completed. Interview on 9/7/17 at 2:30 p.m. with the director of nursing (DON) regarding the significant changes for resident 2 revealed: *She had confirmed a Significant Change in Status Assessment should have been completed on their most recent MDS assessments. *The MDS assessment should have been completed according to the RAI manual directions. 5. Review of the October, 2016 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14, Pp. 2-22 to 2-24 revealed: *A SCSA (Significant change in Status) is appropriate when: -There is a determination that a significant change (either improvement or decline) in a resident 's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and -The resident's condition is not expected to return to baseline within two weeks. *The MDS completion date was to have been no later than fourteen days after the determination that the criteria for a significant change in status was met. *When a SCSA is completed, the nursing home must review all triggered care areas compared to the resident 's previous status. If the CAA (Care Area Assessment) process indicates no change in a care area, then the prior documentation for the particular care area may be carried forward, and the nursing home should specify where the supporting documentation can be located in the medical record.

Based on observation, record review, and interview, the provider failed to ensure 8 of 28 sampled residents' (1, 2, 3, 5, 7, 15, 17, and 31) care plans were updated to reflect their current care needs. Findings include: 1. Review of resident 3's medical record revealed: *A 10/7/16 admitted . *Diagnoses: [REDACTED]. Review of resident 3's 4/18/17 and 7/6/17 Brief Interview for Mental Status (BIMS) revealed scores of five and six indicating severe memory impairment. Review of resident 3's 10/28/16 through 8/23/17 fall report notes revealed he: *Had nine falls with three major injuries. *Was instructed with each fall to use the call light and not transfer himself. *Had not used the call light for seven of the falls. *Continued to have the intervention documented to remind to use his call light to prevent further falls. Review of resident 3's undated Elder Care Plan inside the clothes closet in his room revealed no documentation he was at risk for falls. Review of resident 3's last reviewed 4/17/17 care plan revealed: *I have a history of a [MEDICAL CONDITION] and I fell and fractured (my) left shoulder from a fall. *I require total assist of two with transfers. *I do extensive assist with one with toileting. I will let you know when I have to go to the bathroom. I am usually continent of bowel and bladder. *I have now had three falls with major injury in the last year. Staff continue to educate me and my wife on the importance of calling for assistance and I don't seem to understand the importance of calling for assistance. *Impaired balance. *I would like to be free from major injury falls. I would like to follow the instructions of staff and call for assistance. *Please make sure that everything is in its proper place and within reach of me. Please make sure there is nothing laying on the floor due to me trying to pick things up off the floor. *Staff will continue to make sure that all of my needs are met so that I have no further falls. *Staff have explained to me that every fall that occurs sets me back further with regaining my independence. *Call light will be within reach at all times. *New interventions put in place are to see if PT and OT can evaluate and educate on the importance of calling for assistance. *Will leave a light on in the bathroom to try to allow resident to see. *There was no documentation regarding the use of a TABs alarm or floor alarm. *None of the above interventions were on the above undated Elder care plan. Refer to F323. 2. Observation and interview on 9/7/17 at 8:15 a.m. with unlicensed assistive personnel Q with resident 31 in her room revealed: *A camera was located on top of a small night stand located next to her dresser. *The lens of that camera was pointed at the resident's bed. *Resident 31 was asked about the camera by this surveyor, and she was unsure of what it was or why it was there. Observation on the above date at 8:16 a.m. at the nurses station: *There was a three and one-half inch screen. *On that screen there was video display from the above camera with audio from resident 31's room. Interview and record review on 9/7/17 at 10:40 a.m. with registered nurse (RN) household coordinator P regarding the camera with video monitor for resident 31 revealed: *Review of her revised 7/28/17 care plan revealed: -Motion alarm PRN (as needed)- TRY TO POINT TOWARD BED AT NIGHT. *The interventions had included: --Motion alarm PRN in my room to let you know if I am up during the night. *It had not addressed family had been notified or were aware of that motion alarm. *Resident's undated Elder care plan had included: -Camera in room. -Monitor@ nurses station. *The video monitor had not been included in her care plan. *She had called her son today and discussed the camera monitor in her room to help prevent falls. *She reported he had been aware of that being used, and he was in agreement with its use. *There was no prior documentation in her medical record before 9/7/17 above phone call with her son that he had been notified or was in agreement of the camera in her room. Review of resident 31's medical record revealed: *She had [DIAGNOSES REDACTED]. *On her 7/6/17 Minimum Data Set (MDS) assessment she had scored a four on her cognitive assessment indicating she was severely cognitively impaired. Interview on 9/7/17 at 11:00 a.m. with the director of nursing regarding the camera in residents 31's room revealed there was no documentation in the care plan regarding resident 31's family awareness or agreement of the video monitor prior to 9/7/17. 3. Review of resident 2's 6/8/17 quarterly MDS revealed: *She required extensive assistance with bed mobility. *She was at risk for pressure ulcers. *A stage one pressure area was identified. *Skin and ulcer treatment had included: -Pressure reducing devices to her chair and bed. -Pressure ulcer care. *The pressure ulcer treatments had not included a turning/repositioning program. Review of her medical record revealed: *Falls on 5/17/17, 6/7/17, 7/1/17, 7/2/17, and 7/17/17. *On 5/2/17 RN N had documented a hardened area to her left buttocks. The color was documented as Skin appropriate color for race. *Documentation on 5/10/17 and on 5/30/17 indicated the area was unchanged. *On 6/12/17 a Braden skin assessment was a score of sixteen indicating mild risk for breakdown. Skin interventions included: -A panacea mattress to help reduce pressure. -A ROHO air-filled cushion in her wheelchair. *On 6/13/17 she was seen by eLTC for a left hip bulge and a discolored lump on her upper left buttock. At that time the physician had documented the area was a dark reddened area and intact. Does not resemble ulcerated area, skin intact over area. Reported by nursing staff that patient has had several falls recently. *On 6/23/17, RN O had documented the area to the buttocks had a fluid-filled blister and was a stage 2 opened area. Dressings were applied. A pressure reducing air bed was initiated. *On 7/24/17 a Braden skin assessment score was sixteen indicating mild risk of skin breakdown. Skin interventions included: -An air mattress was placed on the bed. -A ROHO cushion remained on her chair. -Heel protectors when lying in bed. *The documented area had continued to worsen, and on 7/25/17 had required surgical debridement. *The surgeon who performed the debridement on 7/25/17 had left orders for the resident to be moved every hour. *On 8/2/17 the surgeon had left orders to Keep pressure off area & change position frequently. *On 8/9/17 the surgeon had left orders to Make sure pt.(patient) is being repositioned at least every two hours. Review of the registered dietitian's documentation for resident 2 revealed: *On 7/25/17 her weight was 156.5 lb indicating a one lb loss in thirty days. *On 8/15/17 her weight was 150.5 lb indicating a significant weight loss of five percent in one month. *The dietitian had planned to: -Keep her on a feeding record and encourage snacks. -Increase her protein. -Continue use of dietary supplements to provide calories to prevent further weight loss and protein for healing. Review of the updated 6/18/17 care plan revealed: *The resident had a potential for skin breakdown. -The goal was she would be free from skin breakdown. -A 7/22/17 updated intervention of a dressing change twice daily to her wound. *Interventions for the ulcer had included: -Preventative skin care. -Lotion skin as needed. -Creams to her private area as needed. -A Panacea mattress on her bed. -A cushion in her chair. *The interventions had not included assistance with repositioning. *Review of the updated 8/4/14 dietary care plan revealed:-The resident was on a therapeutic diet. -She would like to get her weight down to 150 lb. *The plan had not included: -Concerns for her weight loss or pressure ulcer. -Interventions of extra protein, calories, or assistance. Review of the undated Elder Care Plan used by the direct care staff to provide care revealed regarding repositioning: *Leans forward. *Need to lie down (after) noon. Will refuse. Please educate. *Night routine rounds indicated: 2. *There was no further documentation the resident was to have been repositioned routinely by staff. Review of the undated Elder Care Plan regarding dietary needs had not included: *Concerns of weight loss, skin ulcer, or a skin ulcer. *Extra dietary interventions for calories, protein, or encouragement to eat. Interview on 9/7/17 at 2:00 p.m. with RN unit clinical coordinator D regarding resident 2's pressure area and interventions to prevent pressure revealed: *She was also in charge of completing MDS assessments. *The resident often refused to reposition or to lay down. *She was offered a recliner on 6/12/17, but she refused to move out of her wheelchair. *She provided documentation regarding education she had provided to the resident on 7/22/17, 7/25/17, and 8/5/17 regarding repositioning, use of heel protectors, and pillow positioning. *The occupational therapist had also documented on 6/28/17, 7/27/17, 7/31/17, and 8/14/17 regarding the resident's refusal of laying down during the day or pillow positioning. *The direct care staff did not document when they had repositioned her. Repositioning documentation was not an expectation of the caregivers. *The direct care staff did not document refusals of repositioning. *She was aware of the physician's orders [REDACTED]. *She confirmed: -She had not added a repositioning plan to the care plan or the elder care plan. -The care plan had not addressed weight loss or pressure ulcers. Interview on 9/7/17 with the director of nursing revealed her expectation was the resident would have had a repositioning plan on her care plan. 4. Random observations of resident 15 on 9/5/17 from 4:00 p.m. until 6:00 p.m. and on 9/6/17 from 7:20 a.m. until 6:30 p.m. revealed he: *Was alert to person and situation, was confused about time, and had poor recall. *Came out to the dining room for meals and fed himself independently with some cueing. *Spent the majority of daytime hours in bed other than at mealtime. -He listened to the radio or talking books. *Required the assistance of two people to get him out of bed using an EZ stand mechanical lift. *Had a dime sized unstageable pressure ulcer on his left heel. *Wore padded boots on both feet to prevent pressure to his feet when he was in bed. *Had a scratch like scab in the middle of the sole of his foot. Review of resident 15's 6/29/17 Minimum Data Set (MDS) assessment revealed he: *Scored a six on his cognitive assessment indicating he was cognitively impaired and had memory issues. *Had no pressure ulcers at that time. *Had sleep issues, felt down, and he would have been better off dead. Review of resident 15's 8/24/17 skin ulcer/complex assessment revealed: *Wound assessment label: Left heel. *Skin irregularity appearance: Dry, red, crusted. *Surrounding Tissue appearance: Length 1.0 centimeter (cm), Width 0.8 cm. *Stage: Suspected Deep Tissue Inj (injury); 0 % slough (yellow). *Dry, dark red, not soft, mushy or boggy feeling. Review of resident 15's Message Information Sheet (physician communication) revealed: *7/6/17: Has been refusing cares @ times, refuses to get up for meals @ times. Talking about wanting to die. Noted to have reddened area on (L) heel, a closed dry, intact reddened yellowish area on bottom of (l) foot. No open areas on feet. -Physician Instruction: Ok with (with symbol) above. Cont (continue) to monitor. *7/20/17: (arrow up) Increased confusion. (arrow up) anxiety. Doesn't want to get out of bed. Overall (as spelled) failing. Any recommendations? -Physician Instruction: Ordered [MEDICATION NAME] 20 mg (milligram) daily for five days, then 10 mg daily for five days, and duloxetine 20 mg twice a day. *9/4/17: Resident is resisting morning cares and not wanting to come to meals. Attempted approaching situation differently and addressing pain, repositioning, trying other staff, coming back later, etc. Resident continues to resist care and meals. Could it possibly be pain related? Considerations? -On 9/5/17 the physician increased the [MEDICATION NAME] to 30 mg twice a day. Interview on 9/6/17 at 11:00 a.m. with clinical unit coordinator (H) regarding resident 15 revealed: *He had a sudden change recently and was refusing to get out of bed. *He had several residents he visited with die in a short period of time, one of which he was pretty close to. -He voiced he was ready to die and was just giving up. *Because he was spending so much time in bed, and that was when he started having problems with his feet. -He developed sores on his toes, and then the heel of his foot. -He had the area on the bottom of his foot they determined was a deep tissue injury. -It met the criteria closest to that using the pressure ulcer guide they follow for staging a pressure ulcer. --She could not say for sure what had caused that area, but concurred it might have been caused when the foot rested on the foot board because he was a tall man. *The physician had ordered the [MEDICATION NAME] for pain that he had in his legs. Interview on 9/6/17 at 2:45 p.m. with social worker L regarding resident 15 revealed: *They had noted a change with him after he lost his friend at the facility. *She would just stop by and see him but could not recall if they had ever had a psychiatric consult for him when he became depressed. *The staff would just come by and tell her when he was refusing care or made comments regarding being down. *He did not have a lot of family involvement, and his family would not answer the phone when they were called. Review of resident 15's 9/5/17 Care plan or Elder Care Plan revealed: *8/5/16 Problem: I have been more depressed and needing more assist. -The interventions were to check vital signs and weight weekly, and to give a weekly bath. --It did not address how they had helped him following the loss of his friends. *8/5/16: Problem: My overall status has decreased. I am at more risk due to cognition, depression, poor eating, and impaired mobility. -There were no specific interventions to: --Improve his mood. --Address his refusals with care or eating. *8/3/16 Problem: I can make my needs known and can communicate my needs but I do like for my daughter to be involved with bigger decisions. -It did not address that his daughter was not real involved and not always responsive to their attempts to contact her. *The care plan did not address his pain. 5. Review of resident 17's medical record revealed: *He was admitted on [DATE]. *He had returned from an overnight hospital stay with an abductor brace in place on 6/30/17. *He had developed two pressure ulcers since his admission. -A stage II pressure ulcer on his back was discovered on 7/16/17. -A bed sore/fluid-filled blister at left heel was reported to his physician on 7/19/17. Review of his 9/6/17 care plan revealed: *A problem area of skin integrity updated on 8/29/17. -I have developed stage 2 ulcer on mid back and left heal (heel). -I wear an immobilize brace at all times. -I have wool skin surrounding as I have very fragile skin. *A goal to Improve my skin integrity in the next 90 days. *Interventions for skin integrity were High risk for skin breakdown, monitor skin with cares/dressing. *Interventions for pressure reducing devices were: -Air mattress on bed, be sure working. -Horn cushion in W/C (wheelchair) per PT (physical therapy) to help keep hip abducted. *Interventions for cast/splint were: -8/3/17 Continue abductor brace until surgery, can use abductor pillow at night. -Abductor brace at all times (ok to have abductor brace off during shower but use hip precautions). *Interventions for skin care protection were: -Wear protective boots any time in bed. -Float heals. -Put moisture cream on arms q (every)shift - Rub lightly as is tender. Review of his undated current Elder care plan revealed: *It did not mention he had pressure ulcers. *Float heels and heel protectors were not circled. *Wool skin to abductor brace was not listed. Review of his undated, current communication sheet revealed it did not mention that he had pressure ulcers or to use protective boots. Interview on 9/7/17 at 2:05 p.m. with household coordinator H regarding interventions for resident 17 revealed she: *Was responsible for updating his care plan. *Was not able to find documentation to support when the above interventions had been initiated. *Stated the use of an air mattress was the only intervention in place prior to the development of either pressure ulcers. *Confirmed his Elder care plan and the communication sheet did not mention he had two pressure ulcers nor had they included all of the specific interventions staff were to do. Interview on 9/7/17 at 2:55 p.m. with the DON regarding resident 17's care plans and communication sheet revealed she: *Agreed those documents were not complete and did not reflect his current needs. *Would have expected more specific interventions for residents who were at risk for skin issues. *Stated the resident would have been at a high risk for developing skin issues. *Confirmed the use of an air mattress was the only intervention in place prior to the development of his pressure ulcers. 6. Random observations of resident 7 on 9/5/17 from 4:00 p.m. until 6:00 p.m. and on 9/6/17 from 7:15 am until 6:15 p.m. revealed she: *Would go back to her room and sleep between meals. *Sat in the dining room at a table that faced the window. *Had little to no interaction with other residents at her table. *Was very pleasant and cooperative during the resident interview with her daughter present. *Was not observed out in the dining area for any structured activities. Review of resident 7's current physician's orders [REDACTED]. *Received [MEDICATION NAME] 25 milligram (mg) scheduled in the a.m. *Received [MEDICATION NAME] 50 mg scheduled at bedtime (HS). *Current Diagnoses: [REDACTED]. Interview on 9/7/17 at 10:15 a.m. with unit clinical coordinator H regarding resident 7 revealed: *The documentation from care staff was probably not the best regarding call light use as a way to capture resident increased anxiety. *Her anxiety was demonstrated through the use of her call light and frequent worrying about her need to go to the bathroom. *When she had been admitted from home it was reported her anxiety led to over use of her antianxiety medication ([MEDICATION NAME]). *She was obsessed about the need to urinate and worried about being constipated. Review of resident 7's 9/6/17 care plan revealed: *Listed Problems: -Current Lifestyle: --Intervention - Mood and Behavior -LTC (long term care). ---Chart Q (every) shift due to restlessness at night. ---Monitor PRN (as needed) for increased anxiety. ---Need to chart due to on [MEDICAL CONDITION]. *Fall risk indicated for staff to encourage the resident to use the call light for bathroom assistance as an intervention to prevent falls. *The care plan did not address: -What caused her to become anxious. -Non-medicinal approach to managing her anxiety. -Medications she received to manage her concern about constipation. -Plans for a gradual dose reduction. Interview on 9/7/17 at 11:00 a.m. with unit clinical coordinator H confirmed resident 7's care plan did not comprehensively address her anxiety. 7. Review of residents 5's medical record revealed she had acquired two stage two pressure ulcers to her left and right heels while receiving care in the facility. There had not been preventative interventions according to the wound care policy included on his care plan for those pressure ulcers. Interview on 9/7/17 at 9:20 a.m. with RN and clinical unit coordinator D regarding resident 5's care plan revealed: *She had: -Agreed the care plan should have been updated to reflect the resident's current condition. -Confirmed care plans were a guide for staff on how to care for the residents. *The interdisciplinary team updated the care plans as needed. Interview on 9/7/17 at 10:15 a.m. with the DON regarding resident 5's care plan revealed: *She had confirmed the above interview with RN and clinical unit coordinator D. *There was no specific policy and procedure in place for the staff to follow for care plan development. -They would have followed the federal rules and guidelines to guide them with developing the resident's care plans. Refer to F314, finding 1. 8. Review of resident 1's medical record revealed: *A 8/31/15 admitted . *Diagnoses: [REDACTED]. Review of resident 1's 4/6/17 and 6/29/17 Brief Interview for Mental Status (BIMS) revealed scores of ninety-nine and five indicating severe memory impairment. Review of resident 1's 11/11/16 through 8/15/17 fall report notes revealed: *He had fifteen falls with five minor injuries. *He was instructed to use the call light eight of the fifteen falls. *Documented on nine of the fifteen falls he had been too cognitively impaired to utilize the call light. Review of resident 1's medical records revealed he had been on [MEDICATION NAME] HCls. Review of resident 1's undated Elder care plan inside the clothes closet in his room revealed: *No documentation he had been at risk for falls. *No documentation he had been on [MEDICATION NAME] HCls. Review of resident 1's last reviewed 8/5/17 care plan revealed: *I have a history of falls. *Impaired balance. *Impaired mobility. *I take hypertension and diuretic medication. *I require extensive assist of 2 and EZ stand for transfers. *I do like to attend several of the activities but can't be left unattended as I wander away from the event. *I have snacks in my room-candy that I munch on independently. *Impaired cognition. *I forget that I cannot transfer myself. *I will have no falls in the next 12 weeks. *None of the above interventions were on the above undated Elder care plan. *No documentation he had been on [MEDICATION NAME] HCls.

Based on observation, record review, interview, and policy review, the provider failed to thoroughly investigate and put individualized interventions in place for two of three sampled residents (1 and 3) who had multiple falls. Findings include: 1. Review of resident 3's medical record revealed: *A 10/7/16 admitted . *Diagnoses: [REDACTED]. Review of resident 3's 4/18/17 and 7/6/17 Brief Interview for Mental Status (BIMS) revealed scores of five and six indicating severe memory impairment. Observation on 9/6/17 at 10:00 a.m. of resident 3 revealed: *His wife was visiting him in his room. *He informed his wife he needed to use the toilet. *Certified nursing assistant (CNA) C assisted him onto the toilet. *He did not have a TABs alarm in his wheelchair. *He had not turned on the call light. Interview at that time with CNA C regarding resident 3 revealed he: *Sometimes would use the call light when he needed to transfer. *Was assisted to the toilet at least every two hours, or more often as he requested. Review of resident 3's 10/28/16 through 8/23/17 fall report notes revealed the following nine falls that included three separate fractures: *10/28/16 at 7:30 p.m.: -Resident had fallen from his chair in the dining room. -He said he was trying to move a chair out of his way to go back to his room and slipped out of his wheelchair. -Resident had hit his head on the wall, a small blood blister on the top of his head had been hit and there was a small amount of bleeding. -Resident had been instructed to use the call light as a fall precaution. -What could have been done to prevent this from happening:' Resident was educated to wait for assistance when leaving the dining room. Staff could come to assist him in a more timely manner back to his room.' *10/29/16 at 5:30 a.m.: -Resident was found on the floor in his room between his bed and chair. -He was confused and could not tell us what he was trying to do. It looked like he was trying to self-transfer from the bed to chair. -He had hit his hand and there is a small skin tear on the top of his left hand and dressing was applied. -He was Hoyer lifted back into bed and a TABs alarm was placed. -Call light was within reach of the resident. The resident had been instructed to use the call light as a fall precaution. The resident did not attempt to use the call light prior to the fall. -Resident is confused and forgetful and does not always remember to use his call light. -Resident needs to be reminded to use his call light. TABs and floor alarm on to notify staff if he is trying to get up. *11/4/16 at 6:00 p.m.: -Resident found on floor in front of toilet hanging on to the railing. -Certified nursing assistant (CNA) had been in the bathroom to check on him but he said he was not done. CNA left and returned in about two to three minutes. -Call light was within reach of the resident. The resident had been instructed to use the call light as a fall precaution. The call light was not on at the time of the fall. The resident stated he thought he could do it himself. -Cause of fall was call light was not used. -Remind resident to use call light for assistance. -There was no documentation regarding the use of the TABs alarm or floor alarm. *12/22/16 at 11:00 a.m.: -Found on floor. Stated that he was attempting to take himself to the bathroom and he forgot to lock his brakes. When he stood up the wheelchair went out from behind him. -Call light was within reach of the resident and was on at the time of the fall. Resident did attempt to use the call light prior to the fall. -Cause of fall was resident did not follow instructions. -Continue to monitor. Educate to lock brakes. *1/12/17 at 9:00 a.m.: -Staff heard someone call for help. Staff walked in and resident was laying on the floor outside his bathroom on his left side. He said he had one brake on and on brake off on his wheelchair. He had just used the bathroom and was coming out of his bathroom and he said he slipped out of the chair. -He denies hitting his head. Skin tears noted to 3rd and 4th digits on right hand. Started to complain of increasing pain to left hip after breakfast which he insisted going to. He does have limited mobility to the left extremity. -Call light was not on at the time of fall and was not within reach. He had been instructed to use the call light as a fall precaution. Resident was independent with toileting and he was not able to reach his call light because he was in his wheelchair on his way out of the bathroom. -Gave a Tramadol and offered to send him over to get his hip x-rayed. He said that was probably a good idea. -Educated resident to call for help. Educate on wheelchair brakes, otherwise resident is independent with his cares. -Fractured left hip. *3/11/17 at 8:45 p.m.: -Resident was sitting in his recliner and threw away a Kleenex but the Kleenex missed the garbage can. Resident then got into his wheelchair in order to pick it up. When he leaned over to pick it up he ended up falling out of his chair. -Call light was within reach of the resident. Call light was not on at the time of the fall. -Resident is non-compliant. -Resident has been educated about the risks of falls when he transfers himself. -Remind resident to call for help instead of bending over himself. *3/13/17 at 6:45 a.m.: -Resident was found laying on his left side with legs bent at knees near bathroom entrance. Wheelchair was over top of resident with front wheels up by his shoulders. -Small amount of blood noted on floor under his head. Old wound noted to have dried blood around it, and blood on floor was dried and circular shaped in the shape of wound on head. Resident stated did not hit his head but must have rubbed it on the floor when he was trying to scoot himself out from under the wheelchair. -Only pain is in his left shoulder. -Resident was lifted to his wheelchair where it was then noted he had blood on the back of his shirt. Skin assessment found a large abrasion on upper left scapula. Resident states pain is in the area of the abrasion. Resident is unable to move/raise left arm on his own.- -Call light was within reach of the resident. Call light was not on at the time of the fall. Resident has been instructed on use of call light as a fall precaution. -Resident instructed to use call light when needing to use restroom. Stated he used it, but then stated he could not find it. Call light was on arm of recliner where resident was sitting prior to fall. -State report was completed due to a fracture to the left humerus. Resident and his wife have been educated on the importance of calling for assistance. Therapy is working with resident and they are reminding resident to call for assistance. Staff are rounding on resident every hour at least when he is in his room to decrease the chances of him falling. -High fall risk, monitor often, toilet on night rounds and in morning. Keep educating to use the call light for ambulating. *6/23/17 at 7:30 a.m.: -A tapping noise was heard from resident's room. Resident found laying on his left side on the floor in front of his dresser. Left arm was tucked under resident and right arm was free and holding onto the dresser drawer handle that he was moving back and forth to get the attention of the staff. Wheelchair was out in the hallway. Bed was unmade. Staff states resident had not gotten up from bed at that time yet for them. Resident was asked what he was trying to do at time of fall and he stated that he got up out of his recliner to go pick up a med (medication) cup that was laying on the floor by his dresser. A med cup was noted to be on top of his tall dresser. -Denied hitting his head and said he fell backwards landing on his back. He has pain in his lower back just above the coccyx area. -Call light was not within reach of the resident and was not on at the time of the fall. Resident had been instructed on use of the call light as a fall precaution. -Recorder asked resident why he did not use his call call to have someone pick up the med cup for him. He stated he was just walking over there to get the med cup and ended up laying on his back. -Resident did not use call light to ask staff to help him. He got up and ambulated on his own without assistive devices or staff assistance. -Resident has been educated many time throughout the days to make sure to call for assistance. His wife posted a sign on his dressing that reminds him to call for assistance. -Check on resident at change of shift to make sure he is not up wandering by himself in his room. Has been noted to be more confused in the morning and in the evenings. -Broken pelvis. *8/23/17 at 8:15 p.m.: -Resident found laying next to his recliner. Attempted to self-transfer. -Noted to have 1.1 centimeter (cm) by 0.3 cm skin tear to right elbow and 0.3 cm by 0.3 cm skin tear to the left side of his neck. -Call light was within reach of resident at time of fall and was on at the time of the fall. The resident has been instructed on use of the call light as a fall precaution. -Resident was in recliner. Was toileted at 8:00 p.m. and placed in recliner per resident request. Resident did use call light but did not wait for staff and self-transferred. -Encourage resident to wait for staff assistance. Encourage resident to lay down in the evening to help with falls. Interview on 9/7/17 at 8:00 a.m. with registered nurse clinical coordinator A regarding resident 3 revealed he: *Had a Foley catheter in his bladder from 6/25/17 to 8/17/17 due to his inability to void. He was not trying to transfer himself to the toilet during that time. *Saw the urologist on 5/31/17 with no changes and a return appointment in four months. He was to continue on the medications Proscar and Flomax for his bladder. *Would wheel his wheelchair into the hallway to tell them he needed to use the toilet after his Foley catheter was discontinued. *Would not usually use his call light to alert them he needed assistance to transfer. *Would still respond at times to turning on his call light, and they staff continued to educate him to do that. *Was more alert at times and appeared to comprehend the need when they educated him to use his call light. *Was both continent and incontinent of urine. *Had been more continent of urine the past week. *Was assisted to the toilet at least every two hours or more frequent as he requested. The staff did not document each time they had assisted him into the toilet but documented at the end of the shift. *Did not need to have staff stay in the bathroom with him. *Liked to sit on the toilet for awhile, so the staff frequently went back and checked on him. *Was checked on more often by the staff, but the staff did not document each time they checked on him. *Had the door to his room left opened, so staff could see him. *Was allowed to sleep in later in the mornings per his request. *Had been working with physical therapy (PT) and occupational therapy (OT) due to his high risk for falls and his fractures. They had been reminding him also to always use the call light and wait for staff assistance with transfers. *Had never had a TABs monitor or floor alarm since he had been on this unit. The unit he was on now was alarm free. *Had his first three falls on another unit, and she did not know much about those falls. *Had refused restorative care, but there was no documentation of that. He had participated in the group exercises a couple times in May 2017. *Had tried being out in the day room in the evening to look at magazines to keep him out of his room and decrease the potential for self-transfers. *Had not had his urine retention checked since his Foley catheter had been discontinued on 8/17/17. She did not really think that was why he was trying to self-transfer himself to the toilet. *Had used his call light a couple times prior to the above falls. They had not determined why the staff had not answered the call light in a timely manner prior to him self-transferring. Review of resident 3's undated Elder Care Plan inside the clothes closet in his room revealed: *TABs monitor no. *Motion alarm in wheelchair. *Confused at times. *Catheter discontinued. *Transfers one assist and E-Z stand. *Would like to go to bed or recliner by 7:00 p.m. *Night routine walk to toilet or urinal was not checked yes or no. There was no documentation how often rounds were done at night. *There was no documentation regarding his toileting needs or he was a high fall risk. Review of resident 3's last reviewed 4/17/17 care plan revealed: *I have a history of a hip fracture and I fell and fractured my left shoulder from a fall. *I require total assist of two with transfers. *I do extensive assist with one with toileting. I will let you know when I have to go to the bathroom. I am usually continent of bowel and bladder. *I have now had three falls with major injury in the last year. Staff continue to educate me and my wife on the importance of calling for assistance and I don't seem to understand the importance of calling for assistance. *Impaired balance. *I would like to be free from major injury falls. I would like to follow the instructions of staff and call for assistance. *Please make sure that everything is in its proper place and within reach of me. Please make sure there is nothing laying on the floor due to me trying to pick things up off the floor. *Staff will continue to make sure that all of my needs are met so that I have no further falls. *Staff have explained to me that every fall that occurs sets me back further with regaining my independence. *Call light will be within reach at all times. *New interventions put in place are to see if PT and OT can evaluate and educate on the importance of calling for assistance. *Will leave a light on in the bathroom to try to allow resident to see. *There was no documentation regarding the use of a TABs alarm or floor alarm. Review of the provider's 5/15/17 Fall Evaluation and Injury Prevention policy revealed: *To provide a standardized process for evaluating a residents risk for falls and assessing circumstances after a fall or near fall in order to minimize risk of future falls. *Avera realizes the potential for serious risk of injury related to resident falls. Facilities will evaluate each resident upon admission, readmission, significant change, and after a fall to identify interventions to prevent falls that are specific to the individual resident's cognitive and physical abilities. *Any identified interventions that could prevent future falls will be documented in the Fall Follow-Up-LTC, added to care plan and communicated to care staff. *At the minimum with each fall sign off the review button in the footer of the Plan of Care indicating that the plan has been reviewed. 2. Review of resident 1's medical record revealed: *A 8/31/15 admitted . *Diagnoses: [REDACTED]. Review of resident 1's 4/6/17 and 6/29/17 Brief Interview for Mental Status (BIMS) revealed scores of ninety-nine (he chose not to participate or he had 4 or more items that were coded 0 because he did not answer or the answer was nonsensical) and five indicating severe memory impairment. Observation on 9/6/17 at 8:20 a.m. of resident 1 revealed: *He had been wheeled back to his room in his wheelchair. *Certified nursing assistant (CNA) T assisted him onto the toilet. -Had used an E-Z Stand for the transfer. *He did not have a TABs alarm in his wheelchair. Interview at that time with CNA T regarding resident 1 revealed he: *Was assisted to the toilet at least every 2 hours, or more often as he requested. *Was checked on at least every 2 hours as he had been at high fall risk -He is so confused and forgets to use his call light and this is why we check on him so often. *Did not have a TABs alarm on his wheelchair. -A TABs alarm might help prevent some of his many falls. Observation on 9/6/17 at 2:00 p.m. of resident 1 revealed: *He had been resting in his lift chair in his room. The call light was within reach. *A candy jar with wrapped candy had been on the table beside the lift chair. Observation on 9/6/17 at 2:47 p.m. of resident 1 revealed: *He had been up in his wheelchair in the dining room. -People watching, visiting with staff. -Listening to music. Observation on 9/6/17 at 4:00 p.m. of resident 1 revealed: *He had been resting in his lift chair in his room. The call light was within reach. *Had an empty candy wrapper in his lap. Review of resident 1's 11/11/16 through 8/15/17 fall report notes revealed: *11/11/16 at 4:15 p.m.: -Found sitting on floor in front of recliner. -Was assisted into recliner approximately one hour prior with legs elevated. -ROM (range of motion) intact, denies pain, no apparent injury. -Resident cognitively unable to provide event details. -Call light was within reach of the resident. The resident had been instructed to use the call light as a fall precaution. The resident did not attempt to use the call light prior to the fall. -Cognitively unable to follow instructions to use call light for assistance. -Confused Disoriented. -Cause of fall was does not remember that he requires assistance with ADLS and transfers. -No change in physical or cognitive status noted upon initial assessment. -Safety devices implemented after the fall: Assist Rail and Low Bed. -What could have been done to prevent this from happening: 'continue to monitor resident frequently due to increased falls.' *11/19/16 at 11:15 a.m.: -Staff found (resident) laying on the floor in his room, in front of his (wheelchair), laying on his right side. -He said he was trying to pick up some M&M's off the floor that he dropped. -Unsure if he hit his head, unwitnessed fall. -No injury, no diagnostics. -Call light was within reach of the resident. The resident had been instructed to use the call light as a fall precaution. The resident did not attempt to us the call light prior to the fall. -Staff helped (resident) off the floor with a Hoyer lift. Put him back in his (wheelchair) and brought him out for lunch. -Continue to monitor, no injury noted at time of fall. -What could be done to prevent this from happening: 'monitor (resident), unsure if he should be eating M&M's with the mechanical soft diet.' *11/20/16 at 7:30 p.m.: -Resident found to be lying on floor in front of his wheelchair, on his right side. legs straight out in front of him but bent at knees. Arms were crossed across his chest. -Abrasion, two small cuts on right forehead. Small abrasion on left forearm. -Resident able to move all extremities. Responds to questions. (complained of) headache. -Confused Disoriented. -Call light was not within reach of the resident. The resident had been instructed to use the call light as a fall precaution. The resident did not attempt to use the call light prior to the fall, -Cause of fall was resident has been attempting to stand up when in wheelchair frequently and is unable to support self. -Resident is transferred with E-Z stand. -Abrasion cleansed with wound cleanser and TAO applies. Resident (complained of) headache, Tylenol was given. Will monitor per fall protocol. -Safety devices implemented after the fall: Positional Cushions. -What could be done to prevent this from happening: 'continue to reinforce with resident that he cannot stand on his own. Monitor resident closely.' *12/10/16 at 6:00 a.m.: -(Resident) was found at 0600 laying next to bed, slightly sitting up a little, bed was in low position. -Abrasion to right toe and left knee. -Last seen rounded on at 0530. -Asked (resident) what he was doing, he was unable to answer. -(Resident) is cognitively unable to remember to use call light appropriately. -Call light was within reach of the resident. The resident had been instructed to use the call light as a fall precaution. The resident did not attempt to use the call light prior to the fall, -(Resident) didn't use call light for help and is cognitively unable. Attempted to get up on own and is not strong enough or able to. -What could be done to prevent this from happening: 'monitor, get up if restless.' *1/01/17 at 2:50 p.m.: -Heard (resident) yelling 'HELP' and found him laying on his right side next to his bed, which was in low position. -He states he was trying to get up and go out. -Abrasion to his forehead. -Call light was within reach of the resident. The resident had been instructed to use the call light as a fall precaution. The resident did not attempt to use the call light prior to the fall, -(Resident) cognitively unable to follow instructions or remember. -What could be done to prevent this from happening: 'monitor (resident), encourage call light use.' *1/22/17 at 7:15 p.m.: -Resident slid out of (wheelchair) in hallway. Alert to person. Resident did not hit head. -Head was leaning against cushion of (wheelchair) and was in sitting position on buttocks on floor with hands at side. No (complaint of) pain. -What could be done to prevent this from happening: 'recommend utilization of anti skid material in (wheelchair).' *1/29/17 at 4:00 p.m.: -Resident found on floor in his room. Wheelchair behind resident just inside his room. -Seemed to have rolled onto his left side/shoulder in front of the his restroom. -Resident has been wandering around more than usual in his wheelchair, going through drawers in kitchen, trying to lean over in his wheelchair. -Resident left dining room and wheeled himself to his room, and a couple minutes later staff heard him yelling help. -What could be done to prevent this from happening: 'provide activities for resident, check to see if he needed to use the restroom.' *2/2/17 at 7:15 p.m.: -Found sitting on floor next to (wheelchair) with head leaning against his mat. -(Patient) lacks cognition to utilize call light. -Confused per usual. Had just finished supper meal in dining area. -What could be done to prevent this from happening: 'continue to utilize fall mat. Possible utilization of anti skid material in (wheelchair).' *2/13/17 8:00 p.m.: -Resident was found lying on (right) side on the floor in his room no injuries noted. -Call light was within reach of the resident. The resident had been instructed to use the call light as a fall precaution. The resident did not attempt to use the call light prior to the fall, -Resident is confused on does not remember to use call light and forgets that he cannot stand up by himself. -What could be done to prevent this from happening: 'have CNAS perform HS cares right after supper.' *3/2/17 at 6:45 p.m.: -(Patient) found lying next to (wheelchair) attempting to grab at paper on floor. -Call light was within reach of the resident. The resident had been instructed to use the call light as a fall precaution. The resident did not attempt to use the call light prior to the fall, . -The resident did not attempt to use the call light prior to the fall (patient) lacks cognition. -What could be done to prevent this from happening: 'continue to cue resident to utilize call light and remind not to attempt to pickup items on floor.' *4/2/17 at 5:15 p.m.: -Resident found sitting on floor in his room. His back was against his recliner, legs out in front, holding onto recliner control. -Wheelchair was next to resident on his left side. -Resident stated he was trying to get into his recliner and his legs not's work. Resident is confined to a wheelchair. -What could be done to prevent this from happening: 'frequent checks, activities.' *5/4/17 at 5:00 p.m.: -Resident was found on the floor of his room laying on his right side facing towards the bathroom door. His head was off the floor, right arm was up under his head/neck, left was bent at side. Wheel chair was up by his head, recliner was at his feet. -Resident stated he was trying to get into his recliner. Resident denies hitting his head. -Wandering halls/room in his wheelchair after bingo. -What could be done to prevent this from happening: 'put resident in his recliner after he is done playing bingo in the afternoon.' *5/17/17 at 11:00 a.m.: -Resident was taken to the cinema to watch a movie with other residents in his wheelchair. -Resident was laying on his right side, with a staff member holding his head off the floor for comfort. -A small amount of blood was noted on his left ear. -Resident should be a (one-to-one) when off neighborhood. He was left in the cinema while the staff member went to bring other residents to the theater. -Wound on left ear and left knee cleaned with wound cleanser. -What could be done to prevent this from happening: 'educate staff to not leave resident unattended when off neighborhood.' *7/11/17 at 4:35 p.m.: -Resident was sitting in wheelchair in room. CNA saw him trying to get into his recliner and he fell on to his buttocks before she could help him. The CNA helped lower him to his right side.-Resident said he felt he could do it himself. -Call light was within reach of the resident. The resident had been instructed to use the call light as a fall precaution. The resident did not attempt to use the call light prior to the fall. -What could be done to prevent this from happening: 'make sure resident is were he wants to be.' *8/15/17 at 5:30 p.m.: - Resident found by staff laying on the floor of his room by his doorway. -Nonslip socks were on his feet. -A candy wrapper was on the floor in front of the wheelchair. -Abrasion was noted on his right upper forehead. -Resident did not attempt call light use prior to fall. Cognitively not able. -Stated he was trying to pick up a candy wrapper off the floor. -Abrasion to upper right forehead, cleaned with wound cleanser. -What could be done to prevent this from happening: 'put residents candy in a drawer, give him pieces throughout the day and dispose of the wrappers.' Interview on 9/7/17 at 2:00 p.m. with registered nurse unit clinical coordinator A regarding resident 1 revealed he: *Had not been assessed by physical therapy (PT) for mobility according to their policy for November 2016, January 2017, and February 2017. *No order for restorative therapy. *Restorative therapy on August 2, 3, 7, and 23, 2017, only per nurses notes. *Restorative therapy consisted of group therapy with a balloon for reaches and stretches of the upper and lower limbs. *They had done away with TAB alarms approximately one and a half years ago. *The resident was confused and did not use his call light. *Was checked on more often by the staff, but the staff did not document each time they checked on him. *Had the door to his room left opened, so staff could see him. *Was assisted to the toilet at least every two hours. The staff did not document each time they had assisted him into the toilet but documented at the end of the shift. *Had tried being out in the day room in the evening to look at magazines, puzzles, sort buttons, and adult coloring to keep him out of his room and decrease the potential for self-transfers. *Had never had a TABs monitor or floor alarm since he had been on this unit. The unit he was on now was alarm free. *He had multiple falls trying to pick up candy wrappers on the floor. *Should store candy without wrappers. *Daughter recently made resident an apron to catch candy wrappers. Review of resident 1's undated Elder care plan inside the clothes closet in his room revealed: *TABs monitor yes. *Motion alarm in wheelchair. *Transfers one assist and mechanical stand. *Relaxing in room preference recliner. *There was no documentation of his confused state. *There was no documentation he was a high fall risk. Review of resident 1's last reviewed 8/5/17 care plan revealed: *I have a history of falls. *Impaired balance. *Impaired mobility. *I take hypertension and diuretic medication. *I require extensive assist of 2 and EZ stand for transfers. *I do like to attend several of the activities but can't be left unattended as I wander away from the event. *I have snacks in my room-candy that I munch on independently. *Impaired cognition. *I forget that I cannot transfer myself. *I will have no falls in the next 12 weeks.

Based on interview, record review, and policy review, the provider failed to ensure one of one sampled resident (7) who received an as needed (PRN) antipsychotic medication had a clarifying physician order [REDACTED]. Findings include: 1. Review of resident 7's medical record revealed she: *Was admitted to hospice on 11/21/2016. *Her [DIAGNOSES REDACTED]. Review of resident 7's Hospice Plan of Care from 2/19/17 through 5/17/17 revealed she was to receive: *[MEDICATION NAME] 25 milligram (mg) tablet, 1/2 tablet (12.5 mg) every a.m. and afternoon as needed (PRN) and 1 tablet (25 mg) at bedtime and may repeat 1 tablet in one hr if initial dose is not effective; Purpose agitated anxiety. *[MEDICATION NAME] 0.5 mg tablet, one to two tablets every two hours as needed for anxiety, Purpose: Anxiety. Review of resident 7's medication administration from 2/19/17 through 3/22/17 indicated she had received the medication nine times. No validation or follow-up from the nurse as to why the medication had been given. Review of the following documentation of resident 7's Mood and Behavior - LTC notes and summaries revealed: *On 12/1/16 at 2:12 p.m.: Resident does consistently ring call light. She did get moved closer to nurses station for closer monitoring. Hoping this will help ease her mind as well. *On 2/14/17 at 11:09 a.m.: Discussed with hospice ongoing anxiety that really seems to consume her. We are seeing no help with the [MEDICATION NAME] and [MEDICATION NAME] that she is on Does ring call light repeatedly . *From 1/2/17 through 3/19/17 revealed random event recording of call light use fifty-six times. Review of a Message Information Sheet faxed to the physician revealed: *On 3/27/17 at 1500 (3:00 p.m.) requested a change to [MEDICATION NAME] dose. There was no indication on the note why the request was being made. The physician had agreed with a change in the medication. *On 4/28/17 at 10:30 a.m. the note stated: (Resident name) was placed on [MEDICATION NAME] when on hospice. Is working great for her. Need dx (diagnosis): do you feel 'major [MEDICAL CONDITION]?' yes__ or no__. -The physician replied back on 4/28/17 and indicated yes by placing an X at the yes. Review of the following Consultant Pharmacist's Medication Regimen Review revealed: *The physician had signed on 5/01/17 and stated: That medication was just recently started. *At present (resident name) has been doing the best we have seen her. *Arrow down (decreased) anxiety, decreased talk of death, arrow up (increased) appetite, increased activity involvement. *Changing/reducing at present could cause step back - recently D/c'd (discontinued) off of hospice. Interview on 9/7/17 at 10:15 a.m. with unit clinical coordinator H regarding resident 7 revealed: *The documentation from care staff was probably not the best regarding call light use as a way to capture the resident's increased anxiety. *Her anxiety was demonstrated through the use of her call light and the need to get up to the bathroom. *She was admitted from home where it was reported anxiety issues led to over use of her antianxiety medication ([MEDICATION NAME]). *She was obsessed about urinating and feeling constipated. *It was reported the resident went to the bathroom regularly. Interview on 9/7/17 at 1:15 p.m. with the director of nursing regarding resident 7 revealed: *She stated anxiety was not an acceptable [DIAGNOSES REDACTED]. *Her expectation of PRN documentation would have been for the nurse to: -Obtain the order from physician. -Notify the pharmacist of the order. -Enter the order into the electronic Medication Administration Record [REDACTED] -Chart the effectiveness of the PRN medication. *The provider used(NAME)and Duell for professional standards guidelines. -However she was unable to produce professional standards on documentation of a PRN antipsychotic medication. Review of the provider's September 2009 Medication Administration policy revealed: *2. Medications are administered in accordance with written orders of the physician. If a dose seems excessive considering the patient's age and condition, or medications order seems to be unrelated to the patient's (resident) current [DIAGNOSES REDACTED]. *10. When a PRN medications are administered, the following documentation is provided: -d. Results achieved from giving the dose and the time results were noted.

Based on observation, record review, interview, and skin/wound care guideline review, the provider failed to ensure adequate interventions were in place for the prevention of pressure ulcers for one of four sampled residents (9) in building 1. Findings include: 1. Review of resident 9's medical record revealed: *A [DIAGNOSES REDACTED]. The disease had been in remission. A blood test and bone biopsy confirmed he was no longer in remission. The resident began [MEDICAL CONDITION]. *He had episodes of skin breakdown in the past including a skin ulcer to his left upper leg in November, 2012. *He had been evaluated by the physician on 4/21/14 for a stage II (partial thickness of skin loss) pressure ulcer to his right upper thigh, over the bone. That ulcer had developed into a stage IV (a full-thickness tissue (muscle/bone) loss) on 5/20/14. *A physician report of a stage II ulcer to his left upper thigh on 5/23/14. *Documentation in the skin care report of blisters to his left and right heels on 5/20/14, 6/3/14, 6/13/14. *On 6/16/14 the physician was notified of an open right heel ulcer and requested orders for treatment. Review of resident 9's Minimum Data Set (MDS) assessment on 9/26/13 revealed: *He required extensive assistance of two staff for bed mobility (moving in bed) and transfers. *He required extensive assist of one staff for toileting. *He was frequently incontinent of (leaked) urine. *He was not at risk for skin breakdown. *treatment for [REDACTED]. *His Care Area Assessment (CAA) for pressure ulcers indicated he was incontinent of urine and required assist with bed mobility. A 9/26/13 Braden (an assessment to measure risk for skin breakdown) score indicated he was at mild risk for skin breakdown. The 3/27/14 MDS revealed: *He required extensive assistance of two staff for bed mobility and transfers. *He was occasionally incontinent of bowel and frequently incontinent of urine. *He was not at risk for skin breakdown. *He was not on a repositioning program. A 3/27/14 Braden score indicated he was at mild risk for skin breakdown. The 5/28/14 MDS revealed: *He required extensive assist of two staff for bed mobility and transfers. *He was frequently incontinent of urine. *He was at risk for skin breakdown. *He had one stage IV ulcer. *treatment for [REDACTED]. *His CAA for that MDS assessment indicated: -He had a stage IV ulcer. -He had been sitting in his chair for long periods of time. -He was incontinent of urine with leaking, spilling, and not getting cleaned up. -He would eat breakfast and then left the unit to visit his wife. -He remained off the unit in his chair for long periods of time, returning only for his evening medication. -He would try to use the urinals, and it would spill. A 5/28/14 Braden score indicated he was at moderate risk for skin breakdown. Review of resident 9's 6/25/14 care plan revealed: *A problem of impaired skin integrity evidenced by limited mobility and breakdown under his knee braces. *The goal for that problem was to be free from red or open areas. *5/13/14: Staff were to encourage him to reposition in bed and chair every two hours. *5/28/14: Dressing change to his right buttock. *7/10/14: Dressing change to his lift hip. *There was no mention of the ulcers on his left or right heels nor any treatment for [REDACTED]. Interview on 8/5/14 at 8:00 a.m. with registered nurse (RN) O revealed: *The resident was active and doing well, leaving the unit daily to visit his wife, and remaining off the unit until after supper. *He became ill quickly and worsened after the [MEDICAL CONDITION] had begun. *The ulcers had opened a week after beginning [MEDICAL CONDITION]. *He spent most of his time in bed due to the pain from the pressure ulcers. *He was already wearing heel protectors (padded heel covers) when he developed the heel ulcers. *The care plan had not indicated the heel protectors were to have been used. *Since the development of the ulcers there had been no new interventions for the heels other than the dressings. Documentation in the medical record reflected an air mattress had been ordered on [DATE]. RN O indicated it had taken two or three weeks for the mattress to have been delivered due to the large bed size. *The resident had not liked the mattress so he had it removed after approximately two weeks. Chart documentation indicated the mattress had been removed on 7/15/14. *When asked if staff had used pillow support to keep the heels off the bed, she reported they did do that. Random observations from 8/5/14 through 8/7/14 revealed no pillow support had been used to raise the heels off the surface of the bed. The heels, covered only by the heel protectors, had remained on the bed. Observation on 8/6/14 at 12:10 p.m. of RN U performing a dressing change to resident 9's heels revealed: *The nurse applied fluffed gauze to the right heel to protect it, then secured it with a gauze wrap. *She applied an OpSite (a transparent clear dressing) to the left heel. Review of resident 9's medical record revealed:*An 8/4/14 order to discontinue the current right heel dressing of Allevyn (a foam covering) and begin [MEDICATION NAME] ointment (for treating infections and burns), gauze, and tape. *No physician's order could be located for the OpSite to the left heel. *A 6/16/14 physician's order had indicated the use of Allevyn to both heels. Interview on 8/6/14 at 5:45 p.m. with RN U and RN O revealed: *Both nurses had been aware the dressing to the right heel had been incorrect. *They decided not to remove it and redress it with the correct dressing, because it was scheduled to be done by the evening nurse. *There was not an order for [REDACTED]. *When asked how they knew what dressing was to be applied to the heels RN U reported there was a place on the electronic record called an "I did it" that indicated what they were supposed to dress the ulcers with. *RN U pulled up the "I did it" on the computer screen which reflected she had dressed the right heel with the [MEDICATION NAME] ointment. RN U agreed she had not used that type of dressing. Interview on 8/7/14 at 9:45 a.m. with the director of nursing revealed: *The resident was up and about prior to his illness. *She was not sure what the indication on the MDS of "No risk" for skin breakdown had meant. *She was not sure if "mild risk" on the Braden assessment had indicated "no risk" for skin breakdown. *The resident was resistive with assistance and had not wanted to return to the unit when he was off-unit for the day. *His treatment for [REDACTED]. *He was not really incontinent of urine but spilled urine when he attempted to use a urinal by himself. *She did not think the previous MDS assessments (9/26/13 and 3/27/14) had reflected his true status, because he required more assistance now. *She agreed the heel ulcers had not been care planned. Interview on 8/7/14 at 12:35 p.m. with the DON and RN O revealed: *RN O had miscoded the risk for skin breakdown on the MDS. *She believed the resident had not been at risk, because the preventative measures of the pressure-relieving mattress and chair cushion had taken care of the risk. *She reported resident 9 had not wanted to return to the unit to receive assistance with toileting when he was visiting his wife. That had changed only after the family complained about the odor. *The DON was asked to locate documentation of education provided to the resident with the risks for not complying with skin care. *Documentation provided by the DON on 8/4/14 had included resistance with behaviors, but it had not included documentation of education. Review of the provider's July 2005 Skin/Wound Care Guidelines revealed: *The objectives were: -To implement appropriate measures on admission and with changes in condition. -To assess for risk of pressure ulcers. *General instructions had included: -A skin assessment would be done on admission and repeated regularly and with changes. -Interventions from the Braden Protocol were to have been included. *Those Braden interventions for mild risk of skin breakdown had included: -Managing moisture. -Protect heels. *Braden interventions for moderate skin breakdown had included: -Foam wedges for thirty degree lateral positioning to have kept the resident from laying flat. -No wedges had been utilized. *Recommendations were to have been added to the care plan. *Treatment plans for wounds were to be re-evaluated every two to four weeks to determine a need for a change in treatment. *If a resident refused or was resistant to staff interventions to reduce the risk of skin breakdown or treat ulcers they would receive education of potential consequences.