Every finding on record at Bethany Home - Brandon

Based on a South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure residents were free of significant medication errors for one of one sampled resident (3) who received 2.5 milliliters (mL) of Morphine Sulfate (narcotic) by mouth instead of the ordered dose of 0.25 mL from a certified nursing assistant (CNA)/medication aide (MA) E and experienced decreased oxygen levels, lethargy (abnormal drowsiness or sluggishness that involves low energy, decreased alertness, reduced mental and physical activity), respiratory distress (trouble breathing), and required the use of Narcan (a medication that reverses the effects of opioids).Findings include:1. Review of the provider's 5/15/26 SD DOH FRI revealed that resident 3 had a physician's order for 0.25 mL of Morphine Sulfate, 100 milligrams (mg)/5 (mL), to be administered orally as needed for pain or shortness of breath (SOB).On 5/14/26 at 8:45 p.m., resident 3 was administered 2.5 mL of morphine from CNA/MA E, which was the incorrect dose. This was 2.25 mL of morphine over the prescribed dose. On 5/14/26 at 9:01 p.m., Ecare (telehealth service) was consulted and informed of the medication error of morphine that involved resident 3. They were directed to monitor the resident.Approximately twenty to thirty minutes after resident 3 received the incorrect dose, he experienced decreased oxygen levels, lethargy, respiratory distress, and required the use of Narcan. LPN F received an order for Narcan and administered the dose to resident 3.2. Review of resident 3's electronic medical record (EMR) revealed LPN F documented that resident 3 was administered 2.5 mL of morphine 2.5 orally, and the physician's order was for 0.25 mL. The director of nursing (DON), B, and Ecare were notified of the medication error. LPN F was instructed to monitor resident 3 and report any changes. Resident 3 was alert and responded initially to the staff after he was administered the morphine, but after twenty to thirty minutes after he began to have apnea (a temporary pause or stop in breathing). His vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were within normal limits. A physician's order was received from the hospice nurse to administer Narcan. The facility's oncoming night nurse RN H, was notified of the medication error regarding resident 3 by LPN F, and the hospice nurse, RN N, came to the facility to assess the resident.No documentation in resident 3's EMR indicated vital signs were taken or if assessments were completed by LPN F after the incorrect dose of morphine was administered. There was no documentation of the time of day calls made to hospice or Ecare, no incident report completed to report the medication error, and no physician's order for the Narcan that was provided by Hospice. The verbal order for Narcan that LPN F received from RN N was not entered into the MAR with the corresponding ordering physician's name.3. Review of resident 3's EMR indicated that LPN F called ecare. CNA/MA E called DON B. Ecare then called hospice registered nurse (RN) N. RN N then called the facility back around 9:45 p.m. to check on how resident 3 was doing when she was made aware of his apnea, oxygen levels, and lethargy. RN N then called the facility back and gave LPN F a verbal order for Narcan.4. Interview on 5/27/26 at 3:00 p.m. with LPN F revealed that she did not know what time the events happened or when her assessments were completed on resident 3 after the medication administration error. She assessed the resident 5-10 minutes after the medication was given. She then left the hallway for 15-20 minutes to give another resident their medications leaving CMA E on the hallway to monitor the resident. LPN F stated I told her [CMA E] to stay with him and keep a close eye on him.5. Interview on 5/27/26 at 4:27 p.m. with MA E revealed she did give the 2.5 mL of Morphine to resident 3 on 5/14/26 and did not realize her error until going back to the medication administration record (MAR) to document the dosage. She said she normally double checks her doses but did not on that night. After MA E realized the error, she called DON B and told her, I made a significant medication error. MA E then went to find LPN F and DON B instructed LPN F to call Ecare. LPN F then called Ecare. Ecare then informed LPN F to watch resident 3 for drowsiness. Hospice RN N, then called the facility as they were notified of the error by Ecare to inquire how resident 3 was doing. RN N told LPN F to monitor the resident.6. Interview on 5/28/26 at 1:25 p.m. with Hospice RN N revealed she gave instructions to LPN F to monitor resident 3 as the morphine would peak at 1 hour after administration. Hospice RN N then called the facility back after an hour and was told from either the MA or LPN that resident 3 was lethargic (more than usual), and his breathing was shallow with up to 20-second pauses, with oxygen saturation dropping into the mid to lower 80's. Hospice RN N then told the person on the phone that she was going to call the doctor for an order for Narcan. RN N then confirmed she went to the facility to assess resident 3. At that time, he had already received the Narcan. He was alert and able to talk. His only complaint was a dry mouth. RN N was in the facility for about forty-five minutes. Before leaving, she completed education with LPN H about Narcan and when she would be able to administer additional morphine if needed. That education was there were to be no additional narcotics given for 90 minutes.7. Interview on 5/28/26 at 3:45 p.m. with DON B revealed she considered resident 3's morphine incident a significant medication error. She expected that MA E would notify LPN F right away, and the nurse would complete a nursing assessment on the resident. She expected the nurse to assess and document, especially with a narcotic medication error, the resident's respiratory rate, blood pressure, pulse, oxygen, temperature, and orientation status, or how alert the resident was. She expected that the date and the time of the assessment being completed to be documented.8. Review of the provider's reviewed February 2025 Medication Administration policy revealed 3. medications must be administered in accordance with the orders, including any required time frame. 7. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to report incidents to law enforcement and the ombudsman for two of two sampled residents (1 and 4) when they were administered vaginal medication in the dining room by one of one registered nurse (RN) (L). The facility failed to report to the resident's representative, primary care provider (PCP), law enforcement, and the ombudsman for one of one sampled resident (2) who was verbally abused by one of one certified nursing assistant (CNA) (M) when she provided resident 2 personal care. The facility also failed to report resident 2's incident within a timely manner to the SD DOH. 1. Review of the provider's 2/4/26 SD DOH FRI revealed that residents 1 and 4 had a physician's order for medicated vaginal cream. On 2/4/26 around 7:00 p.m. CNA/medication aide (MA) J reported that she witnessed RN L prepare and administer the vaginal cream to residents 1 and 4 in the dining room, where other staff and residents were present, by pulling their pants and incontinent (involuntary urine or bowel leakage) briefs down and to the side. The director of nursing (DON) B and Assistant director of nursing (ADON) D called and spoke with RN L. RN L stated to DON B and ADON D that she did administer the cream by pulling the resident's brief and pants out and putting her hand in the brief and squirting the cream in the vaginal area. The DON explained to RN L that this is improper administration of this medication and that the administration of this medication should be completed in the privacy of the resident's room. RN L was sent home from her shift and suspended at that time. The FRI revealed that the abuse/neglect allegation was substantiated as RN L acknowledged she did this incident. 2. Review of resident 1's electronic medical record (EMR) revealed an order for 1 gram (gm) of Conjugated (mixture of Estrogens) Cream 0.625 mg/gm, was to be inserted vaginally at bedtime every Monday, Wednesday, and Friday for urinary incontinence. Resident 1's 5/7/26 Brief Interview for Mental Status (BIMS) assessment score was 99, which indicated the assessment could not be completed by the staff. Her care plan indicated that the resident had impaired cognitive function/thought process related to dementia (a group of symptoms affecting memory, thinking, and social abilities). The staff was to communicate with the family about the residents' capabilities and needs. 3. Review of resident 4's EMR revealed that she was admitted to the facility on [DATE]. She had medical diagnoses that included dementia with other behavioral disturbances, Alzheimer's (a brain disorder that slowly destroys memory and thinking skills), urinary incontinence, chronic kidney disease (CKD) stage three (mild to moderate kidney damage), and anxiety (a feeling of worry, nervousness, or unease). She had a physician's order for Estradiol Vaginal cream 0.1 MG/GM insert 1 GM vaginally one time a day every Monday, Wednesday, and Friday for vaginal health. On 4/25/25, her Brief Interview for Mental Status (BIMS) assessment score was documented as not applicable (NA), which indicated her cognition was severely impaired. Her current care plan, dated 5/7/26, included that she has impaired cognitive function/thought processes related to her diagnosis of dementia, and to communicate with her family regarding her care and needs. She is incontinent at times and wears briefs for protection and dignity. 4. Interview on 5/28/26 at 12:45 p.m. with CNA/MA J regarding the incident on 2/4/26 with resident 1 and 4 revealed she saw RN L prepare and then administer the vaginal cream to a resident sitting by the medication cart and a resident that was sitting at a dining table. She then notified DON B within thirty minutes, as she thought administering the vaginal cream in the dining room was not the right thing to do. 5. Interview on 5/28/26 at 3:45 p.m. with DON B revealed she acknowledged that RN L administered vaginal cream in the dining room for those two residents. She agreed that it was not an appropriate area to administer the cream and that vaginal cream should be administered in privacy, such as the resident's room. 6. Review of RN L's employee file revealed her employment with the facility was terminated on 2/6/26 due to the incident that occurred on 2/4/26. 7. On 5/28/26 at 10:55 a.m., Department of Health surveyors requested documentation that the facility had notified law enforcement and the ombudsman of the incident on 2/4/26 regarding residents 1 and 4. Per DON B, no notifications were made to these entities because they did not classify it as an abuse concern, but rather as a dignity concern. 8. Review of the provider's 2/13/26 SD DOH FRI revealed that on 2/13/26 at 8:00 p.m., resident 2 was verbally abused by CNA M when she provided assistance with his personal care. CNA K reported this incident on 2/14/26 at 10:11 p.m.to DON B via text message. 9. Review of resident 2's EMR revealed his 4/23/26 Brief Interview for Mental Status (BIMS) assessment score was 3, which indicated his cognition was severely impaired. 10. On 5/28/26 at 1:12 p.m., Department of Health surveyors requested documentation that the facility had notified the ombudsman, family, and the resident's physician of this incident. Per Administrator A, no notification was made to these entities. 11. Review of CNA M's employee file revealed her employment with the facility was terminated on 2/19/26 due to the incident that occurred on 2/13/26. 12. Interview on 5/28/26 at 3:45 p.m. with DON B revealed that due to this incident, she has completed education with staff, including CNA K, on when and how to report concerns of abuse and neglect. She stated that depending on the staff title or position, they report to their supervisor. That information would then get to DON B, and she reports to administrator A. They both then start the investigation process, which she stated includes the notification of DOH, law enforcement, the Department of Human Services (DHS), family members, and the primary care provider. Staff involved in the incident are suspended during the investigation. She acknowledged that the facility has two hours to report allegations of abuse or a resident being injured, and 24 hours for anything else. 13. Review of the provider's June 2025 Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy revealed The DON or their designees immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. the local/state ombudsman (if applicable); c. the residents representative; d. Dakota at home; e. law enforcement officials; the resident's attending physician; and g. the facility medical director.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure resident privacy and dignity during the administration of personal care treatments for two of two sampled residents (1 and 4) who were administered vaginal cream in the dining room by registered nurse (RN) L where other residents and staff were present. Findings include1. Review of the provider's 2/4/26 SD DOH FRI revealed that residents (1 and 4) had an order for medicated vaginal cream. Certified nursing aide/medication aide (CNA/MA) J reported that she witnessed RN L prepare and instill cream in the dining room for residents (1 and 4). 2. Review of resident 1's EMR revealed a physician's order for 1 gram (gm) Conjugated Estrogen Cream 0.625 mg/gm, to be inserted vaginally at bedtime every Monday, Wednesday, and Friday for urinary incontinence (unintentional passing of urine). Resident 1's 5/7/26 Brief Interview for Mental Status (BIMS) assessment score was 99, which indicated the assessment could not be completed. Her care plan indicated that the resident had impaired cognitive function/thought process related to dementia (a group of symptoms affecting memory, thinking, and social abilities). The staff was to communicate with the family about the residents' capabilities and needs. 3. Review of resident 4's EMR revealed that she was admitted to the facility on [DATE]. She had medical diagnoses that included dementia with other behavioral disturbances, Alzheimer's (a brain disorder that slowly destroys memory and thinking skills), urinary incontinence, chronic kidney disease (CKD) stage three (mild to moderate kidney damage), and anxiety (a feeling of worry, nervousness, or unease). Resident 4 had a physician's order for 1 gm of Estradiol Vaginal cream 0.1 milligram mg/gm to be inserted vaginally one time a day every Monday, Wednesday, and Friday for vaginal health. On 4/25/25, her Brief Interview for Mental Status (BIMS) assessment score was documented as not applicable (NA), which indicated her cognition was severely impaired. Her current care plan, dated 5/7/26, included that she had impaired cognitive function/thought processes related to her diagnosis of dementia, and to communicate with her family regarding her capabilities and needs. 4. Interview on 5/28/26 at 11:00 a.m. with registered nurse (RN) I revealed that oral medications and insulin are the medications she will give in the dining or public area. These are only administered if the residents give their permission. 5. Interview on 5/28/26 at 12:45 p.m. with CNA/MA J regarding the incident on 2/4/26 with resident 1 and 4 revealed she saw RN L prepare and then administer the vaginal cream to a resident sitting by the medication cart and a resident that was sitting at a dining table. She then notified DON B within thirty minutes, as she thought administering the vaginal cream in the dining room was not the right thing to do. 6. Interview on 5/28/26 at 2:32 p.m. with CNA/MA K revealed that oral medications are what she would administer in the dining area of the facility. She would ask the resident's permission prior to giving the medication. 7. Interview on 5/28/26 at 3:45 p.m. with DON B revealed she acknowledged that RN L administered vaginal cream to residents 1 and 4 in the dining room for those two residents. She agreed that was not an appropriate area to administer the cream and that medication of vaginal cream should be administered in privacy such as the resident's room. 8. Review of RN L's employee file revealed her employment with the facility was terminated on 2/6/26 due to the incident that occurred on 2/4/26. 9. Review of the provider's 11/18/22 Resident Rights Guidelines revealed [it is the resident's right to] maintain individual privacy and confidentiality. 10. Review of the provider's November 2022 Resident Dignity policy revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem. 1. Residents are treated with dignity and respect at all times. 2. The facility culture is on [one] that supports and encourages humanization and individuation of residents, and honors resident choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's stay in the facility. 10. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

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 safety for one of one sampled resident (3) who fell onto the floor and hit his face while being pushed in his wheelchair by certified nursing assistant (CNA) (C), who did not attach and use the wheelchair foot pedals as required when transferring resident 3 to the dining room.Findings include: 1. Review of the provider's 3/3/26 SD DOH FRI revealed that on 3/3/26, resident 3 was being pushed in his wheelchair by CNA C to the dining room with no wheelchair foot pedals attached. Resident 3 put his feet down and fell forward onto the floor, hitting his face. Resident 3 was upset after the incident. He had a raised egg-shaped lump to the center of his forehead and open skin abrasions to the bridge of his nose. There was a small skin tear noted on his right hand between his thumb and pointer finger. The area was cleansed; skin was put back over, and a steri-strip bandage was applied. Neurological evaluations (assessment of nerve function, reflexes, coordination, motor skills, sensation, and mental status) (neuros) were started and found to be within normal limits for resident 3. His son, the director of nursing (DON) B, and administrator A were notified of the incident. Staff continued to monitor resident 3. CNA C acknowledged that she was not following the policy in ensuring residents are utilizing foot pedals when being pushed in a wheelchair. CNA was terminated immediately. 2. Review of resident 3's electronic medical record (EMR) revealed his 2/26/26 Brief Interview for Mental Status (BIMS) assessment score was 11, which indicated his cognition was moderately impaired. Resident 3's care plan dated 3/2/26 had an intervention added on 3/5/26 that indicated that foot pedals should be on resident 3's wheelchair at all times when someone was pushing him in his wheelchair. He had a history of putting his feet down while the wheelchair was moving and falling forward. 3. Interview on 5/28/26 at 11:00 a.m. with registered nurse (RN) I revealed she was the nurse who responded to the incident that occurred on 3/3/26, which involved resident 3 falling out of his wheelchair. Resident 3 was being pushed by CNA C to the dining room for breakfast, and had put his foot down onto the floor, which caused him to fall headfirst out of his wheelchair. Ecare (telehealth service that provides virtual medical services) was contacted by RN I and instructed her to monitor the resident. 4. RN I stated that the staff was trained to put the wheelchair pedals on, and CNA C did not. RN I indicated that assistant director of nursing (ADON) D and she had both told CNA C that the wheelchair pedals were to be put on when assisting a resident in their wheelchair. 5. Review of CNA C's personal file revealed she completed training on 2/4/26, which provided education that all residents must have wheelchair foot pedals on when the staff were pushing residents in their wheelchairs. 6. Interview on 5/28/26 at 3:45 p.m. with director of nursing (DON) B revealed that wheelchair foot pedals were to be attached to wheelchairs and used when the staff were assisting residents. 7. Review of the provider's reviewed April 2025 Use of Wheelchair Pedals policy revealed 1. Foot pedals will be used for residents who use wheelchairs while they are in their wheelchair, unless deemed safe and care planned otherwise.

Based on observation, interview, and policy review, the provider failed to:*Maintain food safety requirements related to one of one Maple Valley neighborhood pantry room, and one of one Maple Valley kitchenette. *Maintain clean and sanitary conditions for three of three foodservice handwashing sinks in the [NAME] Creek neighborhood.*Implement interventions to supervise and monitor resident refrigerator temperatures to identify any hazards of foodborne illness for two of two observed residents (17 and 24).Findings include:1. Observation on 12/16/25 at 9:47 a.m. of the Maple Valley neighborhood food service pantry revealed:*A wheeled cart was inside that room. Clean drinking cups, coffee mugs, silverware wrapped in napkins, a water pitcher, and a plate guard sat on a towel on top of that cart. One end of the cart had openings for pushing the cart. There were multiple, dried white-colored runs down the inside lip of that end of the cart near the edge of the towel and by the clean kitchenware. The clean kitchenware was not stored in a way that would mitigate contamination.*There were two wire shelving units inside that pantry room. A Clean sign hung on the front of and below the top shelf of the first unit. A sign next to the first sign read All dishes placed on this rack must be faced down and on a tray. It was unclear if those signs applied to the items on the top shelf, the second shelf, or both shelves. The following items were not stored in a manner to protect them from becoming contaminated:-A rolling pin and muffin tin sat directly on the top shelf. There was an opened plastic bag of Styrofoam food storage boxes, also on the shelf.-A lidded plastic cup with a flexible straw, stacked bowls, a plastic water pitcher, a plastic measuring cup, insulated lids, plastic cups, and other miscellaneous kitchen items sat directly on the second shelf. *On top of a dorm-sized freezer next to the above shelving unit were measuring cups, bowls, a water pitcher, a food thickening dispenser, and a plastic-covered pan of dessert. *The second wire shelving unit was directly across from the first. Hanging from the second shelf of that unit was a Dirty sign. Sitting directly on that same shelf, there were stacks of folded clean dish rags. -To the right of the rags was a Styrofoam cup lid lying directly on the shelf, and an open sleeve of the same type of lids. Behind that, a small stack of Styrofoam food containers and plates lay directly on the shelf.-To the left of the dish rags was an open sleeve of Styrofoam cups. In front of that bag were several plastic forks lying directly on the shelf. A spray bottle containing sanitizer hung off the shelf next to that. Behind that was an opened box with plastic spoons and Styrofoam cups inside it. *On the bottom shelf, a baking sheet lay directly on top of that shelf. A plastic fork sat on top of the sheet. There were Styrofoam plates and plastic lids next to a bottle of Goof-Off (latex paint and adhesive remover) and a gallon-size jug of dish soap next to it. Behind those cleaning supplies were multiple used flower vases. 2. Continued observation of the Maple Valley neighborhood kitchenette area revealed:*Inside the cabinet next to the steam table, Styrofoam bowls, plates, canned soup, and snacks were stored. The inside of those cabinet doors appeared to be coffee-stained. Two of the shelves inside that same cabinet appeared to be coffee-stained. *Inside the top drawer beside the stove were two soiled oven mitts and a pair of scissors stored with a spatula and a set of tongs. 3. Observation and interview on 12/16/25 at 10:26 a.m. with resident 17 in his room of the Cottonwood Court neighborhood revealed: *He had a personal refrigerator in his room. *He mentioned that his children were responsible for cleaning and disposing of expired food items. *He said staff would check the temperature of his refrigerator approximately once a week. *The refrigerator was mildly dirty, with small food particles observed on the shelves and inside the door. *The freezer section had a moderate buildup of frost and ice. *There was a small opened jar of strawberry jam, an opened squeeze-bottle of Miracle Whip salad dressing, an opened container of French onion dip, and an opened package of sliced cheese stored in the door of the refrigerator. *There was no temperature log located on or near the refrigerator. *There was no thermometer in the refrigerator to know the current temperature of it. 4. Interview on 12/16 at 3:45 p.m. with certified nurse aide/unlicensed medication aide (CNA/UMA) AA inside the Maple Valley pantry revealed that the cart holding the clean dinnerware remained in that room. She agreed that the cart was unclean, but she had not known who was responsible for cleaning it. She thought the Dirty sign on the second shelving unit should have been removed. She had not known who was responsible for organizing and keeping the pantry room clean. Items in the pantry and kitchenette should have stored or covered in a manner to protect them from potential contamination. 5. Interview on 12/16/25 at 4:10 p.m. with director of nursing (DON) B in the Maple Valley pantry and kitchenette revealed that a combined effort between nursing staff and dietary staff was expected to maintain the pantry and the kitchenette cleanly and safely for food service and cookware. There was nothing for those staff to refer to for them to know the expectations for maintaining the pantry and kitchenette cleanly and safely, who was responsible for what tasks to maintain those areas, or how frequently it was expected that those tasks occurred though. She agreed that based on the above observations, the pantry and kitchenette had not been maintained in a manner to keep it organized, clean, and sanitary for food service. 6. Interview on 12/16/25 at 4:00 p.m. with dietary manager (DM) D regarding the Maple Valley pantry and kitchenette revealed that nursing staff were responsible for maintaining those areas. Nursing staff were also responsible for returning the carts with dirty dishes to the kitchen for cleaning. Dietary staff were responsible for returning the cleaned carts to the neighborhood. 7. Observation and interview on 12/16/25 at 4:30 p.m. with resident 24 in his room of the [NAME] neighborhood revealed: *He had a personal refrigerator in his room. *He said that his children were responsible for cleaning and disposing of expired food items. *He was unsure if the staff checked the temperature of the refrigerator daily. *There was an open package of potato lefse (a soft flatbread made from riced potatoes, flour, butter, and cream or milk) stored on a shelf in the refrigerator. *There was no temperature log located on or near the refrigerator. *There was no thermometer in the refrigerator to know the current temperature of it. 8. Observation on 12/17/25 at 8:06 a.m. in the [NAME] Creek neighborhood pantry room behind the kitchenette revealed the handwashing sink had unidentified food scraps that appeared to have been tomato skins stuck to the drain catch. 9. Observation on 12/17/25 at 9:55 a.m. in the [NAME] Creek dining room revealed the handwashing sink next to the beverage dispensers was stained with what appeared to be coffee or brown-colored rust. 10. Interview on 12/17/25 at 10:35 a.m. with registered nurse (RN) G revealed: *She stated resident families were responsible for the residents' personal refrigerators. *The nursing staff was not responsible for the resident refrigerators. 11. Interview on 12/17/25 at 10:43 a.m. with RN/neighborhood leader H revealed: *She stated that residents and resident families were responsible for cleaning, disposing of outdated food items, and checking the temperatures of the refrigerators. *The nursing staff was not responsible for the resident refrigerators. 12. Interview on 12/17/25 at 11:03 a.m. with director of nursing (DON) B revealed: *She stated that residents and families were notified and given the information about personal refrigerators upon admission or as they had requested. *She stated that residents and families were responsible for cleaning and disposing of outdated food items on a routine basis. *She indicated housekeeping was responsible for checking the residents' refrigerator temperatures daily and maintaining the logs of those temperatures. *She confirmed that resident refrigerators should have had a thermometer in them and that it was the responsibility of the facility to have one for each resident refrigerator. *The refrigerator temperatures should have been maintained between 36 and 46 degrees Fahrenheit (F) for food safety. *She agreed that to avoid a hazardous foodborne illness, resident refrigerators should have been checked daily for appropriate temperatures. *It was her expectation that the temperatures for the refrigerators in resident rooms were checked and documented daily by housekeeping. 13. Interview on 12/17/25 at 11:43 a.m. with maintenance supervisor E revealed: *He was asked to provide the residents' refrigerator temperature logs for the past two months. -He stated that the previous maintenance supervisor and housekeeping had not maintained the resident refrigerator temperature logs. *He stated that he was unaware that the refrigerator temperatures in residents' rooms needed to be checked daily. *He stated that the housekeepers did not know and were not told or educated to check the resident refrigerator temperatures daily. *He confirmed that no resident refrigerator temperatures had been completed, and no logs had been maintained for those refrigerators. *He agreed that to avoid a hazardous foodborne illness, temperatures in resident refrigerators should be checked and documented daily to ensure they were in the appropriate temperature range for food safety. 14. Interview on 12/17/25 at 1:51 p.m. with housekeeping P revealed: *She stated that she had not checked or documented any resident refrigerator temperatures. *She indicated that she had not been told or educated to perform that housekeeping task. 15. Interview on 12/18/25 at 10:50 a.m. with DM D and DON B revealed that the nursing and housekeeping departments were responsible for cleaning the handwashing sinks on the resident neighborhoods. DM D said that food and beverages were not supposed to be poured down the handwashing sinks in those areas. 16. Interview on 12/18/25 at 10:55 a.m. with CNA L revealed that the CNAs cleaned the tables and counters after each meal. She was not sure who was responsible for cleaning the handwashing sinks in the dining room, in the kitchenette, or in the pantry room. She did not know if there was a cleaning checklist or not. 17. Interview on 12/18/25 at 10:57 a.m. with licensed practical nurse (LPN) J revealed that she thought that there was a cleaning checklist for the CNAs for the kitchenette and dining room areas. She looked through several binders in the kitchenette and nursing station cupboards, but she could not find a cleaning checklist for them. 18. Observation on 12/18/25 at 10:59 a.m. in the [NAME] Creek kitchenette revealed there were food scraps and coffee grounds in the handwashing sink located to the right of the oven. The unidentified food scraps that appeared to have been tomato skins (from the observation on 12/17/25 at 8:06 a.m.) were still present in the handwashing sink located in the pantry room. 19. Interview on 12/18/25 at 11:02 a.m. with housekeeper Q revealed that she gave conflicting responses when asked if the housekeeping staff were responsible for cleaning the handwashing sinks in the resident neighborhoods. She at first said that she cleaned them every day, but then she said she cleaned them once per week. She said she does not clean the handwashing sink in the pantry room located behind the kitchenette. 20. Interview on 12/18/25 at 11:57 a.m. with administrator A revealed he expected staff to refrain from pouring food and beverages down the handwashing sinks. He explained that it was the housekeeping staff's duty to perform regular cleaning of the resident areas like the dining room, kitchenette, the beverage station, and the handwashing sinks. Review of the providers reviewed 8/2025 Resident Refrigerator policy revealed: *Policy: - C. Nursing will obtain the thermometer from dietary which will be placed in the refrigerator. -D. Housekeeping checks the temperature of the fridge in resident's room. -E. Resident/family will ensure that all food placed in the refrigerator is covered. After opening the container, it is to be used or removed within an acceptable time frame. -F. The refrigerator is to be cleaned by the family member. -G. Housekeeping staff will check to ensure the resident or family member is removing and disposing of open items and keeping the refrigerator clean. -.I. If the resident or family member is unable to maintain the refrigerator according to the policy/procedure, staff will advise the family that it will have to be removed.

Based on record review, interview, and policy review, the provider failed to involve five of thirty (4, 9, 19, 44, and 59) sampled residents' primary care provider (PCP) in the development of the resident's advanced directives according to facility policy, failed to update one of five (44) sampled resident's electronic medical record (EMR) after the resident's code status had changed, failed to include one of five (59) sampled resident's code status on their care plan according to facility policy, and failed to make the resident's updated code status form available to direct care staff in the resident's EMR, which created potential confusion for staff when the most updated form was not available.Findings include:1. Review of resident 4's EMR revealed his code status was Do Not Resuscitate (DNR) on the top dashboard. His current care plan indicated his code status was DNR. There was no scanned document of his signed code status form in the Miscellaneous section, where scanned documents were stored. There was no documentation found anywhere in the EMR regarding the resident's code status.2. Review of resident 9's EMR revealed her code status was DNR on the top dashboard. Her current care plan indicated her code status was DNR. There was no scanned document of her signed code status form in the Miscellaneous section.3. Review of resident 19's EMR revealed his code status was DNR on the top dashboard. His current care plan indicated his code status was DNR. There was no scanned document of his signed code status form in the Miscellaneous section.4. Review of resident 44's EMR revealed his code status was DNR on the top of the dashboard. His current care plan included an intervention that read, I am a FULL CODE. That intervention was initiated on [DATE] and revised on [DATE]. The most recent code status form in the Miscellaneous section was from [DATE], which indicated that resident 44 wished to receive CPR (cardiopulmonary resuscitation) if he was in cardiac arrest (when the heart stops beating).5. Review of resident 59's EMR revealed her code status was DNR at the top of the dashboard. Her current care plan did not include her code status. There was no scanned document of her signed code status form in the Miscellaneous section.6. Interview on [DATE] at 1:56 p.m. with director of nursing (DON) B revealed that social services director (SSD) F was responsible for obtaining the resident's code status upon their admission to the facility. Their process was to have two staff members witness the resident or their representative sign the code status form. Then, SSD F was responsible to send the code status forms to the resident's PCP for review. The resident's PCP was supposed to sign the form and send it back to SSD F. Then, SSD F was supposed to scan the signed resident code status form into the resident's EMR.She provided copies of resident 4, 9, 19, 44, and 59's code status forms, and explained that they were in the Document Manager section of the resident's EMR, which was not available for staff or the survey team to review. She explained that none of the resident's code status forms were forwarded to the resident's PCP for review.7. Review of resident 4, 9, 19, 44, and 59's code status forms revealed that resident 4 signed his DNR choice on [DATE], resident 9 signed her DNR choice on [DATE], resident 19's representative signed his DNR choice on [DATE], resident 44 signed his DNR choice on [DATE], and resident 59's representative signed her DNR choice on [DATE]. There were no PCP signatures on any of the residents' code status forms.8. Interview on [DATE] at 8:43 a.m. with SSD F revealed that at the time of a resident's admission, she had a conversation with the resident or their representative to explain what the advanced directives were, what a full code meant, and what a DNR meant. She typically had a witness present during that conversation, so two staff members witnessed the form being signed by the resident or their representative.They switched to a Document Manager electronic form management in their EMR. After the resident or their representative signed the electronic copy, she would forward that to the resident's PCP for final review and obtain their signature. She stated that some of the PCPs they work with will sign the code status form right away, while other PCPs preferred to have a conversation with the resident in person to verify their decision before signing the form.She confirmed that she was responsible for forwarding the resident's code status form to the resident's PCP. She said that the system is not perfect when speaking about the process of involving the resident's PCP. She confirmed that she did not involve resident 4, 9, 19, 44, and 59's PCP in the development of the resident's advanced directives. She forwarded those resident's code status forms to their respective PCPs on [DATE] during the survey. She confirmed that resident 4, 9, 44, and 59's PCP had signed the code status forms and sent them back on [DATE]. She was still waiting on resident 19's PCP to review, sign, and send back his code status form.9. Interview on [DATE] at 9:01 a.m. with licensed practical nurse (LPN) V and LPN J revealed that if a resident were found unresponsive, they would check the resident's code status at the top of the dashboard in the EMR before responding to the resident.When asked specifically about resident 44, LPN V went to his profile in the EMR and indicated that the resident's code status was DNR. When she clicked on the Advanced Directives link that was next to the DNR code status, it brought her to the Miscellaneous scanned documents portion. She pointed out that the most recent code status form (from [DATE]) available to her indicated that resident 44 was a Full Code. She would have gone by that form. She confirmed she did not have access to the Document Manager section of the EMR.10. Interview on [DATE] at 9:06 a.m. with LPN J revealed that she remembered when resident 44's code status was changed. She mentioned that SSD F was responsible for uploading the current code status form into the Document Manager section of the resident's EMR. She mentioned the Document Manager section was not available to the floor nurses, so they may not have the most updated information to respond if a resident had an event that required knowledge of their advanced directives.LPN J opened the resident care plan binder and pointed out that SSD F changed the paper copy of resident 44's care plan. She confirmed that the resident's electronic care plan had not been updated yet and still indicated that resident 44 was a full code. When asked which care plan version she would refer to, she indicated the electronic care plan.11. Interview on [DATE] at 9:19 a.m. with neighborhood leader (NL) W revealed that she was not aware the Document Manager portion of a resident's EMR was not available to the other staff members, like the floor nurses, certified nursing assistants, and certified medication aides.12. Interview on [DATE] at 12:25 p.m. with assistant DON (ADON) C revealed that they included a resident's code status on the resident's care plan. Each department had its respective section on the resident's care plan. The advanced directive section of the resident's care plan was maintained by SSD F.13. Interview on [DATE] at 12:28 p.m. with SSD F revealed that she was involved in developing the resident's care plan. She formulated the following sections: discharge planning, advanced directives, cognition, mood, and psychosocial well-being, and behaviors. The behaviors section was a collaborative effort with the nursing department.She confirmed that pretty much everyone will have an advanced directive section. She confirmed that she included the resident's code status on their care plan.She was not aware that resident 59's electronic care plan did not include her code status.She was aware that resident 44's electronic care plan was not updated after his code status changed to DNR on [DATE]. She explained that she hand-wrote the resident's code status change in the paper copy of the resident's care plan in the care plan binder on the unit. She usually updated the resident's electronic care plan each quarter with their Minimum Data Set (MDS) assessment. Resident 44's code status was changed after his [DATE] quarterly MDS assessment, so she had not updated the electronic care plan yet.14. Review of the provider's 10/2025 Advance Directives policy revealed the policy statement read, Advance directives will be respected in accordance with state law and facility policy.7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.20. The Director of Nursing Services or designee will notify the Attending Physician of advance directives to that appropriate orders can be documented in the resident's medical record and plan of care.15. Review of the provider's 4/2025 Do Not Resuscitate Order policy revealed that the policy interpretation and implementation section included: 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record.a. While awaiting the physician's order to withhold CPR, facility staff should immediately document discussion with the resident or resident representative, including, as appropriate, a resident's wish to refuse CPR. At a minimum, a verbal declination of CPR by a resident, or if applicable a resident's representative, should be witnessed by 2 staff members and documented in the resident's medical record. 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the resident's medical record.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to protect three of three sampled residents (16, 37, and 50) and one of one closed sampled resident (101) from alleged verbal abuse and neglect. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include: 1. Review of the provider's 9/12/25 submitted to SD DOH FRI final report revealed:*On 9/11/25 at 9:28 a.m., director of nursing (DON) B received a text message from certified nurse aide/certified medication aide (CNA/CMA) Y about CNA/CMA N's interactions with residents in the Maple Valley neighborhood (residential living unit). That neighborhood was a memory care unit (an area where specialized care is provided in a structured, safe, and supportive environment to meet the unique needs of residents with significant memory and cognitive decline, which is secured to minimize unsafe wandering). In her text message, CNA/CMA Y indicated CNA/CMA N was:-Withholding fluids from residents during meals because the residents had made a mess [drinking their fluids] or they won't eat they'll be full of their drinks. -Denying resident 50's request for coffee. [Resident 50] had been asking for hours for coffee and [CNA/CMA N] kept yelling and saying NO.-Not allowing resident 35 to leave the dining room table during a meal after she [resident 35] had mentioned being full. She [CNA/CMA N] was making her [resident 35] more agitated by forcing big bites in her mouth and yelling 'EAT!'. In a similar instance, CNA/CMA Y had informed CNA/CMA N that resident 101 had finished eating when she [CNA/CMA N] tried to shove a huge bite [of food] in his mouth because 'he's [the resident ] not eating enough' and he spit it [the food] at her.-Yelling at residents quite often and I [CNA/CMA Y] feel like it creates anxiety and they [the residents] have more behaviors.-Scolding resident 16, who loves to change her outfits, for wanting to change her clothes too often. CNA/CMA N stated, You're [CNA/CMA Y] creating work for us and laundry. 2. Interviews on 12/17/25 at 10:10 a.m. and 1:45 p.m. with DON B and review of CNA/CMA N's personnel record revealed:*CNA/CMA N's date of hire was 10/15/24. She had a complete and timely background check that was reviewed. Her CNA and CMA certifications were up to date. She had completed resident rights, dementia, and abuse/neglect education in October 2025. There were two disciplinary actions (11/15/24 and 12/24/24) in her file regarding medication administration errors. DON B stated she was not aware of any concerns related to CNA/CMA N's care or treatment of residents before the 9/11/25 text she received from CNA/CMA Y.*CNA/CMA N was suspended from work on 9/11/25 at 11:00 a.m. pending an investigation of CNA/CMA Y's allegations. CNA/CMA N self-terminated after that suspension and was not interviewed regarding the allegations due to her no longer working at the facility.*Additional staff interviews completed by DON B after 9/11/25 regarding CNA/CMA N's care and treatment of residents in the Maple Valley neighborhood supported the allegations made by CNA/CMA Y. DON B confirmed the FRI was substantiated for CNA/CMA N's behaviors towards the residents. *Staff education was initiated on 9/11/25 and included a review of the provider's Abuse/Neglect policy. Staff signed and dated an individual acknowledgement of their understanding of the education that was provided for them. Beneath their signature was the following statement: This form may be used for all types of counseling, including warning records and disciplinary action records.*Two audits were initiated related to the above event. An Abuse/Neglect audit focused on the respectful treatment of residents, resident privacy, the provision of care to meet residents' needs, and staff interactions with residents during care provision. A Staff Reporting audit focused on staff observations of other caregivers, including their interactions with and treatment of residents; if an observation was considered abusive or neglectful, was it appropriately reported, and finally, the audit included whether or not the staff understood the reporting requirements in the facility's Abuse/Neglect policy.3. Interview on 12/17/25 at 10:20 a.m. with CNA/CMA AA and telephone interview on 12/17/25 at 10:40 a.m. with CNA/CMA Z confirmed they were provided education in September 2025 regarding resident abuse and neglect and the expectations for reporting resident abuse and neglect. They described the audits that occurred after the education was provided, which reinforced the importance and understanding of that education.4. Observation on 12/16/25 at 9:30 a.m. of CNA/CMA AA with resident 7 in the Maple Valley neighborhood revealed CNA/CMA AA assisted the resident into her room to complete the resident's morning grooming and personal care. There were no concerns regarding CNA/CMA AA's care or treatment of the resident.5. Observation on 12/16/25 at 10:00 a.m. of CNA/CMAs AA and BB with resident 37 in the Maple Valley neighborhood revealed that the CNA/CMAs assisted the resident into his room. They used a mechanical lift to transfer resident 37 from his wheelchair into the bathroom. After assisting the resident with his personal care, they used the mechanical lift to transfer the resident out of the bathroom and back to his wheelchair. There were no concerns regarding either CNA/CMA AA's or CNA/CMA BB's care and treatment of the resident.6. Interview on 12/16/25 at 10:15 a.m. with resident 7's spouse in the Maple Valley lounge area revealed his wife resided at the facility for about four years. He visited resident 7 each day from mid-morning until mid-afternoon. He ate lunch with his wife and participated in afternoon activities with her. He voiced no concerns related to the care and treatment staff provided his wife and the other residents in that neighborhood. 7. Observations on 12/16/25 and 12/17/25 of the Maple Valley dining room during the noon meal service revealed no concerns regarding the staff's care and treatment of the residents.8. Interview on 12/17/25 at 2:00 p.m. with administrator A revealed that he had not observed any concerns nor received any staff concerns about CNA/CMA N's care or treatment of residents before 9/11/25.9. Interview and record review on 12/17/25 at 1:45 p.m. with DON B revealed the interviews, education, and audits referenced in the provider's 9/12/25 submitted SD DOH FRI were completed and documented. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 12/17/25 after record review revealed the facility had followed their quality assurance process, education was provided to all direct care staff resident abuse and neglect, FRI-related audits were performed, and observations and interviews confirmed staff understood what constituted resident abuse and neglect as well as the expectations for reporting resident abuse and neglect.10. Based on the above information, non-compliance at F600 occurred on 9/11/25, and based on the provider's implemented corrective actions initiated on 9/11/25, for the deficient practice confirmed on 12/17/25, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to follow their policy and provide the necessary respiratory care and services for four of four sampled residents (4, 8, 10, and 49), resulting in inadequate storage, humidification, and replacement of those devices.Findings include:1. Observation and interview on 12/16/25 at 10:45 a.m. with resident 49 in her room revealed:*She was sitting in her recliner chair.*She had an oxygen concentrator machine (a machine that filters room air into pure oxygen and then delivers it through a tube with prongs that fit in the nostrils or a mask) next to the foot of her bed.*She had oxygen nasal cannula tubing (tubing that delivers oxygen through the nose) stored on top of the concentrator.-The tubing was not dated, and there was no storage bag or other container to hold the tubing when it was not in use.*A nebulizer machine (a medical device that turns liquid medicine into a mist that is then inhaled into the lungs through a mask or mouthpiece) was sitting on the floor between her two recliner chairs.*The nebulizer tubing and mask were attached to the nebulizer machine and were not dated.*The nebulizer tubing and mask were then draped over the right arm of the light green recliner.*The nebulizer mask rested on a pink plush blanket that was in the chair.-The nebulizer machine and mask were not stored on a clean barrier to protect them from potential contamination. Review of resident 49's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She was diagnosed with chronic obstructive pulmonary disease (COPD).*She had an order for oxygen via nasal cannula as needed to keep oxygen saturation greater than 90 percent.-That order started on 6/26/24.*There was no documentation on her electronic medication/treatment administration record (EMAR/ETAR) for December 2025, indicating she used oxygen.*There were no physician or nursing orders to change the humidification bottle on the oxygen concentrator or the oxygen tubing on a scheduled basis. *There were no physician or nursing orders to change the nebulizer tubing or replace the mask on a scheduled basis. 2. Observation and interview on 12/16/25 at 11:18 a.m. with resident 4 in his room revealed he had an oxygen concentrator machine next to his bed. There were no markings on the oxygen tubing or the humidifier bottle to indicate when those were last changed. He said that he used the oxygen machine when he first admitted to the facility on [DATE] but had not used it in a long time. Review of resident 4's electronic medical record (EMR) revealed he had a physician's order for Oxygen via [nasal cannula] as needed to keep oxygen saturation [greater than 90 percent]. That order was started on 11/18/25. There were no physician's or nursing orders to change the humidifier bottle or oxygen tubing on a scheduled basis. The last time it was documented that the resident used the oxygen concentrator machine was on 11/19/25, when his blood oxygen concentration was measured at 95 percent Oxygen via Nasal Cannula. 3. Observation on 12/16/25 at 2:05 p.m. of resident 8 in her room revealed*She was lying in her bed and wearing oxygen via a nasal cannula.*She had an oxygen concentrator machine next to her bed that was running and set at 4 liters.*There was a humidification bottle connected to the concentrator.-The connection tube, humidification bottle, and nasal cannula tubing were not dated.*She had a nebulizer machine on top of the wooden dresser, and the nebulizer tubing was wrapped around the machine.*The nebulizer tubing was not dated. Review of resident 8's EMR revealed:*She was admitted on [DATE].*She was diagnosed with hypoxia (low oxygen levels in the blood).*She had an order for oxygen via nasal cannula as needed to keep oxygen saturation greater than 90 percent.-That order started on 12/21/20.*She had an order that oxygen may be titrated from 1 liter up to 5 liters to maintain oxygen saturation greater than 90 percent or above every shift.-That order started on 12/1/25.*It was documented that she wore the oxygen every shift.*There were no physician or nursing orders to change the humidification bottle or the tubing on a scheduled basis. *There were no physician or nursing orders to change the nebulizer tubing or replace the mask on a scheduled basis. 4. Observation on 12/16/25 at 3:19 p.m. in resident 10's room revealed:*He had an oxygen concentrator machine next to his bed.*There was a humidification bottle connected to the concentrator.-The connection tubing that connected the humidification bottle to the concentrator was dated 10/26.-The humidification bottle was not dated.*He had a continuous positive airway pressure (CPAP) machine (a machine to treat sleep-related breathing issues) on top of the dresser next to the bed.-The oxygen tubing on the concentrator that connected to the CPAP was dated 10/26.*The oxygen tubing was on the floor, and there was no storage bag or other container to hold the tubing when it was not in use to protect it from potential contamination. Review of resident 10's EMR revealed:*He was admitted on [DATE].*He was diagnosed with obstructive sleep apnea (a sleep disorder where breathing repeatedly stops and starts during sleep) and acute respiratory failure with hypoxia (low oxygen levels in the blood).*He had an order to wear the CPAP per home settings at night. -That order started on 4/24/24.*It was documented that he wore the CPAP every night.*He had an order for oxygen via nasal cannula as needed to keep oxygen saturation greater than 90 percent.-That order started 9/17/25.*There were no physician or nursing orders to change the humidification bottle or the oxygen tubing for his concentrator and CPAP on a scheduled basis. 5. Interview on 12/17/25 at 9:50 a.m. with registered nurse (RN) G regarding respiratory equipment in resident 10's room revealed:*She was unsure if the oxygen tubing residents used was changed every two weeks or once a month.*She stated that the oxygen tubing should be dated and stored in a bag when it was not in use.*Oxygen tubing was to be replaced by the night shift when the task was generated on the resident's EMAR/ETAR.*She stated that staff received annual oxygen training that was offered in the spring and fall.*She confirmed that resident 10's oxygen and connection tubing were dated 10/26.*She agreed that it had not been changed in over a month and removed the tubing. 6. Interview on 12/17/25 at 10:08 a.m. with RN/neighborhood leader H revealed:*She stated oxygen tubing for residents was to be changed every two weeks, dated, and possibly initialed by the staff who changed the tubing.*Oxygen tubing was to be in a storage bag when it was not in use to protect it from potential contamination.*She stated that the humidification bottles on the oxygen concentrators were to be changed on the same schedule as the oxygen tubing. 7. Interview on 12/17/25 at 10:42 a.m. with RN/neighborhood leader I revealed:*She was unsure when oxygen and nebulizer tubing for residents were to be changed. 8. Interview on 12/17/25 at 10:51 a.m. with director of nursing (DON) B revealed:*She stated that the residents' oxygen tubing was to be replaced twice monthly, and the nebulizer tubing and the mask/pipe were to be replaced every seven days according to their policy.-All oxygen and nebulizer tubing and supplies were to be dated and initialed by the staff when they were changed.*The night shift nursing staff were primarily responsible for the task of replacing the oxygen and nebulizer tubing as scheduled, but on occasion, this task could be assigned to the day shift nursing staff to complete. *There was to be a storage bag for the oxygen tubing to be stored in when it was not in use, and it was to be dated and initialed by the staff who changed it.*She stated staff were expected to place a clean barrier for the storage of the nebulizer mask/pipe to be stored on when not in use. *It was her expectation that nebulizer machines should not be stored on floors because dirty floors were a potential source of infection.*It was her expectation that oxygen tubing should be replaced twice a month and nebulizer tubing should be replaced once a week. -The supplies should be dated, initialed by staff who changed them, and appropriately stored. Review of the providers reviewed 10/25 Oxygen Administration policy revealed:*Preparation:-1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.*Steps in the Procedure:*Cleaning Schedule:-1. Oxygen tubing and humidifier: changed the 1st and the 15th of the month and as needed along with the storage bag.-2. Oxygen tubing, humidifier, and storage bag should be dated and initialed when changed. Review of the providers reviewed 12/25 Administering Medications through a Small Volume (Handheld) Nebulizer policy revealed:*Preparation:-1. Obtain a physician's order as needed.- .17. Rinse the nebulizer equipment according to facility protocol, or:--a. wash pieces with warm, soapy water;--b. rinse with hot water;--c. allow to air dry on a paper towel or in nebulizer drying bags.- .19. Change equipment, tubing, and drying bag every seven days. Equipment should be dated and initialed when changed.-20. Disinfect outside of the Nebulizer Machine between residents, according to manufacturer's instructions.

Based on observation, interview, and policy review, the provider failed to:*Ensure staff members followed proper storage and cleaning procedures for both clean and dirty utility rooms in two of the four facility neighborhoods ([NAME] Creek and [NAME] Wood) to prevent the spread of infection.*Discard products found in one of four resident neighborhoods, such as hand sanitizer and germicidal (germ-killing) wipes, on or before the expiration date which had the potential to affect all people in the facility.Findings include:1. Observation on [DATE] at 2:03 p.m. in the common area outside the beauty/barber shop revealed an automatic hand sanitizer dispenser on the wall. The hand sanitizer had expired on [DATE]. 2. Observation on [DATE] between 2:16 p.m. and 2:24 p.m. in the soiled utility room of the [NAME] Creek neighborhood revealed: *A four-product disinfectant dispensing system that was mounted inside the door on the left wall with black and white discharge tubes and hoses connected to dispense the chemicals. *An unconnected, black discharge hose, approximately five feet long, was coiled up and lying in the bottom of the drain tub. *The caulking around the drain tub had a black substance coating it. *There was a stainless steel two-compartment sink with counterspace cluttered with chemicals, glass jars, vases, and a pink basin of items. *One compartment of the sink contained a white bucket with dirty water that had a white film on the top. *The counter space on the left side of the sink contained two opened containers of Micro-Kill disinfectant. -The lids were off and faced down, lying on the countertop next to a dirty micro-fiber rag and a blue writing pen. *The right side of the counter space contained three empty glass jars and one empty glass flower vase. *The right side of the counter space contained a pink basin that held a container of Lime-Away, a spray bottle of Clorox Urine Remover, a plastic bag that contained instructions for the splash guard (a shield to prevent splashing by blocking liquid waste and protecting workers), and a soiled blue and white sponge. *Four floor tiles under the left side counter space of the sink had a dry white film substance on them. *An empty cardboard box was on the floor near the left side of the sink. *There were three empty clothes baskets on the floor under the right side of the counter space. *The soiled hopper sink (a plumbing fixture that safely disposes of liquid or semi-solid biological waste) was missing the splash guard. -The splash guard was lying on the floor between the hopper and the hand-washing sink. *The rinse hose was hanging from the holder and submerged in the dirty water of the hopper sink. *The hopper sink had a strip of black sticky material approximately ten inches long that ran along the front edge, where the splash guard had once been attached. *There were no gowns, gloves, or goggles available near the hopper for staff use. *Areas of the floor were visibly soiled with dirt, lint, and dust fibers. 3. Observation on [DATE] between 2:25 p.m. and 2:34 p.m. in the clean utility room of the [NAME] Creek neighborhood revealed: *A sign posted on the door read: CLEAN UTILITY ROOM: ONLY ITEMS THAT ARE CLEAN OR HAVE BEEN CLEANED CAN BE IN HERE. *On the floor just inside the door, along the left wall, was an oxygen concentrator machine that appeared dirty. *It had a humidification bottle that contained approximately 1/3 of water and a connection tube attached. *There was a black wire storage container on the floor that had a gray bin, and a black wall-mount clock stored in it. *There were two large boxes and two small boxes of Halloween decorations stacked on top of two white laundry baskets stored on the floor. *On the floor just inside the door, along the right wall, there was a white three-drawer bin, and the drawers were visibly dirty with lint, material fibers, and dirt. *There were four large white clothes baskets stacked on top of each other and stored on the floor next to the three-drawer bin. *There was a large opened cardboard box on the floor that contained yellow disposable gowns, boxes of N95 respirator masks, and clear plastic mountable file holders. *There was a tall wooden stand with four visibly dusty compartments stored on the floor, and a nebulizer machine that appeared dirty stored on top of it. *On the floor was a large box with Halloween and fall decorations, with a large, clear garbage bag of fall decorations stored on top of it. *The left countertop next to the sink stored two unopened cardboard boxes of hand soap, two unopened boxes, and one opened box of N95 respirator masks, which could have become wet if someone washed their hands at the sink. 4. Observation on [DATE] between 2:35 p.m. and 2:45 p.m. in the soiled utility room of [NAME] neighborhood revealed: *A four-product disinfectant dispensing system that was mounted inside the door on the right wall with black and white discharge tubes and hoses connected to dispense the chemicals. *An opened multi-surface disinfectant container was stored on the floor in front of the drain sink. -The disinfectant had one end of a white discharge tube placed into the opening of the black lid, while the other end of the discharge tube was lying on the visibly soiled floor next to the drain sink. *The caulking around the drain tub had a black substance coating it. *A yellow mop bucket that appeared dirty was stored in the drain sink. *A clear discharge hose, stained brown, contained brown and black residue on the inside of the tube and was coiled around the cold-water faucet handle. *The wall behind the drain sink was coated in dirt and a layer of brown film. *A tan wheeled cart cluttered with paint supplies was placed just inside the door, which blocked the entrance and needed to be moved to access the room. *There was a stainless steel two-compartment sink with counter space cluttered with various items and chemicals. *The right side of the counter space contained five opened containers of cleaning chemicals. -The spray nozzle for the opened container of multi-surface peroxide was stored next to it. *There was a large black bucket in one sink compartment that contained used paint rollers and supplies with water that had formed a milky-gray film on top. *A visibly soiled white bath towel was draped over the right edge of the sink. *The left side of the counter space was blocked by a cupboard door approximately four feet tall and a large black and yellow wheeled floor cleaning machine. *The stainless steel two-compartment sink with counterspace contained a white bucket with dirty water in one compartment of the sink that had a white film that formed on top of the water. *The soiled hopper sink was missing the splash guard, and it was lying on the floor up against the wall next to a black trash bag. -The hopper sink had a paint pan with dried paint stored on top of it. *The hopper sink had a strip of black sticky material approximately ten inches long that ran along the front edge, where the splash guard had once been attached. *There were no gowns, clean gloves, or goggles available near the hopper for staff use. *There were two fans visibly soiled with dust fibers and a small black and green spot cleaner with an attached hose stored on the floor in front of the handwashing sink. *There were two opened boxes of large and medium disposable gloves stored on the sink behind the handwashing faucet. -The gloves in the medium box were visibly stained and dirty with a dried, dark brown liquid substance. *The dark-brown liquid substance was noted at the bottom of the sink around the drain, and the sink tub was visibly soiled with dirt and brown film. *There was a white lid for a chemical container stored on the inside ledge of the sink, and there were white lids for chemical containers on the floor under the sink. *The floor was visibly soiled with dirt, lint, and dust fibers.*The right countertop next to the sink stored four large cardboard boxes of unopened copy paper, which could have become wet if someone washed their hands at the sink. -On top of a box of copy paper was a brown wicker basket that contained a silk flower arrangement. *The floor was visibly soiled with dirt, lint, and dust fibers. 5. Observation on [DATE] at 2:36 p.m. in the [NAME] Creek whirlpool tub room revealed that there was an automatic foaming hand sanitizer dispenser on the wall. The bottle of hand sanitizer product had a manufacturer's expiration date of [DATE] according to the label. In a cupboard under the sink, there was a container of Micro-Kill AF2 disinfecting wipes with a Best By date of [DATE] according to the manufacturer's label. There was another container of SANI-CLOTH BLEACH germicidal wipes with an expiration date of 03/2021. There was a date of Opened on [DATE] handwritten on that container. A second container of the SANI-CLOTH BLEACH germicidal wipes had an expiration date of 03/2024. 6. Observations throughout the [NAME] Creek neighborhood on [DATE] from 2:45 p.m. to 2:53 p.m. revealed there were several bottles of green aloe hand sanitizer throughout the [NAME] Creek unit that were expired. There were three bottles of the aloe hand sanitizers on shelves outside of resident 9, 12, and 58's rooms. The bottles outside of resident 9's and 58's room had expiration dates of [DATE]. The bottle outside of resident 12's room had an expiration date of [DATE]. 7. Observation on [DATE] between 2:46 p.m. and 2:55 p.m. in the clean utility room of [NAME] neighborhood revealed: *On the floors inside the door, along the left and right walls, were multiple cardboard boxes of opened and unopened supplies that lined the entire length of both walls. *Between the two walls, adjoined a countertop with a sink and cupboards that were blocked with opened and unopened cardboard boxes of supplies on the floor. *Some opened cardboard boxes contained toilet paper, hand soap, and chemicals. *The countertop sink and cupboards were also blocked by a black three-shelf cart on wheels that had a piece of masking tape posted on the middle shelf that read: MAINTENANCE. *The black wheeled cart was cluttered with cans of paint, green hose, cardboard boxes, a pink bin that stored light bulbs, and other unidentified maintenance supplies. *The countertops next to the sink were cluttered with used paint supplies and other items. *The left countertop stored used paint brushes, paint sticks, paint cans, rollers, roller handles, plastic bags, chemicals, a spray bottle of paint, a package of peri-wipes, and a large box of trash liners. *The right countertop stored used paint containers, paint sticks, paint pans, and a stack of white paint sheets. *The sink contained used paint pans and containers with dirty paint supplies stored in them. -The sink and the wall behind the sink were soiled with dried tan paint and covered with a white film. *There was trash, cardboard, and empty spray bottles on the floor. *The floor was visibly soiled with dirt, lint, and paint fibers. 8. Observation on [DATE] at 2:54 p.m. in the dirty utility room on the [NAME] Creek neighborhood revealed that the protective shield for the hopper (a type of flushing sink with a spray hose nozzle used for rinsing soiled laundry prior to washing) was not attached. It was sitting on the floor underneath the handwashing sink. There was no personal protective equipment (PPE), such as aprons, face shields, and gloves, available in the dirty utility room for staff to use if they needed to rinse soiled laundry. 9. Observation on [DATE] at 2:54 p.m. in the [NAME] Creek neighborhood clean utility closet revealed there were at least two containers of germicidal wipes that were expired. One container of Micro-Kill Bleach wipes were open to air and the wipes were dry. That expiration date was [DATE]. Another container of SANI-CLOTH BLEACH wipes was also open to air and dry, with an expiration date of 03/2024. 10. Observation and interview on [DATE], starting at 3:00 p.m. with assistant director of nursing (ADON) C in the clean and soiled utility rooms of [NAME] Creek and [NAME] neighborhoods revealed: *She stated it was the maintenance and housekeeping's responsibility to maintain and keep those areas organized and clean. *She confirmed that the clean and soiled utility rooms in both neighborhoods were cluttered, unkept, and could pose safety risks for staff. *She expected that all utility rooms in the neighborhoods should be organized, well-maintained, and cleaned by the maintenance and housekeeping departments. 11. Observation on [DATE] at 3:01 p.m. in the [NAME] Creek neighborhood dry storage room revealed several cases of the green aloe hand sanitizer that had an expiration date of [DATE]. There were other various partially used bottles of hand sanitizer that had all expired over a year ago. 12. Observation on [DATE] at 3:07 p.m. in the hallway between the [NAME] Creek neighborhood clean utility, dirty utility, and dry storage rooms revealed there was a plastic set of drawers. It appeared to have been a transmission-based precaution supply kit that contained personal protective equipment and signage for enhanced barrier precautions. There was a container of Micro Kill AF2 wipes with a Best By date of [DATE]. 13. Observation on [DATE] at 9:46 a.m. in the kitchen revealed there were at least two bottles of green aloe hand sanitizer, one with an expiration date of [DATE], and the other with an expiration date of [DATE]. 14. Interview on [DATE] at 3:24 p.m. with ADON C revealed that the automatic hand sanitizer dispensers were managed by the maintenance department. She said, I would like to tell you there's a process for checking expiration dates, but there isn't one. She confirmed there was no set process to check the expiration dates on the hand sanitizers or germicidal wipes. She was not aware of the expired hand sanitizer bottles throughout the [NAME] Creek neighborhood. She expected staff to check the product dates before using it, and to discard the product and find a replacement if the product was expired. 15. Interview on [DATE] at 10:57 a.m. with maintenance supervisor E and housekeeping O revealed: *They both agreed and confirmed that the clean and soiled utility rooms in both neighborhoods were cluttered, unkept, and could pose safety risks for staff. *They both agreed that it was the maintenance and housekeeping staff's responsibility to keep those areas maintained, organized, and clean. 16. Interview on [DATE] at 11:18 a.m. with director of nursing (DON) B revealed: *She stated it was the maintenance and housekeeping's responsibility to maintain and keep resident rooms and all facility areas organized and clean. *She expected that all resident rooms and utility rooms in the neighborhoods should be organized, well-maintained, and cleaned by the maintenance and housekeeping departments. Review of the provider's [DATE] Infection Prevention and Control Committee policy revealed:*1. The objectives of the infection prevention and control program (IPCC) are to:-.b. provide facility guidelines for a safe and sanitary environment;-c. review, establish, and monitor environmental infection prevention and control practices in accordance with CDC/HICPAC/OSHA guidelines and local or state requirements;*.8. Assist in monitoring and assessing facility-wide environmental infection prevention and control practices.*.13. Collaborate with environmental services director to establish policies and procedures that are consistent with environmental infection prevention and control best practices.*Risk Exposure Categories: The infection prevention and control committee shall advise the administrator about working conditions and specific tasks that employees are expected to encounter that may pose an infection risk, including:-b. developing, or supervising the development of, standard operating procedures (SOPs) for tasks involving exposure to blood/body fluids. These SOPs include mandatory work practices and protective equipment for identified tasks.-c. monitoring the effectiveness of work practices and protective equipment. This includes:--(1) surveillance of the workplace to ensure that required work practices are observed and that protective clothing and equipment are provided and properly used. Review of the provider's [DATE] Maintenance Service policy revealed: *Policy Interpretation and Implementation. -1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. -2. Functions of maintenance personnel include, but are not limited to: -.b. maintaining the building in good repair and free from hazards. - i. providing routinely scheduled maintenance service to all areas. - 5. Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments. -6. The maintenance director is responsible for maintaining the following records/reports: -.b. Work order requests. -7. Records shall be maintained in the maintenance director's office. -8. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

Based on observation, interview, and policy review, the provider failed to ensure a coffee maker/hot water dispenser in the Maple Valley neighborhood dining area was securely stored to protect the safety of vulnerable residents.Findings include: 1. Observation on 12/16/25 at 9:45 a.m. in the Maple Valley neighborhood (residential living area) revealed it was a memory care unit (an area where specialized care is provided in a structured, safe, and supportive environment to meet the unique needs of residents with significant memory and cognitive decline, that is secured to minimize unsafe wandering). The unit's dining area was large and opened into a living room and a lounge area for the residents. Residents used the dining area not only for meals and snacks but also for structured social activities. Some of the six to eight residents who were present in the dining area during the observation walked independently or with the use of an assistive device, such as a walker. Other residents relied on the staff for their mobility. There was a countertop that extended the length of a wall on one side of the dining area. There was a set of tall cabinet doors on top of the countertop. The cabinet doors were positioned close enough to the edge of the countertop to be easily opened. There was an approximate one-inch gap when the two cabinet doors were closed. There was a broken, plastic safety device near the top of the cabinet doors to prevent the doors from opening. There was a cam lock (an L-shaped locking mechanism used to secure a cabinet door) towards the bottom of the right cabinet door. It was not engaged. Nothing prevented the cabinet doors from being opened. Behind the unsecured cabinet doors was a coffee maker that was equipped with a coffee warmer and a hot water dispenser. It was turned on and able to dispense hot liquids. 2. Observation on 12/17/25 at 3:45 p.m. in the Maple Valley dining area revealed that the above cabinet doors were closed and nothing prevented them from being opened. The temperature of the water dispensed from the hot water dispenser was tested by the surveyor, and it was 170 degrees. That was hot enough to have caused a third-degree burn if it had touched a resident's skin. 3. An interview conducted at the same time with certified nurse aide (CNA) X revealed that residents who had wandered towards the unsecured cabinet doors were redirected by staff before they were able to open the doors. CNA X was unsure how long the plastic security device on the cabinet door had been broken or if the maintenance department was aware that it needed to be fixed. She had not known where or if there was a key to secure the cam lock on the cabinet doors. She was not aware of any resident burn injuries related to a resident accessing hot beverages from behind those cabinet doors. She confirmed that the hot liquid temperature posed a burn risk if a resident accessed that machine. 4. Interview on 12/17/25 at 4:00 p.m. with administrator A and maintenance supervisor E regarding the above cabinets in the Maple Valley dining area revealed that they were not aware that the safety devices on the cabinet doors were either broken or unable to be used. It was expected that the staff would have promptly notified the maintenance department of this failure, so a temporary measure could have been implemented to ensure the residents' safety from a potential burn from the coffee maker/hot water dispenser until a permanent solution was in place. Review of the provider's January 2025 Hot Liquids Burn Prevention policy revealed 2. The cabinet containing hot liquids on Maple Valley is to remain inaccessible by use of childproof locks. Staff on Maple Valley also provide oversight to ensure that residents are not accessing hot liquids when they are unable to do so safely.

Based on observation, interview, and policy review, the provider failed to ensure that one of two medication carts was secured while administering medications.Findings Include:1. Observation on 12/17/25 at 11:35 a.m. of licensed practical nurse (LPN) K revealed:*LPN K had walked away from the [NAME] Way medication cart to talk to a resident in the dining area and had left the medication cart unsecured and unattended.*LPN K was not standing at the medication cart and returned to lock the cart at 11:41 a.m.*Several residents were seated in the dining area. 2. Interview on 12/18/25 at 11:00 a.m. with LPN K revealed:*She recalled walking away from the medication cart and not locking it on 12/17/25.*She reported she made a mistake, and she usually locked it when she walked away from it. The medication cart should have been locked each time she walked away from it to ensure it was secured from unauthorized access. 3. Interview on 12/18/25 at 12:00 p.m. with registered nurse (RN) neighborhood leader I revealed:*She witnessed LPN K when she walked away from the medication cart on 12/17/25.*She expected the medication cart to be locked anytime the employee administering medications walked away from it.*She confirmed that medications should be secured at all times. 4. Review of the provider's 1/2025 Security of a Medication Cart policy revealed:*The nurse/medication aide must secure the medication cart during the medication pass to prevent unauthorized entry.*Medication carts must be securely locked at all times when out of the nurse's/medication aide's view.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (19), who had a medication pill at his bedside, was assessed for the ability to safely self-administer medications and had a physician's order to self-administer medications according to the provider's policy.Findings include:1. Observation and interview on 12/16/25 at 4:12 p.m. with resident 19 in his room revealed there was a small white oval pill in a plastic medication cup sitting on his bedside table. The pill had 0164 stamped on one side, and the letter R stamped above the number 5 on the other side. Resident 19 said that if he is sleeping, staff would leave his pills on his bedside table so he could take them later. He swallowed the medication at that time with a drink of water.2. Review of resident 19's electronic medical record (EMR) revealed that he was admitted to the facility on [DATE]. He did not have a physician's order to self-administer any medications. There was no record of medication self-administration assessments. His current care plan did not include any medications that he could self-administer.3. Interview on 12/17/25 at 10:00 a.m. with certified nursing assistant (CNA) L revealed that she was also a certified medication aide (CMA). Resident 19 was independent with activities of daily living (ADLs) such as getting up from his bed, walking, brushing his teeth, and changing clothes. She did not know if he had an order for medication self-administration. She explained that sometimes, resident 19 would become upset if staff stood there to watch him take his medications.She confirmed that if a resident did not have an order to administer their medications by themselves, staff were to observe the resident take their medications rather than leave the medications with the resident.4. Interview on 12/17/25 at 10:13 a.m. with neighborhood leader (NL) W revealed that she confirmed that resident 19 did not have an order for medication self-administration. She confirmed that at around the time the pill was found on 12/16, resident 19 would have been given his olanzapine (an atypical antipsychotic medication).NL W unlocked the medication cart and confirmed the small white oval pill with 0164 stamped on one side, and the letter R stamped above the number 5 on the other side was resident 19's olanzapine.She expected the licensed nurses and CMAs to watch the resident take their medications if the resident did not have an order to self-administer their medications. She stated that if a resident wanted to self-administer their own medications, the nurse and resident would complete a medication self-administration assessment, contact the physician, and update the resident's orders.Continued interview on 12/17/25 at 10:40 a.m. with NL W revealed that she contacted the nurse who was working on 12/16/25. That nurse said that she thought she saw him take the pill, so she did not know why the pill was still in the medication cup when it was observed by the survey team on 12/16/25 at 4:12 p.m. that day.5. Interview on 12/17/25 at 3:32 p.m. with assistant director of nursing (ADON) C revealed that resident 19's medications should not have been left in his room. The person administering his medications should have observed resident 19 take his medications and ensured that he actually took them. She confirmed that resident 19 had not been assessed to take his medications by himself, and he did not have a physician's order for medication self-administration.6. Interview on 12/17/25 at 4:00 p.m. with director of nursing (DON) B revealed that if a resident did not have an order for medication self-administration, the staff person administering the medications should be observing the resident take their medications.She confirmed that resident 19 did not have an order to self-administer his medications.She explained that if a resident wished to self-administer their medications, the nurse assessed the resident's cognition and filled out the Self-Administration of Medications form. That form consisted of quizzing the resident on what each medication was, what was it prescribed for, what the potential side effects were, what the dosage was, what route was it to be administered, and what time it should be administered. If the resident could not confidently list each topic for the medication, they could not safely self-administer their own medications.7. Review of the provider's 1/2025 Self-Administration of Medications policy revealed that the policy interpretation and implementation section contained the following items: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 2. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident:a. The medication is appropriate for self-administration;b. The resident is able to read and understand medication labels;c. The resident can follow directions and tell time to know when to take the medication;d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff; ande. The resident is able to safely and securely store the medication. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. 4. If the team determines that a resident cannot safely self-administer medications, the nursing staff [will] administer the resident's medications.6. Self-administered medications are stored in a safe and secure place. 7. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

Based on observation, interview, and policy review, the provider failed to maintain resident rooms in a clean and well-kept manner, free from damage to walls, for two of two sampled residents (10 and 17) in one of four facility neighborhoods (Cottonwood Court).Findings include:1. Observation on 12/16/25 at 10:16 a.m. in resident 10's room and interview on 12/17/25 at 11:50 a.m. with resident 10 in a resident common area between the neighborhoods revealed:*There were at least three gouges with chipped paint, which were approximately quarter-size, and a gouge with exposed drywall about half-dollar size, in the left wall, between two to three feet above the floor, just inside the resident's door. Additionally, there were vertical scratch marks with chipped paint along the entire length of the left wall. *There were at least three gouges with chipped paint that ranged from one to four inches in size, and vertical scratch marks with chipped paint on the wall to the right, just outside of his bathroom. Additionally, there were vertical scratch marks with chipped paint on the bathroom door frame. *There was a vertical gouge in the wall behind his oxygen concentrator (a machine that takes room air and delivers pure oxygen through a nasal cannula or mask) that was approximately six inches in size.*Along the baseboard beneath his window, there was a vertical gouge about five inches long with exposed drywall and chipped paint. Additionally, there were at least 12 gouges, ranging from the size of a pencil eraser to a dime, along with vertical scratch marks and chipped paint that extended for most of the wall's length. *The resident stated that he accidentally caused the big gauges in the walls when he caught his electric wheelchair on the bed, which caused the bed to hit the wall.*The resident stated that the minor gouges and scratch marks were caused by him moving his electric wheelchair too close to the walls. 2. Observation and interview on 12/16/25 at 10:26 a.m. in resident 17's room revealed:*There were at least six gouges with chipped paint, each about the size of a pencil eraser, and a vertical gouge with chipped paint, approximately two inches long, in the left wall, about two feet above the floor, just inside the resident's door. Additionally, there were vertical scratch marks with chipped paint along the entire length of the left wall. *Along the baseboard of that same wall, there were at least three additional gouges with chipped paint that ranged from dime to quarter size, and vertical scratch marks with chipped paint. *There were at least nine gouges with chipped paint that ranged from a pencil eraser to quarter-size in the right wall, about two feet above the floor, just inside the resident's door.*There were four vertical gouges with exposed drywall on the wall between the resident's bed and his three-drawer wood dresser, approximately three to six inches in size. *There was a hole with exposed drywall and chipped paint in the wall behind the resident's bed, approximately the size of a football.*The resident stated that he caused the damage to the walls by accidentally running his electric wheelchair into them, or when he had maneuvered it too close to the walls. 3. Interview on 12/18/2025 at 10:20 a.m. with registered nurse (RN) G revealed:*Staff were to complete a maintenance request form when they needed something repaired in the facility. *The forms were located on the wall outside the maintenance room door.*She stated that the maintenance office was located in the [NAME] neighborhood. *She stated that maintenance staff had applied bumpers to residents' beds and placed sandbags behind resident recliner chairs to help prevent damage to the walls.*She stated maintenance staff responded pretty quickly to the request forms completed by staff. 4. Interview on 12/18/2025 at 10:32 a.m. with certified nursing assistant/certified medication aide (CNA/CMA) M revealed:*Staff were to complete a maintenance request form and turn it into the maintenance box when something needed to be repaired in the facility. *She said that staff could call the maintenance staff with an issue, but they would also be asked to fill out a repair form for it. *She stated that the maintenance staff responded quickly to things that needed to be repaired. 5. Interview on 12/18/2025 at 10:57 a.m. with maintenance supervisor E and housekeeping O revealed: *The request/repair requisition forms for maintenance-related work requests were stored in a box attached to the wall in the hall, next to the maintenance office door, labeled work order forms.*Staff members were to complete a form if something required a repair and put the completed form in the box with the slot labeled repair requests. *Request forms for repairs were addressed promptly by maintenance staff to ensure the most critical issues were addressed first to maintain resident safety. *Housekeeping O stated that it was hard to repair damaged walls in resident rooms when residents were in their rooms.*Maintenance supervisor E stated that discussions with management had been held to apply bumper pads on walls to help prevent damage in the residents' rooms.*They both clarified that they were aware of the damaged walls in residents 10 and 17's rooms. *They both agreed that it was the maintenance and housekeeping staff's responsibility to keep those areas maintained, organized, and clean. 6. Interview on 12/18/2025 at 11:18 a.m. with director of nursing (DON) B revealed: *She stated it was the maintenance and housekeeping's responsibility to maintain and keep resident rooms and all facility areas organized and clean.*She expected that all resident rooms and utility rooms in the neighborhoods should be organized, well-maintained, and cleaned by the maintenance and housekeeping departments. Review of the provider's January 2025 Maintenance Service policy revealed:*Policy Interpretation and Implementation.-1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.-2. Functions of maintenance personnel include, but are not limited to:-.b. maintaining the building in good repair and free from hazards.- i. providing routinely scheduled maintenance service to all areas.- 5. Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments.-6. The maintenance director is responsible for maintaining the following records/reports:-.b. Work order requests.-7. Records shall be maintained in the maintenance director's office.-8. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, observation, record review, and policy review, the provider failed to ensure certified nursing assistant (CNA) L had used the whirlpool bath chair safety belt according to the provider's policy during resident 6's bath, CNA K had used the whirlpool bath chair safety belt according to the provider's policy during resident 7's bath, and CNA M had followed resident 4's care plan regarding safe transfers with the mechanical lift equipment. Resident 6 fell out of the bath chair and sustained a pelvic fracture. Resident 7 fell out of the bath chair and sustained multiple fractures to her lower spine, pelvis, and tibia. Resident 4 was transferred using the wrong mechanical lift equipment according to her care plan, and sustained leg bruising and a tibia fracture. Residents 4, 6, and 7 were hospitalized related to their injuries. This citation is considered past noncompliance based on review of the corrective actions the provider implemented immediately following the incidents. Findings include: A. 1. Review of the provider's 8/14/25 final FRI submitted to the SD DOH revealed that on 8/11/25 at around 7:15 a.m., CNA L was giving resident 6 a bath in the whirlpool tub. CNA L had removed the whirlpool chair safety belt to cleanse the resident's skin folds and turned away from the resident to grab the nail clippers. While she was turned away, resident 6 fell forward out of the bath chair. Registered nurse (RN) N was alerted and came to the whirlpool room to assess the resident. Her statement indicated that the bath chair was at her waist height and the brakes were not engaged. RN N assessed resident 6 for injuries and noted that her left elbow was reddened and started to swell. Resident 6 reported she was in pain but was unable to verbalize where she was having pain. Four staff members were able to lift her from the floor using the full body mechanical lift (a device with a sling used to transfer a person's full body). Staff later attempted to transfer the resident with the stand aid mechanical lift (a device used to assist a person from a seated position to a standing position), but resident 6 displayed pain and difficulty with standing. Resident 6's power of attorney (POA) was notified of the incident and agreed to have X-ray imaging of the resident performed at the facility. The X-ray showed that the left part of [resident 6's] pelvis was clearly broken. Resident 6 was sent to the local emergency department, where it was confirmed that she had a pubic rami [the bones that connect the front of the pelvis to the hip bones] fracture that was nonsurgical [would not be repaired by surgery]. The provider suspended CNA L on 8/11/25 pending their internal investigation. The provider reviewed the policy for bathing on 8/11/25 and documented that all nursing staff were educated on [8/14/25] or prior to their next working shift. A bathing audit was started on 8/15/25 which would include ensuring the bath belt is in place. Audit expectations are 10 audits for 2 weeks and 5 audits for 2 weeks. CNA L was terminated on 8/15/25 as she admitted to removing the bath belt prior to being ready to transfer [resident 6]. 2. Review of resident 6's electronic medical record (EMR) revealed that she sustained a pubic rami fracture because of the fall from the whirlpool bath chair on 8/11/25. She was sent to the emergency department on 8/11/25 and returned to the facility on 8/13/25. Her primary care provider (PCP) ordered Oxycodone HCl [hydrochloride] Oral Tablet 5 MG [milligrams] Give 2.5 mg by mouth every 4 hours as needed [PRN] for Pain that started on 8/14/25. She received that PRN pain relief medication 17 times in August, one time in September, and had not received that medication in October through the end of the survey. 3. Observation and interview on 10/20/25 at 4:17 p.m. with resident 6 revealed that she was resting in bed. Her bed was in the lowest position to the floor, and there was a cushioned floor mat next to her bed. She could not remember falling out of the bath chair. She denied any current pain. 4. Review of the provider's 8/15/25 final FRI submitted to the SD DOH revealed that on 8/14/25 at around 6:30 a.m., CNA K was giving resident 7 a bath in the whirlpool tub. CNA K removed the whirlpool chair safety belt to dry the resident off with a towel. CNA K turned around to throw the towel in the basket and resident 7 leaned forward and fell out of the chair. Licensed practical nurse (LPN) O came to evaluate the resident for injuries. CNA K stated that [resident 7] definitely hit [her] head and landed on [her] knees. Resident 7 had an abrasion and bruising on the top of her head and reported that her right knee was hurting. Resident 7's right kneecap appeared to be sitting more lateral [to the side] than what would be normal. The resident was not able to extend her knee. Resident 7 was sent to the local emergency department where it was determined she has a hip and pelvic fracture and a possible knee fracture. CNA K was provided with immediate education on bath chair use and safety. As stated in the FRI from the 8/11/25 incident with resident 6, the provider educated all staff on bath chair use and safety on 8/14/25 or prior to their next working shift. In addition to the staff education, the environmental services director assessed all bath chairs on 8/15/25 and determined [the bath chairs] to be in functional working order. The audits to verify bathing safety compliance were a continuation of the above-described audits initiated for the 8/11/25 FRI regarding resident 6's fall. 5. Review of resident 7's EMR revealed that she fell out of the bath chair on the morning of 8/14/25 and was transferred to a local emergency department. She readmitted to the facility on [DATE] with new diagnoses of fracture of unspecified parts of lumbosacral spine [the lower portion of the spine] and pelvis, unspecified fracture of unspecified acetabulum [the socket of the hip bone], and displaced bicondylar fracture of right tibia [two fractures at the top of the tibia, below the kneecap]. Upon readmission on [DATE], she was noted to have an abrasion and bruising on the top of her head, scattered bruising to her upper extremities, and multiple surgical incisions to her pelvic and pubic areas. She experienced increased pain and anxiety after she readmitted to the facility. Resident 7's PCP made several medication changes such as hydroxyzine, buspirone, duloxetine, and lorazepam for anxiety, and oxycodone, tramadol, methadone, acetaminophen, lidocaine patches, diclofenac external gel, and buprenorphine transdermal patches for pain management. Resident 7 continued to decline in health status, was suspected to have contracted an infection, and was prescribed antibiotics on 9/2/25. She was transferred to the local emergency department on 9/3/25 due to throwing up and low oxygen saturation levels. She was placed on intravenous antibiotics in the hospital due to suspected pneumonia and a urinary tract infection. She returned to the facility on 9/3/25. Resident 7 was admitted to hospice services on 9/4/25 and was discharged to a local inpatient hospice provider on 9/10/25. 6. Interview on 10/20/25 at 4:50 p.m. with CNAs D and J revealed that they were aware of resident 6's fall that occurred on 8/11/25 and resident 7's fall on 8/14/25. They confirmed there was education provided recently on proper bathing procedures and the use of the whirlpool chair safety belt. They indicated that the policy was to have two staff members assisting with all resident transfers when using the mechanical lift equipment. 7. Interview on 10/20/25 at 4:54 p.m. with CNA F revealed that the bathing education involved in-person demonstrations on how to properly use the safety strap on the whirlpool chair safety belt. She stated that it was facility policy to have two staff members present for all resident transfers when using the mechanical lift equipment. 8. Interview on 10/21/25 at 11:18 a.m. with DON B revealed that CNA L's employment was suspended on 8/11/25 after resident 6's falling incident, pending their investigation per their policy. Verbal education was provided by the nursing managers to all nursing staff on 8/14/25 on proper use of the whirlpool chair safety belt. The leadership team met on 8/11/25 and reviewed and revised the bathing policy and procedures and started to develop a formal education and audit plan. On 8/14/25, each neighborhood nurse leader held a meeting with the staff present on each unit and demonstrated proper bathing procedure education with an emphasis on using the safety belt. The staff who were not present at the facility on 8/14/25 were provided education by phone to ensure everyone received the education timely. The audits consisted of observations of staff performing resident baths. The audits were completed for 10 observations for two weeks, then five audits for an additional two weeks. After that time, she submitted the audit data to the provider's quality assurance and performance improvement (QAPI) committee for review and recommendations. The QAPI committee recommended to discontinue those audits at that time due to sufficient compliance with the provider's bathing policy. 9. Review of the provider's bathing incident investigation documentation confirmed that the director of nursing (DON), assistant director of nursing (ADON), and the neighborhood leaders (NHLs) provided education to all nursing staff related to proper bathing procedures and the use of the whirlpool chair safety belt on 8/14/25. Staff who received that education in-person signed documents confirming the education was provided. Staff who were not present for the education were called and provided the education over the phone by the DON, ADON, and NHLs on 8/14/25. The DON, ADON, and NHLs performed observational audits of several staff across multiple shifts performing resident baths to ensure proper safety procedures. If the resident baths were already completed by the time of the audit, the CNA demonstrated the steps to performing a resident's bath to the auditing staff person. The audits started on 8/15/25 and lasted four weeks as described in the above FRIs. Review of the provider's QAPI committee documentation revealed the committee reviewed the audit data at the conclusion of the four weeks of observations and recommended to discontinue the audits. 10. The provider's 8/14/25 implemented actions to ensure the deficient practice does not reoccur was confirmed on 10/21/25 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding proper bathing techniques and the use of the whirlpool bath chair safety belt, interviews revealed staff understood the education provided regarding those topics, observations of resident transfers and bathing revealed no concerns, and a review of the provider's follow-up audits revealed substantial compliance. Based on the above information, noncompliance at F689 occurred on 8/11/25 and 8/14/25. Based on the provider's implemented corrective action for the deficient practice confirmed on 10/21/25, the noncompliance is considered past noncompliance. B. 1. Review of the provider's 9/25/25 FRI submitted to the SD DOH regarding resident 4 revealed on 9/18/25 at around 3:00 p.m., CNA M failed to transfer the resident with another staff person and had not used the mechanical total lift, as instructed in the resident's comprehensive care plan, while CNA M was transferring the resident from the resident's wheelchair to the bath chair, resulting in resident 4 sustaining an acute fracture of the proximal tibia of her lower left leg. On 9/18/25 at 6:45 p.m., CNA M had gotten resident 4 ready for bed and noticed she had a red bruise on her left anterior lower leg. On 9/18/25 at 6:51 p.m., LPN G was alerted by CNA M of the bruise and resident 4 was assessed at that time. Her statement indicated the bruise was red and purple in color with no open areas or swelling noted. LPN G asked resident 4 if she had pain to her left lower leg, and the resident stated, yes. Resident 4 had an active order for Tylenol 1000 milligrams (mg) to be given at 8:00 p.m. and that was administered to the resident for the pain. LPN G indicated she completed a dressing change on resident 4 earlier in the day, and did not notice any concerns with the resident's leg at that time. The dressing change was not on resident 4's left lower leg, but did allow visualization of her leg at the time of that dressing change. Resident 4's primary physician, her son, DON B, ADON C, and the resident's hospice provider were notified of the incident. Resident 4 was receiving hospice care through a local hospice provider. On 9/19/25, DON B spoke with CNA M. CNA M denied any concerns with resident 4's transfer when she gave the resident her whirlpool bath on 9/18/25. On 9/21/25, resident 4 was observed having face grimacing and was grabbing at her left lower leg when she was transferred from her wheelchair to bed after lunch with the use of the mechanical total lift and two staff members. The resident was assessed, and a large dark purple bruise was noted below her left knee and extended down to her left ankle. A bounding pedal (feet) pulse, and circulation (presence and strength of blood flow) was noted to be present in each toe. Administrator A and DON B interviewed CNA M on 9/25/25 and CNA M revealed she had transferred resident 4 alone with the use of the mechanical total lift from the resident's wheelchair to the tub chair and back to her wheelchair after she had given the resident a bath on 9/18/25. Administrator A had asked CNA M why she had used the mechanical total lift alone, as the provider's policy was that two staff members must assist with the use of the mechanical total lift for resident transfers. Administrator A had informed CNA M that she was suspended effective immediately pending further investigation. During the investigation process, Administrator A had been informed that CNA M had verbally stated she had used the mechanical stand aid to transfer resident 4 and not the mechanical total lift. On 9/30/25, administrator A informed CNA M that her employment at the facility was terminated. On 9/29/25, skin assessments had been completed on all facility residents for potential injuries from improper mechanical lift use. No additional resident injuries were found. The provider educated all staff on the mechanical total lift and stand aid policy on 9/18/25 or prior to their next working shift. In addition to the staff education, staff competencies for total lifts were completed with full-time and part-time staff by 10/10/25 and prior to their next working shift for any as needed (PRN) staff and seasonal staff who did not receive the education before 10/10/25. Audit expectations were for five audits per week for one month. After one month, the results of the findings would be brought to QAPI committee for review and recommendations. 2. Review of resident 4's EMR revealed she was under the care of a local hospice provider and received Morphine 0.25 milliliters (ml) by mouth every hour as needed. On 9/22/25, new orders were received from her hospice provider to administer Morphine 0.25 ml by mouth every four hours scheduled and to continue with the previous as needed Morphine order for the resident's pain. On 9/23/25, resident 4 was seen by her primary care physician and an order was received for an X-ray of the lower left extremity of tibia (shin bone) and fibula (calf bone). On 9/25/25, X-ray results revealed an acute (sudden onset) fracture (break in bone) of the proximal tibia (upper part of the shinbone that forms the bottom of the knee joint) of her lower left leg. 3. Observation and interview on 10/20/25 at 4:14 p.m. with CNA I and CNA H revealed the use of the total lift with resident 1 required two staff for the transfer. CNA H stated she orientated new CNAs and observation of proper use of mechanical lifts was required by new staff before their orientation was completed. 4. Observations on 10/20/25 at 4:34 p.m. of CNAs D, F, and J revealed they were using the stand aid mechanical lift to assist resident 6 up from the bed. CNAs D and F helped resident 6 with sitting upright from the laying position. All CNAs helped apply the safety straps onto resident 6 to use the stand aid mechanical lift. CNAs D and J then transferred resident 6 to use the toilet. They helped the resident clean up and get dressed for supper. The resident did not display any signs or symptoms of pain during the process. There were no observed concerns with how the CNAs were utilizing the stand aid mechanical lift. 5. Observation and interview on 10/21/25 at 8:30 a.m. with CNA H and CNA K revealed two staff must assist with the use of the mechanical stand aid. Resident 2 had been transferred from his wheelchair to the tub chair. The sling used with the mechanical stand aid was properly placed around the resident's back and underneath his arms. The safety straps had then been attached to the mechanical stand aid prior to the transfer. Once resident 2 had been seated on the tub chair, the sling had been taken off and the safety belt on the tub chair was applied around the resident's waist and properly fastened. The safety belt remained around the resident's waist until he had been fully redressed after he received his bath. The mechanical stand aid sling had then been reapplied prior to the transfer. Both CNAs indicated they recently received additional education on the usage of the mechanical total lift and stand aid. 6. Interview on 10/21/25 at 8:45 a.m. with resident 2 revealed two staff have always been present when he was transferred with the use of the mechanical stand aid. 7. Interview on 10/21/25 at 10:45 a.m. with DON B revealed all unknown injuries to residents must be reported to the SD DOH, such as the incident that had occurred on 9/18/25 for resident 4. 8. Interview on 10/21/25 at 10:58 a.m. with LPN G revealed she was informed of the bruise noted to resident 4's left lower leg by CNA M on the evening of 9/18/25. She had indicated the bruise looked fresh with a red color noted to it. She stated resident 4's primary physician, her son, DON B, ADON C, and resident 4's hospice provider was notified of the incident. 9. Interview on 10/21/25 at 11:32 a.m. with ADON C revealed she received a call from LPN G on 9/18/25 reporting that resident 4 had an unknown injury noted to her left lower leg. She indicated that LPN G reported it was a new bruise that was red in color. 10. Interview and observation on 10/21/25 at 10:45 a.m. with DON B revealed documentation that included names of all full-time and part-time staff and PRN and seasonal staff. Each staff member who had completed their competency for the mechanical total lift and stand aid by 10/10/25 had an X next to their name. For any PRN and seasonal staff, they were required to complete their competency prior to their next working shift. 11. Interview with resident 4 was not completed during the survey, as she was not able to provide viable information. 12. Interview with Administrator A was not completed, as he was unavailable during the survey. 13. Interview with CNA M was not completed, as her employment at the facility was terminated on 9/30/25, prior to the survey. 14. Interviews with other random resident throughout the survey from 10/20/25 to 10/21/25 revealed that there were no concerns with staff interactions or transferring with the mechanical lift equipment. 15. On 10/21/25, documentation was provided from the provider that revealed CNA M had received education on the limited lift agreement on 7/15/25, at the time of her orientation. On 7/18/25, CNA M had signed the floor training checklist that she acknowledged she received proper training on the mechanical total lift and stand aid. 16. Review of the provider's undated [NAME] Home: Using a Mechanical Lifting Machine Policy revealed at least 2 nursing assistants are needed to safely move a resident with a mechanical lift. 17. The provider's 9/25/25 implemented actions to ensure the deficient practice does not reoccur was confirmed on 10/21/25 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding safe resident transfers with the use of the mechanical total lift and stand aid, interviews revealed staff understood the education provided regarding those topics, observations of resident transfers and bathing revealed no concerns, and a review of the provider's follow-up audits revealed substantial compliance. Based on the above information, noncompliance at F689 occurred on 9/18/25. Based on the provider's implemented corrective action for the deficient practice confirmed on 10/21/25, the noncompliance is considered past noncompliance.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (3) who fell out of her wheelchair and received a laceration to the left side of her forehead that required sutures. The fall was related to assistive devices (wheelchair pedals) not being in place to prevent an accident. Findings include: 1. Review of the provider's 3/15/25 SD DOH FRI regarding resident 3 revealed: *On 3/15/25 at 8:30 a.m. certified nursing assistant (CNA) Q yelled out while in resident 3's room. *CNA D responded and went to assist resident 3 in her room and alerted licensed practical nurse (LPN) R that resident 3 was on the floor. *LPN R entered the room and found resident 3 lying on the floor on her left side and bleeding from the left side of her forehead from an approximately ½ inch laceration with immediate swelling/bruising to forehead with bleeding unable to be controlled with pressure at this time. *911 called and resident [was] picked up via ambulance. *[Resident 3] returned with sutures in her head. *Resident's fall was due to no wheelchair petals [pedals] on her wheelchair. 2. Review of resident 3's closed electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. *Her diagnoses included traumatic subdural hemorrhage with loss of consciousness, repeated falls, and unspecified dementia with other behavioral disturbance. *Her 3/5/25 Brief Interview for Mental Status (BIMS) assessment score was ten which indicated she was moderately cognitively impaired. *A progress note on 3/15/25 at 11:49 a.m. indicated: -Writer heard CNA yell out while in resident's room. 2nd CNA went to assist and alerted writer that resident was on the floor. Upon entering the room, resident was laying on left side and bleeding from left side of forehead. CNA applied pressure to wound after writer assessed wound. Noted approximately half inch laceration with immediate swelling/bruising to forehead with bleeding unable to be controlled with pressure at this time. Assessed noted injury, . *A progress note on 3/15/25 at 2:15 p.m. indicated: -Resident returns from ED [emergency department] at 1345 [1:45 p.m.] via wheelchair express. Paperwork returned to writer . Generally confused at this time. Resident received 3 sutures to [her] left forehead. Will continue neuro [neurological] checks for fall/hitting head. *Her comprehensive care plan revealed: -A focus area that indicated I am at risk for falls. -Interventions that included: --I have reported 4-5 falls in the past 6 months, one of which resulted in my subdural hematoma and is why I am here at [provider's name]. --I suffered a witnessed fall . on 3/15 that resulted in an injury to my head. I was transported to the hospital for evaluation. I fell forward out of my wheelchair as I was being propelled by staff . *On 5/6/25, resident 3 was transferred to another nursing home. 3. Interview on 5/29/25 at 11:36 a.m. with CNA D revealed: *She had worked at the facility since August 2024. *Regarding how to ensure the safety of residents using wheelchairs she stated Wheelchair pedals, those are a must and stated they had an incident related to that a couple of months ago. *Regarding that incident, she stated: -She worked the morning of 3/15/25 with another CNA Q and was serving breakfast when she heard a gasp, and she walked into the room and found resident 3 on the floor. -CNA Q stated to her that she did not know what happened. -CNA D stated that resident 3 needed wheelchair pedals as she could walk and would often propel herself in her wheelchair, and her would catch on the floor when transporting her in her wheelchair without the pedals. -She stated CNA Q had been working at the facility longer than she had, so she should have known that. -She stated there was training provided following that incident that included reading and signing an information sheet regarding the importance of using wheelchair pedals with residents. Interview on 5/29/25 at 3:00 p.m. with director of nursing (DON) A revealed: *She stated the training on the use of wheelchair foot pedals with residents was provided on 3/15/25. *She expected staff to use wheelchair pedals with residents while transporting them. *No monitoring mechanism had been put in place to ensure staff used wheelchair pedals when transporting residents. *She stated that during her daily rounds she had observed to ensure foot pedals were in use on residents' wheelchair, but she had not documented those observations. Interview on 5/29/25 at 3:39 p.m. with LPN R revealed: *She recalled resident 3 and the incident that occurred on 3/15/25. *She had heard CNA Q yell out in surprise. *CNA D then stated, She's on the floor. *LPN R entered resident 3's room to assess the resident. *She stated resident 3 was on the floor in front of her wheelchair. *There was bleeding on the left side of her forehead and she could tell she needed stitches. *She had not worked much with CNA Q. *She indicated that CNA Q stated resident 3 had just fallen forward out of her wheelchair. *She stated she had called DON A to let her know about the situation as the resident went to the emergency department. *She stated that DON A had contacted her later that afternoon to ask if she had checked the wheelchair to ensure the foot pedals had been used. *LPN R stated she went to look at resident 3's wheelchair and discovered there were no foot pedals on her wheelchair. *LPN R stated the use wheelchair pedals was common sense. *She felt the provider had addressed the situation appropriately as they immediately suspended CNA Q and then ended up terminating her employment. *She recalled that written education regarding the required use foot pedals was provided and that it had been addressed at the next staff meeting. 4. Review of the provider's 2/2/21 Use of Wheelchair Pedals policy revealed: *Purpose: To ensure each resident who uses a wheelchair had wheelchair foot pedals available and used properly to prevent accidents. *Foot pedals will be used for residents who use wheelchairs while they are in their wheelchair, unless deemed safe and care planned otherwise. *Foot pedals will be provided for each wheelchair used by a resident for mobility. Review of the requested list of the current 54 residents revealed 48 of those residents required the use of a wheelchair.

A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI)reviews, observation, interview, record review, and policy review, the provider failed to protect the resident's right to be free from verbal and physical abuse by certified nursing assistant (CNA) K while providing assistance with undressing to one of one cognitively impaired sampled resident (1) dependent on staff assistance for activities of daily living (ADLs) and known resistance to care. Findings include: 1. Review of the provider's 1/20/25 submitted SD DOH FRI regarding certified nursing assistant (CNA) K's interaction with resident 1 revealed: *Resident 1 had poor cognition and resided in the secured memory care unit. *On the evening of 1/19/25 [CNA K] was getting resident 1 ready for bed . *CNA K [did not know I CNA/certified medication aide(CMA) L] had walked into the room and she [CNA K] was getting frustrated because [resident 1] did not want to take off his sweater . *CNA K was getting upset and was taking his [resident 1's] arm out of his sweatshirt aggressively and he verbally said 'ow'. * .DON [director of nursing (DON) A] spoke with [CNA K] regarding the above incident. -[CNA K] states she went into [resident 1's] room around [9:00 p.m.] to get him ready for bed. -She [CNA K] states [resident 1] starts hitting and kicking her. [CNA K] states she told [resident 1], 'no, I don't want to be hit.' -[CNA K] states she was able to get [resident 1]'s shirt off, but then had to pry it out of his hands. -When questioned if he said 'ow' at any point, [CNA K] states he did when she pulled the shirt out of his hands. -[Resident 1] continued to hit and kick [CNA K], and [CNA K] states she told [resident 1] she was not having this. -[CNA K] states she was eventually able to get [resident 1] into bed. -DON A informed [CNA K] she was suspended pending completion of the investigation. *Investigation Conclusion: -Incident was reported on 1/19/2025 at 10:37 p.m., however this was not seen by DON [A] until the following day as it was reported via text message. -[CNA K] was suspended on 1/20/2025 at noon. -Resident [1] was assessed on 1/20/25 by the floor nurse. No injuries noted. No adverse effects noted. No signs of distress or fearfulness noted. Resident was not interviewed as he has poor cognition and would not understand. -No other residents were interviewed as this incident occurred on our secured memory care unit where all residents would not be able to recall. -No other staff members were interviewed as [CNA L] was the only other staff member actively working with the residents on that neighborhood. -Nursing and administration is looking into dementia education programs and will be doing written education with all nursing staff on abuse and neglect. -Will continue to monitor. -The question Was abuse allegation substantiated? was answered Yes. -[CNA K]'s statement acknowledged abuse. -Personnel terminated was documented in the action taken by facility area of the report. Observation on 5/29/25 at 8:48 a.m. of resident 1 in the memory care unit (MCU)'s dining room revealed: *He sat in his wheelchair and self-propelled his wheelchair around the dining room. *He was pleasantly confused and responded to a greeting, shook hands and responded to simple questions by laughing. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE] to a room in the MCU. *His diagnoses included: Alzheimer's disease with late onset and moderate dementia, with other behavioral disturbance. *His current care plan included interventions: -If resident resists with ADLs [activities of daily living], reassure resident, leave and return 5-10 minutes later and try again. -I require staff assistance with all transfers with use of standing lift. -I require staff assistance with all dressing, grooming, toileting and personal care tasks. *His 4/3/25 Brief Interview for Mental Status (BIMS) assessment score was zero indicated severe cognitive impairment. *A progress note on 1/20/25 at 7:46 a.m. indicated Resident's skin assessed, no lumps, bumps or bruising present to upper extremities. Resident has full range of motion to BUE [bilateral upper extremities]. Does have small less than pea sized scab to right outer forearm. No redness or bruising surrounding. Resident does not appear to be pain or discomfort with passive range of motion. *There was no progress note related to the 1/19/25 incident noted above in the 1/20/25 submitted SD DOH FRI. Interview on 5/29/25 at 9:04 a.m. with CNA P in the MCU regarding resident 1 revealed: *He had worked at the facility since August 2024. *Resident 1 was not responsive most of the time but responded to conversation at times. *He felt resident 1 was pretty good this morning. *He recalled only one time that resident 1 was resistive to care and CNA P got out of [the] way and let him cool off. Interview on 5/29/25 at 11:36 a.m. with CNA D revealed: *She had worked at the facility since August 2024. *She felt no residents in particular were resistive to care in the MCU. *She felt resident's 1's reactions depended on How you speak to him and interact with him. *If a resident was resistive to care, she stated if she could not calm the resident down, she would leave and reapproach the resident later, and added that five minutes later could make a big difference. Phone interview on 5/29/25 at 1:15 p.m. with CNA/CMA L revealed: *She had worked full-time on the night shift at the facility until recently. *She really enjoyed working on the MCU. *She stated a few of the residents on the MCU had mood or behavior problems and required redirection. * She stated some residents were resistive to care, but after giving the resident some time and reapproaching the resident later was most successful. Continued interview with CNA/CMA L regarding the incident on 1/19/25 with resident 1 and CNA K revealed: *It was her first time working with CNA K on 1/19/25. *She worked with CNA K from 8:00 p.m. to 10:00 p.m. that night. *She could not recall the exact time of the incident she observed, but stated she thought it was between 8:00 p.m. and 9:00 p.m. *She noticed CNA K had brought resident 1 to his room. *CNA/CMA L entered resident 1's room to place the unplugged cord for the sit-to-stand mechanical lift that was lying on the ground back on the lift. *CNA K had not noticed CNA/CMA L in the room. CNA K was trying to get resident 1's shirt off and was visibly getting frustrated with him. CNA K yanked, on resident 1's arm to get his shirt off and stated, come on [resident 1's first name] and as he grabbed the shirt, CNA K tried to pry the shirt out of his hands. *Resident 1 exclaimed ow in response to CNA K's actions. *CNA/CMA L stated, I was very uncomfortable with what I had observed. *CNA/CMA L felt after CNA K noticed CNA/CMA L in the room, CNA K tried to act differently and like she had not gotten upset with resident 1. *She questioned if she should have confronted CNA K or if she should have had a supervisor confront her. *After CNA K ended her shift and left the facility sometime after 10:00 p.m. that evening, CNA/CMA L asked the other medication aide on the MCU about the wording she had used in the text message to DON A about the incident. *She had not been in a situation of observing another CNA potentially verbally and physically abusing a resident before that incident on 1/19/25. *CNA/CMA L stated that DON A replied to her text message at 6:00 a.m. the next morning. Interview on 5/29/25 at 3:00 p.m. with DON A revealed: *CNA/CMA L's 1/19/25 text message was at 10:37 p.m. regarding the incident with CNA K and resident 1. *She had replied to that text message on 1/20/25 at 6:52 a.m. over eight hours later. *She expected staff to immediately inform the on-call nurse of allegations of potential abuse so the situation could be dealt with immediately *She stated, during the investigation of the incident, she had educated CNA/CMA L of the need to immediately report an incident by calling the on-call nurse. *Since the incident, no monitoring mechanisms were put in place to ensure staff notified the on-call nurse of suspected incidents of abuse if the DON was not in the building. Further interview on 5/29/25 at 5:12 p.m. with DON A revealed: *They had discussed dementia training for the staff with the regional ombudsman. *They had not scheduled or set up that dementia training. Review of the provider's 11/18/22 Resident Rights Guidelines revealed: *Purpose: To provide general guidelines for resident rights while caring for the resident. *Preparation: Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: -Be free from verbal, .physical, and mental abuse . from anyone . *General Guidelines: .Ask permission to implement the procedure. If the resident refuses, notify your supervisor. Review of the provider's May 2025 Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy revealed: *If resident abuse, . is suspected, the suspicion must be reported immediately to the Director of Nursing (DON) or designee. B. Based on SD DOH, FRI dated 4/29/25, record review, interview and policy review, the provider failed to protect the resident's right to be free from neglect by certified nursing assistant (CNA) F who left one of one cognitively impaired sampled resident (2) dependent on staff assistance with toileting needs and repositioning on a bedpan for an extended period of time that contributed to the resident developing a skin injury. Findings include: 2. Review of the provider's SD DOH FRI dated 4/29/25 with attached baseline care plan revealed: *This was a FRI for suspicion of abuse or neglect. *Resident 2 was found on a bedpan on 4/29/25 at 9:00 a.m. *Linear lines were noted on the resident's buttock that were slow to blanch (skin whitens in color temporarily/lacking blood flow to area). *Day shift staff indicated they had not placed resident 2 on a bedpan yet that day. *During nursing change of shift report the morning of 4/29/25 there was no indication that resident 2 was put onto a bedpan. *The provider's investigation indicated certified nursing assistant (CNA) F reported she had placed resident 2 on a bedpan around 2:00 a.m. that day. *CNA F was suspended on 4/30/25 pending further investigation by the provider. *The resident's primary care provider (PCP) and power of attorney (POA) were notified of the incident. *Resident 2's baseline care plan indicated: -She needed a Hoyer lift (mechanical lift and sling to lift a person's full body) for all transfers. -She used her wheelchair for mobility that was pushed by staff. -She was unable to ambulate. -She slept on a pressure guard mattress and sat on a pressure-reducing cushion in her wheelchair. -She was continent of bowel and bladder. -She used a bedpan for elimination of her bowel and bladder and required total staff assistance with her incontinence care. -Staff were to encourage her to reposition frequently to promote my skin health. -I am unable to take a bath currently, due to my surgical incision. Please assist me with bed bath twice weekly and as needed. -I am receiving hospice services currently. Review of resident 2's of electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE] and admitted to hospice services 4/22/25. *Her diagnoses included: -Acute Kidney Failure. -Weakness. *Her 4/22/25 Brief Interview for Mental Status (BIMS) assessment score was 6 which indicated she had severe cognitive impairment. Resident 2's tasks (care needs provided by staff) included staff were to provide her: -Repositioning as needed (PRN). -She wore an incontinent brief. -Toileting hygiene every day, evening, and night shift. *Her toileting task by the staff was documented as completed at 2:27 a.m. on 4/29/25. *A new physician's order was added 4/30/25 for Triad paste (a wound healing product) to her left buttock daily and PRN. *A progress note dated 4/30/25 indicated: -She had been left on a bedpan the previous day. -Linear markings to her left buttock were parallel to each other, which would be consistent with the edge of a bedpan. -Those areas on her left buttock were slow to blanch. -An order to apply Triad paste to her left buttock was received and started. *Resident 2 passed away on 5/1/25. Interview on 5/29/25 at 2:32 p.m. with CNA F revealed: *Resident 2 was unable to reposition herself. *Resident 2 could use her call light to call for staff assistance. *The resident was on a repositioning schedule and was to be repositioned by the staff every two hours. *She had placed resident 2 on the bedpan between 2:00 a.m. and 3:00 a.m. on 4/29/25. *She then answered two additional resident's call lights. *She had forgotten she had placed resident 2 on the bedpan that day. *She was suspended from work during an investigation of the incident. *She completed the required education related to the incident prior to returning to working for provider. Interview on 5/29/25 at 2:45 p.m. with registered nurse (RN) G revealed: *She had worked on 4/28/25 at 6:00 p.m. until 4/29/25 at 6:00 a.m. *She had given resident 2 medication for pain between 8:00 p.m. and 10:00 p.m. on 4/28/25. *CNA F did not report to her that resident 2 was on a bedpan during that night shift. *She had not attended any education regarding the use of bedpans for residents. *Timers were to be used for up to 30 minutes when placing residents on bedpans to remind staff to check on the resident for removal of the bedpan. *Residents needed to have call lights within reach. Interview on 5/29/25 at 3:30 p.m. with CNA B revealed: *She worked the morning shift on 4/29/25 that started at 6:00 a.m. *Upon coming onto her shift, she walked around and checked on all of the residents. *She got a report of the resident's status from the previous shift. *She was told resident 2 had been changed at 5:00 a.m. *She went into resident 2's room to complete her morning cares at 8:00 a.m. on 4/29/25 and discovered the resident was on the bedpan. *After rolling her off the bedpan she observed a red mark on the resident's left buttock. -There were no open areas on the resident's skin at that time. *She recalled resident 2 had a previous deep tissue injury (DTI) on her coccyx when she had admitted to the facility. *She reported the incident of the bed pan and red mark on the resident's buttock to licensed practical nurse (LPN) C. Interview on 5/29/25 at 3:50 p.m. with LPN C revealed: *She was the day nurse on 4/29/25 for resident 2's wing. *She gave resident 2 her morning medications between 6:30 a.m. and 7:00 a.m. on 4/29/25. *That morning CNA B told her that resident 2 had been found on the bedpan, she was unsure of the time. *LPN C and assistant director of nursing (ADON)/Minimum Data Set (MDS) H assessed resident 2's buttocks after CNA B reported the concern to them. *LPN C did not see a red circle from the bedpan at that time, but the resident's coccyx (tailbone) had a couple of red areas above it that were slow to blanch. *A request was then sent to resident's PCP for Triad paste and foam to apply to the affected area. Interview on 5/29/25 at 3:52 p.m. with ADON/MDS H revealed: *She and LPN C assessed resident 2's buttocks on 4/29/25 after CNA B reported the concern to them. *She observed an initial linear red mark, possibly from the bedpan being left under the resident too long, on resident 2's buttocks. *No open areas or bleeding were noted at that time. *Resident 2 had a previous DTI to her coccyx when she admitted to the facility. *She had faxed resident 2's PCP and described what she found and what had occurred following the assessment to obtain a skin treatment order. Interview on 5/29/25 at 5:20 p.m. with director of nursing (DON) A revealed: *Bedpan education was given to the staff after the incident with resident 2 on 4/29/25. -Timers were to be used for residents who used a bedpan. -Staff were to set the timer for 10 minutes and check on the resident. If an additional 10 minutes was needed, then timer was to be reset. -That process was implemented to ensure staff returned to assist the residents. Review of the providers approved May 2025 Abuse, Neglect, Exploitation or Misappropriation Policy revealed: *All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -b. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, and interview, the provider failed to ensure correct documentation of controlled medications (medications with risk for abuse and addiction) when administered for one of one sampled resident (4). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's 2/6/25 SD DOH FRI for resident 4 revealed: *Director of nursing (DON) A was notified by registered nurse (RN) E of concerns regarding licensed practical nurse (LPN) S that included: -LPN S having left controlled medications sitting on top of a medication cart and unattended. -LPN S having incorrectly documented the administration of resident 4's controlled medications. *Initial evaluation of narcotic sheets showed LPN S had signed out three doses of lorazepam (a controlled antianxiety medication) 0.5 mg tablets on 2/5/25 at 9:00 a.m., 10:00 a.m., and 12:00 p.m. -That medication card contained 29 tablets of lorazepam 0.5 mg tablets, while the controlled drug receipt/record/disposition form stated the count was 26 tablets. *The oxycodone (a controlled pain medication) 5 mg half- tablets medication card contained 26 half-tablets. The narcotic (controlled medication) count sheet for the oxycodone stated the count was 29 tablets. *Review of the resident's February medication administration record (MAR) revealed: -LPN S signed out an as needed (PRN) dose of oxycodone at 10:16 a.m. on 2/5/25. -LPN S signed out an PRN dose of oxycodone at 12:30 p.m. on 2/5/25. -LPN S did not document any lorazepam medication was administered in the MAR on 2/5/25. -LPN S did documented a scheduled lorazepam tablet was administered at 2:37 p.m. on 2/5/25. -The MAR indicated a 2/5/25 at 3:00 a.m. dose of oxycodone 5 mg half-tablet was administered but, it was not signed out in the controlled drug receipt/record/disposition form by RN N. *A narcotic medication count took place on 2/5/25 at 6:00 a.m. with RN N and LPN S, and no discrepancies in the medication counts were noted by them, despite a missing signature for a 3:00 a.m. dose of PRN oxycodone that was given by RN N. *Narcotic counts on 2/5/25 at 4:00 p.m. between RN E and LPN S occurred and, RN E indicated LPN S needed to sign off her narcotic book. *It was undetermined if LPN S signed the narcotic book at the time of the request. *A narcotic count took place on 2/6/25 at 12:00 a.m. with RN E and LPN O with no discrepancies noted. *A narcotic count took place on 2/6/25 at 6:00 a.m. with LPN O and LPN S with no discrepancies noted. *Through the provider's investigation it was determined: -RN N had administered a dose of oxycodone to resident 4 on 2/5/25 and did not sign out that dose on the receipt/record/disposition form. -LPN S admitted she had incorrectly signed out three oxycodone doses under resident 4's lorazepam receipt/record/disposition form. -LPN S admitted she had not documented the administration of that medication in the MAR. -LPN S was placed on suspension on 2/6/25 pending completion of the provider's investigation. -LPN S employment at the facility was terminated on 2/6/25 following the completion of the provider's investigation. 2. Interview on 5/29/25 at 2:20 p.m. with RN E revealed: *On 2/5/25 her shift started at 4:00 p.m. *At the start of her shift that day she noted two unlabeled syringes with liquid in them on top of the medication cart. *LPN S was the nurse who worked the previous shift, and she was not at the medication cart at that time. *When RN E completed the narcotic count with LPN S they noted there were discrepancies to the count for resident 4's oxycodone and lorazepam medications. *She requested LPN S correct the narcotic record. *LPN S left that day without correcting the narcotic record. *RN E notified DON A of the narcotic record counts being off the evening of 2/5/25. *RN E had received education since the 2/5/25 incident occurred from the providers pharmacy regarding controlled substances and correct documentation. Interview on 5/29/25 at 5:20 p.m. with DON A revealed: *LPN S was terminated on 2/6/25 after the provider's investigation into the controlled counts for resident 4 was completed. *The providers pharmacy completed staff education regarding narcotics and documentation with nursing staff. *Audits were completed and documented signed out in MAR, signed out on narcotic receipt/record/disposition form, and narcotic counts are correct. -Audits were completed on all units. -completed at least twice weekly. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 5/29/25 after a record review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding medication administration and diversion education, interviews revealed that staff understood the education provided regarding those topics, review of narcotic records for three of the four wings revealed with no further missing documentation of narcotic records for current residents, and a review of providers Controlled substances policy dated 2/25 confirmed processes for accountability of controlled medications. Based on the above information, non-compliance at F658 occurred on 2/5/25, and based on the provider's implemented corrective action for the deficient practice confirmed on 5/29/25, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to: *Ensure that staff were able to verify the chemical sanitation level required to clean the main kitchen surfaces used for the preparation of residents' food. Failure to ensure that increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the main kitchen. *Maintain the dishwasher sanitation rinse cycle temperature at a minimum of 180 degrees Fahrenheit per the manufacturer's manual for two of four kitchenette dishwashers. Failure to ensure that increased the potential risk of foodborne illnesses for 27 of 27 residents (1, 3, 14, 17, 18, 21, 23, 24, 25, 26, 27, 31, 34, 35, 36, 38, 39, 40, 41, 42, 44, 46, 47, 48, 49, 50, and 52) who received meals on dishware cleaned in those two kitchenettes. Findings include: 1. Observation and interview on [DATE] at 11:41 a.m. during the initial tour of the main kitchen revealed: *There was a metal cart with visibly soiled dishes in the entryway to the kitchen located between the door and the dishwasher. *The floor below the sink was wet. *A pan marked beef for stroganoff on the counter. *Dietary director (DD) E stated she started in her position two months ago. -She indicated there had been a huge staff turnover. *DD E stated that the residents' food prepared for lunch had already been delivered to the neighborhoods. -Lunch was served starting at 11:30 a.m. *The beverage dispensing machine was taken apart and cleaned. *A red sani-bucket was on a metal cart that contained liquid and a cloth. *The sanitizer strip test kit was labeled expired [DATE]. *The Diversey chlorine test strips were labeled exp [DATE]. *A dishwasher wash and rinse log on the wall had recorded temperatures for breakfast, lunch, and dinner on [DATE]. -No dishwasher wash or rinse temperatures had been recorded on [DATE], [DATE], [DATE] or [DATE]. Interview on [DATE] at 12:11 p.m. with dietary aide S in the main kitchen revealed: *The sanitizer test strips were used for testing the contents in the 3-compartment wash sink and the sanitizer buckets. -They were the only test strips in the kitchen. *There was no log documenting when the strips had been used. *All dishes used in the main kitchen were put through the dishwasher. -It was a high-temperature dishwasher. *There was a log to record the dishwasher temperatures for the washing of the dishes used with each meal service. -The dishes for lunch had not been washed yet that day. Observation and interview on [DATE] at 10:45 a.m. in the main kitchen with cook T revealed: *She used a cloth from the red sani-bucket to wipe the counter where she had prepared fried food. *She rinsed the cloth in the red bucket and continued to wipe the surfaces of the items on the counter with that cloth. *She stated the bucket was filled every two hours or more often when dirty. *She stated she keeps track of her bucket and changes it at least every 2 hours but usually more often when she used it. *She confirmed there was no log or sticker on the bucket that indicated when it had been last changed or tested . *The sanitizer in the bucket was a chemical solution filled from the hose at the 3-part sink. *She stated, They [sani-buckets] are tested every so often. -She was unsure how often the sanitizer was tested . -She stated she did not do the testing. *She confirmed that it was not tested each time the bucket was filled to ensure proper sanitization. Observation and interview at [DATE] at 10:50 a.m. with DD E in the main kitchen revealed she: *Confirmed they did not have a system to test the solution in the sani-buckets to ensure the sanitizer was at the appropriate level or a method to document the testing results. *Confirmed the chlorine test strips were expired. -She stated, But that's ok because we don't use them anyway. *Stated, They [staff] weren't doing it [using the chlorine test strips] when I started. *Was unsure what the facility policy was but stated I will find out. *Confirmed that the solution was J-512 Sanitizer and stated it was a preset system so we do not have to test. *Confirmed the dishwasher was a high-temperature dishwasher. *A dishwasher log was posted on the wall. -The dishwasher log had rinse temperatures recorded over 180 degrees for [DATE] and [DATE]. Observation and interview on [DATE] at 11:22 a.m. in the [NAME] Creek kitchenette with DD E revealed she: *Transported the food from the main kitchen to the [NAME] Creek kitchenette. *Obtained dishes from the cabinet in that kitchenette. *Confirmed that those dishes were washed and sanitized in the dishwasher in the kitchenette. -Confirmed each neighborhood washed its own plates, cups, bowls, and utensils that were used for serving the residents food items. Observation and interview on [DATE] at 12:09 p.m. in the [NAME] Creek dish room with CMA J revealed: *The nursing staff was responsible for washing and sanitizing the dishes in each neighborhood. *She pre-washed the dishes in the sink and loaded them into the dishwasher. *She ran the dishwasher cycle. -The wash temperature reached 165 degrees and the rinse temperature reached 183 degrees. *She stated she did not log or record any dishwasher wash or rinse temperatures. *She stated, If that's [logging of temperatures] done it would be maintenance. *She confirmed there was no dishwasher log located in the kitchenette. Interview on [DATE] at 3:37 p.m. with Administrator (Admin) A revealed: *There were no cleaning logs for the kitchen or kitchenettes. *He expected nursing staff to wash the dishes, to mop the floor, and to keep the area clean. *The neighborhood kitchenettes had not used the sani-bucket. -The cleaner on the kitchenette was the Q 3 disinfectant spray. *He confirmed that in the main kitchen, they used the sani-bucket. *He confirmed that they should be testing the PPM [parts per million of the sanitizer solution] for the sanitizer buckets to ensure the sanitizer was at an appropriate level. -He confirmed there was no record that the sanitizer had been tested . *He was not aware that the sanitizer test strips were expired. Interview on [DATE] at 4:30 p.m. with Admin A revealed: *The provider did not have a Dishwasher/Sanitation policy. *He stated we go by the manufacturer's book. *The provider did not have a Household/neighborhood kitchenette cleaning policy or logs. *The provider did not have a Kitchen equipment sanitizing/cleaning policy or logs. *Maintenance would have had kitchenette dishwasher temperature logs because they oversaw the kitchenette dishwashers. Interview and review of kitchenette dishwasher logs and dishwasher manufacturer specification on [DATE] at 4:31 p.m. with campus environmental service director (CESD) D revealed: *He provided a copy of the [NAME] Model LXIH-4 LHi Dishmachine specifications which included the following: -RINSE AND SANITATION: LXIH: Sanitation is accomplished by means of a built-in booster heater designated to raise temperature of water to a minimum of 180 degrees Fahrenheit from an incoming water temperature of 110 degrees Fahrenheit. *This was the information used when determining the correct dishwasher temperatures. *Neighborhood kitchenette dishwasher temperature logs were completed and kept by maintenance. -Dishwasher temperatures were monitored and logged on each of the four neighborhoods about once every three weeks by maintenance. -He was not aware if any other staff monitored those dishwasher temperatures. *He kept the recorded temperatures in a notebook. *The dishwasher temperatures were checked and logged on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. -All of those wash temperatures were recorded between ,d+[DATE] degrees Fahrenheit. -All of those rinse temperatures were recorded between ,d+[DATE] degrees Fahrenheit. Interview on [DATE] at 7:45 a.m. with Admin A revealed: *He provided the survey team with a Kitchen Sanitation Policy dated ,d+[DATE]. -He confirmed this policy included the main kitchen and the kitchenettes. *He provided the survey team with a Sanitizer Preparation Policy dated ,d+[DATE]. *He confirmed they did not have a separate dishwashing policy and referred to the manufacturer information previously provided. *He stated the dietitian would be at the facility today [DATE]. Observation and interview on [DATE] at 8:12 a.m. with consulting registered dietitian (CRD) H in the main kitchen revealed she: *Visited the facility once a week on Thursdays. *Documented her visits with individual residents in their charts. *Checks-in with DD E when she visited. -She did not document those check-ins. -They also communicated through email. *Was not conducting any current audits in the kitchen. -Was unable to recall if she had completed any audits recently, I would have to check my email. -Confirmed there were no written audits completed. *Stated, There is a cleaning schedule for the kitchen. -Stated she would provide a copy of that cleaning schedule to the survey team. --A cleaning schedule was not provided by the end of the survey. *Was not familiar with the procedures of sanitizing in the kitchen and agreed that we should include DD E in the interview. Continued observation and interview on [DATE] at 8:18 a.m. with CRD H and DD E in the main kitchen revealed: *DD E demonstrated the use of the sani-bucket. -She confirmed the new test strips were not expired. -There was a new log sheet for recording when the sanitizer solution was filled or tested . -She confirmed that the sanitization level in the sani-bucket was 200 PPM. -That had been documented on the log in the kitchen when it had been filled that morning. *DD E confirmed the main kitchen dishwasher temperatures were logged with each meal service three times a day. *DD E was unsure if there was a policy on the frequency of checking the dishwasher temperatures. *DD E confirmed that the dishes used by the residents including plates, bowls, cups, and utensils were washed and sanitized in each of the four neighborhoods. *DD E was unsure how frequently the neighborhood dishwasher wash and rinse temperatures should have been monitored. *CRD H stated she expected it would have been the same frequency as the main kitchen. *DD E stated that maintenance oversees the neighborhood kitchenettes, and any dishwasher temperature logs could be requested from that department. -CRD H and DD E were not aware of what frequency maintenance checked the kitchenette dishwasher temperatures. *When asked how they could ensure that dishes were sanitized in the neighborhood kitchenettes, DD E stated, I couldn't. *CRD H and DD E were not familiar with the procedures of sanitizing dishes in the neighborhood kitchenettes and agreed that we should include maintenance in the interview. Observation and interview on [DATE] at 8:39 a.m. in the [NAME] Way kitchenette with CRD H, DD E, CESD D, and maintenance staff U revealed: *A sign on the dishwasher indicated This is a sanitizer. Not a dishwasher. -Maintenance staff U confirmed that the machine is both a dishwasher and a sanitizer and the sign was inaccurate. -She stated that the dishes are prewashed before putting them in the machine to reduce the food particles in the machines. *Maintenance staff was responsible for overseeing the dishwashers for proper functioning in the kitchenettes. *The dishwasher had an E7 code displayed. -Maintenance staff U stated the code indicated the dishwasher was out of soap. --She changed the soap and reset the machine. *Maintenance staff U stated she checked the dishwashers Every day I am here. -She did not keep a log or record those checks. -She stated she looked at the temperature on the digital display of the dishwasher and as long as it is 150 or above it's good. -When the temperature was below 150 degrees Fahrenheit, she would reset the machine. -There was no need to run the dishwasher through a cycle to check the rinse temperature during those checks, because it's always hot enough. *Maintenance staff U ran the dishwasher. -On the first cycle the wash temperature reached 164 degrees Fahrenheit, and the rinse temperature reached 180 degrees Fahrenheit. *Maintenance staff U stated she expected staff to alert her right away if there were any problems with the dishwashers. Observation and interview on [DATE] at 8:52 a.m. in the Cottonwood Court kitchenette with CRD H, DD E, CESD D, and maintenance staff U revealed: *Maintenance staff U ran the dishwasher. *On the first cycle the wash temperature reached 165 degrees Fahrenheit, and the rinse temperature reached 177 degrees Fahrenheit. *A sign in the kitchenette indicated that plates, bowls, and cups were to be sanitized twice and utensils were to be sanitized three times. *On the second cycle the wash temperature reached 165 degrees Fahrenheit, and the rinse temperature reached 177 degrees Fahrenheit. *On the third cycle the wash temperature reached 162 degrees Fahrenheit, and the rinse temperature reached 174 degrees Fahrenheit. -Those temperatures were confirmed by maintenance staff U, CRD H, DD E, and CESD D. *A copy of the posted sign was requested in the absence of a policy and was not provided by the end of the survey. *CESD D confirmed the last time the kitchenette dishwasher temperatures were checked and recorded was on [DATE]. Observation and interview on [DATE] at 8:58 a.m. in the Maple Valley kitchenette with CRD H, DD E, CESD D, and maintenance staff U revealed: *Maintenance staff U ran the dishwasher. *On the first cycle the wash temperature reached 160 degrees Fahrenheit, and the rinse temperature reached 179 degrees Fahrenheit. *On the second cycle the wash temperature reached 166 degrees Fahrenheit, and the rinse temperature reached 179 degrees Fahrenheit. *On the third cycle the wash temperature reached 167 degrees Fahrenheit, and the rinse temperature reached 177 degrees Fahrenheit. -Those temperatures were confirmed by maintenance staff U. Observation on [DATE] at 9:15 a.m. of maintenance U revealed she walked from Cottonwood Court through the common area outside of the conference room carrying what appeared to be a cordless drill/screwdriver. Interview on [DATE] at approximately 10:00 a.m. with Admin A regarding the dishwasher temperatures revealed: *He requested that the surveyor return to recheck the temperatures of the dishwasher. *He stated the dishwashers had been calibrated and had temped them and they were at the correct temperature. Interview on [DATE] at 9:45 a.m. with CRD H revealed: *She provided the survey team with a 2013 [NAME] & Associates Sanitation of Dishes/Dish Machine policy. -This policy had not been provided earlier. *She stated that this was the regulation that they followed regarding dishwasher temperatures. Review of the 2013 [NAME] & Associates Sanitation of Dishes/Dish Machine policy revealed: *High Temperature Dishwasher Wash Temperature ,d+[DATE] degrees Fahrenheit, Final Rinse Temperature or Sanitization 180 degrees Fahrenheit. Notice: On [DATE] at 8:58 a.m., immediate jeopardy was identified related to failure to maintain the manufacturer's specification for the dishwashers' rinse cycle temperatures of a minimum of 180 degrees Fahrenheit at F812. Notice of immediate jeopardy was given verbally and in writing on [DATE] at 11:55 a.m. to Admin A and director of nursing B of the immediate jeopardy related to failure to maintain the manufacturer's specification for dishwasher rinse cycle temperatures of a minimum of 180 degrees Fahrenheit at F812. They were asked for an immediate removal plan. The current resident census was 52. Interview on [DATE] at 1:18 p.m. with Admin A and the survey team coordinator revealed: *He requested to speak with the survey team coordinator. *He stated he felt like this was certainly tag worthy but from an immediate jeopardy perspective I feel like that is incredibly out of proportion. *He stated, Within five minutes of that temperature being off, it was corrected. *He stated, I would completely understand a tag associated with that, and for corrective action and for not documenting it. *He stated he understood the deficiency was warranted but was concerned with the repercussions from an IJ severity deficiency. *The survey team coordinator asked about the IJ removal plan and stated the team needed to review the provider's IJ removal plan to continue with the process. On [DATE]: *At 1:31 p.m. the removal was received. *At 2:17 p.m. the removal was accepted. On [DATE]: *At 4:06 p.m. while on-site the survey team verified the immediacy was removed. Plan: Survey [DATE] Removal Plan After evaluation and meeting with the survey team, the recipients who could have suffered from this situation are the residents at [NAME] Home [NAME] on Maple Valley and Cottonwood Court as those were the neighborhoods that had temperature readings below 180 degrees. Neighborhood Dish Machine POC [plan of correction]: On [DATE], the Environmental Services Director calibrated the dish machines on all neighborhoods to increase the temperature of the rinse cycle. Both dish machines on Cottonwood Court and Maple Valley did reach the required temperature of 180 degrees before recalibration. All rinse cycles reached at least 180 degrees F [Fahrenheit] after changes made. Beginning [DATE], a dish machine temperature log was implemented on all neighborhood dish machines. IDT [interdisciplinary team] reviewed and revised the policy and procedures related to dish machine temperature logs and the sanitation of dishes/dish machines on [DATE]. Beginning [DATE], all staff responsible for using the neighborhood dish machines will be educated on the policies and procedures related to the dish machine temperature log and the sanitation of dishes/dish machines. All nursing and dietary staff will be educated on this policy by [DATE] via personal in-service. [Admin A initials] [DATE]. Beginning [DATE], all staff responsible for using the neighborhood dish machines will be educated that if the dish machines do not reach 180 degrees F, they are to contact the Environmental Services Director. Beginning [DATE], the Dietary Director, or designee, will audit the dish machine temperature logs. Audits will be daily for four weeks and weekly for two more months. The Dietary Director or designee will present the findings of the audit to the QAPI [Quality Assurance and Performance improvement] committee at their quarterly meeting for review and recommendation. The immediate jeopardy was removed on [DATE] at 4:06 p.m. after verification that the provider had implemented their removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was F with guidance from the long-term care advisor for the South Dakota Department of Health. The current resident census was 52. Review of the provider's [DATE] Kitchen Sanitation Policy revealed: *Purpose: To establish responsibilities for maintaining a clean and sanitary kitchen environment. *Responsibilities: -Dietary Director --Establish and maintain sanitary standards of cleanliness and food handling practices. --Ensure proper maintenance, operation and cleaning of all equipment. -Environmental Services: -- Preventative maintenance will be performed on equipment in the Nutrition Service Department. *Equipment Maintenance: -All equipment used by Nutrition Services meets standards of the State Department of Health -The dishwasher is maintained and operated according to manufacturer's instructions. Hot water dish machines need to run at at 155 degrees for wash cycle and minimum of 180 degrees for rinse cycle. -Temperature/appropriate sanitation levels are checked & recorded daily. -All work surfaces and utensils are cleaned and sanitized after each use. -Cleaning schedules are posted & include frequency, position responsible & off when completed. Review of the provider's [DATE] Sanitizer Preparation Policy revealed: *Purpose: Established the procedure to test sanitation solution for surface cleaning. *Prepare the sanitizer bucket according to the manufacturer's recommendation. *Check expiration date on test strip canister to ensure they are not expired. *Log what results are given by the test strip. 49238 2. Observation on [DATE] at 11:30 a.m. of resident 25 being served lunch revealed: *Hospice certified nursing assistant (CNA) V assisted her to eat a sandwich. -She assisted with her bare hands giving her bites off the sandwich. -She then began cutting the sandwich with a fork and fed her bites from the fork but went back to handling the sandwich with her bare hands. Interview on [DATE] at with CNA V revealed she did not use gloves when she assisted residents to eat. She stated she would wash her hands or use hand sanitizer. Interview on [DATE] at 2:35 p.m. with director of nursing (DON) B revealed that CNA V should have worn gloves when handling the ready to serve sandwich. She stated she would have had the same training as her CNAs for handling ready to serve foods. Interview on [DATE] at 3:00 p.m. with DON B regarding orientation of a Hospice nursing assistant revealed they would shadow with one of her CNAs for one day. She did not have anything in writing or have them sign anything. Interview on [DATE] at 11:57 p.m. with CNA V revealed: *She stopped this surveyor in the hall and stated, I should have worn gloves when handling resident 25's sandwich, I can't believe I did that. she stated she had more training yesterday [DATE]. Review of the provider's General Food Preparation and Handling policy dated [DATE] revealed, 5. Equipment f. Use tongs or other serving utensils to serve breads or other items. Never touch food directly with bare hands.

Based on observation, interview, record review, and job description review the provider failed to ensure the dietitian and dietary director carried out the functions of the food and nutrition services department to ensure the development and implementation of policies and procedures regarding appropriate cleaning, sanitization, and record-keeping were completed in the food and nutrition departments that included the main kitchen and four kitchenettes. Failure to ensure this oversight of the food and nutrition services department increased the potential risk of foodborne illnesses for the entire resident population who received meals that were prepared in the main kitchen and served from the kitchenettes. Findings Include: 1. Refer to F812 2. Interview on 11/08/24 at 12:36 p.m. with dietary director (DD) E revealed: *She was a certified dietary manager. *She had been in her current position for two months. *She had not been aware of the regulations in nursing home kitchens. -Her previous position was not in a nursing home. *She had not seen the policies requested by the survey team until that week. *Consultant registered dietitian (CRD) H visited once a week on Thursdays. -Those visits were not recorded. --CRD H documented in residents' medical records. ---She confirmed that CRD checked-in with her during those visits. *There were no food service related audits being conducted that she was aware of. *No food service related audits had been completed since she started that she was aware of. Review of the provider's undated Dietary Director Position Description revealed: *The Dietary Director is responsible for coordinating the food service program to provide nutrition and variety within a budget. Consult with residents, staff, and dietician to ensure that therapeutic diet needs of residents are met. *The supervisor was listed as the administrator. *Essential job responsibilities included: -Consult with dietician as needed and directed according to state regulation and resident need. -Maintain a clean, orderly and safe kitchen environment. -Develop and implement policies and procedures in the food service program that are in compliance with food service regulations. -Adhere to and carry out all policies and procedures. Review of the providers 7/17/23 Contract for Registered Dietitian Services revealed: *The purpose of this Agreement is to arrange for Registered Dietitian (RD) consultation and management materials for the above named facility. -The facility listed above was a sister facility located in Sioux Falls. *Responsibilities of the Consultant Dietitian included: -Consults with Administration regarding planning of Food & Nutrition Service department policy Development, establishing goals and priorities in integrating Food & Nutrition Services into the Facility's total program. -Supports the Food & Nutrition Services Supervisor in maintaining department standards and all applicable regulations related to food procurement, receiving, storage, preparation, and service. -Assists in evaluating, developing and/or writing Food Service Policies and Procedures. -The Facility and [contract company name] shall mutually, on a periodic basis, review and approve the Food & Nutrition Services policies and establish future goals. -[Contract company name] may make recommendations to ensure quality food service and/or to comply with rules and regulations of the Federal or State governments. The Facility, however, is responsible for approving, implementing and maintaining recommendations made by [contract company name]. *The contract was not signed by the current facility administrator. Review of the provider's undated Maintenance Director Position Description revealed: *The Maintenance Director is responsible to maintain building and grounds. *The supervisor was listed as the administrator. *Essential job responsibilities included: -Carry out the preventative maintenance program. -Repair or replace damaged or broken fixtures or equipment. -Carry out other tasks as assigned by supervisor. *Knowledge Expectations included: Function and operation of kitchen appliances, office equipment maintenance equipment and grounds equipment, with ability to do minor repairs. *The position description review did not reveal oversight of the kitchenettes or monitoring of the kitchenette dishwasher temperatures.

Based on observation and interview, the provider failed to: *Ensure privacy had been maintained during interviews conducted in resident rooms for 13 of 13 (2, 13, 19, 21, 22, 27, 28, 41, 47, 48, 49, 52, and 106) residents with audio and video monitoring devices in their rooms. *Obtain consent for audio and video monitoring use for 6 of 13 (13, 41, 47, 49, 52, and 106) residents with audio and video monitoring devices in their rooms. Findings include: 1. Observation and interview on 11/05/24 at 1:27 p.m. with resident 28 in his room revealed: *An iFamily audio/video camera was on top of his closet facing his recliner. *He was unable to identify the audio/video device in his room. -He was conversive but unable to answer questions about the audio/video monitoring device. *There was no sign at the entrance to the room or within the room that indicated an audio/video monitoring device was used in that room. 2. Observation and interview on 11/05/24 at 2:22 p.m. and again on 11/08/24 at 8:36 a.m. with resident 22 in his room revealed: *An iFamily audio/video camera was on the bedside table next to the lamp. *He was unable to identify the audio/video device in the room. *An Echo Dot device [a smart speaker with an internet connection and a drop-in feature that allows instant connection between connected devices] was located between 2 recliners. *There was no sign at the entrance to the room or within the room that indicated audio/video monitoring devices were used in that room. 3. Observation and interview on 11/05/24 at 2:36 p.m. with resident 13 in his room revealed: *An iFamily audio/video camera was located on his nightstand. *He was unable to identify the audio/video device. -I don't know what that is. *There was no sign at the entrance to the room or within the room that indicated an audio/video monitoring device was used in that room. Review of resident 13's electronic medical record revealed (EMR): *There was no documentation that resident or family consent was obtained for the use of the audio/video monitoring device. *There was no documentation that the care plan had been updated to reflect the use of the audio/video monitoring device. 4. Observation and interview on 11/05/24 at 3:18 p.m. with certified nursing assistant (CNA) L in resident 106's room revealed: -CNA L sat on resident 106's bed visiting with her because she keeps trying to get up and walk. *A white monitoring device was on the windowsill. -CNA L stated that it was an audio-only device. *CNA L confirmed that other devices in the facility had video cameras, but this one did not. *There was no sign at the entrance to the room or within the room that indicated an audio monitoring device was used in that room. Review of resident 106's EMR: *There was no indication that resident or family consent was provided for the use of the audio device. *There was no indication that the care plan had been updated for the use of the audio device. Observation on 11/6/24 at 8:19 a.m. of resident 106's room revealed that the audio monitoring device was no longer present in that room. 5. Observation and interview on 11/05/24 at 3:29 p.m. with resident 19 in his room revealed: *He had an Echo Dot device he called [NAME] in his room. -His son had helped him set it up. -He used it to control his television. *There was no sign at the entrance to the room or within the room that indicated an audio monitoring device was used in that room. 6. Observation and interview on 11/6/24 at 9:55 a.m. with resident 41 and her husband in her room revealed: *Her room was located on the provider's secure Memory Care Unit (MCU). *There was no sign at the entrance to the room or within the room that indicated an audio/video monitoring device was used in that room. *A family interview was conducted with the resident and her husband in this room with the expectation of privacy. Observation on 11/8/24 at 8:43 a.m. of resident 41's room revealed: *No signage at the entrance to the room or within the room that indicated an audio/video monitoring device was used in that room. *An audio/video monitoring device, HelloBaby, sat on her dresser in the room with the camera pointed toward the room. Review of resident 41's EMR revealed: *There was no documentation resident or family consent was obtained for the use of an audio/video monitoring device. *There was a handwritten and undated care plan intervention, I have a camera in my room to help monitor my safety as well as to monitor other residents who may wander in my room. 7. Observation and interview on 11/7/24 at 4:21 p.m. with resident 27 and certified medication aide (CMA) I in resident 27's room revealed: *An iFamily audio/video camera was on the shelf in her room. -The camera had both audio and video functions. *She had turned the camera away from her while assisting resident 27. *An Echo Show device was located on her nightstand between the recliner and the bed. -That device was provided by resident 27's family. -CMA I stated that resident 27's family used that device to talk to other family members when they visited. -CMA I was unaware if that device allowed the family to listen or watch the care provided. *She would have known which resident rooms had a video camera because it was on their daily worksheet. *There was no sign at the entrance to the room or within the room that indicated audio/video monitoring devices were used in that room. Observation and interview on 11/7/24 at 4:30 p.m. with CMA I at the Cotton [NAME] Court neighborhood nurse's station revealed: *The audio/video monitoring screen was positioned facing into the nurse's station. -That screen was visible when facing the nurse's station when you looked to the right side. -That screen could have been seen by a public visitor when standing at the nurse's station. *CMA I confirmed that this device was used by resident 27 because she is the only one in this neighborhood with a camera. *CMA I confirmed that the cameras are listed on the resident care plan. *She stated that all staff who walked by should watch to make sure that resident 27 did not have a fall. -The audio/video monitoring camera and screen remained on even when the resident was not in their room. *She demonstrated the audio and pan and tilt features of the audio/video camera. -The camera viewing angle in resident 27's room was changed with the use of the control features of the monitoring screen at the nurse's station. -That allowed the viewing angle of the camera inside the resident's room to be remotely changed from outside the room. 8. Review of the provider's neighborhood daily worksheets revealed: *The Cotton [NAME] Report Sheet was undated. -It did not indicate that resident 27 had an audio/video monitoring device. *The [NAME] Way Pocket Guide was undated. -It did not indicate that residents 2, 13, and 22 had audio/video monitoring devices. *The [NAME] Creek Pocket Guide was updated on 11/7/24. -It did not indicate that residents 19, 28, and 106 had video or audio monitoring devices. *The Maple Valley Report Sheet was undated. -It indicated residents 21, 41, 47, 49, and 52 had a *Camera in their rooms. -Related to resident 48 it indicated FYI- CAMERA IN ROOM FROM FAMILY - THIS DOES RECORD. 9. Observation on 11/08/24 at 8:13 a.m. of the [NAME] Creek nurse's station revealed: *One audio/video monitoring screen on the counter facing the nurse's station. -There was no indication as to which resident room was being displayed. -That screen was visible when facing the nurse's station when you looked to the right side. -That screen could have been seen by a public visitor when standing at the nurse's station. *The audio/video monitoring device had a pan and tilt feature that allowed the viewing angle of the camera inside of the resident's room to be remotely changed from outside the room. Interview on 11/08/24 at 8:26 a.m. with CMA J regarding the audio/video monitoring devices used on [NAME] Creek revealed: *Resident 28 and resident 106 had video cameras in their rooms. -They were both the same kind. *The viewing monitor was kept at the nurse's station, but it could have been unplugged and carried by staff when needed. -All staff were responsible for looking at the audio/video monitoring screen at the nurse's station for resident safety. *She would have known which residents had video cameras in their rooms because they are in the room, and I can see them. *She was unaware if any family-provided audio or monitoring devices had been used in that neighborhood. Observation and interview on 11/08/24 at 8:41 a.m. with CMA K at the [NAME] Way neighborhood nurse's station revealed: *Two audio/video monitoring screens faced the nurse's station. -One was labeled keep vol [volume] on. -There was no indication of which residents' rooms were monitored. -Those screens were visible when facing the nurse's station when you looked to the left side. -Those screens could have been seen by a public visitor when standing at the nurse's station. -The audio/video monitoring device remained on even when the resident was not in their room. *CMA K stated the audio/video monitors were used for resident 22 and resident 13. -The video cameras were used as fall interventions on their care plans. -All staff were responsible for implementing fall interventions. *The audio/video monitoring device had a pan and tilt feature. -This allowed the viewing angle of the camera inside the resident's room to be remotely changed from outside the room. 10. Observation on 11/8/24 at 8:33 a.m. of resident 49's room revealed: *His room was located on the Maple Valley wing on provider's secure MCU. *There was a HelloBaby audio/video device plugged in and sitting on his four-drawer dresser in front of his flat screen television. *There was no signage on his door or in his room that indicated an audio/video device was in his room. Review of resident 49's EMR revealed: *There was no documentation resident or family consent was obtained for the use of an audio/video monitoring device. *There was a handwritten and undated care plan intervention I have a camera in my room to promote my safety. 11. Observation on 11/8/24 at 8:36 a.m. of resident 47's room revealed: *Her room was located on the Maple Valley wing on the provider's MCU. *There was a vtech audio/video monitoring device plugged in with a MIC [microphone] and the indicator light that was on and green, which indicated the device was on. *Her room door had no signage that indicated audio/video monitoring. Review of resident 47's EMR revealed there was no documentation resident or family consent was obtained for the use of an audio/video monitoring device. 12. Observation and interview on 11/8/24 at 8:40 a.m. with resident 52's husband and of her room revealed: *Her room was located on the Maple Valley wing in the MCU. *She and her husband were in the room and he was aware of the audio/video monitoring with no concerns expressed. *He stated the purpose of the device was related to his wife's falls and to keep her safe so the staff could respond if she falls. *Her room door had no signage that indicated audio/video monitoring. Review of resident 52's EMR revealed there was no documentation resident or family consent was obtained for the use of an audio/video device. 13. Observation and interview on 11/08/24 at 8:56 a.m. with resident 2 in her room revealed: *An audio/video communication device with a screen she called a portal was on her nightstand next to her recliner. *She stated she used the device to talk to her family. -I just say 'hey portal' call whoever I want to call. *She stated it also rang like a telephone, but she could answer it with her voice. *She stated she could see her family on the screen, and they could see her. *There was no sign at the entrance to the room or within the room that indicated an audio/video device was used in that room. 14. Interview on 11/8/24 at 8:55 a.m. with nursing assistant (NA) W revealed she: *Was recently hired on 10/8/24 and was training to be a CNA. *Was aware of audio/video monitoring in some of the residents' rooms. *Stated the audio/video monitoring had not been discussed at the facility's new employee orientation she had attended. *Became aware of the audio/video monitoring when she saw the video monitors at the nursing station's desk. *Stated At least three [residents] have it in their room. Continued interview on 11/8/24 with NA W revealed that the audio and video monitor was on for resident 41's device and stated staff can't really hear it, unless we turn it up. 15. Observation on 11/8/24 at 9:00 a.m. of the nursing station in the provider's MCU revealed five audio/video monitoring units were located on the nurses' station desk area with their screens on and turned toward the kitchenette area. 16. Interview and observation on 11/8/24 at 9:08 a.m. with housekeeper X in Maple Valley MCU revealed she: *Had been working at the facility for seven months. *Stated she was aware of the video monitoring in some of the resident rooms. *Showed this surveyor resident 48's room that had a video camera placed on top of the resident's wardrobe aimed at her bed. *Noted a pink sign on the resident's wardrobe that stated Video Monitoring/Recording in Progress. Please do not Move Camera per Family Request. -She stated today was the first day she noticed that sign on her wardrobe. -She stated she was not aware of all the rooms that had audio/video monitoring but said video monitoring cameras were in some of the resident rooms in other wings. *Could not recall if the audio/video recording had been discussed during her new employee orientation. *Showed this surveyor resident 21's room in the MCU and the iFamily video camera on her dresser and agreed there was no sign displayed of the audio/video monitoring. 17. Interview on 11/8/24 at 9:15 a.m. with CNA/CMA Y revealed: *There were five facility placed audio/video monitors in the MCU. *The audio/video monitors were used by staff to watch for the residents who would rise from their beds at night as a fall prevention. *The staff would also make rounds every couple of hours in the resident wings. *Resident 48's family had placed a video camera in her room. *The facility placed audio/video monitors were not recording devices. *The audio/video monitors all had audio so the staff could also hear what was occurring. 18. Interview on 11/8/24 at 9:41 a.m. with RN G revealed she: *Was the MCU's neighborhood leader. *Stated the audio/video monitoring was used as an intervention for falls. *Pointed to where the audio/video monitors were located on the nursing station desk and stated residents did not typically come into the nurse's station area. *Agreed the audio/video monitoring had occurred during the time of the family interview with resident 41 and her husband on 11/6/24. *Stated staff informed and cleared the audio/video monitoring with the family but did not ask the family to sign an acknowledgment of the monitoring. -That family conversation would be noted in a progress note. -Audio/video monitoring was included in the resident's individual care plan. *Stated It's a thought when asked if the provider should have signage posted for the audio/video monitoring. 19. Interview on 11/08/24 at 11:30 a.m. with administrator A regarding the provider's privacy policy revealed: *They reviewed resident rights at admission and residents would sign an acknowledgment at that time. *The resident admission packet was provided to the survey team during the entrance conference. -All information covered during a resident's admission would be found there. *There was no specific privacy policy. -The residents' right to privacy was covered in that admission packet. 20. Observation and interview on 11/08/24 at 11:50 a.m. with DON B regarding the use of audio/video monitoring devices revealed: *The provider used audio/video monitoring devices in several residents' rooms. -There were several different brands of devices. -All the devices used had audio and video capabilities. *Audio/video monitoring devices were used as a fall intervention. *The interdisciplinary team (IDT) reviewed residents to determine the need for an audio/video monitoring device. *Audio/video monitoring devices not being used were stored in the DON's office or the nurse's storage room. -All nursing staff and maintenance had access to the nurse's storage room where the extra audio/video monitoring devices were kept. -It was confirmed that there were no devices in the nurse's storage room. *There was one audio/video monitoring device in the DON's office. -That device had been removed from resident 106's room because it should not have been in that room. -It [the audio/video monitoring device] must have been left at the nurse's station when a different resident discharged . -She was looking into how it got there [resident 106's room]. *She kept a list of residents who had audio/video monitoring devices. -Resident 106 was not on that list. *She expected that the family would have been notified and consent would have been obtained when the audio/video monitoring device was recommended by the IDT. -Those devices should have been added as an intervention to each resident's care plan who had one in their room. *Family members had provided other devices including [NAME] and Echo devices to residents. -They were to be added to the care plan. *She confirmed that they had not posted any notice in the resident's room about audio/video monitoring devices used in those rooms. *She had not considered the need for privacy during interviews with residents and their families conducted by the survey team or when residents visited with family or other visitors. -She stated staff should turn the camera in the room while providing care. Interview on 11/08/24 at 11:59 a.m. with DON B regarding resident consent and care plans revealed: *They did not use a consent form for audio/video monitoring devices in residents' rooms. *Staff would have documented in the resident's EMR when families would have been notified of the use of an audio/video monitoring device as a fall intervention. *She had provided a copy of all the notifications to families for residents with an audio or video monitoring device that had been completed. -She confirmed that she had been unable to locate notifications to the family for residents 13, 41, 47, 49, 52, and 106. *She confirmed that the care plan had not been updated for resident 13. *She stated resident 106's care plan would not have been updated, because resident 106 had not been reviewed by the IDT for audio/video monitoring device use. 21. Review of the provider's un-dated Resident Admission Packet revealed: *ADMISSION ACKNOWLEDGEMENTS. -The undersigned resident/responsible party acknowledges receipt of the following information. Check the list below. --Resident [NAME] of Right. *A consent form, 8. [NAME] HOME PATIENT & RESIDENT RIGHTS: I have received a copy of the [NAME] Home Patient & Resident Rights form and understand it. *PRIVACY ACT STATEMENT- HEALTH CARE RECORDS. -THIS FORM PROVIDES YOU THE ADVICE REQUIRED BY THE PROVACY ACT OF 1974. THIS FORM IS NOT A CONSENT FORM . *A South Dakota State Long-Term Care Ombudsman Program packet. -You have the right to privacy and confidentiality regarding personal, financial, and medical affairs . --A facility must permit you to: . 2. Use a telephone without being overheard 7. Meet with people in a private setting within the facility. 22. Review of the iFamily Baby Monitor SM650 User Manual revealed: *PAN AND TILT The camera unit can be remotely controlled from the Monitor Unit. *Volume +/ Up key: Press Volume+ to increase the volume Review of the provider's 2/1/24 Video/Audio Monitoring and Recording policy revealed: *This policy outlines the rules for deploying such devices to ensure security, safety and the protection of resident's privacy. *[NAME] allows the use of video monitoring on the campus.' *Management, residents or their authorized representatives may place video monitoring devices in residents' rooms. *Placement of Monitoring Devices owned by [NAME] -[NAME] may place video monitoring devices in resident's rooms/apartments if deemed appropriate and approved by the Administrator, or designee, and agreed upon by the resident or their authorized representative. -Monitoring devices placed in residents' rooms/apartments should be positioned to minimize the monitoring of private areas such as restrooms, bathing areas, and the changing areas as much as possible. *Resident Owned Monitoring. -Before initiating video monitoring, a resident shall provide notice and consent to [NAME]. *The policy did not identify a need to post notices at the entrance to the resident's room that a monitoring device was operational in that room. *The policy did not identify a need to obtain consent for the placement of monitoring devices owned by [NAME] 43021

Based on observation, record review, interview, and policy review, the provider failed to have interventions in place to prevent the development of a pressure ulcer for 1 of 2 sampled residents (4) with pressure ulcers. Findings include: Observation and interview on 6/11/19 at 8:20 a.m. with registered nurse (RN) B while providing wound care to a pressure ulcer on resident 4's left heel revealed: *A pressure ulcer to her left heel. *The area on her heel was open and covered a large portion of the bottom of her heel. *RN B stated: -The area on her heel was open at the time it was identified on 4/1/19. -The hospice provider had changed the wound care orders about two weeks ago. -The wound had been improving before the wound care orders had changed. -The nurses change the dressing daily. -The hospice nurse will observe the dressing change. -The wound nurse (RN C) measured the wound. Review of resident 4's medical record revealed she was admitted on [DATE] from the hospital after a fall at her previous home. *Her 2/21/19 admission skin assessment had indicated: -Her skin color was normal, and skin temperature was warm. -The skin turgor had not been documented. -A bruise to her left eye. -A scab to her left knee. -No other skin concerns were identified. *A 2/21/19 Braden Scale for Predicting Pressure Sore Risk revealed a score of 11, indicating she was at high risk for developing a pressure ulcer. Items identified were: -Slightly limited sensory perception. -Her skin was often, but not always moist. -She was chairfast. -Her mobility was very limited. She made only occasional slight changes in her positioning, but was unable to do frequent or significant changes independently. -Her nutrition was very poor. -Skin friction and shearing was a problem. She required moderate to maximum assistance with moving, and required frequent repositioning with maximum assistance. A 2/28/19 Admission Minimum Data Set (MDS) assessment revealed she:*Required extensive assistance of two staff for bed mobility, transfers, dressing, and hygiene. *Did not walk. *Was totally dependent on one staff person for locomotion. *Toileted with extensive assistance of one. The 2/28/19 MDS assessment, section M (skin) revealed she: *Was at risk for developing a pressure ulcer. *Did not have pressure areas. *Had a pressure reducing device to her chair and bed. *Was not repositioned by staff. The 2/28/19 MDS Pressure Ulcer Care Area Assessment (CAA) indicated:*She had a potential for skin breakdown due to: -Her inability to change positions adequately. -Requiring assistance with bed mobility. *Extrinsic factors: -Had been identified for pressure: Needs special mattress or seat cushion to reduce or relieve pressure. -Had not been identified for the need to reposition the resident on a regular turning schedule. *She did not have a pressure ulcer. *Staff would monitor the resident and note any changes. *The pressure ulcer risk was to have been addressed on her care plan to minimize the risk of pressure ulcers. Review of resident 4's 2/22/19 initial care plan: *Had not included the risk of skin concerns. *Had identified she required extensive assistance of two staff and a mechanical stand lift for transfers. Review of the 3/1/19 hospice skilled nursing admission assessment revealed: *A Braden Scale score of 13, indicating moderate risk for pressure ulcers related to: -Chairfast. -Very limited mobility. -Very poor nutrition. -Friction/Shear problem. *A Palliative Performance Scale indicated a score of forty percent related to: -Mainly sit to lie. -Self care: Total care. *The hospice admission assessment had not included a skin assessment. Review of the 3/1/19 hospice interdisciplinary care plan revealed: *A hospice aide was to visit the resident five times every week for twelve weeks, then three times every week for one week. *Aide duties were to have included repositioning and personal care including skin care. *A hospice nurse was to have visited twice weekly for twelve weeks, then once weekly for one week. *Nurse duties had included assessing her skin condition. Review of resident 4's 2/21/19 through 3/29/19 interdisciplinary progress notes regarding skin concerns revealed: *Seventy-two hour nursing assessments completed on 2/22/19, and 2/24/19 identified an abrasion to her knee and a bruise to her eye. *A Significant change in Condition Nutritional Assessment indicated a Braden Scale score of 11, Very high risk for skin breakdown. A Mighty Shake was added for additional protein. *Full Skin Assessments completed 3/8/19, 3/15/19, and 3/22/19 indicated: -There were no new skin issues. -Her finger and toe nails were trimmed. *A Full Skin Assessment completed 3/29/19 her skin was clean, dry, and intact. A 3/1/19 Significant Change MDS assessment was completed due to the resident's admission to hospice with a [DIAGNOSES REDACTED]. That MDS assessment indicated: *Section G: -The activities of daily living had only changed with the resident's ability to assist with hygiene with limited assistance of one staff. -She continued to require extensive assistance with the other areas. *Section M (skin): -There were no changes in the skin assessment. -The resident was not repositioned by staff. The 3/8/19 MDS Pressure Ulcer CAA: *Had no newly identified concerns or treatments. *Had not identified the need to reposition the resident on a regular turning schedule. *She did not have a pressure ulcer. *Staff would monitor the resident and note any changes. *The pressure ulcer risk was to have been addressed on her care plan to minimize the risk of pressure ulcers. There were no new interventions added to the care plan at that time. Review of the interdisciplinary progress notes on 4/1/19 revealed RN M documented: *A five centimeter (cm) by (x) three cm stage three pressure ulcer to resident 4's left heel. *Wound bed is pink, no bleeding noted. *A dressing was applied. *The physician was faxed with the following information: Resident noted to have a Stage III pressure ulcer to her left heel. Area measures 5 x 3 cm pink peri-wound with circular margins. Small necrotic area to upper aspect. *The physician approved wound care orders and a Sage boot (for heel protection to minimize pressure) at all times except transfers. There was no documentation in the medical record of a skin concern to resident 4's heel prior to identifying the open wound on 4/1/19. A 4/4/19 Wound Integrity Evaluation was faxed to the physician indicating a 3 x 5 cm stage II pressure ulcer: *The wound had a depth of 0.2 cm. *No tunneling or undermining. *The wound bed was Red 100%, Dermal Base (pink/red) Partial thickness. *Periwound edges were macerated (soft/moist).*Infection/critical Colonization: Localized s/s (signs and symptoms); Non-healing: Systemic s/s: Exudate increase, [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. Interview on 06/11/19 12:25 p.m. with RN wound nurse/neighborhood leader C regarding resident 4's pressure ulcer identified on 4/1/19 revealed: *RN B notified her of the pressure ulcer. *It was originally identified as a stage III ulcer by her, but the wound consultant (a dressing sales nurse) corrected the wound to stage II after he assessed it on 4/4/19. *The nurses were to have documented skin assessments weekly with the residents' baths. *Nothing had been identified on the heel until 4/1/19. *The resident's shoes were not appropriate; they had been too large and moved around on her feet. *She used the heel of her foot to push/propel her wheelchair and wandered about the neighborhood. *The friction from pushing with her heel, and laying in bed were the probable causes of the pressure ulcer. *The seat cushion and standard pressure relieving mattress had been in place to prevent skin breakdown. *She stated there was a lack of documentation and communication regarding the skin concerns. *She confirmed no other preventative measures had been in place prior to the identification of the pressure ulcer. *After the ulcer had been identified interventions added included:-A Sage boot was applied to the left foot. -Daily dressing changes. -Repositioning at least every 2 hours. *Nutrition interventions including [MEDICATION NAME] protein, whole milk, Ensure, and fingerfoods. Review of the care plan after the pressure ulcer was identified on 4/1/19 revealed:*On 5/18/19 the dietary department included the [MEDICATION NAME] and Ensure for skin healing. *A pressure ulcer care plan was added on 4/1/19: -The goal was the pressure ulcer would show signs of healing and remain free from from infection. -Turn/reposition at least every 2 hours, more often as needed or requested. -Pressure relieving/reducing device on bed/chair. -On 6/4/19 an intervention of a Sage boot to her left foot was added. -On 6/4/19 an intervention to assess her skin weekly on her bath day and alert the physician of changes. Review of RN/wound nurse C's wound assessments requested by the surveyor revealed a one-page typed list: *4/2/19: Stage 3 (changed to a stage 2 per wound consultant: 5 x 3 cm. *4/12/19: Stage 2: 4 x 2 cm. *4/16/19: Stage 2: 4.5 x 3.5 cm. *4/24/19: Stage 2: 4 x 3.5 cm. *4/30/19: Stage 2: 3.4 x 2.5 cm. *5/7/19: Stage 2: 5 x 7 cm. *5/14/19: Stage 2: 3 x 4 cm. *5/21/19: Stage 2: 4 x 3 cm. *5/28/19: Stage 2: 3 x 2 cm. *6/4/19: Stage 2: 4 x 3 cm. RN/wound nurse C's wound assessments: *Only consisted of the length and width of the wound. *Had not included wound depth measurements, except for the initial 4/4/19 assessment by the wound consultant. *Had not included further documentation of undermining, tunneling, exudate, or symptoms of infection. Review of the interdisciplinary progress notes, other nurses: *Had documented drainage, maceration, necrotic areas or black spots. *Some of that documentation included wound measurements. *Some measurements had been documented in inches rather than centimeters. Phone interview on 6/12/19 at 4:20 p.m. with hospice nurse D regarding resident 4's pressure ulcer care revealed:*When asked about not assessing the resident's skin on admission the nurse provided no comment. *She stated: -The pressure area was not identified until 4/1/19. -She did not assess the wound. -She sometimes observed the wound care done by facility nurses. -The pressure ulcer occurred rapidly. -The resident had a seat cushion and a pressure relieving mattress. -The facility did not allow low-air loss mattresses. -Neither the provider nor the hospice provider had added other interventions, such as floating her heels on pillow support. Interview on 6/12/19 at 3:45 p.m. with the director of nursing confirmed:*Preventative measures were not added to the resident's plan of care until the pressure ulcer was identified. *A correction/education with the staff was held after the ulcer had been identified. *RN B had reported at that time she thought the resident's heel was soft or boggy the day before it was identified, but hadn't documented it. *The wound nurse's measurements were not complete. Review of the provider's reviewed (MONTH) (YEAR) Prevention and treatment of [REDACTED]. *The purpose was to: -Identify residents at risk for skin breakdown in order to prevent breakdown. -Aggressively treat and heal skin issues by use of effective interventions. *Prevention was to have included: -Identifying risk factors including decreased mobility, poor nutritional status, and a decreased level of consciousness. -A Braden Scale Assessment on admission, annually and with significant changes. -Establishing a care plan based on assessments. -A dietary nutritional assessment. -A repositioning and turning program. -Monitoring skin daily and providing moisturizers. -Providing pressure reducing cushions or mattresses. *Reducing pressure was to have included: -Use devices such as pillows and foam wedges that totally relieve pressure on the heels (most often raising heels completely off the bed.) -Use positioning devices such as pillows or foam to prevent direct contact between bony prominence's (knees or ankles). -Develop a written plan for the use of positioning devices as well as pressure reducing devices and techniques. *Assessment was to have included: -Assess the location, dimension, depth, stage of wound; Look for sinus tracts, undermining and tunneling. Look at the wound base to determine if it is clean, infected or necrotic; see also the wound edges and status of surrounding tissue. Is there exudate (color, volume, odor)? Assess and treat pain. -Reassess and measure skin ulcers weekly or sooner if deterioration is noted. -The skin assessment was to have been documented weekly in the nursing progress notes and/or the skin assessment sheet. -The Compromised skin was to have been reported to the dietary department for immediate nutritional support. -Skin issues were to have been discussed and monitored by the interdisciplinary team on a weekly basis. -Standard precautions were to have been followed when treating ulcers.

Based on observation, interview, and record review, the provider failed to prevent injuries for one of one sampled resident (17) with major injury from a fall and for one of one sampled resident (29) with a burn. Findings include: 1. Observation from 6/10/19 through 6/12/19 of resident 17 revealed she was constantly laying on her back in her bed watching TV. Review of resident 17's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. Review of resident 17's Minimum Data Set (MDS) assessments revealed: *On her quarterly 12/21/18 assessment she -Was totally dependent on staff and required two staff member physical assistance for bathing. -Had impairment on one side of her upper extremity. -Had impairment on one side of her lower extremity. -Had no pain. -Had no falls. *On her annual 3/22/19 assessment: -Her behavior status had gotten worse. -Bathing had not occurred. -She had impairment on one side of her upper extremity. -She had impairment on one side of her lower extremity. -She had moderate pain occasionally that limited her day-to-day activities. -She had a fall with major injury. Review of resident 17's care plan revealed: *Focus initiated on 10/13/17: -Have had a stroke causing me to be flaccid on the right side of my body. -I am at risk for falls and pressure ulcers. *Interventions/tasks revised on 3/11/19: -I do not like using the belt for the bath chair. I know the risks of not using this belt. Please offer to use the bath chair belt with each bath. -I like to have the bath chair raised high enough to where my feet do not touch the floor. Please keep the chair as low as possible for my comfort and to encourage safety. *Interventions/tasks initiated on 3/15/19, I suffered a fall on 3/2/19 from the bath-chair in spa room that resulted in a major injury of a broken right femur. *Interventions/tasks revised on 3/24/19: -I require extensive 2 assist for bed mobility, dressing, toileting, hygiene, and bathing. -I require extensive assist x 2 with bathing. Review of resident 17's 3/2/19 at 9:00 a.m. registered nurse (RN) progress note revealed: -Called into Spa room. Resident found lying on the floor tilting slightly to the left. Her head was by the tub. She was on her back and her right leg was bent at the knee and under her left leg. CNA (certified nurse aide) states resident was sitting on the bath chair and the CNA was drying her right arm. Resident suddenly slumped forward and fell on the floor. The bath chair was in high position. Resident denies hitting her head. She is able to move her left arm and leg. Right extremities flaccid from old stroke. She denied having pain. A Hoyer lift was used to pick resident up and place her in her wheelchair. Resident returns to lying position in her bed. She flinches when her left leg and arm moved. -When lying in bed, she flinched when her right extremities were moved. -Resident transported to (hospital name) ER. Review of resident 17's 3/2/19 fall report revised on 3/7/19 revealed: *One staff member witnessed her fall. *Initial cause note, Resident went unresponsive and did not have bath belt on. *Interventions, Resident requests to not have bath belt on and requests to have bath chair at a higher level so her feet do not touch the floor. Will try educating resident on importance of bath belt and see if she will allow the bath belt to be on. Review of resident 17's 3/14/19 physician's progress note revealed, She slid out of a shower chair and fractured her femur. She underwent surgical repair. She ended up in the hospital for over a week. Interview on 6/12/19 at 9:18 a.m. neighborhood leader/RN C confirmed resident 17 needed two staff members to assist with her bathing. Interview on 6/12/19 at 11:00 a.m. with the director of nursing (DON) regarding resident 17's fall revealed: *She had not liked the bath belt. *She liked the chair up higher so her feet would not touch the ground. *The chair was up higher and she had an unresponsive episode. *Two staff members had assisted her from her wheelchair to the bath chair. *When she was in the tub there was only one staff member with her. *When she moved from inside the tub to outside the tub still on the bath chair she would only expect one staff member to assist. *When she moved from the bath chair back to her wheelchair after the bath she expected two staff members to assist. *After her fall, she agreed to use bath belt and not to have the chair so high. Continued interview on 6/12/19 at 11:30 a.m. with the DON confirmed: *Moving a resident from inside the tub to outside the tub while still on the bath chair was considered a transfer. *With resident 17's diagnoses, her refusal to use the bath belt, and her wanting the chair higher, two staff members should have assisted her with the transfer in and out of the bath tub. 2. Review of resident 29's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. Review of resident 29's MDS assessments revealed: *On her 7/10/18 significant change assessment: -Her Brief Interview for Mental Status (BIMS) score had been five that indicated her cognition was severely impaired. -The inattention behavior was present and fluctuated day to day. -She needed extensive assistance from one staff member for eating and drinking. *On her 4/15/19 quarterly assessment: -Her BIMS score had been a two that indicated her cognition was severely impaired. -The inattention behavior was present and fluctuated day to day. -The disorganized thinking behavior was present and fluctuated day to day. -She needed extensive assistance from one staff member for eating and drinking. Review of resident 29's care plan revealed: *Focus area revised on 11/13/17 noted she had impaired visual function related to [MEDICAL CONDITION] and diabetic retinopathy. *Focus area revised on 2/7/19 noted she had poor vision. *Interventions/tasks revised 3/25/19 noted she needed assistance with eating. Review of resident 29's health status notes revealed: *On 4/26/19, Was noted during bath resident has a two inch by one inch partially intact blister in right inner thigh. Unsure of cause. Will monitor. *On 5/2/19, Resident seen during physicians round this morning. New order to apply house barrier cream to blistered area of right upper inner thigh with each brief change. *On 5/6/19, -When doing rounds, resident noted to have eight by two cm (centimeters) burn-like area to her right inner thigh. -Consistent with resident dropping hot liquids such as coffee or hot chocolate which is not uncommon as resident has [DIAGNOSES REDACTED]. Review of resident 29's 5/6/19 notification to physician form noted, Resident noted to have burn-like abrasion to her Rt (right) inner thigh. Resident will often tumble with drinks et (and) may have spilt coffee or hot chocolate in her lap. Area measures 8 x 2 cm with slough to peri-wound. Interview on 6/12/19 at 2:45 p.m. with neighborhood leader/registered nurse (RN) C, neighborhood leader/RN G, and RN L regarding: *Coffee and hot chocolate: -Residents were able to have coffee and/or hot chocolate any time. -They would prefer residents ask for assistance with coffee and/or hot chocolate. -Nursing staff had not monitored the temperature of the coffee. -Thought coffee mug lids had been ordered. *Resident 29: -She drank a lot of coffee. -Confirmed there was a coffee spill on her inner thigh. -Had ice added to her coffee since the coffee spill. -Since the spill have been trying to have someone sit with her while she drinks her coffee. Interview on 6/12/19 at 4:12 p.m. with the DON regarding resident 29 revealed: *She liked her coffee. *She often had trouble tipping the coffee up to her mouth or may have gotten sleepy at the table. *She was unable to get her own coffee. *Since the spill they tried to cool down her coffee. Interview on 6/12/19 at 4:40 p.m. with the certified dietary manager regarding coffee revealed: *Residents were able to self serve themselves. *The dietary department had not monitored the coffee temperature. *Disposable coffee mug lids were available on the neighborhoods. *She expressed concern the disposable lids were a dignity issue. *They were researching a more dignified coffee mug. Further interview on 6/12/19 at 4:45 p.m. with the DON confirmed: *They had been researching coffee mugs with lids. *They had not completed hot beverage assessments. *They had no policy related to hot beverages.

Based on record review, interview, policy review, job descriptions, and daily staffing record review for [DATE] and [DATE] the provider failed to ensure professional standards were followed for: *Resident assessment; *Physician, hospice, and family notification of changes; *Documentation for one of one sampled resident (1) with an acute change in a condition; *Reallocation of staff to one of four nursing units (Maple Valley) to provide for increased care needs for one of one sampled resident (1). Findings include: 1. Review of resident 1's undated care plan revealed: *"Is receiving hospice (terminal care) services." *"His needs will be met, he will be kept comfortable, and free from pain." *"Coordinate with hospice services." *"Is a high risk for falls related to impaired cognition (memory) and impaired mobility." Review of an undated registered nurse (RN) or licensed practical nurse (LPN) job description revealed: *"Implement clinical policies and procedures to ensure safe, sanitary, and efficient practices supporting professional standards of nursing care. Assure that documentation, medication administration, resident nursing care, safety, and resident rights are in compliance with facility standards." *"Monitor health, safety, and well-being of the residents." *"Observe and document information pertaining to changes in residents' functional status and personal needs." *"Assist in keeping the environment safe for residents." Review of the provider's revised [DATE] Care of the Dying Resident policy revealed: *When a resident's condition becomes critical: -Notify the physician. -Notify the family and clergy if family desires. *After a resident's death: -Notify the physician. -Obtain an order from the physician to release the body to the mortuary. *Points of emphasis: -Documentation of symptoms, vital signs (blood pressure, pulse and respirations), care given, and those who were notified is extremely important. -The physician was to have been notified as soon as possible. Review of undated hospice information in resident 1's medical record revealed: *"Before getting any new orders and with any changes in condition call hospice services." *"Use nursing judgement to ensure the patient is safe, comfortable, and treated with any current as needed (PRN) medications/treatments. Then call the hospice nurse for further directions in care." Review of undated hospice service standards provided by the administrator revealed: *"A call must be made for every call received reporting a change in the patient's condition." *"To assess customer satisfaction, the director of clinical services must call the family the day after an evening or weekend call anytime there are changes in the resident's condition." *"We strive to be present at every patient's death." Review of a [DATE] faxed hospice change in condition notice from the hospice administrative registered nurse revealed the provider must notify hospice immediately: *"Regarding a significant change in the resident's physical, mental, social, or emotional status." *"Any clinical complications that suggests a need to alter the plan of care." *"A condition unrelated to the terminal condition that might require transfer of the resident from the facility." *"A resident's death." Interview on [DATE] at 1:45 p.m. with the director of nursing regarding the above revealed: *There was usually a total of seven staff on duty during the 10:00 p.m. to 6:30 a.m. shift. There was two staff on Cottonwood Court, Plum Creek, and Willow Wood Way. There was always only one staff on Maple Valley (a registered nurse (RN) or a LPN). *They had made some staffing changes for the 10:00 p.m. to 6:30 a.m. shift on [DATE] through [DATE]. Some of the evening (2:00 p.m. to 10:30 p.m.) staff stayed later, and one staff member came in early that worked the 6:00 a.m. to 2:30 p.m. shift. *Despite those staffing changes the total number of staff hours was equivalent to 6.5 staff and should have been adequate to meet the nursing needs of all the residents on all the units. *Staffing for the 10:00 p.m. shift on [DATE] through 6:30 a.m. shift on [DATE] documented on the daily census sheet revealed: -Cottonwood Court: -- RN O from 10:00 p.m. to 12:00 a.m. -- LPN G from 2:00 a.m. to 6:00 a.m. -- CNA B from 10:00 p.m. to 2:00 a.m. -- CNA D from 10:00 p.m. to 6:00 a.m. -Maple Valley: -- LPN A from 10:00 p.m. to 6:30 a.m. -Plum Creek: -- RN C from 10:00 p.m. to 6:30 a.m. -- CNA P from 10:00 p.m. to 2:00 a.m. --CNA B from 2:00 a.m. to 6:00 a.m. -Willow Wood Way: -- LPN H from 10:00 p.m. to 6:30 a.m. *She agreed there was adequate staff for the four units that night, but impaired nursing judgement interfered with a staff member from another unit staying on Maple Valley with LPN A due to the significant change with resident 1 and another resident that was awake hollering all night. *The nurses for that shift would have been able to make the determination increased staff needs should have been focused on Maple Valley that night. Interview on [DATE] at 2:10 p.m. with LPN A regarding resident 1 revealed: *Asked the 10:00 p.m. staff (LPN E and certified nursing assistant (CNA) (F) on [DATE] at approximately 10:20 p.m. to put a resident back in bed who had just had a projectile (forceful) emesis (vomiting), had decreased alertness and responsiveness, and was grey in color. *Told them if they did not put him back in bed she would have no one to help her. The resident required two staff assistance with the use of a Hoyer (mechanical) lift for transfers. *Was the only one on duty that shift in the Maple unit. *Spent the majority of her time between 10:00 p.m. on [DATE] and 3:20 a.m. on [DATE] going between resident 1's room and another female resident in the room next door to him who was yelling all night. *CNA B did come over from another unit to assist her with rounds (repositioning and toileting) the residents. *She did not consider his projectile (forceful) emesis, change in responsiveness, and grey colored skin tone was a significant change in his condition. *She did not notify the family or hospice services on [DATE] at 10:00 p.m. through [DATE] at 3:20 a.m. when he expired (died ). *She did not notify the physician about his significant change in condition or his death. *She had asked the previous shift to lay him down in bed again after he had been vomiting, because she would have no help to lay him down. She was aware of his high risk for aspiration and his hospitalization in [DATE] with pneumonitis due to inhalation of food or vomitus. Refer to F309.

Based on record review, interview, policy review, and product user-service manuals the provider failed to ensure: *The physical, mental, and psychosocial needs were met during a resident change in condition ending in death for one of one resident (1). *Appropriate assessment and care for one of one sampled resident (1) at end of life. *Fall incidents and the use of grab bars on the bed were assessed and evaluated for safety for two of two sampled residents (1 and 2). Findings include: 1. Review of resident 1's medical record revealed: *An [DATE] admitted . *[DIAGNOSES REDACTED]. *He had a grab bar on the left side of his bed since admission on [DATE]. *There was no assessment of his ability to use the grab bar. *Hospice services had been initiated on [DATE] due to terminal [DIAGNOSES REDACTED]. *Hospice had put an alternating pressure mattress on the bed. *He expired (died ) at the facility on [DATE]. Review of resident 1's [DATE] physician's orders [REDACTED]. *"Terminal [DIAGNOSES REDACTED]." *"Patient's prognosis is six months or less if the disease runs its normal course." Review of resident 1's [DATE] hospice plan of care revealed: *Caregivers were knowledgeable of care and need to report changes of LOC (level of consciousness). *Facility staff was knowledgeable and involved in hospice plan of care for the patient. *Patient would receive personal care and hygiene including other activities of daily living to their optimal level. *Hospice nurse to coordinate plan of care with facility staff. Review of resident 1's [DATE] nursing progress notes revealed: *"Nurse heard noise from resident's room. Found him lying on floor mat next to bed with legs and torso on the floor next to his bed wrapped in the blanket." *"Resident's head was still on the bed. Did not appear to hit his head." *"Resident was propped on right side with pillows behind him." *"Bed was in lowest position. Floor mat on floor." *"Call light on bed. Resident does not use." *"Skin tear to right elbow 1.0 centimeter (cm) by 1.8 cm u-shaped." *There was no documentation the use and safety of the grab bar had been evaluated. 2. Review of resident 1's [DATE] at 3:20 a.m. nursing progress notes revealed: *"CNA B entered room just ahead of writer (LPN A). CNA B turned and said (He is on the floor). When writer got further in the room, resident was lying on his left side next to the bed." *"The bed was in lowest position with his neck caught on the side rail of the bed. Writer called for assistance from other staff. Registered nurse (RN) C and CNA D responded. We disengaged (took apart) the side rail and laid resident's head on a pillow." *"No respirations (breathing) noted and no pulse palpable (felt). Color of skin very pale and cool to touch. Resident was incontinent of urine and bowel movement. Assist of four staff resident was gently rolled over on to a sheet then lifted into bed. Resident was changed and cleaned up." *"Director of nursing (DON) was called, police called, and hospice nurse called. Paramedics responded with police. Necessary paperwork provided to both. Hospice nurse responded. DON responded and administrator. Police questions answered and paperwork provided. Police investigation completed and autopsy requested by police. Resident's body was transferred per ambulance to a skilled hospital. DON notified family." Review of resident 1's [DATE] at 3:21 a.m. and 6:05 a.m. nursing progress notes by LPN A revealed: *3:21 a.m. "Resident was found on floor by bed with head caught between grab rail and mattress. Skin pale and cool to touch. No respiration or palpable pulse. Necessary phone calls and paperwork filled out with DON. Resident sent to skilled hospital per ambulance." *6:05 a.m. "CNA B entered room at 3:20 a.m. just ahead of writer. She stated he is on the floor. When writer went closer resident was lying on his left side on the floor by the bed, which was in position, with his head caught on grab bar on side of bed. Resident was pale and cool to touch. No pulse palpable or respiration noted. Resident was incontinent of urine and feces (bowel movement). Writer called for assistance from other staff. Side rail was disengaged and resident's head laid on a pillow. With assist of four persons resident was gently rolled onto a sheet, then lifted on to the bed with the sheet. Resident cleaned up and changed. DON was called. Hospice nurse called. Police called. Paramedics, police, DON, hospice nurse, and the administrator responded. Police assessed the situation and requested an autopsy. Body transported per ambulance to a skilled hospital." Phone interview on [DATE] at 4:10 p.m. with CNA B regarding resident 1 revealed: *Approximately 3:00 a.m. resident found with legs on floor. Was half in and half out of bed. One shoulder was on the bed and the other shoulder was on the floor. Both arms were on the floor. His head and the underside of his jaw was against the bar or under the bar. *Clear liquid all over the floor; guess it was urine. *His left jaw had a red indentation. It stayed that color, as there was no blood flow. *He never used the grab bar to help with repositioning. *RN C struggled to disengage the grab bar. *There was no documentation regarding any of the above in LPN A's nursing progress notes. Review of facility internal investigation report review by CNA B provided by the administrator revealed: *CNA B provided the information on [DATE] at 3:30 a.m. regarding the care of resident 1. *"When I was fully in the room I noticed the resident out of the right side of his bed (a grab bar was only on the left side of the bed) with the right side of his jaw hooked on the side rail of the bed." *"The resident's eyes were open and his skin was yellow." *"The first thing we did was remove the side rail from the resident's jaw, slowly lowering his head to the floor." *There was no documentation regarding any of the above in LPN A's nursing progress notes. Review of facility internal investigation report review by LPN A provided by the administrator revealed: *LPN A provided the information regarding the care of resident 1 on [DATE] through [DATE] between 10:00 p.m. to 6:00 a.m. *10:00 p.m. "Resident was being cleaned up after having a projectile emesis in bed. Out to station per wheelchair and vitals (blood pressure, pulse, and respirations) taken. Resident is afebrile (no temperature) and vitals within normal limits." *11:00 p.m. "Resident transferred to bed with assistance from evening nurse and writer." *12:10 a.m. "Resident resting on right side. No emesis." *1:00 a.m. "Resident incontinent of urine and small bowel movement. Cleaned up and changed. Repositioned to left side. CNA B stated resident still looks real pale (white). Resident alert by not smiling and happy self." *2:15 a.m. "Resident resting quietly on left side with eyes closed. Skin warm and dry. No emesis. Voiced no complaints." *There was no documentation of any of the above in LPN A's nursing progress notes. Interview on [DATE] at 11:00 a.m. with the DON and administrator regarding the above revealed: *It was likely due to the nature of the incident the nurses omitted to document some of the above in the medical record. *It was important that the above was documented somewhere even though it was not in the medical record. Review of resident 1's undated care plan revealed: *"Impaired cognitive (memory) function." *" High risk for falls. Bed in low position at night. Encourage to use call light." *"Has pressure relieving mattress on his bed." *"Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface." *"Is extensive assist of 1 to 2 staff participation to reposition or turn in bed." *The use of the grab bars or his ability to use them with bed mobility were not addressed. Review of a facility internal investigation report interview with licensed practical nurse (LPN) A provided by the administrator regarding resident 1 revealed: *LPN A provided the information below regarding the care of resident 1 on [DATE] to [DATE] between 10:00 p.m. and 6:00 a.m. *10:00 p.m. "Resident was being cleaned up after having a projectile (with great force) emesis (vomiting) in bed. Out to station per wheelchair and vitals taken. Resident is afebrile (no temperature) and vitals (blood pressure, pulse, and respirations) within normal limits." *11:00 p.m. "Resident transferred to bed with assistance from evening nurse and writer." *12:10 a.m. "Resident resting on right side. No emesis." *1:00 a.m. "Resident incontinent of urine and small bowel movement. Cleaned up and changed. Repositioned to left side. Certified nursing assistant (CNA) B stated resident still looks real pale (white color). Resident alert but not smiling and happy self." *2:15 a.m. "Resident resting quietly on left side with eyes closed. Skin warm and dry. No emesis. Voiced no complaints." *3:20 a.m. "CNA B entered room just ahead of writer (LPN A). CNA B turned and said (He is one the floor). When writer got further in the room, resident was lying on his left side next to the bed. The bed was in lowest position with his neck caught on the side rail of the bed. Writer called for assistance from other staff. Registered nurse (RN) C and CNA D responded. We disengaged (took apart) the side rail and laid resident's head on a pillow. No respirations (breathing) noted and no pulse palpable (felt). Color of skin very pale and cool to touch. Resident was incontinent of urine and bowel movement. Assist of four staff resident was gently rolled over on to a sheet then lifted into bed. Resident was changed and cleaned up. Director of nursing (DON) was called, police called, and hospice nurse called. Paramedics responded with police. Necessary paperwork provided to both. Hospice nurse responded. DON responded and administrator. Police questions answered and paperwork provided. Police investigation completed and autopsy requested by police. Resident's body was transferred per ambulance to a skilled hospital. DON notified family." 3. Review of resident 1's [DATE] at 10:29 p.m. by licensed practical nurse (LPN) E's nursing progress notes revealed: *"Checked at 9:30 p.m. and was resting quietly in bed on his right side." *"At 10:00 p.m. certified nursing assistant (CNA) F heard unusual noise from his room and resident was found to be having projectile (forceful) emesis (vomiting). Emesis was noted to be coming out of his nares (nose) as well as mouth." *"Was assisted up into wheelchair per Hoyer (mechanical) lift." *"Some audible congestion noted which lessened as resident sat upright and coughed a few times. Does report feeling some better after episode. States he woke up and it hit him fast." *Blood pressure ,[DATE] (normal ,[DATE]), pulse 68 (normal ,[DATE]), respirations 20 (normal ,[DATE]), and temperature 98.1 (normal 98.6). Oxygen saturations 95 percent (%) (normal greater than 90 %) on room air." *[DATE] at 3:21 a.m. by LPN A "Resident was found on bed with head caught between grab rail and mattress. Skin pale and cool to touch. No respiration or palpable pulse. Necessary phone calls and paperwork filled out with DON. Resident sent to skilled hospital per ambulance." *[DATE] at 5:59 a.m. by the DON "Called resident's son to alert him that his dad had passed away. Told him that we found him in between the mattress and the side rail around 3:30 a.m. Told him that he had been ill during the night with vomiting. Told him that we had called the police since he was found this way and per their direction we had him taken to the morgue at a skilled hospital for an autopsy. I asked him if he had any questions and I gave him my condolences. Called administrator with an update prior to this phone call." *[DATE] at 6:05 a.m. by LPN A "CNA B entered room at 3:20 a.m. just ahead of writer. She stated (He is on the floor). When writer went closer resident was lying on his left side on the floor by the bed, which was in position, with his head caught on grab bar on side of bed. Resident was pale and cool to touch. No pulse palpable or respiration noted. Resident was incontinent of urine and feces (bowel movement). Writer called for assistance from other staff. Side rail was disengaged and resident's head laid on a pillow. With assist of four persons resident was gently rolled onto a sheet, and then lifted on to the bed with a sheet. Resident cleaned up and changed. DON was called. Hospice nurse called. Police called. Paramedics, police, DON, hospice nurse, and administrator responded. Police assessed situation and requested an autopsy. Body transported per ambulance to a skilled hospital." a. Interview on [DATE] at 10:00 a.m. with the DON regarding resident 1 revealed: *The DON was not an active participant in the following interviews b through l but a listener to the interviewees responses. *When the nurses had stated his arms were hanging she thought they meant hanging by his side and were on the floor. *She could not remember any education that had ever been specifically done for the staff related to the use of grab bars on the beds. Every resident had one put on their bed when the facility had opened in [DATE]. No one had every really been assessed if they used them or even needed them on their bed until his death on [DATE]. *She was the nurse on call on [DATE] and [DATE]. *She was called by the facility regarding his death about 4:00 a.m. on [DATE] and arrived about 4:30 a.m. (lives approximately about 30 miles from facility). *When she got to the facility he was in bed all covered up. She did not hear the paramedics say anything unusual. *The paramedics were already here when I got here. I informed the family at 5:00 a.m. I told them the truth his head had been in between the grab bar on the bed and the mattress. They did not tell me they were not going to come to the facility but they did not. *I needed to spend a lot of my time helping the nurses as the situation was such a devastating event. *She could not find any documentation the physician had been informed of his condition or his death. b. Phone interview on [DATE] at 10:30 a.m. with LPN G regarding resident 1 revealed: *She came into work on [DATE] at 2:00 a.m. and planned to stay until 2:00 p.m. that day. It was not her usual shift but wanted to come in and see how the staff had done at night. *About between 3:00 a.m. and 4:00 a.m. CNA B told her she was going over to his unit to help LPN A with rounds. LPN H came and told her he had died about 15 minutes after CNA B had gotten over to the unit. *She went over there to see if they needed help calling people. The DON was called twice. The first phone call she wanted more information than just that he had died and fallen out of bed. She checked with LPN A and found out when he had fallen it was not a complete fall but had caught his head in the grab bar. That was how the staff found him and the DON was called the second time. *She only left a message for the hospice RN. She did not call the physician and was unsure who did. The family was contacted by the DON. c. Interview on [DATE] at 1:30 p.m. with the administrator regarding resident 1 revealed: *He was unsure what the nurse's meant when they said his arms were hanging. *Felt the staff on duty from [DATE] at 10:00 p.m. through his death on [DATE] did not feel his projectile vomiting was a significant change in his condition and were justified in not calling the hospice RN, the physician, or his family. It was likely the vomit was on the walls because when he did vomit he was lying on his right side which faced the wall. *He was sure any formal education had been done on the use of the bed bars to the staff, but felt the staff were aware of their function and who used them. The company they had bought the beds and grab bars from promoted their use because they were not considered restraints. *After his death on [DATE] all residents were assessed by nursing, occupational therapy, and physical therapy for the grab bars on their beds and if they really needed them to assist the staff with repositioning. Maintenance had removed some of the grab bars and had put another one on some of the beds that had been determined residents used them. Prior to that it was not felt necessary to do any type of assessments despite the warnings by the manufacturer that assessments should have been done. *He was unsure why many of the interviews and the documentation showed discrepancies. He had done interviews with the staff on duty from [DATE] at 10:00 p.m. through [DATE] at 6:00 a.m. and felt that was the accurate information. He did not think it was of crucial significance that the information he was given in his interviews with the staff was not also documented in his medical record. *The hospice administrator and hospice head RN had told him it was important to keep them updated of resident's change in conditions but not mandatory. *Hospice had put a mattress on his bed and had told him that the slippery surface of the mattress might have caused him to roll out of bed. Another hospice resident that had the same mattress as him was removed by hospice after resident 1's death on [DATE]. d. Phone interview on [DATE] at 2:00 p.m. with CNA D regarding resident 1 revealed: *She was on a different unit and was called over between 2:00 a.m. and 3:00 a.m. to help with him. *There was a lot of body fluids on the floor; unable to tell if it was urine and she was told he had projectile emesis during the night. *It took four of us to get him into bed. We changed his adult brief as it was soiled with urine and bowel movement. *LPN H and another nurse said we needed to call the police. Our initial thought was to get him cleaned up to call the coroner to make him look presentable. e. Phone interview on [DATE] at 2:10 p.m. with LPN A regarding resident 1 revealed: *When she came on about 10:00 p.m. on [DATE] LPN E and a CNA (unsure who) were in his room with him. They didn't describe what his emesis looked like but that it had bounced off the walls. They had to put him in his wheelchair so they could change his bed and clean the walls. They put a comforter around him. LPN E said all his vitals were within normal limits. Stated he looked tough. His color was pale/grey colored. He wasn't his usual jovial self. She had worked the night before and his color was good and looked different tonight. They brought him out to the nurse's desk after they got him up. *He was at the nurse's desk a little bit and she had said how about we put him to bed. That was about 10:20 p.m. to 10:25 p.m. He was out by the nurse's station maybe about fifteen to twenty minutes. He was transferred back into bed with a Hoyer lift. They put a pad by his face in case he threw up again. They put him on his right side she believed and elevated his head a little bit. He maybe had a half smile but had no response when he was assisted back into bed. LPN E wondered if he eaten something bad with the supper meal but he was the only resident who had gotten sick. She did say he looked tough and his eyes were droopy. *She went in about 11:00 p.m. and he had his eyes closed like he was sleeping. He did not seem uncomfortable. He was dry. She did not wake him up and left him lying on his right side. The turn bar was on the left side of the bed. The call light was laying across his stomach if he needed it despite the fact he never used it. *The resident next door to him yelled most of the night and she also spent a lot of time in her room. *She went to his room about 12:15 a.m. and he was the same as before at 11:00 p.m. She left him on his right side until a helper came to help her turn him. He had no more emesis, appeared to be resting, and his breathing was okay with no distress. She was going between his room and the resident next door that was yelling most of the night. *CNA B came over at 1:00 a.m. and they changed him. He opened his eyes and did not say anything. CNA B said that he looked terrible and his color was pale grey/pasty. He was wet with urine but no bowel movement. They turned him to his left side as they turn residents only side to side at night. He did not wake up and did not look like he was feeling good. He was not himself and joking like usual. They did not check his vitals signs at that time as they had been normal earlier when LPN E had done them. They also did not want to do anything extra to aggravate him. His extremities (arms and legs) were cool to touch as usual and he did not feel febrile (with a temperature). He did not look like he was in pain. He had no mottling (blueness of extremities). His skin was dry. They thought something he had eaten had not set with him. *Everyone was good except him and the other resident that was yelling. About 2:00 a.m. she went back in his room to check him. He was the way we had left him earlier and had not moved at all. His color was still not good. Did not seem any different. She did not turn or reposition him since they had done that at 1:00 a.m. *At about 3:00 a.m. she and CNA B went into his room. CNA B was ahead of her and stated he was on the floor. His head was caught on the grab bar on the bed about at his Adam's apple (middle of neck). His arms were just hanging. He had slid off his bed onto the floor. He had no color and was grey. He was not moving or breathing. She sent CNA B to get help. The grab bar would not let loose so she turned his head a little bit to release pressure on his Adam's apple. *RN C, CNA D, and CNA B came to assist her. RN C was able to get the side rail loose. They put his head on a pillow and lowered him to the floor. They thought we needed to get him cleaned up and put back in bed. They could not feel a pulse or respirations. RN C stated that LPN G had called his family. That is why they got him off the floor but found out later LPN G had not called his family. The DON called his family about 5:00 a.m. *She did not make any calls. She did not know if anyone called his physician. The police were called by LPN H and were there before the DON arrived. *The DON had given directives that the police should be called. The paramedics arrived between 3:30 a.m. to 4:00 a.m. He was taken to the hospital between 5:00 a.m. and 5:15 a.m. His family never came. *The hospice nurse was not called by LPN E or her. They did not know their protocol. If something had been significant with him they would have called them. They did not think projectile vomiting was significant but only a passing bug. They did not contact the physician as they were going to watch him overnight and see if he got better. She did not take any vital signs on him. They did not call his family as they thought it was something he ate and by morning he would be better. They thought it was a 24 hour thing with him in hospice. *None of the other residents had experienced any vomiting after eating the taco meat and Tatar tots they had for supper. *No one had told her that he had three emesis. She thought he had only one emesis. She and LPN E had not discussed the need to call the hospice RN or the physician for a medication to relieve his nausea and vomiting. f. Phone interview on [DATE] at 4:10 p.m. with CNA B regarding resident 1 revealed: *She was not on his unit the night of [DATE], but she went over to help LPN A with rounds. *They checked on him between 12:45 a.m. and 1:00 a.m. They repositioned him and changed his adult brief as it was wet with urine. They positioned him on his left side and did not remember where his call button was. She knew he did not use his call light anyway. The turn bar was on the left side of his bed. He was talking to us like he usually did, but she did not think he looked good. He looked a little bit pale. She couldn't be sure but she thought he said don't or ouch that hurts and get out of here. He normally did not like to roll on his sides. *Between 3:00 a.m. and 3:30 a.m. she went into his room. His legs were on the floor and looked like he had rolled out of bed. She called out for LPN A. Half his body was on the floor and the other half was on the bed. One shoulder was on the bed and the other shoulder was on the floor. His legs were on the floor and both his arms were on the floor. His head the underside of the jaw was not under the grab bar but against the grab bar; it is difficult to explain. LPN A tried to get his pulse. LPN A told her to get help and she got RN C. RN C said he was dead; his body and face were yellow. CNA D helped them move him. LPN A held his head and RN C moved the bed bar out of the way. They lifted him into the bed on a sheet. They cleaned him up as he was soiled of urine and bowel movement. The entire floor was wet with clear liquid which she guessed was urine. They changed his pad and gown. *The paramedics and the police came in after they had cleaned him up. *She and LPN A did not hear anything in the hallway when he had rolled out of bed. His left jaw had a red indentation and stayed that color as he had no blood flow. RN C struggled to disengage the bed bar. She didn't think they ever had any education how to release the bed bars in an emergency. She thought he never had used the bed bar to aide the staff when they had repositioned him. g. Phone interview on [DATE] at 4:30 p.m. with hospice RN J regarding resident 1 revealed: *She was his primary care hospice RN and saw him at least twice weekly. *The provider had been told to call hospice with any changes in a resident's condition no matter how trivial; that would include falls, fevers, or any changes in condition. *She had never known him to have a problem with nausea or vomiting. *From [DATE] at 10:00 p.m. until his death on [DATE] at approximately 3:20 a.m. was a significant change for him. He had never had problems with vomiting before, especially projectile vomiting. The staff should have informed the hospice RN of his significant change in condition during that time frame and not waited until they found him dead. h. Phone interview on [DATE] at 4:40 p.m. with hospice RN K and the DON regarding resident 1 revealed: *They called her on [DATE] at about 4:00 a.m. and told her he had died . She asked them if his family had been called and they told her no. They were unable to give her many details to what had happened. *She got there about 4:50 a.m. and the paramedics told her what had happened to him. She did not go into the room to see him but the paramedics had told her he had his head stuck in the side rail. She offered to call the family but the DON told her it would probably be better if she called them. *Hospice had told the staff to inform them of any change in a resident's condition; no matter how small the problem. The expectation should have been the hospice RN should have been informed about his condition at 10:00 p.m. on [DATE] due to his projectile vomiting, change in responsiveness, and grey colored appearance. That would have been considered a significant change in his condition. i. Phone interview on [DATE] at 5:10 p.m. with RN C regarding resident 1 revealed: *She was working on another unit on the night of [DATE]. CNA B came to her about 3:00 a.m. and told her LPN A needed help as he had fallen and was unresponsive. *She went over to help and it was obvious he was deceased . He was not breathing, was pale, and was cold. He was on his left side on the floor. His body was on the floor except his head. His head and part of his shoulder were on the bed in between the bed and the side rail. LPN A was holding his head but she could not get the side rail down. There was urine all over. She was able to open the side rail. *They put a sheet on the floor and four of us moved his body into the bed. She felt for a carotid (in the neck) pulse and there was none. They all cleaned him up of bowel movement. She did wonder why there was urine all over the floor as he had on an adult brief. The brief was intact and was saturated with urine. The fluid all over the floor was pretty clear but it could have been vomit. *LPN H called the police after directed to do so by the DON. She was not sure if the physician was ever notified. j. Phone interview on [DATE] at 9:30 a.m. with CNA F regarding resident 1 revealed: *She was out by the nurse's desk about 9:00 p.m. on [DATE]. She heard a weird voice coming from his room.*When she went into his room he was yelling at her to help him. He was half way in bed with his legs out of bed. His head was in the corner of the bed that was next to the window and he was throwing up a lot. *She yelled for LPN E to come help her. They cleaned him up and while they were cleaning him up he had two more emesis. It was a lot of emesis with chunks of food. They had to get him out of bed and put him in his wheelchair so they could clean his bed and the walls. He was very sick. *He was out by the nurse's station for a short while. They (LPN E and CNA F) put him back to bed as the next shift LPN A told them to. She had no one to help her lay him down if they left him up. *He didn't say anything when we laid him back down. His color was white and he looked like he did not feel well. k. Phone interview on [DATE] at 9:35 a.m. with CNA I regarding resident 1 revealed: *She had been working on a different unit the night of [DATE] but had come over to his unit about 9:30 p.m. to 10:00 p.m. to make sure he was okay before something else happened to him. He was up in his wheelchair at the nurse's station. LPN E did not tell her who had helped her get him out of bed; only that he had been vomiting. *He looked pale like he was really sick. LPN E again said he had been vomiting and did not want him to aspirate. l. Phone interview on [DATE] at 10:15 a.m. with LPN E regarding resident 1 revealed: *CNA (unidentified) from another wing walked through approximately 9:30 p.m. to 9:40 p.m. on [DATE] and started hollering at her to help. Resident was throwing up all over his hair, walls, floor, and bed. It was chunks of Tatar tots. It was a hard vomit. It looked like he was trying to hold his head off the bed or get his face off the bed since he was vomiting. Was trying to think what we had for supper which was tacos and Tatar tots. He ate well but drank a lot. He had no complaints after supper and took his bedtime pills okay. *Got him up in his wheelchair as he was at risk for aspiration and was on thickened liquids. CNA F helped get him up in the wheelchair using the Hoyer lift. They washed him up. He was pale and not retching or gagging. She figured it was a one time thing. They took him out to the nurse's desk and his vitals were ok. CNA F was going home. The resident said he was feeling good and it had hit him fast. Color was good. His color was kinda pale when they first got him up. Maybe at first his color was kinda grey or maybe pale. *She wanted to keep him up but the next shift wanted him put back to bed as there was no one to help LPN A lay him back down in bed. They laid him down about 11:00 p.m. (CNA F and LNP E). He was feeling good by then. *She thought he had one emesis but it could have been three emesis. *She did not notify his family, the physician, or the hospice nurse as she thought it was a one time thing and the taco meat disagreed with him and he had a bad tummy. Did not think notifying them was necessary as he felt better and had relief after throwing up. *Her gut feeling was to leave him up in the wheelchair by the nurse's station so they could keep an eye on him with his high risk of aspiration. The next shift wanted him laid down back in bed as the nurse had no one to help her lay him back down. If she had been on that shift, she would have left him up in his wheelchair. He had aspirated some time back and ended up in the hospital with pneumonia. *There was no documentation in LPN A ' s progress notes of any of the findings reviewed with CNA B and LPN A during the facility internal investigation. Interview on [DATE] at 11:00 a.m. with the DON and administrator regarding the lack of documentation in the progress notes of LPN A revealed: *It was likely due to the nature of the incident the nurse omitted to document some of the above in the medical record. *It was important that the above was documented somewhere even though it was not in the medical record. 4. Review of resident 2's medical record revealed: *A [DATE] admitted . *diagnoses XREDAC

Based on record review, interview, policy review, and product user-service manuals for the use of the bed frames and assist bed handles, the provider failed to assess and monitor the use of the the assist bed handles for two of two sampled residents (1 and 2). Findings include: 1. Review of an undated product user-service manual for Joerns bed frames (type used on the residents' beds) revealed: *"Residents/patients may become entangled in pendant cord. Residents/patients with reduced mental acuity should not be allowed access to pendant. Unsupervised use of pendant could result in injury or death." *"Use a mattress that is properly sized to fit mattress deck, that will remain centered on mattress deck relative to state and federal guidelines. Joerns Healthcare recommends the use of a mattress with minimum dimensions of 35 inches wide and 6 inches deep. Length should match mattress support platform. Use of an improperly fitted mattress could result in injury or death." *"If a resident/patient's mental or physical condition could lead to a resident/patient entrapment, the mattress support platform should be left in the flat position when unattended. Failure to do so could result in injury or death." *"An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraints and bed system entrapment guidance." *"Use a properly sized mattress in order to minimize the gap between the side of the mattress and assist device. This gap must be small enough to prevent resident/patient from getting his/her head or neck caught in this location. Make sure that raising or lowering bed, or contouring the sleep surface, does not create any hazardous gaps. Excessive gaps may result in injury or death." *"Locate mounting brackets for assist devices strictly according to instructions. Gap between head/foot panel and assist device must be small enough or large enough to prevent resident/patient from getting his/her neck caught in this location. If multiple assist devices are used, position each so that gap between them is large enough for trunk and hips to pass through easily. Make sure raising or lowering bed, or contouring sleep surface does not create any hazardous gaps. Failure to do so could result in injury or death." *"Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment." *"The assist device is intended for use as an aid in entering or exiting the bed sleep area, as well as a stable handhold during self-positioning within the bed sleep area." *"Proper combinations of bed, mattress, head/foot panels, and assist devices are needed to minimize the risk of entrapment." 2. Review of resident 1's [DATE] and [DATE] incident reports provided to the surveyor revealed: *[DATE]: -"Writer heard a noise and went to go check on resident. Found resident with legs and torso (upper body) on the floor next to his bed wrapped up in his blankets. Resident's head was still partially on the bed. Resident assisted back into bed via Hoyer lift. Resident noted to have obtained a 1 centimeter (cm) by 1.8 cm skin tear on right elbow. Resident oriented to person but confused. Was lying on left side facing away from the wall. Was found laying on right side facing the wall." -"Staff instructed not to have resident propped on too many pillows to be sure he does not roll off easily. If we prop resident with pillow, prop on right side so he is facing the wall and will not roll off bed. Instructed to do frequent rounds on resident when in bed." *[DATE]: -"CNA B entered resident's room just ahead of writer (licensed practical nurse A). CNA B stated he was on the floor. He was on his left side on the floor beside the bed, which was in lowest position with his neck caught at the Adam's apple (neck) on the grab rail of the bed. Resident was pale in color and skin cool to touch. No pulse palpable or respiration noted." -"Writer tried to move resident's head to see if airway could be opened. Resident's body weight pulled making it impossible to release resident's head completely. Writer unable with resident's head pulling at grab bar to get grab bar to release. Help arrived and grab rail released and resident's head placed on a pillow on the floor. Resident had been drowsy with impaired memory." -[DATE] addendum- "This report filed late due to writer (LPN A) and director of nursing not knowing it was required with previous paperwork submitted." -[DATE] addendum- "Resident ill earlier in the evening and being checked frequently by nursing staff. Currently receiving hospice services. Checked on at approximately 2:15 a.m. and noted to be resting quietly in bed. At 3:30 a.m. staff entered room to find him half on the bed and half on the floor. His head was noted to be against the deluxe assist handle and his back against the mattress going down towards the floor. Staff unable to find a pulse. Body taken to morgue." *Police investigation closed on [DATE] as coroner's office had completed a medical examination and determined cause of death accidental positional asphyxiation. Provider notified Food Drug Administration (FDA) and manufacturers of incident. Provider evaluated all beds with deluxe assist handles. Review of the [DATE] FDA report regarding resident 1 revealed: *Adverse event of death on [DATE]. *"About 3:00 a.m. a certified nursing assistant and a nurse found resident one-half on floor with his head still on bed between mattress and assist bar. The resident was not responsive and had expired." *"Resident had been ill/vomited earlier in evening. Receiving hospice services since [DATE]. Medical [DIAGNOSES REDACTED]." *"Suspect products Joerns Deluxe Assist Handle and Invacare Alternating Pressure Mattress." 3. Review of resident 2's medical record revealed: *A [DATE] admitted . *[DIAGNOSES REDACTED]. Review of resident 2's [DATE] incident report provided to the surveyor revealed: *"Resident was found in his room sitting on the floor mat. Resident's back was up against his bed and his head was resting between the grab bar and his bed. No injuries were noted. Resident was confused with impaired memory." *"Staff followed proper safety precautions by lowering bed to floor and having floor mat next to bed. Grab bars were removed from the bed since resident does not use them during transfers." 4. Interview on [DATE] at 1:40 p.m. with occupational therapist (OT) L regarding the use of grab bars revealed: *When the facility opened in [DATE] all fifty-eight resident beds had at least one grab bar on them. *OT and physical therapy (PT) had not been involved in assessing any residents if they used them or not to enhance their bed mobility until [DATE] with resident 1's death. *Sometimes a nurse would inform them they thought a resident needed to have two grab bars on instead of one. Maintenance would be informed and would put the second one on. *The interdisciplinary team talked about the grab bars and if a resident used them to make them more independent with bed mobility. None of the staff documented anything in the resident's medical record. *She was not aware if any education had ever been done regarding the use of the grab bars. OT and PT had never been involved in any education to the nursing staff. *After resident 1's [DATE] death, nursing immediately evaluated what residents had grab bars on their bed, who did not have them, and who would benefit from them on their bed. Nursing then informed social services who then informed OT and PT. Maintenance was then informed and either removed grab bars from residents' beds if they did not use them or need them or put a second grab bar on the residents' beds that needed them. Interview on [DATE] at 1:55 p.m. with maintenance man M regarding the grab bars revealed: *He had removed grab bars from some residents' beds and put an additional one on others if directed by the nursing staff. *He had thrown away all the nursing request slips from [DATE] through today, so he did not remember all the resident's beds he had worked on. Interview on [DATE] at 2:00 p.m. with the administrator regarding grab bars revealed: *When they had bought all the beds back in [DATE] the selling point had been the grab bars were not considered a restraint. *They had not done any formal assessment for each resident and did not feel that was necessary, since they were not considered a restraint but were a benefit for the resident. *He knew they talked to the staff about the grab bars, but no formal education or documentation had been done. *No one had told him the grab bars were hard to release. *They had not felt it necessary to assess any other residents and the use of grab bars after resident 2 had his head between the grab bar and mattress on [DATE]. He had not been hurt. He was not sure why resident 2 even had the grab bars on his bed since he had not used them. *He was aware of the multiple warnings in the user manuals, but all products came with warning labels. A person would never be able to use a product if they were scared off with the warnings everything came with. *Hospice had supplied the air mattress for resident 1's bed. He was unsure if they were aware of the manufacturer's warning to not use them unless the benefits outweighed the risks. He knew he had a problem with skin breakdown so it was a benefit but was unsure if there was any specific documentation in his record reflecting that. Review of two handwritten sheets given to the surveyor by the administrator revealed: *The handwritten sheets had no dates and were titled "Nursing evaluations" and "Therapy evaluations." *All fifty-eight residents were evaluated for their ability to use the grab bars on their beds after the death of resident 1 on [DATE]. *Ten residents had no grab bars on their beds. There was no documentation regarding when those grab bars had been removed from their beds. Maintenance had removed them sometime between [DATE] and [DATE]. He had no records of what residents he had removed the grab bars from their beds or when they had been removed. *Four residents were assessed to have grab bars on their beds that they did not use. *One resident was assessed "Not sure if uses." *One resident was assessed "Has but never in her bed." *One resident was assessed "Probably does not need them." *One resident was assessed "Has two but only needs one."