Every finding on record at Bethesda Home

Based on record review, interview, and policy review, the provider failed to ensure the staff educated the resident or the resident's representative of the risks versus benefits of medications or of alternative treatments to make an informed decision for the consent for the use of psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) before they were administered to three of three sampled residents (1, 12, and 25). Findings include:1. Review of resident 1's electronic medical record (EMR) revealed that he was admitted to the facility on [DATE]. His 2/11/26 Brief Interview Status (BIMS) assessment score was 10, which indicated his cognition was moderately impaired. His diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), major depression (mood disorder characterized by persistent, severe feelings of sadness, worthlessness, and a lack of interest in previously enjoyed activities for at least two weeks), anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and a psychotic disorder with delusions (false beliefs and distorted views of reality). On 2/19/26, resident 1's psychiatric provider ordered to decrease his Seroquel to 12.5 mg BID and 50mg at HS for psychosis and physically aggressive behaviors and to Start Seroquel [an antipsychotic medication] 12.5 mg [milligram] BID [twice a day] PRN [as needed] for 14 days. A 2/19/26 nurse's progress note indicated resident 1's representative was notified of the psychiatric provider's new orders for Seroquel. There was no documentation that resident 1 or his representative was informed of the indication for the medication change, the risks versus benefits of the medication, or alternative treatments to the medication. 2. Review of resident 12's EMR revealed that she was admitted to the facility on [DATE]. Her 3/16/26 BIMS assessment score was 10, which indicated her cognition was moderately impaired. Her diagnoses included Neurocognitive disorder (a decline in cognitive functions like memory, attention, and language due to brain damage) with Lewy bodies (abnormal clumps of protein that build within nerve cells) with hallucinations (to see, hear, smell, taste or touch something that is not there)/psychiatric disturbances, Auditory hallucinations, Dementia (a group of symptoms affecting memory, thinking, and social abilities), and Post-Traumatic Stress Disorder (a mental health condition triggered by experiencing or witnessing terrifying, life-threatening or traumatic events). Resident 12 had a 2/25/26 physician's order for Olanzapine (an antipsychotic) 15 mg tablet to be taken once daily by mouth. There was no documentation that indicated the staff provided information to resident 12 or her representative regarding resident 12's psychotropic medication Olanzapine. Her 2/26/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) identified a problem area: ADLs [activities of daily living] Functional Status/Rehabilitation Potential A goal stated that the Resident will remain free of adverse side effects of medications while maintaining current participation in ADL task., with an intervention of Receives psychotropic medication as directed, see eMAR [electronic medication administration record]. Monitor for effectiveness of the medication and side effects with MD [medical doctor] updated when [they are] noted. Pharmacy reviews [resident 12's] medications monthly. Monitor for increase in behaviors, changes in overall physical ability, notify MD when [they are] noted. 3. Interview on 4/15/26 at 1:57 p.m. registered nurse (RN) manager/infection preventionist (IP) C revealed she was responsible for keeping track of the residents' psychotropic medications and contacting and updating resident representatives of residents' medications changes. She indicated she reviewed psychotropic medications when residents were admitted to the facility and when residents' medication orders were changed. She educated residents and their representatives on an individual basis with psychotropic medication changes. She indicated that informed consents regarding psychotropic medications and their risks versus benefits were obtained verbally from residents or the resident's representative, and the facility did not use a written informed consent form. 4. Review of resident 25's EMR revealed that he was admitted to the facility on [DATE]. His BIMS assessment score was 2, which indicated his cognition was severely impaired. His diagnoses included dementia with agitation and insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and being unable to return to sleep). Resident 25 was prescribed quetiapine (an antipsychotic medication) 12.5 mg (milligrams) to be administered at bedtime when he was admitted to the facility. On 10/24/25, a nurse's progress note indicated that the resident's representative was contacted by phone by registered nurse RN manager/IP C, and they discussed whether resident 25 should receive psychiatry services for his dementia. The resident representative agreed that resident 25 should receive psychiatry services and signed the consent forms for those services. A referral for the resident to receive psychiatry services was sent to resident 25's physician that same day (10/24/25). There was a 10/29/25 physician's order for trazodone (an antidepressant medication) 50 mg tablet to be administered at bedtime for insomnia. RN manager/IP C notified resident 25's representative, by phone, of the physician's new medication order. The progress note did not indicate that the representative gave their informed consent for resident 25 to be administered that medication or that education regarding the risks versus benefits of that medication was provided by RN manager/IP C. There was no documentation of written consent in Resident 25's EMR. There was a11/3/25 physician order for resident 25 to be administered an additional dose of quetiapine 6.25 mg, one time a day PRN (as needed) for his agitation. There was no documentation in resident 25's EMR indicating that resident 25's representative was notified and gave their informed consent for the additional antipsychotic medication, that education regarding the risks versus benefits of the medication was provided, or that written consent was obtained. There was an 11/6/25 physician's order to change the administration of resident 25's quetiapine from 12.5 mg at bedtime to 12.5 mg three times daily, discontinue the additional 6.25 mg PRN dose, and start Celexa (an antidepressant medication) at 10 mg daily for resident 25's mood disturbance. RN manager/IP C notified resident 25's representative by phone of the physician's new medication order. The progress note did not indicate that education on the risks versus benefits of the new antidepressant medication was provided, or that written consent for the changes in medication and dosage was obtained. On 11/8/25, a nurse's progress note indicated that resident 25's representative and family member visited and informed RN K that resident 25 was snowed [heavily sedated] and was upset about the medication changes. The family stated that the 12.5 mg dose of quetiapine being administered three times a day was like a chemical restraint and asked the physician to reduce the quetiapine to 6.25 mg twice daily. RN K contacted the physician immediately, and the physician ordered a reduction in resident 25's quetiapine to 6.25 mg twice daily. The physician also ordered an additional 6.25 mg dose to be given once daily as needed for resident 25 when increased agitation occurred. Resident 25's representative was satisfied with those medication orders. On 11/9/25, resident 25's representative called and spoke with licensed practical nurse (LPN) L, requesting that resident 25's Celexa be held and that she would visit with RN manager/IP C on 11/10/25 to discuss the request. Resident 25's representative wanted resident 25 to be off psychotropic medications and believed resident 25's behaviors were related to chronic pain. Resident 25's Celexa was discontinued by the physician on 11/13/25 at resident 25's representative's request. On 1/22/26, resident 25 received a physician order to change his quetiapine to 6.25 mg twice daily PRN for 14 days. RN manager/IP C notified resident 25's representative by phone of the new order. Resident 25's quetiapine 6.25 mg PRN medication was discontinued on 2/5/26. His 2/3/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) identified a problem area: The resident requires assistance with activities of daily living (ADLs) throughout the day to ensure his needs are met as he has a diagnosis of dementia. A goal stated that the Resident will remain free of adverse side effects of medications while maintaining current participation in ADL tasks, with an intervention of Administer medication as ordered and monitor for side effects. The 2/3/26 care plan also identified a problem area of Mood, Behavior, and Sleep with a goal to Adjust to the nursing home without increased signs and symptoms of anxiety or depression. The interventions included Nursing to follow up on all physician recommendations for medication management, Nursing will monitor for effectiveness of mood, behavior, and sleep medications and report any concerns to the provider, and if needed, A referral will be made to psychiatry for added medication management. 5. Interview on 4/15/26 at 1:57 p.m. with RN manager/IP C revealed that she was responsible for keeping track of residents' psychotropic medications, contacting residents' families, and updating residents' representatives regarding medication changes and new medication orders from physicians. The residents' medications were reviewed and the side effects were discussed with the residents and their representatives upon admission to the facility. She educated the resident or the resident's representative about the psychotropic medication(s) on an individual basis. RN manager/IP C stated that progress notes documenting medication changes, new medication orders, and family/resident representatives' notifications were recorded in the resident's EMR, but that the notes did not include specific details about the risk-versus-benefit information provided to the resident or the resident's representative regarding the resident's psychotropic medications. RN manager/IP C stated that progress notes documenting medication changes, new medication orders, and family notifications were recorded in the resident's EMR, but that the notes did not include specific details about the risk-versus-benefit information provided to the resident or the resident representative regarding the resident's psychotropic medications. RN manager/IP C indicated that residents who were admitted to the facility while taking psychotropic medications, or were admitted before they started a psychotropic medication, did not have written informed consent forms obtained from the resident or the resident's representatives. The informed consents were obtained verbally by staff from residents or residents' representatives. RN manager/IP C acknowledged that there was no documentation in resident 25's EMR to indicate information was provided to his representative, that written informed consent forms were obtained for every medication change, or before starting him on a new psychotropic medication, and that his care plan did not address the risks versus the benefits of the psychotropic medications. 6. Interview on 4/15/26 at 2:57 p.m. with administrator A revealed that she believed the facility's process for educating and obtaining consent from residents or resident representatives regarding the use or initiation of a psychotropic medication was adequate. She stated that RN manager/IP C was diligent in notifying families or resident representatives of residents' medication changes and new medication orders, obtaining verbal consent for the use or initiation of psychotropic medications, and documenting the information in the residents' EMR. Administrator A acknowledged that the facility did not use a written informed consent form for residents taking psychotropic medications, which outlined the risks versus benefits and alternative treatments. She was unaware that documentation of the risks versus benefits reviewed with the resident or the resident's representative should be in the resident's EMR. She expected RN manager/IP C and all nurses to discuss the risks and benefits of medications, the reason a medication was started, or any medication dose change with the resident or the resident's representative, and to document those actions in the resident's EMR. 7. Review of the provider's 2/13/26 Psychotropic Medication policy found that Psychotropic medications will only be used when medically necessary, after non-pharmacological interventions have been attempted and documented, unless contraindicated, and that All psychotropic medications require dose, frequency, duration, and a clear indication for use. Informed consent must be obtained from the resident or the responsible party, and Written consent or other documentation is acceptable. Residents have the right to be informed of treatment options, and To ensure the safe, appropriate, and clinically justified use of psychotropic medications in accordance with CMS regulations and applicable state requirements while promoting residents' rights, safety, and quality of life.

Based on record review, interview, and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure one of one sampled residents' (1) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment was accurately coded for the area of PASARR, and one of one sampled residents' (12) MDS assessment was accurately coded for the area of active diagnoses. Findings include:1. Review of resident 1's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His 2/11/26 Brief Interview of Mental Status (BIMS) assessment score was 10, which indicated his cognition was moderately impaired. His diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), major depression, anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and a psychotic disorder with delusions (false beliefs and distorted views of reality). Resident 1's 4/10/25 comprehensive admission and his 11/14/25 comprehensive MDS Assessment, section A (PASRR) under Preadmission Screening and Resident Review (PASRR) section did not have the Level II PASRR at A1500 marked as a yes. Resident 1's 4/12/17 Level I PASRR review was completed when he was admitted to a different facility. That Level I PASRR was sent for a Level II determination and was approved for a long-term care stay of 30 days or less. His 5/11/17 Level II PASRR approved him for a 60-day long-term care stay, and his 7/26/17 Level II PASRR determined he was approved for a long-term-care stay for an unlimited amount of time. 2. Interview and EMR review on 4/15/26 at 2:16 p.m. with MDS coordinator D confirmed resident 1 did have a mental health diagnosis of major depressive disorder. MDS coordinator D had indicated in his MDS assessments that he did not have a Level II PASRR. She further indicated that she had made a mistake by indicating he did not have a Level II PASRR. 3. Review of the 2025 South Dakota PASRR Level 1 and Level II PASRR Outcomes instructions revealed that when a Level II PASRR was approved for a long-term-care stay, the MDS was to be completed to indicate that resident had a Level II PASRR. 4. Review of resident 12's EMR revealed she was admitted to the facility on [DATE] and had a diagnosis of post-traumatic stress disorder (PTSD). Her 3/4/26 admission MDS Assessment, section I (active diagnoses) under Psychiatric/Mood Disorder did not have the diagnosis I6100 Post Traumatic Stress Disorder marked. 5. Interview and EMR review on 4/15/26 at 2:39 p.m. with MDS Coordinator D revealed she acknowledged that resident 12 had a diagnosis of PTSD upon admission to the facility on 2/25/26. She confirmed resident 12 had received psychiatric services before she was admitted to the facility, and that resident 12 received psychiatric services on 3/26/26 with a new provider. She reviewed resident 12's admission MDS assessment, section I and acknowledged that I1600 Post Traumatic Stress Disorder was not marked. When completing the resident's MDS assessment she referred to the resident's information that was sent with them to the facility when they were admitted , which included diagnosis, medication order's and physician progress notes. She did not consider resident 12's PTSD an active diagnosis since the resident did not have any medications prescribed for PTSD. She referenced the CMS Long-Term Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 to complete the residents' MDS assessments. 6. Review of the CMS Long-Term Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed review of the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed section A, item A1500 revealed Code 1, yes if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition. Section I, Page I1 and I2, Steps for Assessment: 1. Indicate the resident's primary medical condition category that best describes the primary reason for the Medicare Part A stay. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available.

Based on observation, interview, record review, policy review, and review of budesonide (a steroid used to treat lung inflammation) manufacturer's instructions the provider failed to ensure staff administered the budesonide nebulizer (a device that converts liquid medication into an inhalable mist) according to the manufacturer's instructions for one of one sampled resident (7) who developed thrush (a yeast infection in the mouth and throat). Findings include:1. Observation on 4/13/26 at 2:44 p.m. of resident 7's room revealed there was a nebulizer machine and mask on his bedside table between his bed and recliner. The nebulizer mask was assembled and sitting on the nebulizer machine. 2. Observation and interview on 4/14/26 at 8:29 a.m. with resident 7 in his room revealed he was admitted to the facility after he was in the hospital for shortness of breath. The nurses and certified medication aides (CMAs) administered a nebulizer treatment to him two times a day, once in the morning and once at bedtime. The nurse or CMA would set up his nebulizer and often left the room while he was taking the nebulizer treatment. Sometimes the nurse or CMA returned to his room and rinsed out the nebulizer mask, sometimes they did not. When he finished with his treatment he would place the nebulizer mask on top of the nebulizer machine, which was on his bedside table. The medication chamber attached to the nebulizer mask appeared hazy with an unknown substance.The staff did not ask him to rinse out his mouth after he received his nebulizer treatments and he did not know he should rinse out his mouth after his nebulizer treatments. He knew one of his nebulizer medications caused him to get thrush sometimes, and he would take a lozenge (a medicated tablet to be held in the mouth to dissolve) to treat it. 3. Review of resident 7's electronic medical record (EMR) revealed he was admitted to the facility on [DATE], had a 1/30/26 Brief Interview for Mental Status (BIMS) assessment score of 12, which indicated his cognition was moderately impaired, and his diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and can make it difficult to breathe) (COPD). His 4/14/26 care plan indicated he had his own teeth and to assist with oral cares in am [a.m.] and pm. [p.m.].He had a 10/13/25 physician's order for clotrimazole troches (a medication to treat thrush) lozenge 10 milligrams (mg) one time a day at bedtime for thrush and a 11/5/25 physician's order for a budesonide nebulizer 0.5 mg/ 2 ml (milliliters) two times a day with instructions that stated, Make sure mouth is being rinsed with water after to help prevent oral thrush.On 10/30/25 resident 7's physician was notified by registered nurse (RN) M that resident 7 was requesting that he get 5 clotrimazole troches every day because he feels like he has oral thrush. No white spots noted in [his] mouth but [the] resident states that he has had it twice before and 'this is exactly what it was before when I had it'. On 10/30/25 Resident 7's physician ordered clotrimazole troche five times per day for two weeks for thrush. 4. Interview on 4/15/26 at 10:58 a.m. with RN G revealed when she administered a resident's nebulizer she would set up the nebulizer treatment, remained in the room with the resident, and when the treatment was completed, she shook out the excess liquid from the nebulizer medication chamber and placed the mask in a vented storage bag to dry. A resident who received steroid medications such as budesonide should be encouraged to rinse their mouth after that nebulizer treatment. 5. Interview on 4/15/26 at 4:23 p.m. with director of nursing (DON) B and RN manager/infection preventionist (IP) C revealed DON B expected that after a resident's nebulizer was completed, the nebulizer mask would be rinsed out. RN manager/IP C corrected DON B and stated the provider's policy had changed and any excess liquid from the nebulizer treatment was to be shaken out of the nebulizer medication chamber and the nebulizer mask was to be placed in a vented storage bag to dry.DON B expected a resident's mouth to be rinsed if the nebulizer treatment was a steroid such as budesonide and if the nebulizer mask was soiled it was to be rinsed out with distilled water. She was not aware the budesonide nebulizer manufacturer's instructions were to wash the nebulizer mask with a mild detergent after each administration of the medication. 6. Review of the provider's 8/11/23 Nebulizer Administration policy revealed that if the resident's nebulizer is to be reused, discard any excess solution and place in vented storage bag and if residue is noted, discard nebulizer and replace with new or rinse with sterile water and allow to air dry in a vented bag. Do not rinse with tap water. 7. Review of the 2/13/23 budesonide manufacturer's instructions revealed the incidence of candidiasis [yeast infection] can generally be held to a minimum by having patients rinse their mouths out with water after each nebulization treatment. The nebulizer chamber should be cleaned after every administration. Wash the nebulizer chamber and mouthpiece of face mask with hot tap water using a mild detergent. Rinse it well and dry by connecting the nebulizer chamber to the compressor or air inlet.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review the provider failed to ensure drugs and biologicals were labeled, securely stored, and discarded regarding:*One of one fentanyl patch (a medications with risk for abuse and addiction) pain medication for resident 35 that was not administered or securely stored after it was removed from the double locked storage on medication cart C by registered nurse (RN) K.*One of one sampled resident's (24) Vicks Vaporub, Gold Bond Medicated Powder, Blu-Emu Cream (a pain-relieving cream) Voltaren 1% cream (a pain-relieving cream), and seawater nasal spray that were not securely stored to prevent other residents from accessing them.*Medications with shortened expiration dates (medications that, after opening, expire before the manufacturer's expiration date) that were not labeled and disposed of after being outdated for two of two sampled residents (13 and 18), latanoprost eye drops in two of three observed medication carts.*Expired insulin syringes that were not disposed of and available for use in three of three observed medication carts and one of one observed medication room. Findings include:1. Review of the provider's [DATE] SD DOH FRI revealed that director of nursing (DON) B was notified by RN K that there was a missing (not accounted for) fentanyl patch at 9:05 a.m. on [DATE]. RN K stated she placed the fentanyl patch on top of a Tegaderm (clear adhesive dressing) to carry into resident 35's room, and when she was going to place the fentanyl patch on resident 35, she did not have the fentanyl patch. RN K reported to DON B that she had searched resident 35's room including the resident's chair, the garbage can next to her chair, and the floor. RN K then went back into the hallway, looked on the floor in the hallway, checked the bottom of her shoes, and the garbage can on the medication cart, and RN K was unable to find the fentanyl patch.After director of nursing (DON) B was notified of the missing fentanyl patch, she notified additional staff members to assist in looking for the missing fentanyl patch. Those staff members looked in the laundry room including the washer, dryer, lint traps, and the dirty laundry from hallway C. The drawers were removed from medication cart C. Housekeeping staff searched the hallway, resident 35's room, and the vacuum. Maintenance took the vacuum apart to be sure the fentanyl patch was not in a vacuum hose.DON B asked RN K if she had the fentanyl patch in her hands when she went into resident 35's room and RN K stated she thought she did. She had taken the patch out of the locked controlled substance drawer in medication cart C, wrote her name and initials on the fentanyl patch, and laid it on the Tegaderm package. She then picked up the Tegaderm, fentanyl patch, resident 35's other medications, and her Voltaren cream, brought them into resident 35's room and placed them on her bedside table. When RN K was going to place the fentanyl patch on resident 35 RN K noticed she had written on the plastic piece that was attached to the adhesive part of the fentanyl patch, and that the patch was not there.RN K stated she had gone into medication cart C, taken out another fentanyl patch, and placed it on resident 35. DON B asked RN K why she did not notify her or one of the other managers of the missing fentanyl patch before 9:05 a.m., and RN K stated she was waiting until DON B arrived at the facility to notify her.When DON B looked through the garbage, all the packaging pieces for one of the fentanyl patches were found, but only a small piece of packaging from the top and the side of the other fentanyl patch was found in the garbage. The piece that RN K stated she had written her name and date on was not found.DON B, RN Manager/infection preventionist (IP) C, and RN/staff development coordinator (SDC) H watched the facility's [DATE] camera footage to determine a timeline and to assist in the search for the missing fentanyl patch. Medication cart C was placed between two resident rooms in hallway C. At 6:35 a.m. RN K unlocked and opened the controlled medication drawer in medication cart C and removed a fentanyl patch from that drawer. At 6:37 a.m. RN K entered resident 7's room, and exited that room at 6:39 a.m. RN K stood at medication cart C until approximately 6:45 a.m. She then returned to resident 7's with certified nursing assistant (CNA) E. At 6:46 a.m. RN K exited that resident's room, grabbed the items off the top of medication cart C, and entered resident 35's room.At 6:48 a.m. RN K exited resident 35's room, looked on the top of medication cart C, then looked on the floor beside the cart. She then spoke with CNA E and she and CNA E entered resident 35's room. At 6:51 a.m. RN K exited resident 35's room, checked the bottoms of her shoes, and the garbage can on the side of medication cart C. At approximately 6:52 a.m. RN K went back into resident 35's room, CNA E exited the room, and RN K remained in resident 35's room until 6:57 a.m.At 6:57 a.m. RN K exited resident 35's room with garbage bags. She took those garbage bags into the medication room, put gloves on and got down on the floor to look through the garbage bag. At 7:00 a.m. RN K exited the medication room and went down the A hallway and notified the other RN on duty. RN K returned to hallway C at 7:03 a.m. She took another fentanyl patch out of medication cart C and showed the patch to other staff members. At 7:08 a.m. RN K took the second fentanyl patch that she had removed from medication cart C into resident 35's room and applies [the] new patch to resident [35]. The missing fentanyl patch was not located. RN K resigned from her position on [DATE]. 2. Review of resident 35's electronic medical record (EMR) revealed she admitted to the facility on [DATE] and discharged to her home on [DATE]. She had a [DATE] physician's order for a fentanyl 12 micrograms/hour patch to be applied to her skin every 72 hours and to remove the old fentanyl patch before the new one was applied.Resident 35's medication administration record (MAR) indicated on[DATE] that RN K removed the old fentanyl patch and applied a new patch on resident 35's skin. 3. Review of resident 35's Controlled Drug Record for Patches indicated she had received ten fentanyl patches from the pharmacy. On that form, the nurse was to document the date, time, if a patch was wasted, and to sign it with an additional nurse. Above the signature columns it stated, Signature (Denotes Patch Applied/Wasted)/ 2nd Nurse Signature.On [DATE] at 7:00 a.m. patch number 5 was documented as one patch missing and signed by RN K and RN J. On [DATE] at 7:00 a.m. patch number six was documented as one patch wasted and signed by RN K and RN J. The missing fentanyl patch was documented on the Controlled Drug Record for Patches by RN K and RN J after the fentanyl patch was removed from the controlled medication drawer, to be placed on resident 35, and was discovered to be missing. 4. Review of RN K's education following the missing fentanyl patch revealed, No medications should be prepped [prepared] and left on [the] top of [the] med [medication] cart in [the] hallway. Meds [medications] should be prepped right before med administration. Narcotics should be handled carefully. Fentanyl patch [es] should be carried in [the] package to [the] residents [resident's] room as it should be handled with gloves d/t [due to] potency and risk for exposure. DON, nurse manager, SDC, CEO [chief executive officer] should be notified immediately to ensure thorough search is completed. 5. Interview on [DATE] at 11:07 a.m. with RN J revealed she was working on [DATE] when the above fentanyl patch went missing. RN K had notified her that the fentanyl patch was missing. RN K and CNA E looked for the fentanyl patch, but it was not found. RN J verified she had signed the Controlled Drug Record for Patches when the second patch was removed from the locked compartment in medication cart C to be placed on resident 35 after the old patch was removed. 6. Interview on [DATE] at 11:19 a.m. with CNA E revealed she was working in hallway C on [DATE] when resident 35's fentanyl patch went missing. RN K notified her that the fentanyl patch was missing early during their shift, approximately between 6:00 a.m. and 7:00 a.m. She looked for the fentanyl patch with RN K in the garbage bags, in the medication cart, on their shoes, and all over hallway C, but they did not find it. 7. Observation on [DATE] at 4:42 p.m. of resident 24's room revealed his door was open and there was a container of Vicks Vaporub medicated ointment on his over the bed table. 8. Observation and interview on [DATE] at 8:54 a.m. with resident 24 in his room revealed there was bottle of seawater nasal spray on his bedside table, Vicks medicated ointment and Blu-Emu cream on his over the bed table, Gold Bond medicated powder on the table behind his door. Resident 24 stated he used the Vicks in his nose when he was congested but had not used that for quite a while. He used the seawater nasal spray in his nose, and the bottle was almost empty. Resident 24 stated the medications were left in his room for him to use when he needed them. 9. Review of resident 24's EMR revealed he admitted to the facility on [DATE]. He had a [DATE] Brief Interview for Mental Status (BIMS) assessment score of 14, which indicated his cognition was intact.His physician's orders included an [DATE] order for Voltaren cream 1% to be applied to his left thumb two times a day as needed, and he could keep it at his bedside. An [DATE] order for Blu- emu cream that could be applied up to four times per day to feet as needed, and he could keep it at his bedside. An [DATE] order for Vicks Vaporub to be applied to his feet as needed for pain, and he could keep it at his bedside. A [DATE] order for nasal moisturizing spray to use as needed and he could keep it at his bedside. A [DATE] order for Bedside med assessment: Vicks, Voltaren cream 1%, Blu-emu cream, and Gold Bond powder, Costco Fiber Tablet/Gummies, Vaseline, and nasal moisturizing spray. Once A Day on Fri [Friday].Resident 24's [DATE] Self-Administration of Medications assessment indicated he could safely administer Pills, creams and ointments with set up provided by nursing staff and that the self-administered medications were stored in the nursing medication cart.His [DATE] care plan indicated a goal of Resident will continue to use and store medication appropriately with the approach of Has order for bedside and self administration of medications. See physician's orders. Nursing staff monitors usage and storage with MD [medical doctor] updated for changes in ability/cognition noted. 10. Observation and interview on [DATE] at 1:40 p.m. with RN manager/infection IP C in the medication room revealed there was a plastic container of 100-unit insulin syringes with needles that outdated on [DATE]. RN manager/IP C stated ward clerk N was responsible for ordering, stocking, and checking the supplies in the medication room for outdates weekly. 11. Interview and observation on [DATE] at 1:55 p.m. with RN manager/IP C of medication carts A, B and C revealed there was a paper medication cup in the top drawer of medication cart C labeled with two letters. RN G was the nurse who was administering medications from medication cart C on [DATE]. RN manager/IP C verified there were two paper medication cups stacked on top of each other with a medication between the two medication cups and a resident's initials were written on the top medication cup in black ink. She stated the medications were prepared and left in medication cart C rather than being immediately administered to that resident.In the top drawer of medication cart C there were ten 100-unit insulin syringes with needles that outdated on [DATE]. There was a bottle of resident 13's latanoprost eye drops (medication used to lower eye pressure related to glaucoma) that did not have a date when the medication was opened. RN manager/IP C verified there was no date to identify when the latanoprost eye drops were opened. She stated she did not expect the nurses to date the latanoprost eye drops when it was opened for administration.In medication cart B there were five 100-unit insulin syringes with needles that outdated on [DATE] and in medication cart A RN manager/IP C was observed removing an undisclosed amount of 100-unit insulin syringes with needles that outdated on [DATE]. 12. Review of resident 6's EMR revealed she had a [DATE] physician's order for torsemide (a medication to decrease swelling) 80 mg two times a day at 8:00 a.m. and 2:00 p.m. 13. Review of resident 13's EMR revealed she had a [DATE] physician's order for latanoprost eye drops, one drop in both eyes daily at 8:00 p.m. 14. Observation and interview on [DATE] of medication cart A with RN F revealed there was a bottle of resident 18's latanoprost eye drops that was not dated when it was opened for administration. RN F verified there was no date documented on the bottle or box that indicated when resident 18's latanoprost eye drops were opened for administration. 15. Review of resident 18's EMR revealed she had a [DATE] physician's order for latanoprost eye drops, one drop in both eyes daily at 7:30 p.m. 16. Interview on [DATE] at 10:58 a.m. with RN G revealed she had prepared resident 6's medication and placed it in the top drawer of medication cart C because after she prepared it she found out resident 6 was out of the facility for an appointment so she could not administer the medication to her. RN G stated she put the medication back in the medication cart between two paper medication cups, labeled the cup with resident 6's initials, and administered the medication to her when she returned from her appointment. RN G stated she did not prepare residents' medication ahead of their administration times routinely but sometimes if the residents were not available after she had prepared their medications, she would label them with their initials and lock them in the medication cart until that resident was available to have their medications administered to them. 17. Interview on [DATE] at 11:09 a.m. with RN J revealed she would use the drug reference book or call the pharmacy to determine if a medication had a shortened expiration date after it was opened. She was not aware that latanoprost eye drops had a shortened expiration date after they were opened. It was not her common practice to label eye drops when they were opened. She did not know when the latanoprost eye drops for residents 13 and 18 would expire since they were not labeled when they were opened.Ward clerk N was responsible for checking the outdates and rotating the medical supplies in the medication room. The nurse scheduled on the night shift was responsible for checking for outdated medications and supplies in the medication carts. 18. Interview, EMR review, and policy review on [DATE] at 4:23 p.m. with DON B revealed she investigated the missing fentanyl patch and reported the incident to the SD DOH. On [DATE] she entered the facility at about 8:50 p.m., when she was notified by RN K that there was a missing fentanyl patch. RN K told her that she was going to change resident 35's fentanyl patch and when she entered resident 35's room, the patch was not in the package. RN K stated she had taken the fentanyl patch out of its package to write on the fentanyl patch, but she had written on the plastic attached to the fentanyl patch and not the patch itself.She had watched the video footage on [DATE] and the camera that recorded hallway C was at the nurses' station, so the patch could not be seen on the footage due to its distance from medication cart C. After RN K removed the fentanyl patch from the locked compartment in medication cart C, she left the cart and entered resident 7's room. She exited resident 7's room and went into resident 35's room. After she went into resident 35's room, RN K went back into the hallway, looked on the top of medication cart C and picked up the garbage bag on the medication cart.DON B expected controlled medications such as fentanyl to be removed from the locked compartment in the medication cart and administered to the resident immediately. The nurse who administered the fentanyl patch to the resident, was to remove it from its packaging, write the nurse's name and the date on it and place it back into packaging before bringing the fentanyl patch into the resident's room to place it on the resident. If a fentanyl patch was missing, she expected to be notified immediately.DON B acknowledged the missing fentanyl patch could not be witnessed as having been wasted since it was not found. She stated that is why she had RN K and RN J document that it was missing on the Controlled Drug Record for Patches. The video footage could not be viewed because the saved format was unable to be opened, and the provider's camera system did not save video footage for that long of period.DON B stated she expected the medications with shortened expiration dates to be dated when they were opened. The pharmacy was supposed to attach a label on medications with shortened expiration dates to prompt the nurses to date those medications when opened and when they would expire, but the pharmacy was not doing that routinely. The staff who administered medications were not aware that there were other medications, other than insulin, that had shortened expiration dates after they were opened so they did not date them when they opened them.Medications were to be stored in a secure location to prevent the residents from accessing those medications. She was aware that resident 24 had medications in his room on his table and acknowledged that those medications were not stored securely which created the potential for other residents to have access to those medications.She acknowledged the self-administration of medications policy and resident 24's self-administration assessment indicated the medications were to be stored in the medication cart. She stated that the self-administration of medications policy was not considered when the bedside medications policy was initiated.Medications were not to be pre-prepared for administration to the residents, but at times the residents were not available after their medications were prepared, so the medications were placed in a medication cup with their initials written on the cup in the locked medication cart and were administered when that resident was available. She stated the nurses did that because otherwise they would need to waste the medications if the resident was at an appointment. DON B acknowledged there was the potential for a medication error when pre-prepared medications were stored in the medication cart.Ward Clerk N was responsible for checking outdated medications and supplies weekly. Every Friday, Saturday, and Sunday, the nurse scheduled to work the night shift was responsible for checking the medication carts for outdated medications and supplies. DON B acknowledged there were outdated insulin syringes in the medication room and all three medication carts that could have been used to administer a medication to a resident. 19. Review of the provider's [DATE] Narcotic [controlled] Medication policy revealed the provider requires accountabilities for all controlled substances. All staff including licensed nurses and medication aids are responsible for narcotics given during their assignment. Schedule II controlled substances [a fentanyl patch] are to be double locked. When [a] discrepancy is noted [the] charge nurse if to notify DON/Administrator immediately. 20. Review of the provider's [DATE] Self-Administration of Medications policy revealed, Medications will be stored in [a] med [medication] cart and given to the resident at scheduled times for self-administration. 21. Review of the provider's [DATE] Shortened Expiration Medication policy revealed, All medications with shortened expiration dates must be labeled upon opening or removal from refrigeration and used or discarded in accordance with manufacturer's guidelines. Medications with shortened expiration dates include but are not limited to 1. Eye drops 2. Insulin 3. Injectables 4. Nasal sprays 5. Emergency inhalers. Nursing staff are responsible for referencing expiration day calendar sheet for expiration dates. 22. Review of the [DATE] latanoprost eye drop manufacturer's instructions revealed, Once a bottle is opened for use, it may be stored at room temperature. for 6 weeks. 23. Review of the provider's [DATE] Outdated Supplies policy revealed the provider was to maintain a system to identify, remove and properly dispose of expired or outdated supplies to ensure resident safety. Expired or damaged items shall never be used for resident care. Each department shall conduct routine inspections of supply areas: i. Monthly at minimum or more frequently as indicated. Expired or compromised supplies shall be: Removed immediately from active stock. 24. Review of the provider's [DATE] Medication Storage policy revealed, All medications must be stored in locked compartments when not in use. Controlled substances must be stored in a separately locked, permanently affixed compartment. All medications must be clearly labeled with: i. Resident name ii. Medication name iii. Strength and dosage iv. Expiration date. Medications without proper labeling shall not be administered. 25. A policy regarding bedside medications was requested but was not provided by the end of the survey.

Based on observation, interview, document review, and policy review the provider failed to ensure practices were in place to ensure the residents' right to privacy for six of six (1, 12, 20, 25, 37, and 42) sampled residents with audio and video monitoring devices in their rooms. *Obtain consent for audio and video monitoring use for six of six (1, 12, 20, 25, 37, and 42) sampled residents with audio and video monitoring devices in their rooms. Findings include: 1. Observation on 1/7/25 at 2:18 p.m. of residents' (12 and 37) room revealed: *An [NAME] device with a screen was sitting on the over-the-bed table beside a recliner. *The device was on. *The screen displayed the current weather. *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.Resident group interview on 1/8/24 at 1:25 p.m. revealed: *Resident 10 was the resident council president and started the meeting reviewing the resident rules. -The rule addressed at that time was regarding video monitoring. *Resident 10 stated, We don't do that, I don't think. *She asked if the other resident present had heard or seen video monitoring, but there was no response. 3. Interview on 1/9/25 at 9:29 a.m. with certified nursing assistant (CNA) L revealed: *She was unaware of any video or auditory monitoring devices in residents' rooms. *There were devices in residents' rooms used to make and receive calls. *Some of the devices had video screens. *She was unaware that some devices had the ability, for someone outside the facility, to listen to what was happening in the room. 4. Interview on 1/9/25 at 9:57 a.m. with registered nurse (RN) I revealed: *She was unaware of any video or auditory monitoring devices in residents' rooms. *Some residents had [NAME] devices in their rooms. *She was unaware that some devices had the ability, for someone outside the facility, to listen to what was happening in the room. 5. Interview on 1/9/25 at 10:07 a.m. with licensed practical nurse (LPN) M revealed: *She was aware that some devices had the ability, for someone outside the facility, to listen into a resident's room with an [NAME]-type device. *She identified residents 1, 12, 20, 25, 37, and 42 as having [NAME]-type devices. *She stated that the provider supplied the devices in resident 25's and resident 42's rooms. *The other devices were provided by residents' families. 6. Observations and interviews on 1/9/25 between 1:22 p.m. revealed: *Resident 1 had two [NAME] devices: -She had an [NAME] Echo on her dresser and she stated she used it to listen to music. -She had an [NAME] Echo Show on her over-the-bed table. --The [NAME] Echo Show had a video screen. --She stated that she used that device to call her family. -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. *Residents 12 and 37 shared a room. -An [NAME] Echo Show was on an over-the-bed table beside a recliner. -Resident 12 stated that they used it to make video calls to family and to check the weather. -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. *Resident 20 had an iPad on her over-the-bed table. -She stated she used it to make video calls. -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. *Resident 25 had an [NAME] Echo Pop on her shelf. -Music was playing on the 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. *Resident 42 had an [NAME] Echo Pop on her bedside table. -Music was playing on the 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. 43844 7. Interview on 1/9/25 1:55 p.m. with DON B regarding audio video monitoring devices in resident rooms revealed: *She stated all of the devices were put into place in the last month. -Resident 1 used her's to make phone calls. -She was not aware residents 12 and 37 had a device. -They were mostly used for psychosocial reasons such as playing music. -She was not aware the devices had a drop in feature (when a someone with access to the device, was able to initiate video monitoring without the residents or staff knowledge). -They did not have residents sign an informed consent form. -She had recently developed a written a policy for audio and video monitoring devices. -She confirmed the audio and video monitoring device policy was written on 1/8/25 an not on 1/8/24. 8. Review of the 11/2020 South Dakota State Long-Term Care Ombudsman Program resident rights handbook the provider includes in their admission packet for newly admitted residents revealed: *Video monitoring device -a camera or other device, which captures, records or broadcasts video and which is placed in a resident's room and used to monitor the resident or activities in the room. *Before initiating video monitoring, a resident shall complete and submit to the facility a notice and consent form . *The facility shall post conspicuous signage at the entrance to the resident's room indicating that the room is being monitored by means of a video monitoring device. 9. Review of the provider's 12/3/24 Video/Audio Monitoring 'policy revealed Video and audio monitoring are not allowed in resident rooms and bathrooms. 10. Review of the provider's 1/8/24 (1/8/25 per DON B interview) [NAME] Device Policy revealed: *The facility has the responsibility and authority to manage, monitor, and establish protocols for the use of the [NAME] devices. -Protocols may be amended, and be communicated, as resident interests, staff ability, and technology changes. *This policy does not supersede nor negate existing policies addressing, but not limited to the following -The facility values and standards of behavior are not compromised. 11. Review of the provider's undated Personal Smart Device Protocol revealed: *Devices may be initiated by facility for psychosocial reasons *Devices may be initiated by family for connectivity.

Based on interview, observation, record review, and policy review, the provider failed to implement an effective grievance process to ensure two of two sampled residents (10 and 32) who had reported grievances included documentation, investigation, and follow-up with the resident regarding issues of resident care and quality of life that were important to the resident. Specifically, the provider failed to ensure the following: *All written grievance decisions included the date that the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to have been taken by the provider as a result of the grievance, and the date the written decision was issued. *Prompt efforts to resolve grievances and to have kept the residents informed of progress toward the resolution. *Staff completed a grievance form if given an oral grievance, investigated, and followed up with the resident and their representative. *The resident council was informed in writing of the responses to concerns brought up in the resident council meetings and provided a prompt update on efforts by the provider to resolve any grievances. Findings include: 1. Interview on 1/7/25 at 10:50 a.m. with resident 32 revealed she: *Had lived in the facility for close to three years. *Had concerns regarding the main dining room: -She felt the dining room was cold and she had to wear two sweaters when she went to the dining room for her meals. -She thought the air exhaust vent that was located on the wall close to her table was filthy. -The menu board in the dining room, which listed what was being served, sometimes had food items listed that you've never heard of and she had no idea what that food item was. -She had discussed those concerns with staff but stated Nothing was done. *Had concerns regarding the meals she was provided: -She was diabetic since childhood. -Stated she was a picky eater and had a list of things she could not eat, which included: --Oleo/margarine. --Mayonnaise. --Cheesy potatoes. --Chicken. -She had discussed her meal preferences with staff. -She stated those preferences were honored if the right cook was working. -There were times when those preferences were not honored and she was served something she could not eat. 2. Observation on 1/9/25 at 11:30 a.m. of the air exhaust vent on the wall next to resident 32's table revealed it was coated with dust particles that were easily removed with a finger swipe. 3. Interview and observation on 1/9/25 at 11:33 a.m. with dietary cook J revealed: *Dietary director E was not at work in the facility that day, 1/9/25. *She had not heard of any resident concerns regarding the posted menu. *She had visited with resident 32 regarding her food preferences and specific dislikes the resident had. *She revealed resident 32 disliked butter, margarine, luncheon meat, and chicken. *Observation of resident 32's dietary card with dietary cook J revealed the Dislikes section on her dietary card was blank. *The dietary card for each resident was referenced by the dietary cooks when preparing each resident's meal. 4. Review of resident 32's electronic medical record (EMR) revealed: *She had been admitted on [DATE]. *Her diagnoses included diabetes mellitus type 2 and gastroesophageal reflux disease (GERD) with esophagitis, without bleeding. *Her Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *Her 11/18/24 care plan included a nutritional status section that included the following approaches: -Regular Diet, Thin liquids. May request ground meat . -Offer tray set up assistance as needed at mealtime . -Honor personal requests at all meals . -No specific meal preferences or food dislikes were listed. 5. Review of the requested grievances from July 2024 through January 2025 received and recorded by the provider revealed two complaints/grievances were documented from resident 32: *A Safety Zone electronic event form for a verbal complaint on 8/12/24 received from resident 32 regarding her Care/Treatment and meals during an assessment interview with licensed social worker (LSW) H. -The electronic event form's Follow up section documented the following actions were taken: --Minimum data set (MDS) coordinator C addressed the resident's concerns regarding her care. --The Dietary Manager followed up with [resident 32] on 8/16/24 to discuss food preferences, offering her 2nds, and the way the staff delivers her plate. --LSW H followed up with the resident's daughter on all these concerns. -There was no documentation regarding the resident or the resident's daughter's follow up's Reaction to issue having been either satisfied or dissatisfied. -There was no documentation regarding the follow up's Expectations of either: --Apology. --Better communication. --Billing adjustment. --Compensation. --Doesn't want to happen to anyone else. --Face to face. --Notification to . --Talk with administration. --or Other. *A Safety Zone electronic event form for a grievance on 10/18/24 received from resident 32 regarding her care and her food preferences. -The electronic event form's Follow up section documented the following actions were taken: --Director of nursing B had followed up with the resident on 10/18/24 to address her care concerns. --Dietary director E had followed up with the resident on 10/22/24 to address her food preferences. -The follow up's Reaction to issue area was documented as satisfied. -The follow up's Expectations area was documented with: --Apology. --Better communication. *There was no complaint/grievance form that documented resident 32's concern regarding: -The dining room being cold. -The air exhaust vent that was located on the wall close to her table being filthy. -The menu board in the dining room that at times listed food items not understood by the resident. 6. Interview on 1/7/25 at 4:41 p.m. with resident 10 revealed: *She was the current president of the resident council which met monthly to listen to complaints and plan the meal of the month. *Activity director F helped to coordinate the resident council meetings and typed up the meeting minutes. *She was not sure how the complaints from the resident council were addressed. *Stated she had not seen a concern form when asked about the provider's suggestion/concern form. *She was concerned that the dining room was cold. 7. Interview on 1/9/25 at 9:50 a.m. with LSW H revealed: *She was the provider's grievance official. *Resident and family grievances were directed to her and she completed an interview regarding the grievance and used the provider's electronic healthcare Safety Zone program to document the concern. *She reviewed the provider's paper suggestion or concern form when completing admission paperwork with the resident and family. *She was not aware of any difference between a complaint and a grievance in the provider's grievance policy. *Activity director F had been in her position for one year. -She was concerned that activity director F had not been adequately trained for her position. -She had not provided any training to activity director F regarding the grievance process. *She was aware that activity director F typed up the resident council meeting minutes and provided them to the department managers for follow-up. -She had not discussed with activity director F how to handle the concerns brought up at the resident council. *That day, 1/9/25 was LSW H's last day of work with the provider and she was not aware of any replacement, but stated that administrator A would figure it out. 8. Interview on 1/9/25 at 12:55 p.m. with activity director F and director of business D revealed activity director F: *Coordinated the monthly resident council meeting and would take notes at the meeting to assist her in documenting the meeting minutes, but stated she had not saved those notes after she had typed the meeting minutes. *Would discuss verbally the concerns expressed at the meeting with the department manager responsible. -She agreed this was a verbal discussion with no written communication regarding the concern. *Had not reviewed old business from the previous meeting but had the resident council approve the previous month's meeting minutes. -She agreed she had not reviewed resolutions to concerns expressed at the prior meeting. -She agreed that the meeting format could be improved. *Agreed the resident council meeting minutes had not documented resolution of the concerns expressed at prior meetings. 43844 1. Interview on 1/9/25 at 1:44 p.m. with DON B regarding resident grievances revealed: *When a resident had a grievance or complaint it was given to the social service department for follow-up. -The social service department was able to handle generic items by email or phone call. -For complaints that the social service department was unable to take care of immediately, the social service department would notify the department manager related to the complaint for their assistance. *For grievances related to the nursing department she would talk to the resident and try to figure out what the problem was and what was needed to provide a resolution to the problem. *She stated, We are missing that follow-up documentation for grievance resolutions. *Grievances would be documented in Safety Zone (an electronic tracking system). -Those items would be taken from verbal reports and resident's progress notes. -Staff members with access to Safety Zone were the MDS coordinator, dietary manager, infection control preventionist, licensed social worker, administrator, corporate administration, and herself. *Regarding all staff members becoming aware of resident grievances she indicated staff members would become aware through staff meetings, stand-up meetings that were held a couple of times a week, daily report at 2:00 p.m. and at 6:00 p.m., monthly CNA meetings, she would talk to and remind staff. *Her expectation was for all staff to know where grievance forms were located in order to assist residents in completing one. *For resident council grievances, she thought the grievance issue was followed, but there was no written or formal response to the residents. *There was no Grievance Committee. *There was a Quality Assurance committee meeting, grievances were not reviewed at these meetings. 51472 1. Observation on 1/7/25 at 12:25 p.m. of lunch service revealed: *There were cards on the side of the serving table. *The cards were labeled with each resident's name. *There was an area on the card that indicated allergies, dislikes, and specialized diet orders. *Resident 9's card indicated she did not like broccoli. -Broccoli was served to her. 2. Interview on 1/7/25 at 4:08 p.m. with resident 10 revealed: *She was the resident council president. *She felt that some residents did not express their concerns during resident council but talked about concerns before and after the meeting. *Activity director F coordinated the meetings and took notes at the meetings. *Resident 10 felt there was no follow-up on the concerns brought up during the resident council meetings. 3. Resident group interview on 1/8/24 at 1:25 p.m. revealed: *Resident 10 acted as the resident council president and in review of the last meeting asked if there were any questions about the state ombudsman then proceeded going through each facility department asking if any concerns. *During dietary department and food discussion, concerns expressed included: -It's terrible. We all have the same idea. -Can't see how it can't be warm, the carrots could have just as well come out of the freezer. -Voiced they may be served broccoli five days in a row or another vegetable three times in a week, they wanted variety. -They had not been offered salad in three or four months and would like salad, but salad needed to be more than just lettuce. -One resident stated she was the first one in the dining room and the last one served. She stated that her tablemate fell asleep waiting for his food to be served. -Other's stated that they would like fresh fruit, fresh vegetables, and pickles. -One resident stated that she felt the kitchen was trying to educate the residents on new foods. She did not know what some of the dishes on the board were. --She felt the menu board should be simple, like chicken or fish not fritters. --She felt the menus were planned for people younger than we are. *When the maintenance department was discussed one resident stated: -When something was requested there was no response. -She had told maintenance director N that the television in the dining room needed to be cleaned, he told her he did not know whose job that was. *She had told maintenance director N last fall and again a week or so ago the register (the heat register was clarified to be the air exhaust vent) in the dining room needed to be cleaned. *Concerns expressed related to staffing were: *One resident stated: -She had her call light on for over one hour before staff responded. -While she waited for the staff to answer her call light, she was incontinent of urine. -When she was incontinent, she soaked her clothing and her bedding. *Another resident stated: -She had been incontinent of stool while she waited for her call light to be answered. -She had witnessed more than one staff in the soiled utility room visiting with one another. *The residents expressed that staff followed up with them in regarding their expressed concerns but they did not feel anything changed. *A resident stated that she had brought up concerns at her care conference and she did not receive follow-up about her concerns. *A third resident stated that he did not feel that he would be retaliated against if he brought up a concern but did state that the staff made the residents feel like they dislike them if they expressed a concern. -He clarified this to be the most noticeable to him on the evening shift. *Another resident stated that he was offered evening snacks at times, but not every night. *The residents present in the group interview stated they were unaware of where to find a grievance form but no one had ever filled one out. 4. Interview on 1/8/25 at 3:30 p.m. with activity director F about resident council revealed: *Some concerns were brought up repeatedly. *Food was often a concern expressed. *She was told by management not to include detailed information in the resident council meeting minutes. *She followed up on resident concerns by asking the residents if there was a change. *Previously, residents stated that a concern was better, and then later would state nothing had changed. *The concerns that the residents brought up during resident council were not concerns she had not heard previously. *She was unaware that the concerns had not been addressed. *She had not filled out grievance forms for resident concerns. *She sent an email to each manager about the concerns that needed to be addressed. 5. Observation on 1/8/25 at 3:42 p.m. of the television and the air exhaust vent in the dining room revealed: *There were fingerprints and smudge marks on the television. *The air exhaust vent had gray and black dust particles on the vent cover. *The cavity behind the vent cover revealed the majority of the surface area was covered in gray dust particles. 6. Interview on 1/8/25 at 4:39 p.m. with dietary director E revealed: *She received emails from activity director F with concerns brought up during resident council and the selected meal for the month. *She followed up with the resident who expressed the concern. *She stated that the concern expressed today (1/8/25) during resident council about not having had lettuce in the last three to four months was untrue. It had only been one to two months. *She stated that she did not understand how the carrots during lunch could have been cold they were temped (food temperature was taken before they were served). 7. Interview on 1/9/25 at 9:29 a.m. with certified nursing assistant (CNA) L revealed: *If a resident came to her with a complaint or concern, she would have: -Listened to the concern. -Addressed the concern if she was able. -Reported the concern to the charge nurse. *She knew that there were grievance forms, but did not know where they were located. *She had not filled out a grievance form. 8. Interview on 1/9/25 at 9:53 a.m. with registered nurse (RN) I revealed: *She would notify the director of nursing (DON) or the administrator if a resident came to her with a concern. *She had not filled out a grievance form. *She did not know where the grievance forms were located. 9. Review of the resident council meeting minutes from July through December, 2024 revealed: *Old business was not identified as part of the meeting in any of the monthly minutes. *July's concerns were: -Laundry items were missing and put in the wrong places. -Dietary menu to be switched up. *There were no concerns in August, but the resident council was informed a new labeler was being purchased for laundry. *In September the resident council requested the dietary manager to be present at their next meeting. *In October resident council Talked with Dietary Manager. Nothing new to report. *In November there was nothing new to report for all departments. *In December there was nothing new to report for all departments. 10. Review of the emails sent from activity director F to the managers, addressing the resident council concerns from July to December 2024 revealed: *The 7/22/24 email stated: -Resident 32 not enjoying her current room because of her window view and would like to be notified of any room openings down B or C hall for her to look at and possibly switch rooms. -Housekeeping supervisor O- residents had a complaint with housekeeper P not cleaning anything in their rooms, and just doing the floors. -Dietary director E- residents stated, there is BBQ everything and would like a change, and sides switched. -The back patio was not what was recommended by them when asked for their input. For most residents it is not accessible alone, due to the decline on the sidewalk, and also the back door entrance they want leveled out. *The 8/2/24 email to dietary director E stated: -Can you switch resident 1's breakfast card to say cream of wheat instead of oatmeal? I mentioned it the other week to the cook, but no one had done it yet. *The 8/22/24 email to dietary director E stated: -Some residents were not happy with dessert today. --They received ice cream instead of cherry pie. They stated they were not informed why the dessert was switched. -Can you add the DAY OF supper meal to the board when the cook writes the lunch menu? -Can you send out the monthly meal calendars to residents' rooms? *There were no emails documented for the months of September, October, or November. *The email communication from12/5/24 through 12/9/24 between activity director F and dietary director E stated: -From activity director F, Still complaints on meals, food being too tough, or too many of the same things in a week or comes cold. I'm not sure where you guys want me to go with this. -From dietary director E, I will check into this. Can you tell me what meals are cold? My menu's come from [supplier name]. The meat that have been tough is the pork. -Activity director F did not have the requested information. 11. Review of the provider's 1/9/25 admission agreement packet revealed: *Residents are encouraged to participate in resident council. It is held monthly and provides discussion among the residents to communicate the group' wants and needs. It is led by the residents to empower them and give them a voice for change. *You have the right to voice grievances to the staff of Bethesda Home, or any other person, without fear of discrimination or reprisal. Bethesda Home must resolve the issue promptly. *The last page of the packet was a form labeled BETHESDA HOME SUGGESTION OR CONCERN. -That form listed options of suggestion concern/grievance and recognition. -That form included the following areas with space for documentation followed by space to identify who completed each section along with the date: --Report of suggestion or concern. -Investigation. -Resolution. -Follow up comments/Reviewed with concerned party. -The following statement was at the bottom of the form Upon completion of the Suggestion or Concern form, please return the form to [provider's name] by mail or drop it off with the Social Services Director, Administrator or in the Front Office. Thank You. 12. Review of the November 2020 South Dakota State Long-Term Care Ombudsman Program resident rights handbook the provider included in their admission packet for newly admitted residents revealed residents have the right to raise concerns: *Present grievances to staff or any other person, without fear of reprisal adn with prompt efforts by the facility to resolve those grievances and report the resolution. *Discuss Care *Discuss Quality of Life. 13. Review of the provider's 1/8/24 Nutrition & Hydration policy revealed, the facility provided Food and drink that accommodates resident allergies, intolerances and preferences. 14. Review of the provider's 10/1/17 Grievance Policy revealed: *A complaint was identified as A verbal concern regarding resident care or services, which is resolved at the point of service; or A verbal concern that could have been addressed by staff present at the point of service if staff had been informed of the complaint at that time. *A grievance is identified as A verbal complaint that cannot be resolved by the staff present, is postponed for later resolution, is referred to other staff for later A written complaint is always considered a grievance. *Grievance Committee: An IDT (interdisciplinary team) committee designated by the governing body to Investigate, review and resolve resident grievances. This committee will be comprised of more than one person and may include the administrator, director of nursing, nurse manager, MDS (minimum data set) coordinator, social worker, activities director, dietary manager, laundry/housekeeping manager, maintenance manager, and/or the business manager. *For concerns that cannot be promptly resolved, or that for other reasons are considered grievances rather than complaints, Bethesda will review, investigate, and respond to the patient/resident/representative in a manner compliant with its grievance policy. *A complaint is considered resolved when a resident or their representative is satisfied with the actions taken on their behalf. A complaint that is unresolved shall be handled as a grievance. *On average, an appropriate time frame of response will be 7 business days. *There may be situations where Bethesda has taken appropriate and reasonable actions on the resident's behalf in order to resolve the resident's grievance and the resident or their representative remains unsatisfied with Bethesda's actions. In these situations, Bethesda may consider the grievance closed for the purpose of satisfying CMS [Center's for Medicare and Medicaid Services] regulation.

Based on interview, record review, and policy review, the provider failed to maintain the physical, mental, and psychosocial wellbeing by ensuring staff promptly respond to call lights for five of five residents (2, 10, 17, 32, and 35) who used call lights to alert staff of their assistance needs. Findings include: 1. Interview on 1/7/25 at 9:03 a.m. with resident 35 revealed: *She stated she had to wait too long for her call light to be answered. -It took up to 45 minutes for the call light to be answered, usually it was one-half hour, and seldom was it 15 minutes or less. -The wait time was especially worse in the mornings. *She needed help to get dressed and undressed. -She did not need assistance to use the bathroom. 2. Interview on 1/7/25 at 9:09 a.m. with resident 17 revealed he: *Needed assistance in the mornings to dress. -Would use call light to notify staff when he wanted to get dressed. -Stated he had to wait for them to help him get dressed in the mornings. --His care conference was scheduled for that day (1/7/25) in the afternoon, and he was going to discuss this issue. 3. Interview and review of call light logs on 1/9/25 at 9:36 a.m. and again at 1:28 p.m. with MDS coordinator C revealed: *She was unable to print the call light logs. -She was kind of surprised how long some of the call light wait times were. *The facility was currently in a COVID-19 outbreak. -There were four residents currently COVID-19 positive. -She thought this might have contributed to the call light wait times. *Staff had forgotten to shut of a residents call light after they had provided the resident's care. 4. Review of resident 2's call light log revealed: *From 11/1/24 through 12/31/24 she waited after activating her call light was: -From 15 minutes to 29 minutes 43 times. -From 30 minutes to 44 minutes 15 times. -From 45 minutes to 59 minutes 3 times. -Over 59 minutes twice. *From 1/2/25 through 1/9/25 the time she waited after activating her call light was: -On 1/2/23 at 12:33 p.m. she waited 45:03 minutes. -On 1/4/25 at 7:30 a.m. she waited 32:22 minutes. -On 1/4/25 at 12:53 p.m. she waited 18:14 minutes. -On 1/6/25 at 7:43 a.m. she waited 39:22 minutes. -On 1/6/25 at 8:39 a.m. she waited 22:21 minutes. -On 1/6/25 at 9:27 a.m. she waited 26:04 minutes. -On 1/7/25 at 7:17 a.m. she waited 24:45 minutes. -On 1/8/25 at 7:22 p.m. 28:40 minutes. 5. Review of resident 32's call light log revealed: *From 11/1/24 through 12/31/24 the time she waited, after activating her call light, more than 30 minutes was three. *From 1/2/25 through 1/9/25 the time she waited after activating her call light was: -On 1/5/25 at 8:19 a.m. she waited 25:22 minutes. -On 1/8/25 at 8:29 a.m. she waited 16:12 minutes. *November and December 2024 were not reviewed. 6. Review of resident 35's call light logs revealed: *From 11/1/24 through 12/31/24 the time she waited, after activating her call light, more than 30 minutes was six times. *From 1/2/25 through 1/9/25 the time she waited after activating her call light was: -On 1/4/25 at 4:41 p.m. she waited 15:38 minutes. -On 1/6/25 at 7:33 a.m. she waited 30:12 minutes. -On 1/7/25 at 7:25 a.m. she waited 24:55 minutes. -On 1/8/25 at 7:34 a.m. she waited 16:30 minutes. 7. Review of resident 10's call light log revealed: *November 2024 and December 2024 were not reviewed. *From 1/2/25 through 1/9/25 the time she waited after activating her call light was: -On 1/3/25 at 10:35 a.m. she waited 15;55 minutes. -On 1/6/25 at 11:13 a.m. she waited 22:50 minutes. -On 1/7/25 at 10:08 a.m. she waited 15:45 minutes. 8. Review of resident 17's call light log revealed: *November 2024 and December 2024 were not reviewed. *From 1/2/25 through 1/9/25 the time he waited after activating his call light was: -On 1/5/25 at 8:19 a.m. she waited 25:22 minutes. -On 1/8/25 at 8:29 a.m. she waited 16:12 minutes. 9. Interview and review of call light log wait times on 1/09/25 at 2:04 p.m. with DON B revealed: *When a resident expressed a complaint regarding their call light wait time she would look at that. *They had set assignments for staff members to if there was a concern, they would be able to determine who had provided care for the resident on that day. *She had not received any reports of long call light wait times. *There were no audits completed on residents call light wait times. *She was not able to speak specifically regarding the long call wait times recorded in November and December 2024, and January 2025. -She stated the wait times [reviewed] are unacceptable. 50915 1. Review of call light times for resident 1 from 1/2/25m through 1/9/25 revealed the following extended call light times: -On 1/2/25 at 12:33 p.m., she waited 45:03 (minutes:seconds). -On 1/4/25 at 7:30 a.m., she waited 32:22. -On 1/4/25 at 12:53 p.m., she waited 18:14. -On 1/6/25 at 7:43 a.m., she waited 39:22. -On 1/6/25 at 8:39 a.m., she waited 22:21. -On 1/6/25 at 9:27 a.m., she waited 26:04. -On 1/7/25 at 7:17 a.m., she waited 24:45. -On 1/8/25 at 7:22 p.m., she waited 28:40. 2. Interview on 1/9/25 at 11:25 a.m. with resident (2) revealed: *Sometimes the call lights take a long time to answer. *They are busy. *I have had an [incontinence] accident sometimes. *She said when she needs to pass urine or stool, I don't have much time. *When she has an accident, she is cleaned up right away. 3. Interview on 1/9/25 at 10:41 a.m. with licensed practical nurse (LPN) M and registered nurse (RN) I revealed: *Both agreed call lights should be answered as soon as possible. *Both agreed five minutes was a reasonable goal to answer call lights. *Both agreed the maximum time for a call light to be answered was 15 minutes. 4. Interview on 1/9/25 at 1:20 p.m. with director of nursing (DON) A revealed: *Call lights should be answered as soon as possible. *She said call lights can be answered by all staff. *There is not a specified time for when call lights should be answered. *Five minutes would be a reasonable time for a call light to be answered, but there were busy times when it could take longer than five minutes. 5. Review of the providers 1/2024 Call Light Policy revealed: *Purpose A. To ensure resident always has a method of calling for assistance. *B. To promptly answer the resident's call light. *Procedure, B. When resident's call light is observed/heard, go to the resident's room promptly. *C. Respond to request as soon as possible. Turn call light off and inquire about resident's request. *D. When leaving the room, place call light within easy reach of resident. 51472 1. Interview on 1/7/25 at 9:07 a.m. with resident 21 revealed: *She stated she had turned on her call light and staff did not come to help her. *She did not receive help getting dressed that morning. 2. Interview on 1/7/25 at 4:08 p.m. with resident 10 revealed: *She felt staff were slow to respond to her light. *She understood she was not the only resident who needed assistance with their cares. *She tried to ask for assistance at times when she felt the CNAs were less busy such as mid-morning or mid-afternoon. 3. Resident group interview on 1/8/25 at 1:25 p.m. revealed: *Resident 32 stated: -She had her call light on for over one hour before staff had responded. -While she waited for the staff to answer her call light, she was incontinent of urine. -When she was incontinent, she soaked her clothing and her bedding. *Resident 10 stated that she had been incontinent of stool while she waited for her call light to be answered. 4. Review of a 7/5/24 grievances filed by licensed social worker (LSW) H revealed: *On 7/5/24 at 10:00 a.m. LSW H was notified that resident 16 had a concern about her care. *LSW H was made aware of this concern by a written note from a CNA to the DON. *The note indicated on 7/3/24 at 8:00 p.m. resident 16 stated she was left on the commode for two hours. *Staff present at that time were interviewed and stated resident 16 was upset because she was left on the commode without a call light. *On 7/5/24 when LSW H followed up with resident 16 she could not give specific information. *LSW H noted in her follow-up that resident 16 was more confused and was easily distracted. 5. Review of a 11/5/24 grievance filed by LSW H revealed: *Resident 27 reported to LSW H that she had pressed her call button at about 5:30 a.m. *She felt flushed and wanted a nurse to evaluate her. *Certified nursing assistant (CNA) K answered the call light. *CNA K told resident 27 to wait for the day shift to address her concerns. *The director of nursing (DON) addressed the resident concerns with CNA K and re-educated her on responding to call lights promptly. 6. Review of the provider's 11/27/24 Facility Assessment revealed: *The provider has a blended staffing model to promote resident quality of life and promote a home-like atmosphere. *Staff assignments for coordination and continuity of care for residents within and across the three wings is determined in conjunction from the DON, Nurse Manager, RN, Licensed Nursing Staff, and DON/scheduler. The facility resident census report from 1/2/25 through 1/9/25 indicated there were 44 residents.

Based on observation, interview, and policy review, the provider failed to ensure proper glove use and hand hygiene were performed during two of three meal services by two of three observed dietary cooks (D and E) in the dining room. Findings include: 1. Observation on 9/12/23 from 7:54 a.m. through 8:28 a.m. with cook D revealed she: *Was wearing gloves while serving breakfast from the steam table in the dining room. *Took a resident's menu card from the card rack on the steam table and placed it next to a plate. *Used the scoop from the scrambled eggs pan and placed the eggs on a plate. *Had the same gloves on: -Grabbed a piece of toast from the steam table. -Put it on the plate. -Then grabbed two pieces of bacon. -Put them on the plate. *Then went into the kitchen: -Removed her gloves. -Grabbed an egg from an egg carton. -Cracked it into a frying pan without washing her hands. *Came out of the kitchen and used hand sanitizer. *Put on a new pair of gloves. -Grabbed another resident menu card. -Set it next to a plate. -Grabbed a bowl and set it on the counter. -Took a container of cereal and poured it into the bowl. -Put the cereal container back on the counter. -Grabbed a piece of toast out of the steam table with those same gloves on and put it on the plate. *Picked up the cereal container and poured it into a bowl. *Grabbed another menu card. *Then with the same gloves on she grabbed a piece of toast and put it on a plate. *Took another plate reached into the steam table and grabbed two pieces of bacon and put them on the plate. *Went into the kitchen and removed her gloves without washing her hands. Interview on 9/12/23 1:54 p.m. with cook D revealed she: *admitted she cross-contaminated her gloves by grabbing the resident menu cards. *Usually only wore a glove on one hand so she would not cross-contaminate resident's food while serving. *Had not realized she grabbed the cereal container and a bowl with the same gloves on and then used those same gloves to pick up the toast and the bacon. *Agreed she should have washed her hands after she removed her gloves. 2. Observation on 9/12/23 at 5:54 p.m. with cook E in the dining room revealed she: *Was at the steam table wearing gloves. *Opened a drawer under the counter behind the steam table and then closed the drawer. *Grabbed a plate and set it on the steam table. *Used a ladle to put baked beans in a bowl. *Reached into the steam table grabbed a hamburger bun with her gloved hand and put it on the plate. *Opened the bun with her gloved hands. *Picked up a spoon and scooped tavern meat onto the bun. *Used her gloved hand to pick up the other half of the bun and placed it on top. 3. Interview on 9/13/ 23 at 2:33 p.m. with dietary manager C regarding dietary staff glove use and hand washing revealed: *Cook D usually worked the evening shift and was helping cover for the day cook's vacation. *She was not sure why cook E would open that drawer. -There was only papers in the drawer. -Cook E was probably nervous. *Dietary staff were educated annually on glove use and hand washing. *It was her expectation for staff to follow the policy for glove use and hand washing. *She agreed staff were not using gloves and hand washing according to the policy. 4. Review of the provider's undated Bare Hand Contact with Food and Use of Plastic Gloves policy revealed: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Procedure: 1. Staff will use good hygienic practices and techniques with access to proper hand washing facilities (available soap, hot water and disposable towels and/or heat/air drying methods). Antimicrobial or antiseptic gel is not used in place of proper hand washing techniques. 2. Staff will use clean barriers such as single-use gloves, tongs, deli paper and spatulas when handling food. 3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food). 5. Clean barriers such as single-use gloves are to be used when: a. Handling ready-to-eat foods. b. Handling raw meat, poultry, raw eggs, fish and shellfish. c. Preparing foods such as meatloaf or meat salads. d. Hand tossing salad, mixing coleslaw, potato or macaroni salad. e. Bagging bread or cookies. f. Removing frozen foods from boxes. g. Anytime hands would otherwise touch food directly. 6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. a. After coughing or sneezing into hands, using a handkerchief or tissue, using tobacco or touching hair or face. b. After handling garbage or garbage cans. c. After handling soiled trays or dishes. d. After handling anything soiled. e. After handling boxes, crates or packages. f. After picking up any item from the floor. g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. h. When switching between working with raw food and working with ready-to-eat food. i. After engaging in other activities that may possibly contaminate the hands with bodily fluids. j. After using the rest room. k. After caring for or handling service animals or aquatic animals. l. Any time a contaminated surface is touched. 7. Wash hands after removing the gloves.

Based on observation, interview, and policy review, the provider failed to ensure safe operation of the dietary department's electrical stove top burner by four of four dietary staff for three of three observations. Findings include: 1. Observation on 7/26/22 from 8:48 a.m. to 9:01 a.m. of cook G in the kitchen revealed: *She removed a frying pan from the right front stovetop burner. She did not turn off the burner before she walked into the dining room, thereby leaving the burner unattended. *The burner dial was set between the very lo and med lo settings. *By 9:01 a.m., the burner was still turned on and remained unattended. Surveyor informed dietary manager (DM) E of the situation. DM E turned the burner off by turning the dial to the off position. 2. Interview on 7/26/22 at 9:01 a.m. with DM E revealed she: *Started her position less than a year ago. *Did not know at first the cooks often left the burners on. *Stated it was an ongoing issue with her staff. *Needed to reeducate staff about kitchen safety. 3. Observation on 7/27/22 from 8:10 a.m. to 8:15 a.m. in the kitchen revealed: *The right front stovetop burner was turned on and unattended. *The dial was set to high. *Dietary aide H, cook F, and DM E walked by the stovetop burner several times. None of them turned the burner off. *At 8:15 a.m., cook F turned the burner off. 4. Observation on 7/27/22 at 9:19 a.m. revealed the right front burner was turned on and unattended. The burner dial was between the med lo and med high setting. 5. Interview on 7/27/22 at 11:48 a.m. with DM E revealed: *Leaving the burner on and unattended was a serious safety issue. *It was an ongoing reeducation topic with her employees. 6. Interview on 7/28/22 at 9:31 a.m. with administrator A revealed he: *Was unaware of the issue with leaving the burners on and unattended. *Agreed that leaving the burners on and unattended was a serious safety issue. *Was going to mention the topic at the provider's next quality improvement meeting. 7. Review of the provider's policy titled Equipment Safety revealed: *The policy was part of the 2017 [NAME] & Associates, Inc. policy and procedure manual, section 6-4. *Procedure number nine stated, Equipment should not be left on when unattended.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (29) had interventions in place to prevent a pressure ulcer from developing under a splint. Findings include: 1. Observation on 7/26/22 at 8:45 a.m. of resident 29 revealed: *She was sitting in her wheelchair at a table in the dining room. *Her left leg was in a splint that was wrapped with an ACE bandage and was elevated on her wheelchair leg. Observation and interview on 7/26/22 at 11:00 a.m. with registered nurse (RN) D in resident 29's room revealed: *She and a CNA had transferred resident 29 from her bed to her wheelchair. *We use a Hoyer lift (mechanical lift) for all transfers since her fibula fracture. *She has a Stage II pressure ulcer that started as two small blisters on the left shin, under the brace. The splint is removed once a shift to observe the skin. Observation on 7/26/22 at 4:00 p.m. of resident 29 revealed: *She was lying on her back in bed. *She had the appearance of being asleep - her eyes were closed. *Her left leg was in a splint that went from knee to ankle with the top of it open and it went around her foot at the heel. *The splint was wrapped with an ACE bandage. Review of resident 29's 6/23/22 quarterly MDS (Minimum Data Set) assessment indicated her BIMS (Brief Interview for Mental Status) score was zero, indicating severe cognitive deficit. Review of resident 29's medical record revealed: *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)] without behavioral disturbances. -Primary generalized [CONDITION(S)]. -Fracture of left fibula (7/14/22). The 7/18/22 progress note indicated, Two fluid filled blisters were noted under splint on left leg (in splint for left fibula fracture). *RN I had Discovered the blisters after unwrapping [the splint] to assess skin and rewrapping. -Area was padded and splint with ACE wrap reapplied. The 7/18/22 wound management detail report identified the blisters as a Stage II pressure ulcer with measurements of: *Lateral [side] of shin measured 5 centimeters (cm) by 2 cm. -Medial [middle] shin measured 3 cm by 2 cm. A 7/25/22 progress note revealed: *RN I had unwrapped the ACE bandage and removed the splint. -The blisters were intact. -The blisters were padded with a 4 x 4 gauze dressing and rewrapped. The 7/25/22 wound management detail report indicated measurements of the blisters were: *Lateral [side] of left shin was 5 cm by 0.5 cm. -Medial [middle] of left shin was 3 cm by 0.1 cm. --These were the only progress notes about resident 29's pressure ulcer. Interview on 7/27/22 at 10:00 a.m. with RN/nurse manager C regarding resident 29 revealed her ACE bandage and splint on her left leg were to have been removed once a shift to assess skin. Voiced It isn't always documented. Observation and interview on 7/27/22 at 4:15 p.m. with RN D revealed she unwrapped the resident's ACE bandage and splint from left leg. Blisters remained intact. RN D did not measure the blisters. She then rewrapped the splint. Interview on 7/28/22 at 9:55 a.m. with director of nursing B revealed, The nurses are unwrapping the ACE wrap and removing resident's leg splint once a shift and assessing skin. *When told I had only seen documentation of two narratives and measurement notes regarding removing the ACE bandage and splint in resident's progress notes, she agreed the documentation piece was missing and said, We could do something to make it better. *She and RN/nurse manager C have discussed skin issues and pressure ulcers and the documentation piece of those and are working on a solution. Review of resident 29's 7/15/22 care plan revealed: *Problem start date of 7/15/22 - Has fracture to left fibula. Currently nonweight bearing to left leg. *The goal was that resident would return to her prior level of functioning at resolution of fracture. *Approaches included: -Has splint to left lower leg. Keep splint in place at all times. -Monitor CMS [circulation, motion, sensation] and pulses of the affect [affected] extremity. -Elevate left lower extremity. -Monitor for increase in swelling or pain of affected extremity-notify nursing staff as noted/needed. -Weight bearing status - Nonweight bearing to left leg. *Has pressure areas to left lower extremity related to splint, see EMAR [electronic medication administration record] for treatment/monitoring. -This intervention had been added to her care plan on 7/22/22. -Monitor skin integrity with all cares and activities, reporting to nursing staff any concerns noted. --There were no instructions on how this was to occur. --The care plan did not address how often to unwrap and rewrap the ACE bandage to observe the skin around the splint. Review of provider's 6/1/19 Prevention of Skin Breakdown Policy #NH1 revealed the purpose was to prevent the development of pressure ulcers. The prevention methods were: *All residents would be assessed upon admission, readmission, and every shift for the presence of any skin impairment, and any type of wound, including pressure ulcers. *Observe patient [resident] for reddened or blanched areas over pressure sites, especially rim of ears, shoulder blades, elbows, sacrum, hips, knees, ankles, and heels. *Observe for skin integrity during patient's [resident's] bath or whenever care was given to the patient [resident]. Review of the provider's 6/1/19 Skin Issue (Bruise, Skin Tear/Laceration, Rash/Lesion, Pressure Injury/Ulcer) Policy revealed they were to add a Nursing Order to monitor wound every shift. Then add another, separate Nursing Order to assess wound weekly.

Based on observation, record review, interview, manufacturer's review, and policy review, the provider failed to ensure: *A total body lift sling had been applied properly for one of one sampled resident (24). *Safety belts had been used when whirlpool baths had been given. Findings include: 1. Observation on 10/16/19 at 8:10 a.m. revealed: *Resident 24 was seated on the bathing chair. She did not have a safety belt on. She was unable to maintain her balance in the chair without assistance. *Certified nursing assistant (CNA) A transferred resident 24 from the bathing chair to her bed with a total body lift. As resident 24 was lifted from the bathing chair she slipped down approximately four inches. It was noted the sling had not been positioned under her buttocks. Interview on 10/16/19 at 8:45 a.m. with CNA A revealed: *A safety belt for resident 24 had not been used when she had given her a whirlpool bath. *She did not use safety belts during whirlpool baths unless it had been ordered by the physician and was on the resident's care plan. Review of resident 24's physician's orders and last revised 8/29/19 care plan revealed she had no physician's order for the use of [REDACTED]. No problem, goal, or approach was noted on her care plan for the use of a safety belt during a whirlpool bath. 2. Interview on 10/16/19 at 10:30 a.m. with CNA B revealed she had had given residents on the B wing whirlpool baths. She did not use a safety belt when helping residents' with their baths. She stated most of the residents did not need to use a safety belt. The bath aide determined which resident needed a safety belt during their whirlpool bath. She stated there was no written list of those residents. 3. Interview on 10/17/19 at 2:15 p.m. with the Minimum Data Set coordinator and the administrator revealed: *There was no process to determine who needed to use a safety belt when they had a whirlpool bath.*There was no list of which residents were to have used a seatbelt during a whirlpool bath. *The bath aide was the person who made the decision of who used and who did not use a safety belt. *They were not aware of the manufacturer's recommendations for the use of a safety belt. Review of the provider's 6/1/19 Bathing policy revealed there was no procedure for the use of a safety belt during a whirlpool bath. Review of the manufacturer's recommendations for the two Cascade sit-bath system and the Apollo bathing system procedures revealed a safety belt was to have been used for all residents.

Based on observation, interview, record review, and policy review, the provider failed to ensure assessments were accurate, treatment was changed, and interventions were implemented for one of three sampled residents (9) who had a facility acquired pressure ulcer. Findings include: 1. Review of resident 9's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Type 2 diabetes mellitus. -Essential hypertension. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Chronic renal impairment stage 3, moderate. -[MEDICAL CONDITION] stage 3. *He acquired a stage two pressure ulcer to his right heel on 10/31/18. *He was still being treated for [REDACTED]. *He had a partial amputation of his left foot. Review of resident 9's 7/16/19 Minimum Data Set (MDS) assessment revealed: *He had a Brief Interview for Mental Status score of fifteen indicating his cognition was intact. *He required extensive assistance of one staff member for transferring, locomotion on and off the unit, toilet use, and personal hygiene. *He required supervision of one staff member to walk in his room. *He used a walker and a wheelchair. *He was not steady when walking but was able to stabilize with assistance. *He had a stage one or greater pressure ulcer. *He was at risk to develop pressure ulcers. *The interventions in place were pressure reducing device in his bed and chair and pressure ulcer care. Observation and interview on 10/16/19 at 8:13 a.m. with resident 9 revealed: *He was laying in his recliner with his feet up. *He was friendly and pleasant. *He had gripper socks on both his feet. *He had a sore on his right foot and stated they put a dressing on it everyday. *It was sometimes painful but felt okay today. *He stated he had not been able to walk since he got the sore to his right foot. *He was unsure how long he had the sore to his right foot. Surveyor: Observation on 10/16/19 at 9:00 a.m. of resident 9 during his right heel dressing change revealed: *The wound had peeling skin around the wound, and that area was discolored. *The entire area of the wound including the peri-wound area was two inches in diameter with an opened area in the middle. *The opened area was approximately the size of a quarter. *The middle of the wound was fiery red with no signs of granulation tissue. *There was a thin band of yellow slough around the outer edges of the opened wound. Surveyor: Review of resident 9's right heel pressure ulcer assessment documentation revealed: *10/31/18: Resident had a fluid filled blister to his right heel measuring 3.0 centimeters (cm) by (x) 3.0 cm. *11/7/18: Area measures 1.7 cm x 2 cm of purple/red tissue that is closed. Area is a SDTI (suspected deep tissue injury), but a pressure ulcer in evolution. No pain, odor, drainage to area. Surround tissue is dry clean and intact. *11/8/18: Notification form received in regards to right heel with (primary physician's name) signing it. (MONTH) have order as requested from (for) [MEDICATION NAME] but (primary physician's name) would also recommend early evaluation with podiatry due to prior extremity issues and partial amputation on opposite foot. *11/14/18: No blister noted to right heel area. Right heel has a purple red color scabbed area that is 2.3 x 2.4 cm. No open areas noted to this area. *11/21/18: No blister noted to right heel at this time. Resident does have a dark colored scabbed area that is 3 x 3.2 cm. [MEDICATION NAME] soaked gauze with [MEDICATION NAME] changed daily. *11/28/18: Area to right heel measures 2.5 cm x 3.5 cm. Wound bed is eschar, and surrounding tissue is slough and granulation. Area is unstageable at this time. No drng (drainage), odor, redness noted to wound. He says its tender to touch. Was seen by podiatry and will continue with order of [MEDICATION NAME] and cover with [MEDICATION NAME]. Resident is diabetic and has delayed healing d/t (due to) this and poor circulation. *12/5/18: Area to right heel assessed. Area is necrotic and measures 2x3 cm. Current treatment orders are to cover with [MEDICATION NAME] soaked gauze and cover with [MEDICATION NAME] with border. Resident stated that area is painful, but no signs of pain or discomfort during dressing change. Area is not stageable. Not wearing shoes or [MEDICAL CONDITION] wear at this time. *12/8/18: While changing dressing to resident's posterior heel noted bottom of R (right) foot heel has 5.4 cm x 6.5 cm area looks like a popped blister with skin open but covering the open area with some bleeding noted. Covered with [MEDICATION NAME] dressing and wrapped with gauze and blue bootie applied to foot. *12/11/18: Dressing changed to R heel wound and new popped blister area. Wound has dry dark scab and blister is now flat and skin slid off to side of open area slightly. Is attached enough that cannot be slid back into place now. Difficult to assess drainage to dressing as was [MEDICATION NAME] soaked, but no active drainage now. No odor. Has discomfort and received PRN (as needed) Tylenol. Appt. (appointment) made with podiatrist for 12/13/18. Monitor. *12/26/18: Resident continues to have a dry, eschar area to his heel that started as a stage 2 pressure ulcer. Area then developed into necrosis and is no longer stageable. Towards the inner bottom of the foot resident had a skin tear and this area appears to be almost connected with ulcer. Entire area measures 7.2 cm x 5.5. cm. The tissue of the area where the skin tear occurred is granulated. The eschar area that is pressure related is 4 x 4 cm. Scant amt (amount) of sanguineous drgn (drainage) present. Will continue with [MEDICATION NAME] and wrapping as ordered. Resident is scheduled to see podiatry on 12/31/18. *From 12/26/18 through 5/8/19 the measurements fluctuated between 6.0 cm x 4.0 cm to 10.0 cm x 7.0 cm. -Sometimes getting smaller, but then getting bigger again. *From 5/21/19 through 10/4/19 the measurements fluctuated between 2.8 cm x 2.0 cm to 5.3 cm x 4.0 cm. -Sometimes getting smaller, but then getting bigger again. *On 10/10/19: Right heel has brown area that is 5.5 x 4 cm around open area that is 3 x 2 cm. Wound bed for open area is red beefy coloring with scant amount of bleeding noted after removing dressing. No complaints of pain or discomfort has been reported to any of these areas. *Some of the assessments from 10/31/18 through 10/10/19 were incomplete. -Not all the assessments included measurements or even descriptions of what the wound looked like. *There were five weekly skin assessments missing. Review of resident 9's Braden Scale for Predicting Pressure Ulcer Risk assessments revealed: *On 9/24/18 his score was seventeen indicating he was at risk for pressure ulcer development. -Measures taken were, None of the above. -Plan of action: Continue current plan of care. *There had not been a Braden assessment done on 10/31/18. *On 12/17/18 his score was seventeen indicating he was at risk for pressure ulcer development. -There was nothing marked for interventions. *On 1/25/19 his score was nineteen indicating he was not at risk for development of pressure ulcers. -They had not listed any current wounds. -The interventions were: --Pressure reducing device in chair. --Pressure reducing device in bed. --Pressure ulcer care. --Heel protectors. --Continue with current plan of care. *On 4/30/19 his score was nineteen indicating he was not at risk for development of pressure ulcers. -The interventions were: --Pressure reducing device in chair. --Pressure reducing device in bed. --Pressure ulcer care. --Blanket cradle. --Heel protectors. --No referrals necessary. --Continue with current plan of care. *On 7/10/19 his score was sixteen indicating he was at risk for developing pressure ulcers. -The interventions were: --Pressure reducing device in chair. --Pressure reducing device in bed. --Nutrition or hydration intervention to manage skin problems. --Pressure ulcer care. --Blanket cradle. --Elastic stockings. --Elevate [MEDICAL CONDITION]/affected extremities. --Heel protectors. --No referrals necessary. --Continue with current plan of care. Review of resident 9's current undated care plan revealed: *A problem area: Resident has a pressure ulcer to right heel, Followed by podiatry; initiated on 11/1/18. *Interventions included: -Avoid friction and shearing force during transfer and position changes; initiated on 11/1/18. -Encourage and assist as needed to drink fluids. Be sure to offer fluids frequently throughout the day; initiated on 11/1/18 and edited on 9/4/19. -Keep clean and dry as possible. Minimize skin exposure to moisture; initiated on 11/1/18. -Keep linen clean, dry, and wrinkle free; initiated on 11/1/18. -Use moisture barrier product to perineal area BID (two times a day) and PRN after episodes of incontinence; initiated on 11/1/18. -Use pressure relieving mattress for pressure reduction when resident is in bed. Blanket cradle to foot of bed; initiated on 11/18/18 and edited on 9/4/19. -Use prevalon boots to relieve pressure on heels; initiated on 11/1/18. *There had been no other interventions documented prior to the development of the right heel pressure ulcer. Review of resident 9's Medication Administration Records (MAR) from 11/1/18 through 10/17/19 revealed: *From 11/8/18 through 11/19/18 the order was [MEDICATION NAME] with border changes every three days and as needed to right heel. *From 11/20/18 through 12/13/18 the order was [MEDICATION NAME] soaked gauze and cover with [MEDICATION NAME] daily. *From 12/13/18 through 2/25/19 the order was [MEDICATION NAME] and Kerlix dressing to right heel daily. *From 2/25/19 through 9/30/19 they used [MEDICATION NAME] and gauze. *From 5/6/19 through 8/9/19 the order was to soak 4 x 4 gauze with Dakins solution. *From 8/5/19 through 8/26/19 the order was Endoform to wound base on right heel. *They continued to used [MEDICATION NAME] during and after that. The director of nursing was not available to be interviewed as she was on vacation. Interview on 10/17/19 at 12:43 p.m. and again at 4:40 p.m. with the MDS coordinator revealed: *She was not able to answer how the pressure ulcer had developed. *He had not worn his shoes after the development of the right heel pressure ulcer, but she was not sure when he stopped wearing them. *She stated he had gone to a wound clinic. -The podiatrist was who they considered to be the wound clinic. *His primary physician was the medical director. *His primary doctor let the podiatrist manage the wound. *The primary physician did not look at the wound on rounds. *They had not changed treatments or implemented any other interventions then what was documented above. Interview on 10/17/19 at 5:50 p.m. with resident 9's primary physician revealed: *She had not seen the wound in several months, as she was letting the podiatrist and vascular physician manage the wound. *She knew the wound was not healing very quickly. *She had not provided any recommendations to promote wound healing. *She had not been in contact with either the podiatrist or the vascular physician. *She agreed they could have attempted different interventions to see if the wound would have healed faster. *She agreed [MEDICATION NAME] and Dakins solution were both skin disinfectants and would only keep the wound clean. Review of the provider's 6/1/19 Pressure Ulcer Preventions policy revealed: *All residents will be assessed upon admission and every shift for the following the presence of skin impairment and any type of wound, including pressure ulcers. *All residents will be assessed upon admission and quarterly for Risk of pressure ulcer using Braden skin scale. *Interventions (e.g. repositioning, cushions, boots, mattress, barrier cream, etc.) will be put into place for residents at risk. *Wound care: -Pressure relieving interventions (e.g. turning, repositioning, cushions, boots, mattresses) will be implemented upon discovery. -Pressure ulcers and other wounds will be measured & reassessed by nurse minimally weekly (every 7 days) to assess for response to treatment interventions with documentation in progress notes.

Based on observation, interview, and policy review, the provider failed to ensure: *Appropriate glove use was maintained when handling ready-to-eat foods by one of one cook (D) during one of one observed meal service. *Hand hygiene was done appropriately by one of one dietary aide (E) who had been putting dishes through the dish machine and then putting them away. Findings include: 1. Observation on 10/15/19 from 5:32 p.m. through 6:00 p.m. of cook D revealed: *The main meal being served was fish on a bun, pea salad, and mandarin oranges. *Cook D put on gloves and touched the plates, the handles of the scoops, the counter top, and the diet cards. *After touching those items with her gloved hands she then reached into the bag to get a bun. *She placed the bun on the plate and separated the pieces. *With tongs she placed the piece of fish on the bun. *With her gloved hand she would then place the top of the bun on top of the fish. *She repeated that process throughout the meal service touching items, and then touching the buns with those same gloved hands. Interview on 10/16/19 at 8:45 a.m. with the dietary manager (DM) revealed cook D should not have been touching the buns with her gloved hands. She should have used tongs to put the bun on the plate. 2. Observation and interview on 10/17/19 from 8:38 a.m. through 8:55 a.m. of dietary aide [NAME] revealed: *She had been running dishes through the dish machine. *She put the dirty dishes on the rack and pushed it into the machine. *When the load was done washing she started to put the dishes away. *She had not washed her hands after placing the dirty dishes on the rack. *She ran another rack of dirty dishes through the machine and then started putting the clean dishes away without washing her hands. *Interview with DA [NAME] at that time revealed she agreed she should have washed her hands before putting the clean dishes away. Interview on 10/17/19 at 8:55 a.m. with the DM revealed DA [NAME] should have washed her hands before unloading the clean dishes. She stated it was ongoing education with staff. 3. Review of the provider's 10/10/19 Bare Hand Contact with Food and Use of Plastic Gloves policy revealed: *Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. *Staff will use clean barriers such as single-use gloves, tongs, deli paper and spatulas when handling food. *Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. *Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food). Review of the provider's 10/10/19 Hand Washing policy revealed: *Employees will wash hands frequently as needed throughout the day using proper hand washing procedures. *Hands should have been washed after handling soiled equipment or utensils.

Based on observation, interview, and policy review, revealed the provider failed to maintain infection control practices and techniques for: *For one of one sampled resident (24) during personal care. *For one of one sampled resident (9) during wound care. Findings include: 1. Observation on 10/16/19 at 9:00 a.m. during a wound dressing change for resident 9 revealed registered nurse (RN) C: *Placed a barrier towel on his bed. She then placed the dressing supplies on that barrier. *She washed her hands for less than ten seconds, dried them with a paper towel, and then used that paper towel to wipe the edge of the sink. *Put gloves on, removed his sock, and removed the soiled dressing from his right heel. *Without changing her gloves she took a tube of Aqua-Phor lotion and rubbed some of the lotion on the top and sides of his right foot. *Removed her gloves and with no hand hygiene she put new gloves on. *Removed gauze 4 X 4s from two packages and poured Dakins solution on them. She then placed an abdominal dressing under the 4 X 4s. She stated that was for more padding. She added more Dakins solution onto the 4 X 4s. *Placed that clean dressing on the foot rest of his recliner while she unwrapped a roll of Kerlix. She picked up the dressing and placed the wet portion over the heel wound and wrapped it with Kerlix. *Removed her gloves and without any hand hygiene she placed his sock back on his foot. *Gathered the remaining supplies and then washed her hands. *Again wiped the edge of the sink with the wet paper towel. 2. Observation on 10/16/19 at 8:10 a.m. of personal care for resident 24 by certified nursing assistant (CNA) A revealed she did not wash her hands nor use a hand sanitizer when she changed her gloves. Interview on 10/17/19 at 2:30 p.m. with the Minimum Data Set coordinator agreed the above procedure had not been completed in a manner to prevent cross-contamination. Review of the provider's undated Infection Control policy revealed employees must wash their hands or use an alcohol-based hand rub for at least fifteen seconds. That should have been done after removing gloves, and before and after contact with a resident.

Based on observation, interview, record review, policy review, and procedure review, the provider failed to: *Prevent pressure ulcers from forming while in the facility for one of one sampled resident who had pressure ulcers (1). *Develop care plan interventions for pressure ulcers for two of two sampled residents (1 and 2). Findings include: 1. Review of resident 1's medical record revealed:*She had fallen on 6/17/17 and sustained a compression fracture in her back. *Before the fall and fracture her activities of daily living (ADL) according to the certified nursing assistant documentation were: -Independent with walking with a walker in her room and in the hallway. -Independent with transferring from one surface to another. -Only required limited hands on assistance from one staff person with bed mobility, and personal hygiene. *After the fall and fracture her ADLs had declined, and she required extensive assistance of one to two staff persons with her bed mobility, transfers, moving from one area to another, and personal hygiene. Review of resident 1's 7/13/17 care plan revealed her right heel pressure ulcer was not included. Her left great toe pressure ulcer was added on 7/26/17. That care plan included: *A goal for no signs or symptoms of open skin tissue over the next ninety days. *Interventions to ensure heels were propped up at all times when in the bed or recliner. Review of resident 1's skin risk assessments using the Braden scale revealed: *On 5/18/17 her Braden scale risk score was twenty-one. -That score indicated she was not at risk for the development of a pressure ulcer. -She had no preventative interventions in place. *On 7/5/17 her Braden scale risk score was fifteen. -That score indicated she was at risk for the development of a pressure ulcer. -She had no preventative interventions in place. *On 8/5/17 her Braden scale risk score was fifteen. -Preventative measures implemented included pressure reducing devices for her chair and bed, a turning and repositioning program, nutrition or hydration interventions to manage skin problems, and heel protectors. -This was put in place after her hospitalized from [DATE] to 8/5/17. Review of resident 1's pressure ulcer care area assessment (CAA) from her 7/5/17 significant change Minimum Data Set (MDS) assessment revealed: *She had no current skin issues. *She had a recent decline in condition after a fall that had resulted in increased pain. *She was no longer walking but had been using the wheelchair for her locomotion. *She was being transferred with a standing lift. *She had a poor appetite and consumed only one to twenty-five percent of her meals; had other nutritional interventions in place. *Due to her decline in physical ability she was using a wheelchair and staying in her room. -Rested in her recliner. *She had an increased risk for skin breakdown with a pressure reducing cushion placed in her wheel chair and had her own mattress on her bed. Review of resident 1's skin integrity events regarding the development of two pressure ulcers revealed: *A unstageable pressure ulcer to her right heel on 7/13/17 measuring 1.0 centimeter (cm) by 1.0 cm. *Blue boots were applied to both feet in bed and also a blue boot to her right foot when she was up in recliner. *Use [MEDICATION NAME] to right heel and change every three days as a protector. *A 7/20/17 note stated the pressure ulcer to her right heel continued. It was white with fading purple. No measurements were noted. *A 7/27/17 note stated the pressure ulcer to her right heel continued. It was purple in the center. No measurements were noted. *A 8/5/17 note stated she had been readmitted from the hospital. The pressure ulcer to her right heel continued. It was purple in color and soft and measured 4 cm by 4 cm. *On 7/26/17 she had developed a stage one pressure ulcer on her left great toe pad. *Measures taken were to remove tight socks and shoes and apply slipper socks. *No complete measurements had been taken other than a 1.0 cm darker center was noted. *Weekly pressure ulcer documentation on 8/2/17 revealed a 1.0 cm by 2.0 cm area of redness with a 0.6 cm black area. Protective boots worn in bed. *Pressure ulcer documentation on 8/5/17 after her readmission from the hospital revealed the pressure ulcer measured 1.4 cm by 0.7 cm with the center being purple in color. Interview on 8/8/17 at 4:45 p.m. with the MDS nurse manager revealed: *There had been no care plan developed after the development of resident 1's right heel pressure ulcer. *She agreed the resident had been at a great risk due to her decreased mobility. *No interventions had been put in place for prevention until she had developed the pressure ulcer. *The pressure ulcer was to have been measured and assessed on a weekly basis. *She agreed there was incomplete documentation of the assessments. 2. Review of resident 2's medical record revealed: *She had developed a middle of the spine opened area on 7/7/17. *The bath aid had reported the skin irritation that had measured 1.0 cm. *The staff had been instructed to reposition the resident and place a cushion to the back of her wheelchair. *The area had been healed by 8/4/17. Review of resident 2's 6/7/17 skin assessment revealed she had been at risk for developing pressure ulcers. Review of resident 2's 6/15/17 care plan revealed there was no problem area for her being at risk for pressure ulcers. The pressure ulcer that had developed had not been addressed. Interview on 8/9/17 at 11:30 a.m. with the director of nursing and the MDS nurse manager revealed resident 6's care plan had not addressed her being at risk for pressure ulcers and had not addressed the development of the one on 7/7/17. 3. Review of the provider's 10/26/16 Pressure Ulcer Prevention policy revealed: *All residents would be assessed upon admission and every shift for the presence of skin impairment and any type of wound including pressure ulcers. *All residents would be assessed upon admission and quarterly for risk of pressure ulcer development using the Braden risk scale. *Pressure relieving interventions of turning, repositioning, cushions, boots, and mattresses would be implemented upon discovery. *Pressure ulcers and other wounds would be measured and reassessed by the nurse every seven days to assess for response to treatment interventions with documentation in the progress notes.

Based on observation, record review, interview, and policy review, the provider failed to ensure: *Four of four randomly observed residents (7, 14, 15, and 16) who required assistance with eating had been included in conversation during the evening meal service. *Four of four randomly observed residents (7, 15, 17, and 18) received assistance with eating during two of two meal services. Findings include: 1a. Review of resident 7's 7/17/17 Minimum Data Set (MDS) assessment revealed she had long and short term memory problems. She required limited assistance of one staff member to eat. Review of resident 14's 5/15/17 MDS assessment revealed she had long and short term memory problems. She required total assistance of one staff member to eat. Review of resident 15's 6/19/17 MDS assessment revealed she had long and short term memory problems. She required supervision, oversight, encouragement, and cueing with eating. Review of resident 16's 6/12/17 MDS assessment revealed she had long and short term memory problems. She required extensive assistance of one staff member to eat. Review of resident 17's 6/12/17 MDS assessment revealed she had long and short term memory problems. She required extensive assistance of one staff member to eat. Review of resident 18's 6/12/17 MDS assessment revealed she had a Brief Interview for Mental Status score of fifteen that meant her thinking ability was intact. She required limited assistance of one staff member to eat. Observation on 8/7/17 from 5:35 p.m. through 6:05 p.m. in the dining room revealed: *Residents 7, 14, 15, and 16 had been sitting at table four together. *Residents 17 and 18 had been sitting at table twelve together. *At 5:45 p.m. an unidentified staff member moved from table four to table twelve to assist residents 17 and 18. -They had already had their food at that time. -She had not been assisting anyone at table four. *Certified nursing assistant (CNA) B and CNA C had been talking to each other and had not included residents 7 and 15 who they were assisting with their meals. *At 5:48 p.m. CNA D sat down at table four and was not assisting any residents. -She proceeded to talk with CNAs A, B, and C and had not included any of the residents. *At 5:50 p.m. CNA B got up to go speak with a visitor. -CNA D took over assisting resident 7. *At 5:55 p.m. CNA B returned to table four and sat between residents 7 and 15. -She had not helped any of the residents. -She proceeded to talk with CNAs A, C, and D and had not included any of the residents. *During the above observation CNAs A, B, C, and D had not engaged residents 7, 14, 15, or 16 in their conversation. b. Observation on 8/8/17 from 12:00 noon through 12:30 p.m. in the dining room revealed: *Residents 7 and 15 had been sitting at table 4. *There had been no staff at the table to assist those residents. *At 12:00 noon they each had drinks in front of them and two bowls. -In the bowls was pureed apples and pureed cornbread. *Both residents were eating out of their own bowls. *At 12:06 p.m. resident 7 reached over and had begun eating out of resident 15's bowls. -Resident 15 pushed the bowls towards resident 7. -Resident 7 continued to eat out of resident 15's bowls. *At 12:07 p.m. an unidentified registered nurse walked passed table four and moved the bowls apart. -She had not seen resident 7 eating out of resident 15's bowl and pushed them back in front of resident 15. -Resident 15 ate the rest of the food in those bowls. *At 12:12 p.m. resident 7 and 15 had been served plates of food. -There had been no staff present to assist either of those residents. *Residents 17 and 18 had been sitting at table twelve. -There had been no staff assisting either of those residents with eating during the above time frame. c. Interview on 8/8/17 at 4:15 p.m. with the dietary manager revealed: *Table four and twelve had residents that needed assistance from staff. *Staff who were assisting residents should have been at the table fifteen minutes prior to the residents being served. *The food for residents 7 and 15 should not have been served until staff were ready to assist them. *There should have been staff at table twelve to assist residents 17 and 18. Interview on 8/8/17 at 5:00 p.m. with the administrator and director of nursing revealed staff should have been at tables four and twelve to assist the residents with their meals. The staff should have attempted to engage the residents in conversation and not just talk between themselves. Review of the provider's 2/13/15 Dietary Services policy located in the admission packet revealed residents who needed assistance should not have been placed at the table unless staff were available to assist them. The resident should not have been at the table for more than fifteen minutes before their meal had been served.

Based on observation, record review, and interview, the provider failed to assess 2 of 13 sampled residents (2 and 6) for one-to-one activities programming. Findings include: 1. Review of resident 6's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] due to known physiological condition. -[MEDICAL CONDITION]. -Abnormal weight loss. -[MEDICAL CONDITION], stage 3. -[MEDICAL CONDITION], unspecified. -Other specified disorders of bone density and structure. Review of resident 6's 7/5/17 Minimum Data Set (MDS) assessment revealed: *She had a Brief Interview for Mental Status (BIMS) score of one that meant her cognition was severely impaired. *It had not indicated she wandered. Random observations on 8/8/17 from 8:05 a.m. through 4:00 p.m. of resident 6 revealed she had walked with a walker. She had been confused and was not able to hold a conversation with this surveyor. She got confused on where she was going, and staff would have to assist her to her room and to other areas of the building. She wandered throughout the facility and was not able to remain focused on what she had been doing. Review of resident 6's 7/13/17 care plan revealed: *A problem area for activities had started on 7/10/17. *Interventions stated I have confusion and memory loss but am comfortable with attending chapel as I had in the past when living at (name of apartment). *One-to-one activities had not been addressed. Review of resident 6's July 2017 activities records revealed: *She attended social and coffee time and spiritual activities. *She had been in her room for bingo activities. *There had been no one-to-one activities documented. 2. Review of resident 2's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Peripheral [MEDICAL CONDITION]. -Cerebral infarction. -[MEDICAL CONDITION]. -Urinary tract infection. -Chronic fatigue. -[MEDICATION NAME] degeneration. -Major [MEDICAL CONDITION]. -Anxiety. -Pain. Review of resident 2's 6/12/17 MDS assessment revealed she had a BIMS score of fourteen that meant her cognition was intact. She had a depression score of nine meaning she was mildly depressed. Interview on 8/8/17 at 5:00 p.m. with resident 2 revealed: *She liked to be in her room as she had not liked large group activities. *She had not been crocheting, as she had been in a mood. -The staff had not assisted her with her crocheting. -Her son brought her the crocheting materials. *The pastor had purchased towels from her last year to sell at a festival. -She smiled when she talked about it. -When asked if she was going to do that again she stated I had not thought about that. I should start working on my towels again. *By the end of the conversation she had gotten out the towels she had been working on to show this surveyor. 3. Interview on 8/9/17 at 2:00 p.m. with the director of nursing revealed: *She was not aware of what activities had been set up for residents 2 and 6. *She referred me to the activities director. *She stated each department head is responsible for their own policies. Interview on 8/9/17 at 3:15 p.m. with the activities director regarding residents 2 and 6 revealed: *She had not addressed one-to-one activities for either resident 2 or 6. *She only had four residents on one-to-one activities. *It was primarily for residents with cognitive impairment or who had not wanted to attend group activities. *She had no assessment to determine who would have been appropriate for one-to-one activities. *She felt resident 2 needed to get out of her room to socialize but agreed she was more of a private person. *Resident 2 liked to crochet and do things in her room. -Her son provided the crocheting materials. -She was not aware she had not been crocheting recently. *She felt resident 6 was more confused since she was in the facility than when she had lived at the apartments. -She used to visit when she was in the apartments and assist with activities. -Since living at the facility she had not wanted to assist with those same activities. *When music or movies was marked on the activity records that indicated the residents were in their rooms. *She did not have any policies regarding activities or one-to-one activities.

Based on observation, record review, and interview, the provider failed to *Assess two of six sampled residents (2 and 6) who had a [DIAGNOSES REDACTED]. *Assist one of one sampled resident (5) with a transportation request to attend a family funeral. Findings include: 1. Review of resident 6's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Delirium due to known physiological condition. -Anemia. -Abnormal weight loss. -Chronic kidney disease, stage 3. -[DIAGNOSES REDACTED], unspecified. -Other specified disorders of bone density and structure. Review of resident 6's 7/5/17 Minimum Data Set (MDS) assessment revealed: *She had a Brief Interview for Mental Status (BIMS) score of one that meant her cognition was severely impaired. *She had a depression score of eight that meant she was mildly depressed. Random observations on 8/8/17 from 8:05 a.m. through 4:00 p.m. of resident 6 revealed she had walked with a walker. She had been confused and was not able to hold a conversation with this surveyor. She got confused on where she was going, and staff would have to assist her to her room and to other areas of the building. She wandered throughout the facility and was not able to remain focused on what she had been doing. Review of resident 6's interdisciplinary notes from 7/10/17 through 8/8/17 revealed: *7/11/17 she had a room change to a private room down a different hall. -The family had been notified she had not liked the room change. -The family stated they wanted to give it a try anyway. *7/13/17 it had been documented that the room change has seemed to agitate the resident. -The family was notified and agreed to discuss on 7/14/17. *7/14/17 the family stated they wanted to keep her in the private room. -There had been no documentation regarding education to the family potential issues due to increased agitation. *7/16/17 she had been restless and walked past her old room curious about what she should be doing. *7/17/17 she had been restless trying to get out of bed. *7/31/17 she had been anxious and unable to calm herself. She was continuously standing and setting off the pressure alarm. *8/3/17 staff discussed with the family the increased agitation and the potential need to move the resident to an Alzheimer's unit. -The family would like her to stay at the facility. *8/4/17 the resident attempted to exit out the front door. Review of resident 6's July 2017 activities records revealed there had been no one-to-one activities provided. Refer to F248, finding 1 and 3. 2. Review of resident 2's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Peripheral neuropathy. -Cerebral infarction. -Parkinson's. -Urinary tract infection. -Chronic fatigue. -Macular degeneration. -Major depressive disorder. -Anxiety. -Pain. Review of resident 2's 6/12/17 MDS assessment revealed she had a BIMS score of fourteen that meant her cognition was intact. She had a depression score of nine meaning she was mildly depressed. Interview on 8/8/17 at 5:00 p.m. with resident 2 revealed: *She liked to be in her room as she had not liked large group activities. *She had not been crocheting, as she had been in a mood. -The staff had not assisted her with her crocheting. -Her son brought her the crocheting materials. *The pastor had purchased towels from her last year to sell at a festival. -She smiled when she talked about it. -When asked if she was going to do that again she stated I had not thought about that. I should start working on my towels again. *By the end of the conversation she had gotten out the towels she had been working on to show this surveyor. 3. Interview on 8/8/17 at 4:30 p.m. with the licensed social worker (LSW) revealed: *She had only documented care conference notes for residents 2 or 6 unless something else came up. *Residents 2 and 6 had the option of seeing a counselor outside of the facility for their depression. -Resident 2 had stated she had not wanted to see one. -Resident 6 was unable to participate in counseling due to her impaired cognition. *She had not met with residents 2 or 6 regarding any of their individual needs regarding their depression or quality of life at the facility. *She was unaware of what activities had been provided by the activities department and referred me to speak with the activities director. Interview on 8/9/17 at 2:00 p.m. with the director of nursing regarding residents 2 and 6 revealed: *She agreed resident 6 needed increased staff attention due to her impaired cognition and wandering. *She had been worried about her safety but the family had insisted they wanted her to stay in the facility. *She agreed resident 2 liked to be in her room and that she could used increased staff interventions for her depression. *The LSW was shared between the hospital and the nursing home. *She felt the LSW was not in the facility enough. 4. Review of resident 5's interdisciplinary progress notes revealed a 2/1/17 note had been documented by the health unit coordinator (HUC) in reference when resident 5 had requested assistance for a ride to her nieces funeral. The note was: Upon Writer's arrival to workstation at 0800 (8:00 a.m.), a note was addressed Writer stating 'Please call for a ride to (town name) for (resident name). She would like to leave by 10:00 am for her nieces funeral.' Write approached Resident and explained that Writer only arranges transportation for medical appointments and if a ride is necessary for a personal outing; it would be the Resident's responsibility to arrange. Resident did not understand the logic behind this statement. Resident became upset stating 'I've been trying for days to get a ride but no one will answer their phones.' Resident forcefully asked for the phone number to (town name) district which was provided by Writer and again explained to Resident that transportation can only be arranged by the writer for medical appointments. Review of resident 5's reviewed 7/27/17 care plan for psychosocial well-being/discharge plan revealed: *A problem of: -I like to go out with my family even though it's AMA (against medical advice) due to a history of needing medical help (calling 911 when falling and can't get up) and not being able to care for self when in community. I am encouraged to sign a AMA form when leaving the facility with family. *Goal: -Over the next 90 days, resident will be safe when leaving the facility AMA. *Approaches: -Staff will educate resident on risks of leaving the facility with family but honor resident's right to make her own decisions. -Resident will be encouraged to sign out AMA when leaving with family and provide a phone number to reach her in case of emergency. -Resident's family is encouraged to come to the nursing home and spend time with (resident's name) where she is safe. Interview on 8/9/17 at 8:30 a.m. with the HUC regarding resident 5 revealed she: *Remembered the above conversation with the resident. *Thought the resident had actually gone to the funeral but was unsure of how she had gotten there. *Had not arranged a ride for the resident. *Only set-up rides for resident's medical appointments. *Was not sure who was responsible to assist residents with personal transportation. *Reviewed the provider's resident sign-out sheets dated 2/1/17 with the surveyor and agreed the resident had signed herself out at 12:55 p.m., and no time had been entered for when she returned. *Reviewed the resident's paper medical record with the surveyor and agreed no AMA form was found for her on 2/1/17. Interview on 8/9/17 at 11:00 a.m. with the director of nursing revealed:*After reviewing the documentation from the HUC she agreed the provider should have assisted resident 5 in obtaining a ride. *The resident was required to sign an AMA document when she left, as the provider felt she was not safe out in the community. *The resident had a physician's orders [REDACTED]. *Had not discussed the AMA with the resident's physician and whether the physician agreed with the AMA requirement. Review of resident 5's 8/9/17 physician's orders [REDACTED].

Based on observation, record review, and interview, the provider failed to recognize and implement interventions for one of six sampled residents (6) with significant weight loss. Findings include: 1. Review of resident 6's medical record revealed: *She had been admitted on [DATE]. *Her weight on admission had been 123.0 pounds (lb). *They had documented the following weights: -On 5/31/17, 124.0 lb. -On 6/7/17, 108.0 lb. --That had been a sixteen lb weight loss. --There had been no re-weight on that day. -On 6/8/17 and 6/9/17, 108.0 lb. -On 6/14/17, 103.0 lb. --That had been a five lb weight loss. --The re-weight had been 103.0 lb. -On 6/21/17, 104.0 lb. -On 6/28/17, 105.0 lb. -On 7/5/17, 103.0 lb. -On 7/12/17, 103.0 lb. -On 7/19/17, 105.0 lb. -On 7/27/17, 103.0 lb. -On 8/2/17, 105.0 lb. Observation on 8/7/17 at 5:30 p.m. and again on 8/8/17 at 12:15 p.m. revealed resident 6 had not received staff assistance at meals. She had eaten independently. Random observations on 8/7/17 and again on 8/8/17 of resident 6 revealed she had walked with a walker. She had been confused and was not able to hold a conversation with this surveyor. She got confused on where she was going. Staff would have to assist her to her room and to other areas of the building. Review of resident 6's 7/5/17 Minimum Data Set (MDS) assessment revealed: *She had a Brief Interview for Mental Status score of one that meant her cognition was severely impaired. *She ate independently with set-up help only. Review of resident 6's 7/13/17 care plan revealed: *A problem area for nutrition had started on 5/23/17. -The weight loss had not been documented. *Interventions included the following: -Diet - regular with regular consistency food and fluids. Offer small portions at meals per personal request. -Encourage fluids throughout the day. Provide water pitcher in room at all times, ensuring it is kept within reach and remind when cares are provided. -Honor personal requests at all meals. Allow to choose own time for breakfast. -Monitor weight, food intake, and consult with nursing on skin issues as they occur. Refer to consult dietitian on plan of care. -Offer 4 oz. protein snack BID (two times a day) between meals. 3 p.m. -- yogurt, 7 p.m. - cheese and crackers, offer 4 oz. Boost TID (three times per day), fortify food and 1/2 c fruit at meals TID. -Offer snacks off hydration care (cart) at 7 p.m. Offer beverages and snacks at coffee times 10 a.m. and 3 p.m. -Offer tray set up assistance as needed at mealtime. Encourage to come to dining room for meals for socialization. *All the above interventions had been started on 5/23/17. Review of resident 6's progress notes from 5/22/17 through 8/9/17 revealed: *There was no documentation on 6/7/17 regarding the sixteen lb weight loss. *On 6/9/17 they had documented Weight on admit was 123 lbs, on 5/31/17 was 124 lbs, then on 6/7, 6/8, and 6/9 was 108 lbs. Does have less [MEDICAL CONDITION] to L (left) leg than on admit. Physician notification of this sent to (physician name). *On 6/13/17 they had received a physician's orders [REDACTED]. *On 6/14/17 the physician had increased the supplement to TID. Review of resident 6's food intake sheets from 5/22/17 through 8/8/17 revealed: *The first supplement she received was on 5/28/17. *There were seventy-three days reviewed from 5/28/17 through 8/8/17. *She received one supplement the following times: -May: one time. -June: two times. -July: ten times. -August: three times. *She received two supplements the following times: -June: eight times. -July: six times. *She received three supplements the following times: -June: three times. -July: four times. *She received four supplements the following times: -July: two times. *There was no documentation she had received any supplements on the following dates: 7/10/17, 7/11/17, 7/12/17, 7/17/17, 7/18/17, 7/27/17, 7/29/17, 7/31/17, 8/2/17, 8/4/17, 8/6/17, 8/7/17, 8/8/17. *There had been no documentation regarding how much she consumed for any of the above supplements provided. *She had not received the supplement three times per day as ordered by the physician on 6/14/17. Review of resident 6's June 2017 Medication Administration Record [REDACTED]. Interview on 8/8/17 at 4:15 p.m. with the dietary manager revealed they had not been monitoring resident 6 for a weight loss. She had been receiving supplements. Interview and document review on 8/9/17 at 7:45 a.m. with the director of nursing and the MDS nursing manager regarding resident 6 revealed: *They believed the sixteen lb weight loss had been due to scale issues and not actual weight loss. *They had issues with the scales in the facility. *They had been having issues with the hospital weights not matching their weights. *They should have struck out the weights documented on 5/22/17 as 123.0 lb and on 5/31/17 as 124.0 lb, as they had not felt they were accurate. *Review of the hospital discharge paper work revealed her discharged weight on 5/22/17 had been 125.0 lb. *They stated the resident was on a supplement. *Information was requested at that time regarding any documentation regarding the scale variances and interventions put in place for the weight loss. Interview on 8/9/17 at 10:10 a.m. and again at 11:45 a.m. with the director of nursing revealed: *They had two tub scales in the facility. -One on B hall and one on C hall. *There was also a stand scale. *Resident 6 had been weighed using the tub scale in C hallway. *They had no weight or re-weight policy. *They used a standard of care of the following: -At three lb fluctuation they should have re-weighed the resident. -The next day they should have re-weighed the resident again. *The maintenance supervisor had no logs of when he had re-calibrated the tub scales. *They had not addressed the scale fluctuations with the hospital. *They had not taken the issues of the scales being off to their quality assurance team. *There were no other interventions listed for resident 6 regarding the weight loss.

Based on observation, interview, and policy review, the provider failed to ensure sanitary conditions were maintained for: *One of one sampled resident (7) during personal care by one of one certified nursing assistant (CNA) (E). *One of one sampled resident (1) during a dressing change by one of one licensed practical nurse (LPN) (H). Findings include: 1. Observation on 8/8/17 at 8:43 a.m. of CNA E during care for resident 7 revealed: *She used alcohol foam on her hands and entered the resident's room. *Retrieved clothes and put socks on the resident's feet. *Put two wash clothes in the sink and turned the water on. *Without any hand hygiene she put on gloves. *Took a wet wash cloth from the sink and placed it on the bed sheets beside the resident. *Took a soiled incontinence brief off the resident and performed perineal care. *Placed the soiled brief in the garbage and the soiled wash cloth in another bag. *Removed her gloves and without any hand hygiene put a clean incontinence brief and pants on the resident. *Transferred her to a bedside commode and put on her shirt. *Without any hand hygiene she put on gloves and attempted to perform oral hygiene for the resident. *Removed her gloves and without any hand hygiene took another wash cloth out of the sink and washed the resident's face. *Washed her hands for approximately ten seconds, and turned the faucets off with her wet hands, and put on gloves. *Helped the resident off the commode, performed perineal care, and then transferred her to her wheelchair. *Removed her gloves and without any hand hygiene moved the commode, put gloves on, and emptied the commode. *Removed her gloves and without any hand hygiene removed all the bed linens and placed them in a bag. -She then took the soiled linens and garbage bag to the soiled utility room. *She did not perform any hand hygiene before she continued with her other duties. 2. Observation on 8/8/17 at 10:05 a.m. of LPN H during a dressing change for resident 1 revealed she:*Put the supplies on the nightstand with no barrier down. *Washed her hands, tapped them against the edge of the sink, and then touched the surface of the towel dispenser. *Removed the resident's heel protector boot and stocking. *Without gloves on she removed the soiled dressing, inspected the right heel pressure ulcer, and then placed a new [MEDICATION NAME] dressing on it. *Put her stocking and heel protector boot back on. *Washed her hands, tapped them against the edge of the sink, and then touched the surface of the towel dispenser. 3. Interview on 8/9/17 at 10:00 a.m. with the infection control registered nurse agreed glove use and hand washing had not been competed properly. Both CNA E and LPN H had increased the risk of transmitting infectious organisms due to improper hand hygiene. Review of the provider's 5/9/16 Infection Control policy revealed: *Employees must wash their hands for at least fifteen seconds. *Hands should have been washed after removing gloves and handling items potentially contaminated with body fluids. *Employees could use alcohol-based hand rub as a method of hand hygiene.