Every finding on record at Centerville Care and Rehab Center Inc

Based on observation, interview, record review, and policy review, the provider failed to implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (26) who developed a pressure ulcer to his left heel after he admitted to the facility on [DATE].Findings include: 1. Observation and Interview on 9/1/26 at 1:43 p.m. with resident 26 in his room revealed he had a boot on his left foot, and he stated he had his left foot amputated. 2. Observation and Interview on 9/2/26 at 3:30 p.m. with resident 26 in his room revealed he had a wound on the bottom of his left heel. The wound was black in color, and the skin was not open. Resident 26 denied pain in that area unless the area was pushed on. He stated he thought he may have had that wound when he resided at his home before he admitted to the facility and he had walked on it and had taken care of it himself. 3. Review of resident 26's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His Brief Interview for Mental Status (BIMS) assessment score was a 3, which indicated his cognition was severley impaired. His diagnoses were Dementia (a group of symptoms affecting memory, thinking, and social abilities), Type 2 Diabetes (a condition involving disruptions in how the body regulates blood sugar) with neuropathy (damage or disease affecting the nerves), and acquired deformities of an unspecified foot. His physical nursing data form indicated that it was to be completed within 24 hours of his admission to the facility. The form was signed by DON B but was not dated. The information documented on that form indicated he did not have diabetic foot ulcers, no pressure ulcers, skin redness, or sores. His 6/23/26 baseline care plan (person-centered plan developed and implemented within 48 hours of a resident's admission) did not indicate that resident 26 had any skin concerns, pressure ulcer risks, skin integrity goals, or pressure ulcer interventions such as turn and repositioning, specialty mattress, cushions or wedges, for his wheelchair or recliner, or skin and wound treatments. The baseline care plan was signed by social services (SS) J. A skin wound progress note dated 7/16/25 by registered nurse (RN) M revealed that resident 26's physician was notified that he had an intact blister on his left heel. Resident 26's 7/17/26 physician's order indicated, Betadine to blister on (L) [left] heel and (L) great toe. Put Mepilex covering on blister, DC [discontinue] when healed, every morning and at bedtime for blister (L) heel and (L) great toe. He had a 7/29/26 physician's order that indicated: (L) [left] heel, cleanse with wound cleanser, gauze, soap and water. Apply a betadine moistened 4 [inch] x [by] 4 gauze to the wound bed, cover it with dry gauze, ABD pad [a thick, highly absorbent medical bandage], Kerlix [a woven gauze bandage]. Change BID [twice a day]. Use heel lift boot instead of Rooke boot [specialized medical off-loading device designed to prevent and treat heel ulcers while naturally warming the lower limb to improve circulation] at all times [while he is] in [a] chair and in bed. Follow up in 7 weeks. No tubigrip [an elasticated upport bandage]! The 8/19/26 weekly wound observation tool indicated that resident 26's left heel pressure ulcer was facility acquired and discovered on 7/17/26. The physician was last notified was 8/17/26 and the family was last notified on 8/17/26 that a new bed (air mattress, with bedrail and trapeze bar) was ordered. The resident was on a turning and repositioning routine. The type of wound was documented as a pressure ulcer, and the pressure ulcer was staged originally as a SDTI (suspected deep tissue injury, meaning a purple or maroon localized area of discolored intact skin or blood filled blister due to damge of underlying soft tissue from pressure). The visible tissue area indicated the overall impression of the wound was that it was healing and that eschar covered the entire area. The was no drainage, inflammation, or odor, and the pressure ulcer measurements were 5.3 centimeters (cm) long, width 10 cm wide, with 0 deep. The 8/26/26 weekly wound observation tool indicated the wound clinic was last notified on 8/17/26. The family was updated on 8/26/26 on the resident's continued preventive measures of a special boot and dressing. He continued with the turning and repositioning routine. The wound measurement had not changed, and the overall impression indicated the wound continued to improve. The 9/2/26 weekly wound observation tool indicated there were no new documented pressure ulcer measurements. There was no documented change in the wound treatment. 4. Review of the 8/17/26 VA podiatry progress note indicated that resident 26 was seen for a follow up for his unstageable pressure injury (PI, or pressure ulcer). The note included that the resident's wife stated that the PI developed about 2 weeks after he admitted to the nursing home. The left heel pressure ulcer continued to be present, more stable, 100 % (percent) brown eschar, no odor, and no drainage. He was wearing the heel lift boot at all times. The pressure ulcer was unstageable, and its measurements were 3.0 cm long, 6.2 cm wide, and depth was UTD (unable to be determined). The periwound (the zone of healthy skin that immediately surrounds the outer edge or margin of a wound) was pink, with no drainage, and no signs and symptoms of infection. The interventions were to change the pressure ulcer wound dressing and offload (relieve pressure from) the heel. The resident was to return to the clinic in 3 weeks. 5. Interview on 9/2/26 at 3:30 p.m. with licensed practical nurse (LPN) C during resident 26's and certified nursing assistant (CNA) H during resident 26's in his room revealed his heel wound was healing. LPN C was not sure if resident 26 acquired that wound before or after he admitted to the facility. She stated that the wound was eschar (a thick layer of dead, dark, or black tissue called necrotic tissue) and that the current treatment of Betadine ( an antiseptic medicine containing povidone-iodine that kills germs and helps prevent skin infections) would dry out the black eschar tissue and the scab would later fall off. LPN C stated that she would not take measurements of the wound at that time, as those measurements were taken weekly. CNA H thought the resident's left heel wound may have been from the shoes he had been wearing when he admitted to the facility, and he did not have the wound when he admitted to the facility. After the wound was discovered, he was given a boot with sheep skin it to wear. She thought that the wound was from pressure on the area when he was lying in bed. 6. Interview on 9/3/26 at 2:55 p.m. with director of nursing (DON) B regarding resident 26's pressure ulcer revealed she explained that it started as a blister, then became a pressure ulcer once it popped open. She stated the resident was a diabetic, and that wound was now a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer. That wound was not there when he admitted to the facility. She stated there were no interventions implemented by the staff to prevent the pressure ulcer from developing after his admission. She acknowledged that the pressure ulcer was avoidable. 7. Review of the provider's 4/1/26 pressure ulcer prevention policy revealed the policy's purpose was to prevent pressure ulcers. The policy equipment list indicated using heel protectors and pressure-reducing devices. The procedure list indicated: 11. The use of an alternating pressure mattress, a pressure-reducing mattress, or to use flotation pads if ordered, and 12. Protect bony prominences with cushions and pads.

Based on record review, interview, and policy review, the provider failed to ensure the resident or resident's representative were informed of the risks versus benefits of medications, to make an informed decision and consent for resident 2's use of anti-anxiety (a drug used to help reduce the symptoms of chronic anxiety and panic) and anti-depressant (a drug used to help relieve symptoms of depression, anxiety disorders, and other health conditions by balancing brain chemicals that affect mood and emotion) medications, resident 17's anti-depressant medication, and resident 24's anti-psychotic (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) medication before they were administered. Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body function), unspecified, dementia (a group of symptoms affecting memory, thinking and social abilities), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. He had a 6/18/26 physician's order for Lorazepam (a medication for short-term relief of anxiety disorders and anxiety-related sleep problems) 0.5 mg (milligrams) tablet to be administered by mouth two times daily related to Alzheimer's disease, unspecified. He had a 6/2/26 physician's order for Mirtazapine (an atypical antidepressant primarily used to treat major depressive disorder) 7.5 mg tablet to be administered by mouth at bedtime related to dementia. There was no documentation that resident 2 or his representative were informed of the risks and benefits of receiving those medications, alternative treatment options, or that they provided their consent before those medications were administered to resident 2. 2. Review of resident 17's EMR revealed she admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (the death of brain tissue caused by a sudden loss of blood flow and oxygen), unspecified, and hemiplegia (a medical condition that causes total paralysis on one side of the body) and hemiparesis (weakness or partial loss of movement on one entire side of the body) following a cerebral infarction affecting left non-dominant side of her body. She had a 9/9/25 physician's order for Trazadone (a prescription medication to treat major depressive disorder) 1/2 tablet (25) to be administered by mouth at bedtime for sleep. There was no documentation that resident 17 or her representative were informed of the risks and benefits of receiving that medication, alternative treatment options, or that they provided their consent before that mediation was administered to resident 17. 3. Review of resident 24's EMR revealed he admitted to the facility on [DATE]. His diagnoses included cerebral infarction due to thrombosis of the right middle cerebral artery, and depression (a common and serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities once enjoyed). He had a 2/26/22 physician's order for Aripiprazole (an atypical antipsychotic medication used to treat mental health and developmental conditions) 2 mg tablet to be administered by mouth one time a day for his mood. There was no documentation that resident 24 or her representative were informed of the risks and benefits of receiving that medication, alternative treatment options, or that they provided their consent before that medication was administered to resident 24. 4. Interview on 9/3/26 at 10:23 a.m. with director of nursing (DON) B revealed that she was unaware they needed to provide education to the resident or their representative on the risks versus benefits of receiving a medication before starting the resident on an anti-depressant, anti-psychotropic or anti-anxiety medication. She confirmed there was no documentation that the residents (2, 17, and 24) or those resident's representatives were informed of the risks versus benefits of receiving those medications, other treatment alternatives, or that they provided their consent before those medications were administered to the residents. 5. Interview on 9/3/26 at 12:09 p.m. with administrator A revealed that she was unaware they needed to provide education when an anti-depressant, anti-psychotropic or anti-anxiety medication was started for a resident. She confirmed the provider did not have a form for consent of those medications, but the nurses would inform a resident or their family if a referral was being made for psychiatric counselling was made. 6. Review of the provider's 3/22/26 revised Psychotropic Medication policy revealed, 1. Psychotropic medications are used only when medically necessary to treat a specific, diagnosed condition documented in the resident's medical record.7. All psychotropic medications must have a valid written or electronic order signed by the prescriber. There was no information in the policy regarding education to a resident or a resident's representative.

Based on observation, interview, record review, and policy review, the provider failed to follow standard food safety practices to ensure that food items were not expired in one of one walk-in refrigerator, and that the dish machine temperatures were followed and maintained according to the manufacturer's instructions for use (MIU) to ensure the dishes were sanitized in one of one main kitchen.Findings include: 1. Observation on 9/1/26 at 9:53 a.m. in the walk-in refrigerator revealed eight cartons of Bobalu strawberries that were ordered on 8/26/26. One carton had moldy strawberries in it. A grocery bag had a container of Nature Sweet Cherub tomatoes and two cucumbers that were mushy and slimy in it. 2. Interview on 9/1/26 at 3:09 p.m. with dietary manager (DM) E revealed that the slimy cucumbers in the walk-in refrigerator were placed there by the activity department. The activity department kept a few items in the walk-in refrigerator for cooking demonstrations. She confirmed the strawberries were delivered on the truck on 8/26/26, and the one container of strawberries did have mold growing in it. She expected the dietary staff to go through the walk-in refrigerator weekly and check for items that were past the use-by date or had gone bad. 3. Observation on 9/1/26 at 4:17 p.m. in the main kitchen revealed a clipboard on top of a stainless-steel cart next to the commercial dishwasher. The document on the clipboard was labeled Dishmachine Temperature Record Form. The form was dated August 2026. The wash temperature on the form stated, Wash 120 [degrees Fahrenheit], Chem [chemical] Conc. [Concentrate] 100 PPM [parts per million], and final rinse 120 [degrees Fahrenheit]. There were columns for the morning, noon, and evening shifts to document the findings. The form was missing 17 of the 31 wash temperatures for the morning column, and eight of the documented temperatures were below 120 degrees. The chemical concentrate column was missing 16 levels of chemical. The final rinse column was missing 19 final rinse temperatures, and one of those temperatures was documented below 120 degrees. The noon column had 18 missing or below temperatures for the wash cycle, nine missing chemical concentrates, and 13 missing or below final rinse temperatures. The evening column had 18 missing or below temperatures for the wash cycle, 16 missing chemical concentrates, and 16 missing or below temperature final rinse temperatures. 4. Interview on 9/2/26 at 9:38 a.m. with dietary aide G revealed that the dish machine needed to get to 120 degrees to sanitize the dishes. If it did not get to 120 degrees Fahrenheit, she would repeat the cycle until it got to 120 degrees Fahrenheit. She documented the temperatures and chemical levels on the dish machine form. If there was an issue with the dish machine, she would notify the maintenance department. 5. Interview on 9/3/26 at 1:29 p.m. with maintenance person F revealed that he checked the dishwasher temperature monthly. He was unaware of any low temperature readings. He usually had to adjust the temperature down because the water heater would run too hot. 6. Interview on 9/3/26 at 1:55 p.m. with DM E revealed that the optimal temperature for the dish machine was 120 degrees Fahrenheit. She knew some of the dietary staff were not documenting dish machine temperatures and chemical levels. She expected the dietary staff to document the dish machine temperatures and chemical levels. She was unaware some of the temperatures were documented below 120 degrees Fahrenheit. She had educated the dietary staff to run a few cycles before putting dishes through the dish machine to get it up to 120 degrees Fahrenheit. She agreed the documentation for the dish machine temperatures and chemical levels were not adequate. 7. Interview on 9/3/26 at 3:21 p.m. with administrator A revealed she confirmed that the dietary staff should have been documenting dish machine temperatures and chemical levels. She stated that refrigerated foods should not be kept after three days per the facility's policy.8. Review of the provider's June Dishmachine Temperature Record form revealed the 120 degrees Fahrenheit wash temperature was missing or documented below 120 degrees 42 times, the chemical concentrate was missing 23 times, and the final rinse temperature was missing or documented below 120 degrees 36 times. 9. Review of the provider's July Dishmachine Temperature Record form revealed the 120 degrees Fahrenheit wash temperature was missing or documented below 120 degrees 43 times, the chemical concentrate was missing 27 times, and the final rinse temperature was missing or documented below 120 degrees 42 times. 10. Review of the manufacturer's general operating instructions for the dish machine revealed, 3. To fill with water, push or flip the FILL button. It is recommended that 140 [degrees Fahrenheit] water be used. Report to your supervisor if it is lower than 120 [degrees Fahrenheit] or higher than 160 [degrees Fahrenheit]. 11. Review of the provider's revised February 2026 Food Preparation/Food Storage policy revealed, 5. Expiration dates will be checked on a regular basis and food/fluids which have expired will be discarded. Potentially hazardous foods will be discarded after three days in [the] refrigerator. 12. Review of the provider's revised May 2022 Dishwashing policy revealed, 1. Follow the manufacturer's instructions for operation. 2. Turn on machine. 3. Fill with water. 4. Check temperatures for proper temperature wash, [and] rinse cycle. (IF chemicals are used, check level of chemicals with test strips at least once per meal service.). Low Temp Machine-120 degrees plus 50 ppm of Sodium Hypochlorite (or according to manufacturer's guidelines on label) on dish surface. 5. Record temperature (and/or chemical level) on dishwashing temperature log.

Based on interview and record review, the provider failed to provide restorative therapy to one of one sampled resident (32) who admitted to the facility using her walker to ambulate (walk) and declined to using a wheelchair for ambulation.Findings include:1. Interview on 9/1/26 at 10:21 a.m. with resident 32 revealed that when she was admitted to the facility, she used her walker, but now she had to use a wheelchair to get around. She preferred to use her walker even if she moved slower with it. She thought she had upset the therapy department when she voiced that information to them. 2. Review of resident 32's EMR revealed she admitted to the facility on [DATE]. She had a 5/20/26 Brief Interview of Mental Status (BIMS) assessment score of 12, which indicated her cognition was moderately impaired. Resident 32's diagnoses were acute and chronic respiratory failure with hypoxia (a state in which the body's tissue and organs do not get enough oxygen to function properly), macular degeneration (an eye disease that damages the macula, the central part of the retina at the back of the eye that controls sharp, straight-ahead vision), obstructive pulmonary disease, and diastolic congestive heart failure. She had a 3/25/26 physician's physical therapy (PT) and occupational therapy (OT) to evaluate and treat due to Resident progressively having more and more trouble ambulating on her own. She would like to do some therapy after speaking to her. May we have orders to do PT/OT focus[ing] on leg and arm strengthening. It would benefit her to work with therapy at least a couple times a week. Therapy meeting notes dated 4/1/26 indicated resident 32 was working on standing, strengthening, dressing and toileting. Her 4/21/26 physical therapy treatment encounter note ndicated a restorative therapy program was developed. A PT discharge note indicated that once she was standing, the resident would improve her ability to safely ambulate (walk) at least 10 feet in a room, corridor, or similar space with safety during turning, functional posture, continuous steps, and accurate direction of movement using a four-wheeled walker with supervision or touching assistance from the staff. There was a 4/21/26 restorative program referral that indicated resident 32 was on oxygen, and that she was to work on her active range of motion, AROM (active range of motion), and transferring. The activities to be completed were seated lower extremity exercises, go from a seated position to a standing position with her walker three times, and walk to and from the bathroom or in the hall to walker 10 to 20 feet. The goal was to maintain her strength. A 4/21/26 therapy communication note to the restorative therapy staff indicated, Recommend 1 [staff] assist for transfers to walker and walking to/from bathroom to assist with oxygen tubing safety, and 1 to 2 [staff] assist for in/out bed. 3. Interview on 9/3/26 at 9:03 a.m. with director of therapy L regarding resident 32's therapy revealed resident 32 had admitted to the facility using both a walker and a wheelchair. She stated resident 32 was discharged from physical therapy (PT) to restorative therapy on 4/21/26. She stated she thought resident 32 refused restorative therapy and expected to see those refusals in the restorative notes or that CNA I would have them on paper. 4. Interview on 9/3/26 at 10:22 a.m. with certified nursing assistant (CNA) I revealed she documented the resident's restorative programs. She stated she received the resident's paper therapy orders but if a resident refused restorative therapy, she would throw the resident's restorative therapy order away. She did not document on paper or in the computer if a resident refused that therapy. She looked through her binder but did not find a restorative therapy order for resident 32. She stated that licensed practical nurse (LPN) D oversaw of the restorative therapy program in April 2026. 5. Interview on 9/3/26 at 10:30 a.m. with LPN D revealed resident 32 well could use her walker with the assistance of one staff member when in her room to go to her bathroom. She stated resident 32 refused to come out of her room. LPN D believed resident 32 could start therapy again and that she was a good candidate if she was willing to participate in therapy. LPN D stated she did not work in restorative therapy since April 2026, and she was not aware that CNA I threw away the resident therapy orders if a resident refused therapy. She expected that if a resident refused therapy, it was documented on paper. LPN D thought therapy was discussed at a therapy meeting with resident 32 and a family member, and her family member did not think resident 32 would participate in therapy. Certified medication (CMA)/CNA K worked in restorative therapy and walked residents, and may have documented that resident 32 had refused to walk with her. 6. Interview on 9/3/26 at 10:50 a.m. with CMA/CNA K revealed she did not work in restorative therapy for quite a while. She had worked with resident 32, and the resident refused to participate in therapy, but CMA/CNA did not document resident 32's refusals. 7. Interview on 9/3/26 at 11:25 a.m. with administrator A revealed the facility did not have a restorative therapy policy. The resident's restorative therapy plans were not created in Point Click Care (PCC), their electronic medical record (EMR) system. The information regarding the resident's restorative therapy plans was directed to LPN D, but since LPN D no longer worked in the restorative therapy program, the information was directed to CNA I. 8. Interview on 9/3/26 at 11:56 a.m. with CNA I revealed that she trained at various places for restorative therapy. LPN D had educated her regarding restorative therapy at this facility. She stated that if she had questions regarding a resident's restorative therapy program, she asked LPN D or director of nursing (DON) B. 9. Interview on 9/3/26 at 12:10 p.m. with resident 32 revealed she did not think she ever refused therapy, but thought she upset the therapy department when she told them she admitted to the facility using her walker but was now in a wheelchair. 10. Interview on 9/3/26 at 2:42 p.m. with DON B regarding the restorative therapy program revealed that LPN D had left working in the restorative therapy program and that had left them in limbo. DON B stated she did not have time to get the program up and running. She expected CNA I to have the resident's therapy information in a binder. She was not aware that CNA I threw away therapy orders if the resident did not participate in restorative therapy. She thought that resident 32 had discussed wanting to do therapy again, but she had some diarrhea, and that had become a safety issue. She acknowledged that resident 32 may have had a mobility decline and that there was no documentation to support that resident 32 had refused restorative therapy.

Based on interview, job description review, and policy review, the provider failed to ensure they had a designated qualified infection preventionist (IP) onsite who was responsible for the facility's infection prevention and control program and activities to prevent and control infections. Findings include:1. Interview on 9/1/26 at 9:06 a.m. with administrator A revealed there was no designated IP employed at the facility. She stated the previous IP was licensed practical nurse (LPN) D stepped down from the position in June 2026. 2. Interview on 9/3/26 at 3:40 p.m. with administrator A revealed that the previous IP was LPN D, and she worked at the facility as a nurse, and that another staff member, minimum data set (MDS) N was a certified IP who worked remotely and was not availbable onsite. She stated both of those staff members were available to her and director of nursing (DON) B if they had questions regarding the program, but neither of them worked for the facility as the facility's designated IP. She stated she and DON B performed the IP duties, and she was trying to hire an IP for the facility. She acknowledged the facility did not have an IP since June 2026. 3. Interview on 9/3/26 at 3:40 p.m. with DON B revealed that she was helping complete IP duties and that the former IP (LPN D) in could be available to answer questions if she was in the facility when DON B or administrator A had any questions regarding their infection control program. 4. Review of the provider's undated Infection Preventionist job description revealed the IP was responsible for overseeing the facility's infection prevention and control program and promoting a safe environment for the residents, staff, and visitors. The IP's essential duties included: Monitor and maintain the facility['s] Infection Prevention and Control Program. Conduct infection surveillance and track infections. Monitor compliance with hand hygiene, PPE [personal protective equipment], isolation precautions, and other infection prevention practices. Investigate and report infections and outbreaks as required. Provide infection prevention education to staff. Complete required infection control audits and follow-up. Assist with antibiotic stewardship activities. Maintain required infection prevention records and reports. Collaborate with nursing, dietary, housekeeping, maintenance, and other departments regarding infection prevention. Perform other duties related to infection prevention as assigned. 5. Review of the provider's 2/4/26 Infection Control and Prevention policy revealed the Infection Preventionist will be responsible for the following: Investigation A. Surveillance a. Systemic data collection to identify, trend and track infection in residents b. Any resident or employee illness should be reported to one of the nurses ASAP [as soon as possible] c. Data will be reviewed monthly at the QI [quality improvement] meeting and again annually B. Outbreak Control a. A system for detection investigation and control of epidemic diseases in the Long Term Care Facility C. Isolation a. An isolation and precautions system to reduce the risk of transmission of infectious agent i. When and how isolation should be used ii. Type and duration iii. Isolation should be as least restrictive as possible b. Circumstances to prevent employees with communicable disease or other infectious state from direct contact with residents or their food.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to protect the residents' right to be free from physical abuse for one of one sampled resident (1) who was pinched and scratched on her hand by one of one certified nursing assistant (CNA) D while she was assisting resident 1 to eat.Findings include: 1. Review of the provider's 4/3/26 SD DOH FRI revealed that on 4/2/26 at 6:10 p.m., CNA D pinched and scratched resident 1 on her right hand. CNA D reported to licensed practical nurse (LPN) C that resident 1 asked CNA D to pinch her. LPN C asked resident 1 if CNA D pinched and scratched her and resident 1 replied that she had. LPN C noticed bruising where the resident pointed to indicating where CNA D had pinched her. Administrator A was notified and CNA D was immediately suspended pending an investigation. CNA D was later terminated from employment due to physical harm.2. Review of resident 1's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. Her medical diagnoses included dementia (a decline in mental ability that affects memory, communication, and behavior) with behavioral disturbances. Her 3/17/26 Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated her cognition was moderately impaired.3. Interview on 6/10/26 at 11:25 a.m. with administrator A revealed that she did not interview CNA D after the incident with resident 1 on 4/2/26. LPN C and CNA D gave written statements about the incident. Administrator A indicated that CNA D was given a final warning a few months before the incident due to substandard work performance. Administrator A did not know if resident 1 had any aggressive behavior issues. She reported that social services designee (SSD) E indicated that resident 1 previously had aggressive behaviors but had been receiving behavioral health services.4. Interview on 6/10/26 at 12:20 p.m. with director of nursing (DON) B revealed that I would take [resident 1] for her word. CNA D could be very anxious resulting in a short temper. DON B indicated that CNA D had previously been disciplined for an accusation of being rough with resident 2 on 9/11/25. That accusation could not be confirmed due to resident 2's diminished cognitive status and combative behavior. CNA D was given a final written notice on 9/11/25 in her employee file following the accusation and could no longer provide cares to resident 2.5. Interview on 6/10/26 at 1:10 p.m. with CNA F revealed that she was working on the day of the reported incident between resident 1 and CNA D, but she did not witness it. CNA F could not recall ever witnessing CNA D mistreating any residents.6. Interview on 6/10/26 at 2:10 p.m. with SSD E revealed that CNA D was known to be very anxious. CNA D's speech was difficult to understand and sounded like she mumbled when she spoke. She stated that residents with mentation issues would get frustrated with her.7. Review of LPN C's written statement from 4/2/26 at 7:00 p.m. revealed that on the day of the incident, she witnessed CNA D pushing resident 1 in her wheelchair from the dining hall. CNA D approached LPN C and quietly stated She wanted me to pinch and scratch her. The statement indicated that resident 1 began to wave LPN C over to her. [Resident 1] proceeded to show me her right hand. There was small bruised areas that appeared like they could be from a fingernail. Then the top of her left hand had a lg [large] round bruised area. [Resident 1] stated 'See she did this.' Then [resident 1] proceeded to put her finger up over her lips and said 'I don't want to cause any trouble but she did it.8. Review of the written statement from CNA D written on 4/2/26 revealed She (resident 1) had got my arm and was digging her nails in my arm she had left marks. I gentle [gently] grab her arm to take if off. Than [then] she was saying pintch [pinch] me, grab me, starch [scratch] me bruise me. I had said no like 20x than [then] I tell someone to go get here [her].9. Review of CNA D's employee file revealed that on 9/11/25, a counseling form stating a final warning before termination of employment for reasons that included 1. Unable to follow orders from supervisor. 2. Lack of respect from [for] supervisor. 3. Not completing work appropriately related to bed time cares. 4. Complaints from residents-how you handle them-Feel your [you are] a little rough-with their cares.10. Review of the provider's 2/17/26 meeting sign-in sheet with a topic of Nurses/CNA-Abuse/Neglect revealed that CNA D acknowledged receiving education on abuse and neglect.11. Review of the provider's 3/24/26 nursing assistant job description revealed Observes and reports changes in resident's condition to the charge nurse, handles and treats residents in a manner conductive to their safety and comfort, adheres to instructions issued by the nurse and to established routine, and performs duties in accordance with established methods and techniques and in conformance with recognized standards.12. Review of the provider's 8/22/25 Abuse and Neglect Policy and Procedure revealed a purpose To ensure that the center has in place an effective system that regardless of the source prevents mistreatment, neglect, and abuse of residents or misappropriation of their property. To ensure that residents are not subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving individual, family members or legal guardians, friends or other individuals.

Based on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure one of one kitchen had been cleaned to maintain a sanitary environment to store, prepare, and serve food to residents. Multiple areas within the kitchen appeared unclean. Findings include: 1. Observation on 5/18/25 at 11:30 a.m. of the kitchen revealed: *The plate storage cabinet had dust on top of the cabinet where the plate covers were stored. *The shelves where the dishes had been stored had food debris and stains on the shelves. *The beverage serving cart with prepared residents' beverages on it had food debris and food stains on the shelves. *The kitchen floor, under the stove, and storage racks were soiled with food debris and dirt. *Drawers containing clean utensils had food stains and food debris in them. *The recessed cabinet and drawer handles were soiled with food debris. *The refrigerator door was soiled food debris. 2. Interview on 5/18/25 at 11:50 a.m. with dietary aide M regarding the cleaning of the beverage storage cart revealed the cart should have been cleaned after every use. 3. Interview on 5/18/25 at 1:00 p.m. with cook L regarding the cleaning of the plate storage cabinet revealed: *The cooks had specific cleaning scheduled tasks for kitchen equipment and the dietary aides had specific cleaning scheduled tasks for the kitchen. *She agreed the plate storage cabinet was not clean, and she was unsure of the last time it had been cleaned. 4. Interview on 5/20/25 at 9:15 a.m. with cook N regarding the kitchen cleaning tasks schedule revealed: *There was a task to clean the inside and outside of the cabinet doors by the cooks. *She tried to keep up with the cleaning of the inside of utensil storage drawers. *Everyone should have cleaned the drawers if they had noticed they were dirty. *She had agreed that placing clean utensils in a dirty drawer would not be sanitary. 5. Interview on 5/21/25 at 1:30 p.m. with dietary manager (DM) K regarding the cleaning of the kitchen revealed: *All staff who worked in the kitchen were responsible for cleaning the kitchen if they had noticed something was unclean. *She agreed there was no scheduled kitchen cleaning task for the inside of drawers and cabinets. *She agreed the cabinet, drawer, and refrigerator handles were unclean. *DM K agreed that if the floors had been observed as dirty, then the cleaning had not been completed. Review of the provider's May 2022 Sanitation and Cleaning schedules revealed: *It will be the responsibility of the dietary manager (DM) to provide daily, weekly, monthly, and as necessary cleaning schedules in the dietary areas. *Each dietary staff person will be responsible for knowing his or her assigned duty and carrying it our during the designated work schedule. *The DM is responsible for monitoring staff to ensure that cleaning duties are completed satisfactorily and within proper time frames.

Based on interview and review of Certification and Survey Provider Enhanced Reports (CASPER) reporting data, the provider failed to ensure their Payroll Based Journal (PBJ) (information of the providers daily staffing hours for the appropriate care of the resident)s had been complete and the data had been submitted to the Center for Medicare and Medicaid Services (CMS) for the months of May and June in Quarter 3 of FY 2024. 1. Review of the provider's CASPER reporting data revealed that PBJ data submitted for the following dates in Quarter 3 2024 demonstrated the provider failed to ensure Licensed Nursing Coverage 24 hours per day: -May 1 through 31 for a total of 22 days. -June 1 through 30 for a total of 21 days. Interview on 5/21/25 at 11:00 a.m. with emergency permit holder administrator A (EPH administrator A) revealed: *She was hired at the facility on 1/20/25. *She was aware that the previous administrator who left at the end of December 2024 had not submitted PBJ data or had submitted it incorrectly. *She was not able to document through payroll data that they facility had 24 hours of licensed nursing coverage on the above dates as DON B was responsible for covering any shifts to ensure they met this requirement. *DON B was a salaried employee and had not been required to keep any record of hours worked. Interview on 5/21/25 at 11:15 a.m. with DON B revealed: *She was aware that the provider had previously failed to submit PBJ data. *She was responsible for covering any shifts to provide 24 hours of licensed nursing coverage. *She did not keep any record of days and hours worked and was not required to punch the timeclock. Review of the payroll data and work schedules provided by the facility on 5/19/25 revealed: *Schedules for May and June 2024 showed DON B was scheduled for one floor shift per week. *Payroll data confirmed 24 hours of nursing coverage on 5/9/24, 5/10/24, 5/17/24, 5/18/24. *Employee schedules were not auditable (not able to be verified). Review of provider's April 2023 payroll based journal submission procedure policy revised in May 2024 revealed: *Mandatory submission of staffing information based on payroll data in a uniform format. *The procedure steps were: -Direct care staffing and census will be collected quarterly and is required to be timely and accurate. Staffing data includes the number of hours paid to work by each staff member each with day within the quarter. -Fiscal quarters were Q1: October 1-December 31, Q2: January 1-March 31, Q3: April 1-June 30, Q4: July 1-September 30. -Ensure all data is accurate and timely, submit electronically to CMS each quarter. -Run validation report to ensure the upload was accepted. -Run 1705D Staffing Data Report to confirm no triggers and all staffing requirements are met.

Based on observation, interview, and policy review, the provider failed to ensure staff followed proper infection control practices regarding: *The cleaning of shared resident equipment by two of two observed certified nursing assistants (CNA) (R and T). *Hand hygiene between assisting residents during an observed meal service of one of one CNA (R). *Protecting clean linens from potential contamination during transport by one of one observed CNA (U). *Hand hygiene while changing water mugs for residents by one of one observed dietary aide (Q). *Cleaning and sanitizing the whirlpool tub and chair by two of two CNA's (S and T). *Followed enhanced barrier precautions (EBP) (requires use of gown and gloves with contact care for three of three identified residents (1, 5, and 25). Findings include: 1. Observation on 5/18/25 at 10:19 a.m. revealed: *Certified nursing assistant (CNA) T pushed a stand aid from an unidentified resident's room on the 300 hall. *An unidentified CNA then took that stand aid to another resident's room on the 300 hall. No cleaning of the equipment occurred. Observation and interview on 5/20/25 at 9:36 a.m. of CNA R returning a mechanical lift (lift and sling used to lift a person's full body) from a resident's room on the 300 hall revealed: *She had not cleaned the lift after using it in a resident's room. *They were supposed to clean the shared equipment, such as lifts, between each resident use, but that only occurred with the equipment was visibly dirty or they had time to clean it. *When asked about the cleaning process, she pointed to sanitizing wipes located at the nurses' station and stated after cleaning the equipment of any visible dirt, they are to re-wipe the equipment with a clean sanitizing wipe. Interview on 5/20/25 at 10:25 a.m. with CNA T regarding the cleaning of shared resident equipment revealed staff were to clean the equipment when they were visibly dirty with the sani-wipes located at the nurse's station. Observation of the Super Sani-cloth sanitizing wipes label instructions revealed to keep the surface wet for the entire two minutes to allow the active ingredients enough time to interact with and kill microorganisms. Interview on 5/20/25 at 3:14 p.m. with Minimum Data Set (MDS) Coordinator C revealed: *Staff were trained at orientation and annually to clean the lift equipment between each resident use with a sani-wipe. 2. Observation on 5/18/25 at 12:24 p.m. of CNA R in the dining room as she was seated at a table between two residents that needed full assistance with eating revealed: *She got up from the table and used her hands and arms to assist another staff member lift a resident in their wheelchair. *She returned to the table and continued to assist the two residents with eating without washing or sanitizing her hands. Interview on 5/20/25 at 9:36 a.m. with CNA R revealed: *She was trained on assisting residents with eating during her orientation. *She confirmed she had not completed hand hygiene after having close contact with another resident before she assisted other residents with eating as observed above. *She should have had hand sanitizer at the table and used it between assisting the residents. Interview on 5/20/25 at 3:14 p.m. with MDS Coordinator C revealed: *Staff were trained on proper hand hygiene during their orientation and annually. *Hand hygiene should have been completed between tasks and resident contact. 3. Observation and interview on 5/20/21 at 2:51 p.m. with CNA U in the 100 hall and 200 hall revealed: *She had been restocking towels in resident rooms from a portable linen cart. *She was moving the cart through the hall and day room space without the cover in place. *She stated she was supposed to keep the cover over the linens. *She stated she would close the cover of the cart when she stocked linens in the room of a particular resident who had a communicable disease. Interview on 5/20/25 at 3:14 p.m. with MDS Coordinator C revealed she expected the linen carts to be covered at all times, including when transporting between rooms and through a common area of the facility to protect the linens from potential contamination. Review of the provider's 2/28/24 document titled policies and procedures for laundry revealed the transportation of linen and laundry shall be completed with the clean linen storage containers and racks and covered at all times. 4. Observation and interview on 5/20/25 at 9:34 a.m. with dietary aide Q revealed: *She was delivering fresh water mugs to resident rooms on the 300 hallway. *She had a cart with the clean water mugs and a separate cart where she placed the dirty mugs as she removed them from the resident's rooms. *She took a clean mug into the resident's room and returned with the dirty mug. *She did not complete any hand hygiene between handling the clean mugs and the dirty mugs or between resident rooms. *She reported she had received infection control and hand washing education at their staff meetings. *Her education for passing residents' water mugs was to use separate carts, one for clean mugs and one for dirty mugs. *She was not aware that she should have washed her hands between handling the clean and the dirty mugs. Interview on 5/20/25 at 3:00 p.m. with dietary manager K revealed: *She had recently completed the ServSafe for Food Managers training. *She had not made any changes to the staff's water mug pass process for residents since she started on 9/12/24. *She did not provide any regular training for dietary staff. *Her orientation process for new staff was to work with them for a few days. *She agreed that the current water mug pass process was not sanitary. Review of the provider's 5/2/24 water pass policy revealed: *The purpose was to provide guidelines for staff and volunteers to ensure contamination does not happen when passing fresh water. *The procedure steps included: -Take gray (dirty) cart around to collect all dirty mugs from resident rooms and bring to dishwashing room. -Wash hands using hand hygiene procedure. -Take water pass cart around to resident rooms. 5. Observation and interview on 5/20/25 at 10:28 a.m. with CNA T in the shower room revealed: *She worked as the bath aide approximately one day per week. *She cleaned the whirlpool tub and chair by: -Moving the chair into the whirlpool tub. -Filling the tub with water. -Measuring about a half cup of sanitizing disinfectant in a disposable cup and adding it to the water. -Turning on the whirlpool jets and letting them run for about five minutes. -Draining the tub and rinsing it with the spray wand. *She stated she followed that process when she had completed all of the baths for the day. *In between baths, she would spray the tub and chair with Clorox disinfecting spray, rinse, and dry the chair with a towel. *She did not recall who had trained her on those cleaning techniques. Observation and interview on 5/21/25 at 8:55 a.m. with CNA S revealed: *She cleaned the whirlpool tub and chair by spraying them with the Clorox disinfecting spray, scrubbing them with a towel, let them sit for a few minutes, then sprayed them off with water. *She would wipe the chair seat dry with a towel. *She cleaned the chair legs after all baths had been completed. *She preferred the bleach product above and did not use the sanitizing disinfectant chemical provided by the facility. *She had learned to clean the whirlpool tub and chair from other CNAs. Observation of the tub chair revealed: *The paint on the chair legs was completely chipped away at each end of the legs. *The exposed metal surface was rusted and was an uncleanable. Interview on 5/20/25 at 3:14 p.m. with (MDS)Coordinator C revealed: *She was responsible for ensuring the whirlpool tub cleaning process was followed by staff. *She was not aware there was a Clorox disinfecting spray in the tub room. *The policy directed staff to use the provided sanitizing disinfectant after every resident bath for proper cleaning and disinfection of the tub. Review of the provider's 2/28/25 policy and procedures for cleaning of the whirlpool tub and shower chair revealed the cleaning procedure steps were: - Place chair in the tub, close and lock the tub door. -Press the tub fill button and turn the temperature control knob all the way to the left to its warmest level to heat the disinfectant solution and maximize its effectiveness. -Remove residue by rinsing the inside tub surfaces with water using the sprayer. -Press the fill button again to turn off the water. -Using premixed Classic whirlpool disinfectant and cleaner in a spray bottle, thoroughly spray the interior of tub and chair. -Use the button on the side of the tub to run disinfectant through the outlets. -Use the long-handled brush to scrub all interior surfaces of the tub and chair. -Let the disinfectant stay visibly wet on the surfaces for 10 minutes. -Remove the plug from the drain. -Spray water from the shower sprayer into both outlets until clear water appears from the inlet. -Visibly check that the tub and chair were effectively cleaned during the disinfecting process. If not, repeat procedure. -At the end of the day, use a towel to wipe off all excess water in tub and chair. *The whirlpool tub and shower chair were to be disinfected with the above procedure after each resident use. 6. Observation and interview on 5/19/25 at 12:48 a.m. with resident 5 in his room revealed: *He had a suprapubic catheter (tube surgically placed in the bladder through the abdomen to drain urine) and a colostomy. *There was a rack on the inside of the partially opened bathroom door containing personal protective equipment (PPE). *He stated that staff used the gloves when they emptied his catheter and changed his colostomy bag. *Staff wore gowns sometimes when emptying the catheter bag and providing his personal cares, but not always. *There was a sign inside the bathroom door that EBP (requires use of gown and gloves with contact care) was required. Review of resident 5's care plan revealed: *A focus area of I have Suprapubic Catheter: Neurogenic bladder. Skin breakdown that was initiated on 2/23/21 and revised on 3/3/21. *The interventions included My SP [suprapubic] catheter requires little care. *There was no documentation for the use of EBP while providing his catheter bag emptying or his catheter cares. Review of resident 5's Electronic Medical Record (EMR) revealed: 7. Observation and interview on 5/18/25 at 11:00 a.m. with resident 25 in his room revealed: *He had an indwelling catheter (a tube placed in the bladder to drain urine). *Staff used gloves when emptying the catheter bag and providing his catheter care. *He did not think staff had worn gowns when completing those tasks. *There was no signage in his room that indicted he was on EBP. Review of resident 25's care plan revealed: *A focus area of I have an Indwelling Catheter r/t surgery of the foreskin r/t [related to] (Balanitis) initiated on 3/21/25. *Interventions included catheter care every shift per facility protocol. *There was no documentation in his care plan for the use of EBP while providing his catheter bag emptying or his catheter cares. *There was no signage in his room indicating that EBP should be used when providing catheter cares. Interview on 5/20/25 at 9:19 a.m. with CNA R revealed: *She provided care for residents 5 and 25. *She described the correct process for putting on PPE when emptying the catheter urine bag or providing cares. *She wore gloves but did not always use PPE when emptying or providing cares. *She would not use PPE when helping resident to transfer with the lift. Interview on 5/21/25 at 3:14 p.m. with MDS Coordinator C revealed: *She had not included the use of EBP on residents' care plans. *She did not know she should have included it on residents' care plans. *She thought staff would know to use EBP for some residents because they had a meeting when the new EBP standards were implemented, and they covered it at their mandatory annual staff training. *She felt new staff would know how to use EBP because they work with one of the registered nurses (RNs) for several shifts and the RNs would educate them. *She was not aware of any signage available to post to inform staff or visitors of the need for use of EBP. *They did not have an infection control policy but she had a binder of information she had printed that she had found online. Review of the provider's 4/2025 revised catheter care, leg bag/catheter bag cleaning and storage policy revised revealed: *Procedural steps that included: -Assemble equipment. -Wash hands. -Five steps for disconnecting, using alcohol swabs, cleaning bag, draining, drying, and storage. -Wash hands. *Key Points listed were: -to prevent cross-contamination -to maintain Drainage system -observations of urine -to remove excess urine and minimize bacterial growth, contamination. Do not allow tip of bag to come in contact with any surface. *It did not address the use of EBP. Review of the provider's untitled policy and procedure revised 12/5/24 regarding maintaining a closed system on all indwelling urinary drainage systems as much as possible and decrease the possibility of catheter associated urinary tract infections revealed: *The listed purpose was Maintaining a closed system on all indwelling urinary drainage systems as much as possible and decrease the possibility of catheter associated urinary tract infections. *The procedure steps included Correct hand hygiene and Standard Precautions (or appropriate isolation) to be utilized by all trained staff handling and maintaining catheters. 50015 8. Observation and interview on 5/19/25 at 1:09 p.m. with resident 1 in his room revealed: *He had a suprapubic catheter (a tube surgically placed in the bladder through the abdomen to drain urine). *He had wounds to his coccyx (tailbone) and buttock. *There was no personal protective equipment (PPE) such as gowns, available for use in his room. *He stated staff wore gloves, but no gowns when they emptied his catheter and when completing his wound care. *There was no signage in his room for enhanced barrier precautions (EBP). 9. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated he was cognitively intact. *He had acquired a wound on 3/3/25 to his right inner gluteus (buttock) fold. *He had acquired a wound on 3/3/25 to his coccyx (tailbone). *He had a suprapubic catheter that was to be changed every two weeks. 10. Interview on 5/20/25 at 4:04 p.m. with licensed practical nurse (LPN) D revealed: *She received education on using EBP for resident's 1 and 5. *Staff knew which residents required the need to wear gowns for cares such as, catheter, and wound care. *Changes in residents' care needs are passed along during change of shift report. Interview on 5/20/25 at 4:07 p.m. with Minimum Data Set (MDS) Coordinator C revealed: *Resident 1 had Osteomyelitis, and she did some research which stated resident 1 did not need to be on EBP. *EBP should be included in the care plan for residents with wound care and catheter care needs. Interview on 5/21/25 at 7:24 a.m. with emergency permit holder (EMP) administrator A revealed the provider does not have a EBP policy.

Based on interview and record review, the provider failed to ensure that one of one designated infection preventionist Minimum Data Set (MDS) coordinator C had completed specialized training in infection prevention and control as required by the Centers for Medicare and Medicaid Services (CMS). Findings include: 1. Interview on 5/18/25 at 3:14 p.m. with MDS coordinator C regarding the infection prevention and control program (IPCP) revealed: *She was a licensed practical nurse (LPN) and the designated infection preventionist (IP). *She had been hired by the facility on 11/30/2019. *She was a full-time employee and was responsible for MDS coordination, resident care plan development, restorative therapy, and the IPCP. *She worked two scheduled nursing shifts on the floor per week along with the above duties. *She had not completed the course test required to obtain the IP certification. *She had expressed to the previous administrator that she felt she had too many work responsibilities and was unable to complete the test. *She believed the leadership team was going to get someone else to be the designated infection preventionist in her place. Interview on 5/20/25 at 10:30 a.m. with director of nursing (DON) B revealed: *MDS coordinator C had completed all of the training modules to required to take the certification test. *MDS coordinator C had not completed her infection preventionist certification test. *She believed that MDS coordinator C had exceeded the time requirement to take the certification test and she would not be able to take the test without completing the training course again. *She was hoping that a recently hired LPN would consider taking over the IP duties for the facility. Interview on 5/21/25 at 11:00 a.m. with emergency permit holder (EPH) administrator A revealed: *She was hired as an EPH administrator on 1/20/25. *She was aware that MDS coordinator C had not completed her IP certification. *EPH administrator A stated she was responsible for ensuring the training requirement was met. Review of the training module certificates for MDS coordinator C revealed there was no certificate that indicated she had completed the required training.

Based on interview and Certification and Survey Provider Enhanced Reports (CASPER) reporting data review, the provider failed to ensure their Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) had been completed and submitted to the Center for Medicare and Medicaid Services (CMS) for the months of May and June in Quarter 3 of fiscal year (FY) 2024 to support licensed nurse coverage 24 hours a day had occurred. Findings include: 1. Review of the provider's CASPER reporting data revealed that the PBJ data submitted for Quarter 3 of 2024 indicated the provider failed to ensure licensed nursing coverage 24 hours a day from: *May 1 through May 31, for a total of 22 days. *June 1 through June 30, for a total of 21 days. Interview on 5/21/25 at 11:00 a.m. with emergency permit holder (EPH) administrator A revealed: *She was hired at the facility on 1/20/25. *She stated the previous administrator whose employment at the facility ended at the end of December 2024 either had not submitted the PBJ data or had submitted it incorrectly for Quarter 3 of 2024. *She confirmed the submitted Quarter 3 data did not support licensed nurse coverage had occurred 24 hours a day as indicated in the above CASPER reports. *She was not able to document through the payroll data system that the facility had 24 hours of licensed nursing coverage on the above dates as director of nursing (DON) B was responsible for covering any shifts to ensure the requirement was met. *DON B was a salaried employee and had not been required to keep any record of her hours worked. Interview on 5/21/25 at 11:15 a.m. with DON B revealed: *She was responsible for covering any shifts to ensure the 24 hour licensed nursing coverage in the facility. *She did not keep any record of days and hours she had worked, and she was not required to punch in or out using the facility's timeclock. Review of the payroll data and staff work schedules provided by the facility on 5/19/25 revealed: *Schedules for May and June 2024 showed DON B was scheduled to work one nursing shift on the floor per week. *Payroll data confirmed 24 hours of nursing coverage had occurred on 5/9/24, 5/10/24, 5/17/24, and 5/18/24. *Employee schedules are not acceptable documentation to verify the presence of required staff. Refer to F851.

Based on South Dakota Department of Health (SD DOH) complaint intake review, interview, and policy review, the provider failed to report an allegation of suspected abuse for one of one sampled resident (27). Findings include: 1. Review of a 12/31/24 SD DOH anonymous complaint intake report revealed: *On 12/19/24 the anonymous writer was told by certified nursing assistant (CNA) F that resident 27 was inappropriately touched on the breast by certified medication aide (CMA)/CNA G. *CMA/CNA G tried holding resident 27's hands behind her back. *CNA F had reported the allegations, but thought nothing had been done. 2. Review of resident 27's electronic medical record revealed: *She had a diagnosis of Alzheimer's disease. *Her Brief Interview for Mental Status assessment score was 03 indicating severe cognitive impairment. 3. Interview on 5/19/25 at 9:59 a.m. with resident 27's family member revealed: *She had been told of the allegations of suspected abuse. *She did not believe the accusations. *She felt the provider was transparent about their investigation of the allegation. *She thought CMA/CNA G was wonderful, and she was upset he no longer worked at the facility. Interview on 5/19/25 at 1:17 p.m. with CNA F revealed: *ON the morning of 12/19/24, she was assisting resident 27 in getting up and ready for the day. *Resident 27 was lying across the bed with her legs hanging over the side of the bed and her walker in front of her. *Resident 27's brief was not pulled up and her pajama top was off. *CMA/CNA G came into the room to assist with resident 27. -He jumped on the bed. -His leg was across resident 27's body. -He placed his hand on her inner left thigh. -He rubbed her left shoulder area. -He said resident 27 was his girlfriend. -He said, Let's get you dressed. -CMA/CNA G's hand rubbed along the left side of the resident's breast. *CNA F told CMA/CNA G she would finish with assisting resident 27. *CMA/CNA G then left the room. *CNA F reported the allegation of suspected abuse to registered nurse (RN) H that day. *She reported the allegation to former administrator O on 12/20/24. Interview on 5/19/25 at 3:38 p.m. with RN H revealed: *CNA F had reported the above allegation of suspected abuse for resident 27 to her on 12/19/24. *She told her to report it to former administrator O as she was in the facility on 12/19/24 per provider's policy. *She had received education regarding abuse and neglect in the summer of 2024. Interview on 5/21/25 at 8:34 a.m. with social services designee (SSD) P revealed: *She or former administrator O complete the state reporting documents for the provider for any concerns with potential abuse or neglect. *She would report any abuse allegations within 24 hours to SD DOH, law enforcement and ombudsman. *If immediate jeopardy she would report within two hours to the state. *She assumed former administrator O had completed the initial report to the state as she was who investigated the allegation regarding resident 27 in December 2024. *SSD P stated she was not involved in the investigation for the above allegation regarding resident 27. Interview on 5/21/25 at 8:45 a.m. with director of nursing (DON) B revealed: *She was notified of the above allegation regarding resident 27 on 12/23/24 by former administrator O. *She became involved in the allegation investigation by conducting interviews with CNA F and CMA/CNA G on 12/23/24. *CMA/CNA G was suspended during investigation. *She assumed the state report had been completed on 12/20/24 when CNA F reported it to former administrator O. *Investigation was inconclusive in findings of allegation of abuse. Interview on 5/21/25 at 9:21 a.m. with emergency permit holder (EPH) administrator A revealed: *She was hired on 1/20/25. *She expected allegations of abuse to be reported to SD DOH within 24 hours, and if there were immediate concerns to the resident those should have been reported within two hours. *She confirmed allegation should have been reported. *She and SSD P complete the state reporting for the provider. 4. Review of the provider's revised 5/20/24 Abuse and Neglect Policy and Procedure revealed: *b. Notify the designated agencies in accordance with state law, including the state survey and certification agency. You may need to notify more than one agency in order to fulfill federal and state regulations. If the agencies require an online report to be submitted contact Social Services Designee, DON, or the Administrator. *8. The social worker will report the results of all investigation to the state agency and other officials within five (5) working days of the incident, unless otherwise specified by state law, whichever is stricter.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure adequate supervision for one of one sampled resident (18) identified at risk for wandering to prevent him from leaving the building without staff knowledge or supervision. Failure to provide supervision while the resident was outside of the building put the resident at risk for potential accident and/or injury. This citation is considered past non-compliance based on the provider's corrective actions implemented following the incident. Findings include: 1. A review of the 5/15/25 SD DOH FRI regarding resident 18 revealed: *He had eloped (left the building without staff knowledge) from the facility without staff knowledge or supervision on 5/14/25 at approximately 6:15 p.m. *He had a Brief Interview for Mental Status (BIMS) assessment score of 4, which indicated he had severe cognitive impairment. *He had a history of exit-seeking but had not exited previously without staff supervision. *He frequently believed the building across the road was his hotel or apartment. *Staff believed he was outside for three to four minutes prior to them responding to the door alarm and locating him in front of the building. *He returned to the building with the assistance of staff and their assessment found no harm or injury. 2. Observation and interview on 5/18/25 at 4:45 p.m. with resident 18 in his room revealed: *He was able to answer basic questions but displayed confusion with his responses. *He stated he did not need to call staff for assistance, but he could go to the door and call out for them. *He was unaware that he had a call light to use to call the staff for assistance. *When it was pointed out to him, he was unclear what it was or why to use it. *He was independent in moving around the facility with his walker with a shuffling gait (a walking pattern characterized by dragging the feet instead of lifting them, often with short, quick steps). *He spent most of each day in the dining room near the activities area. *He had no recollection of leaving the building on 5/14/25. Interview on 5/20/25 at 1:27 p.m. with resident 18's spouse revealed: *She spent Tuesday afternoons with him playing bingo at the facility. *His cognition had continued to decline to the point that she wondered if he had been reading the materials he had with him or was just making the motions. *He often did not interact with her when she was there with him but he would actively participate in an activity. *She felt the facility had enough staff to take care of him. *She was not concerned with the staff's ability to keep him safe after his elopement the week prior. Interview on 5/20/25 with registered nurse (RN) W revealed: *She worked the night shift on 5/14/25 when resident eloped from the facility. *She was in a resident's room when she heard the door alarm sounding. *When it continued to sound, she left the resident's room, checked the alarm panel and proceeded to the front door. *She observed resident 18 walking away on the sidewalk that ran against the front of the building. He was approximately 35 feet from the front door. *She called for staff assistance and with certified nursing assistant (CNA) U, was able to assist resident in returning to the building. *He was assessed and had no injury or indictors of harm from leaving the building unattended. *She estimated he was outside, unsupervised, for three to four minutes. *He had no further exit-seeking behaviors that evening. *She educated the staff working that shift to closely supervise him and to respond to the door alarm immediately if it sounded. *She stated he often looked out the doors but did not exit the building unattended. *Resident 18 often would get increasingly confused in late afternoon and evening, thinking he needed to get to his apartment. *She felt they had enough staff and interventions in place needed to keep the residents safe. Interview with Director of Nursing (DON) B revealed: *She was notified by RN W of resident 18's elopement on 5/14/25. *She educated RN W on their elopement policy at that time. *Resident 18 was placed on one-hour safety checks after his elopement on 5/14/25. *She spoke with staff throughout the building over the next several days about interventions they could use when resident 18 was confused about needing to leave the building. *She expected all staff to respond to the door alarm if it sounded. *Facility doors were alarmed, but they were not able to add a wander guard system due to the type of wiring at the facility. *A tab alarm (motion alerting device) was not an intervention option for resident 18 due to his mobility and sensitivity to alarms. *Loud noises such as the fire alarm upset him and caused him increased confusion. *She felt that they had interventions and adequate staff to keep residents safe. Interview and record review on 5/21/25 at 10:17 a.m. with emergency permit holder (EPH) administrator A revealed: *Resident 18 had been placed on hourly safety checks following his elopement. *A notice had been posted for staff on 5/18/25 that resident 18 was at risk for elopement. *Door alarm audits for response to alarms were initiated on 5/16/25 and would continue for three months for timely response to door alarms. *Review of door alarm audits completed from 5/16/25 to 5/21/25 confirmed appropriate staff response with all response times of 62 seconds or less. *Resident 18's care plan had been updated on 5/19/25 to include the hourly safety checks and interventions for exit-seeking behavior. *A staff in-service was held on 5/20/25, where reeducation was provided on caring for residents with unique needs and exit-seeking, along with the elopement and door alarm policies. *Documentation of staff attendance and education materials confirmed that the training has occurred. Review of resident 18's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His diagnoses included: -Parkinson's Disease. -Depression. -Unspecified Dementia. *He had a BIMS assessment score of 4. *A wandering risks scale completed on 3/21/25 had a score of 11, which indicated that he was at high risk to wander. *He was placed on one-hour safety checks as an intervention after his 5/14/25 elopement. Review of resident 18's care plan revealed: *A focus area initiated on 5/19/25 I am a elopement risk/wanderer r/t (related to) history of attempts to leave facility unattended. *The goal initiated that date was my safety will be maintained through the review date. *Interventions included: -Anticipate my needs for going outside. -If I try to go outside unsupervised, please walk with me until I am ready to return to the facility. -Answer door alarms promptly. -Hourly checks. -Offer diversions, structured activity, food, conversation. Review of the provider's 2/24/24 door alarm policy revealed: *All exit door alarms are to remain on at all times. *It is the responsibility of all staff to answer any sounding alarm and check outside of the door of where the alarm sounded. Review of the provider's elopement policy updated May 2025 revealed: *A definition of elopement as when a resident who requires supervision leaves the premises or a safe area without authorization and/or any necessary supervision to do so. *The provider will be responsible for completing an elopement risk assessment to know who is at risk. *Provide appropriate interventions once a residents identified as being at risk for elopement. *Door alarms will be answered promptly. *Staff will investigate why the door is alarming. Based on the above information, non-compliance at F689 occurred on 5/14/25, and based on the provider's implemented corrective action for the deficient practice confirmed on 5/21/25, the non-compliance is considered past non-compliance.

Based on record review, interview and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, the provider failed to ensure the Minimum Data Set (MDS) assessments were completed accurately for one of one sampled resident (29) who was not taking a diuretic medication. Findings include: 1. Review of resident 29's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *There were no current or past medication physician's orders that indicated she received a diuretic (medication to reduce excess body fluid) medication. *Her 6/13/24 Quarterly MDS assessment, section N (medications) indicated the resident was taking a diuretic medication. *Her 9/6/24 Annual MDS assessment, section N (medications) indicated the resident was taking a diuretic medication. *Her 11/30/24 Quarterly MDS assessment, section N (medications) indicated the resident was taking a diuretic medication. *Her 2/23/25 Quarterly MDS assessment, section (medications) indicated the resident was taking a diuretic medication. 2. Interview on 5/20/25 at 1:05 p.m. with MDS Coordinator C revealed: *Resident 29 was prescribed and received Enalapril Maleate (medication to treat high blood pressure). *She reviewed the RAI 3.0 manual and identified Enalapril Hydrochlorothiazide (a combination medication for high blood pressure and a thiazide diuretic) was on the list of diuretics to code in the MDS assessment if received by a resident. *She thought those two medications were the same. *She agreed that resident 29 was not currently receiving a diuretic medication as she received Enalapril Maleate, not Enalapril Hydrochlorothiazide. *She agreed upon further review of discontinued and completed medications orders that resident 29 had not received a diuretic for the last year and MDS assessments were not completed accurately. Interview on 5/20/25 at 3:02 p.m. with director of nursing (DON) B revealed: *She reviewed resident 29's medication list for the last year and confirmed that there was no physician ordered diuretic medication. *After review of resident 29's MDS assessments completed in the last year, she agreed that the resident's diuretic use had been checked in the MDS assessments in error. 3. Review of the CMS Long-Term Facility RAI 3.0 User's Manual Version 1.19.1 October 2024, section N, Page N7 and N8 revealed: *Steps for Assessment: -1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). -2. Review documentation from other health care settings where the resident may have received any of these medications while a resident of the nursing home (e.g., valium given in the emergency room ).

Based on observation, interview, record review and policy review the provider failed to ensure resident care plans had been revised to reflect their current needs for three of three sampled residents (1, 5 and 25) that required the use of Enhanced Barrier Precautions (EBP) for catheter care and/or wound care. Findings include: 1. Observation and interview on 5/19/25 at 1:09 p.m. with resident 1 in his room revealed: *He had a suprapubic catheter (a tube surgically placed in the bladder through the abdomen to drain urine). *He had wounds to his coccyx (tailbone) and buttock. *There was no personal protective equipment (PPE) such as gowns, available for use in his room. *He stated staff wore gloves, but no gowns when they emptied his catheter and when completed his wound care. *There was no signage in his room for EBP. 2. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated he was cognitively intact. *He had acquired a wound on 3/3/25 to his right inner gluteus (buttock) fold. *He had acquired a wound on 3/3/25 to his coccyx (tailbone). *He had a suprapubic catheter that was to be changed every two weeks. *His current care plan had a focus area of: I have a Suprapubic Catheter created on 10/3/2013 with several interventions. *His care plan had a focus area of: I have pressure ulcers r/t Immobility with new diagnosis of Chronic Multifocal Osteomyelitis (bone infection) Unspecified Femur initiated on 5/9/25 with several interventions. -He had a wound that was positive for Methicillin-resistant Staphylococcus aureus (a type of staph bacteria that's resistant to many antibiotics) on 1/31. *He was treated with an antibiotic and universal precautions (standard infection control practices that treat all human blood and certain body fluids) were to be used by staff when they were working with his wound area. -Addressed his catheter and wound care needs, but it did not include EBP was required when staff provided his catheter and wound care. 3. Interview on 5/20/25 at 4:04 p.m. with licensed practical nurse (LPN) D revealed: *She received education on using EBP for resident's 1 and 5. *Staff knew which residents required the need to wear gowns for cares such as, catheter, and wound care. *Changes in residents' care needs are passed along during change of shift report. Interview on 5/20/25 at 4:07 p.m. with Minimum Data Set (MDS) Coordinator C revealed: *Resident 1 had Osteomyelitis, and she did some research which stated resident 1 did not need to be on EBP. *She updated the care plans for all residents. *EBP should be included in the care plan for residents with wound care and catheter care needs. Interview on 5/21/25 at 9:00 a.m. with director of nursing (DON) B revealed that MDS Coordinator C was responsible for updating the residents' care plans regarding care provided by the nursing staff. 51370 4. Observation and interview on 5/19/25 at 12:48 a.m. with resident 5 in his room revealed: *He had a suprapubic catheter (a tube inserted in the bladder to drain urine). *Staff wear gloves when emptying his catheter bag and providing his personal cares and sometimes wear gowns but not always. Review of resident 5's EMR revealed: *He admitted on [DATE]. *His BIMS score was 14 which indicated he was cognitively intact. *He had a suprapubic catheter. Review of resident 5's care plan revealed: *There was a focus area of I have Suprapubic Catheter: Neurogenic bladder. Skin breakdown that was initiated on 2/23/21 and revised on 3/3/21. *The interventions included My SP catheter requires little care. *There was no documentation in the care plan for the use of EBP while providing catheter bag emptying or catheter cares. 5. Observation and interview on 5/18/25 at 11:00 a.m. with resident 25 in his room revealed: *He had an indwelling catheter (a tube inserted in the bladder to drain urine.) *Staff used gloves when emptying his catheter bag and providing his catheter care. *He did not think staff had worn gowns when completing these tasks. Review of resident 25's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 15, which indicated that he was cognitively intact. *He had an indwelling catheter. *He had a diagnosis on admission of a urinary tract infection, acute. Review of resident 25's care plan revealed: *A focus area of I have a Indwelling Catheter r/t surgery of the foreskin r/t (Balanitis [an inflammation of the glans penis]) initiated on 3/21/25. *Interventions included catheter care every shift per facility protocol. *There was no documentation in the care plan for use of EBP while providing catheter bag emptying or catheter cares. 6. Interview on 5/20/25 at 9:19 a.m. with CNA R revealed: *She provided care for residents 5 and 25. *She described the process for donning EBP when emptying the catheter urine bag or providing cares. *She usually just uses gloves. *She doesn't use PPE when helping resident to transfer with the lift. Interview on 5/21/25 at 3:14 p.m. with MDS Coordinator C revealed: *She did not include use the need for EBP on residents' care plans. *She did not know she should have included it on their care plans. *Staff would know to use it because they had a meeting when the new EBP standards were implemented, and they cover it at their mandatory annual training. *New staff would know because they work with one of the registered nurses (RNs) for several shifts and the RN would tell them. *She is not aware of any signage available or the need to post it. Review of the provider's comprehensive care plan and care conferences policy updated 2/4/25 revealed: *A comprehensive Care Plan will be developed for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial problems, needs, and/or strengths that are identified in the Comprehensive Assessment. The Comprehensive Care Plan must deal with the relationship of items or services ordered to be provided for (or withheld) to the facility's responsibility for fulfilling other requirements. Review of the provider's catheter care, leg bag/catheter bag cleaning and storage policy revised on April 2025 revealed: *Procedural steps were included. *It did not address the use of EBP.

Based on interview, record review, policy review, and South Dakota Department of Health (SD DOH) facility reported incident (FRI) the provider failed to ensure two of two sampled residents (1 and 2) had been assessed, care plans were updated, and education was provided to staff regarding having been fondled by a co-located resident (4). Findings include: Notice: Notice of immediate jeopardy was given verbally and in writing on 5/8/24 at 9:10 a.m. to administrator A and regional administrator D of the immediate jeopardy related to resident abuse by a colocated resident at F600 when the provider failed to ensure the following: *A resident assessment, care plan updating, and staff education regarding the fondling of vulnerable residents by a co-located resident. On 5/8/24 at 9:10 a.m. administrator A, regional administrator D, and director of nursing (DON) B were asked for an immediate removal plan. Plan: 1.Centerville Care and Rehab Center understands the severity of this incident and have taken the following actions to provide education to staff and to ensure the safety of our residents. May 6, 2024, 30-minute checks on resident 4 initiated to ensure the safety of all residents. Medical director I discontinued the use of Sildenafil, and will monitor the use of other medications that could lead to sexual temptations. Resident 4 was scheduled to be evaluated by (psychiatry provider) to rule out dementia or other medical conditions that could cause the more frequent sexual behaviors. Resident 4 was seen by (psychiatry provider) 5/7/24. Care plans have been updated. Education was provided to all staff. Managers will provide the education to staff that were not in the building and staff will be required to receive the education before they start their next shift. All staff will continue to monitor behaviors and safety for all residents. Interventions in place will be assessed and will be modified if needed to make sure the issue is being resolved appropriately. On 5/8/24 at 11:53 a.m. the removal plan was received. On 5/8/24 at 12:20 p.m. the provider's immediate jeopardy removal plan was accepted. On 5/8/24 at 1:20 p.m. while on-site the immediacy was removed. Once the immediacy was removed the scope and severity was changed to a G. Review of SD DOH FRI revealed: *On 5/1/24 at 9:00 a.m. resident 4 was inappropriately touching resident 1 between her legs and she is unable to give consent. *On 5/5/24 at 6:00 p.m. resident 4 had taken resident 2's hand and placed it on his groin. Resident 4 moved resident 2's hand in up and down and rubbing motions. Resident 2 does not talk and cannot defend herself. Interview on 5/6/24 at 9:50 a.m. with registered nurse (RN) E regarding resident 1 being fondled by resident 4 revealed: *She had observed resident 1 sleeping in a recliner near the front entrance. Resident 4 had his hands on her groin area and was rubbing it. He was moving his tongue back and forth in his mouth while he was rubbing resident 1. *She had observed resident 4 rubbing on other residents' thighs on other occasions. *RN E notified administrator A, DON B, and social services designee C of the witnessed event. Interview on 5/6/24 at 10:10 a.m. with certified nursing assistant (CNA) F regarding resident 4 touching female residents revealed: *She had observed resident 4 touching other residents and reported the incidents to the charge nurse. *She had observed resident 4 touching resident 3's breast and reported the incident to the charge nurse. Interview on 5/6/24 at 10:40 a.m. with CNA G regarding resident 4 touching female residents revealed: *She had observed resident 2 walking past resident 4 in his wheelchair, he then touched her on her buttock. *CNA G reported the incident to the charge nurse. *She had been informed by other staff members resident 4 would touch other residents inappropriately. Interview on 5/6/24 at 11:00 a.m. with RN E regarding CNA's reporting of having been inappropriately touched by resident 4 revealed: *She had received reports by CNAs and informed administrator A, DON B, and social services C of the incidents. Interview on 5/6/24 at 11:10 a.m. with administrator A, DON B, and social services C regarding the incidents with residents 1, 2, 3 and 4 revealed: *Administrator A had spoken with resident 4 and had contacted the ombudsman. *DON B stated resident 4's son had spoken with him regarding his behavior. *Administrator A had been aware that resident 4 was targeting non-consenting residents. *Resident 2's son had been notified of the incident with his mother. Administrator A stated her son was very concerned of his mother's safety. *They had not been aware that resident 3 was touched by resident 4. Review of resident 1's electronic medical record (EMR) revealed: *She had a diagnosis of dementia and psychosis. *On 3/27/24 her brief interview for mental status (BIMS) was 2, indicating severe cognitive impairment. *Resident 1's care plan had not been updated to indicate she had been a victim of inappropriate touching. Review of resident 2's EMR revealed: *She had a diagnosis of dementia, amnesia, and trans ischemic attack (TIA). *On 3/11/24 her BIMS score was 99, indicating the interview assessment is not successful. *Resident 2's care plan had not been updated to indicate she had been a victim of inappropriate touching. Review of resident 3's EMR revealed: *She had a diagnosis of Alzheimer's disease and dementia. *On 3/11/24 her BIMS score was 99, indicating the interview assessment is not successful. *Resident 3's care plan had not been updated indicate she had been a victim of inappropriate touching. Review of the provider's June 2021 Abuse and Neglect Policy and Procedure revealed: *To ensure that the center has in place and effective system that regardless of the source prevents mistreatment, neglect and abuse of residents of misappropriation of their property. *To ensure that resident are not subject to abuse by anyone, including, not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals. *To ensure that all identified incidents of alleged or suspected abuse/neglect are promptly investigated and reported. *All staff are responsible for reporting any situation that is considered abuse, neglect, or injury of unknown origin, misappropriation of resident property or involuntary seclusion. *The charge nurse will be notified immediately, assess the situation to determine if any emergency treatment or action is required, and complete an initial investigation. If this is an injury of unknown origin, the charge nurse will also attempt to determine the cause of the injury. The charge nurse will also ensure that any potential for further abuse is eliminated by taking on of the following actions: -If it is resident to resident abuse, the abused resident will be removed to a safe environment. *Notification Procedure: -Notify the center administrator immediately of any incident of resident abuse. -Notify the designated agencies in accordance with state law, including the state survey and certification agency. -If the agencies require an online report to be submitted contact the Social Services Designee, DON, and Administrator. -Notify the physician and family regarding the facts of the situation. If there is alleged or suspected abuse/neglect or an injury of unknown origin, inform them that an investigation is in process.

Based on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff schedule and timecard review, and interview, the provider failed to ensure Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data was accurately completed prior to submission to the Center for Medicare and Medicaid Services (CMS) for three of four federal fiscal quarters (2, 3, and 4) of 2023. Findings include: 1. Review of the provider's PBJ data submitted to CMS for federal fiscal quarters 2, 3, and 4 of 2023 revealed the data triggered for days of no registered nurse (RN) hours and days without licensed nursing coverage for 24 hours per day: *From January 1, 2023 through September 30, 2023 there were no RN hours reported for: -Four days in January. -Eight days in February. -Eight days in March. -Five days in April. -Ten days in May. -Seven days in June. -Seven days in July. -Five days in August. -Five days in September. *From January 1, 2023 through September 2023, there were no licensed nursing coverage for 24 hours per day reported for: -31 days in January. -28 days in February. -31 days in March. -30 days in April. -31 days in May. -30 days in June. -31 days in July. -31 days in August. -30 days in September. 2. Review of the provider's 2023 employee staffing schedules and timecards revealed they had RN coverage and licensed nursing coverage 24 hours per day on the dates listed above. 3. Interview on 4/30/24 at 4:42 p.m. with administrator A regarding the PBJ staffing data revealed she: *Stated she was responsible for gathering and submitting the data. *Confirmed the staffing schedules were correct and they had met the requirements to have daily RN coverage and licensed nursing coverage for 24 hours per day. *Was not aware that the staffing data had been inaccurately submitted to CMS. *Believed she had not added two salaried RNs to the staffing report. *Stated the reports were accepted and she did not see any triggers for low coverage.

A. Based on observation, interview, and policy review, the provider failed to ensure as needed (PRN) medications stored in blister pack cards with pharmacist determined expiration dates had been monitored for expiration and removed for destruction for four of four sampled residents (7, 10, 17, and 22) in two of two medication carts (100/200 and 300/400). Findings include: 1. Observation and interview on 4/30/24 at 9:30 a.m. with registered nurse (RN) F of the medication carts revealed the 100/200 medication cart had PRN blister-pack cards (med card) with expired medications for three residents (10, 17, and 22): *Resident 10's meclizine was dispensed from the pharmacy on 1/27/22 and expired on 1/27/23. *Resident 17 had three expired medications: -Fludrocortisone was dispensed from the pharmacy on 5/25/22. --The front of the med card had an expiration date of 5/25/23. --The back of the med card had a handwritten expiration date of 9/2022. --When RN F was asked why there were two expiration dates she stated she did not know. -Quetiapine fumarate had been dispensed on 5/25/22 and expired on 5/25/23. -Butalb-acetamin-caff had been dispensed on 5/25/2022. --The expiration date on the front of the card had been crossed off. --The back of the med card had a handwritten expiration date of 12/2022. *Resident 22 had three expired medications: -Senna-Plus was dispensed on 11/9/2022 and expired on 11/8/2023. -Acetaminophen was dispensed on 12/4/2022 and expired on 11/26/23. -Melatonin was dispensed on 11/9/22 and expired 10/31/2023. 2. Observation of the 300/400 medication cart revealed: *Resident 7's ibuprofen was dispensed on 3/20/2023. -The back of the med card had a handwritten expiration date of 12/23. 3. Continued interview on 4/30/24 at 9:45 a.m. with RN F regarding the expired medications revealed: *She was aware the medications in the med cards expired within one year after they were placed in the med card or earlier if the pharmacist determined it was required. *She did not know who was responsible for monitoring and removing outdated medications in the med cards. 4. Interview on 4/30/24 at 12:45 p.m. with director of nursing (DON) B regarding the expired medications in the above blister packs revealed: *She believed the PRN med cards were monitored and expired medications were disposed of by the pharmacist each time the medication changeover was done. *She contacted the pharmacist and he informed her the consultant pharmacists could check for expiring medications if the provider had requested it, but the pharmacist had not been checking for outdated medication. 5. Review of the undated Medication Storage in The Facility policy regarding outdated medications revealed: *Outdated medications were to have been immediately removed from the inventory and disposed of according to the procedures for medication disposal. *Drugs re-packed [such as the med cards] by the pharmacy staff would carry an expiration date. The pharmacist determined the exact date based on a number of factors as well as applicable laws or regulations. *The nurse was to check the expiration date of each medication before administering it. *Medication storage conditions were to have been monitored on a [monthly] basis by [the consultant pharmacist or pharmacy designee] and corrective actions were to have been taken if problems were identified. B. Based on observation, interview, and policy review, the provider failed to ensure medications were stored separately by route of administration (how they enter the body) to minimize contamination for seven of seven sampled residents (2, 20, 27, 30, 35, 37, and 38) in one of one treatment cart. Findings include: 1. Observation and interview on 4/30/24 at 10:50 a.m. with RN F of the treatment cart revealed: *The drawers in the treatment cart had plastic dividers approximately ten inches square. *The dividers: - Were marked with the residents' names. -Had not been further divided to separate the orally administered medication from the externally used medication and treatments. *Resident 2's divider contained antifungal topical cream, diclofenac 1% topical gel, and artificial tears eye drops. *Resident 20's divider contained hemorrhoid ointment, albuterol sulfate inhalation solution used in nebulizer treatments, and Ventolin HFA inhaler. *Resident 27's divider contained artificial tears eye drops, Rhopressa mesylate eye drops for glaucoma, silver sulfadiazine topical cream, and a bottle of oral nitroglycerin tablets. *Resident 30's divider contained diclofenac 1% topical gel, triamcinolone acetonide nasal spray, and albuterol sulfate HFA inhaler. *Resident 35's divider contained ketotifen 0.025% eye drops, Benadryl topical cream, dipropionate 1% topical cream, and Clotrimazole-betamethasone topical cream. *Resident 37's divider contained brimonidine eye drops for glaucoma, dorzolamide HCL/ Timolol eye drops, and hydrocortisone topical cream. *Resident 38's divider contained Calmoseptine topical cream and an albuterol sulfate HFA inhaler. *RN F stated she did not know that the orally administered medications and eye drops were to be stored separately from externally used medications and treatments. 2. Interview on 4/30/24 at 12:45 p.m. with DON B regarding the separation of the external medications from oral and eye medications confirmed they had not been stored separately but they should have been. 3. Review of the undated Medication Storage in The Facility Policy regarding maintaining a separation between specific medications revealed orally administered medications were to have been kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Eye medications were to have been stored separately according to the facility policy.

Based on observation, interview, record review, and policy review, the provider failed to ensure six of six sampled residents (8, 9, 28, 32, 35, and 141) had: *Received the risks versus the benefits education for side rail use. *Obtained a signed informed consent forms for side rail use. *Quarterly assistive safety device assessments completed for side rail use. *Alternatives to side rails were attempted prior to the installation of side rails on the residents beds. Findings include: 1. Observations on 3/12/23 between 3:06 p.m. and 5:30 p.m. and again on 3/13/23 between 8:00 a.m. and 11:00 a.m. of the above sampled resident rooms revealed all those residents had quarter-length side rails on one or both sides of their beds. Review of the medical records for the residents identified above revealed the following: *No risks versus benefits education for side rail use had been documented prior to side rail installation *No informed consent for side rail use had been documented prior to side rail installation. *No side rail safety assessments had been completed. *There were no documented alternatives to side rail use prior to the installation of side rails. Interview on 3/13/23 at 5:22 p.m. with Minimum Data Set (MDS) assessment coordinator D regarding side rails revealed: *The side rails were assist devices and were not considered side rails. *All beds have side rails on them. *She had not assessed any of the residents for safety with side rail use, offer alternatives to the use of the side rails, provided education to the residents or their family or representative on the risks verses benefits of the side rails, and had not obtained an informed consent. *She would not have added them to the resident care plans. Interview on 3/14/23 at 4:24 p.m. with director of nursing (DON) B regarding the residents use of side rails revealed the following: *Beds were new since the last survey on 10/20/21. *She had considered the side rails as an assist device. *All of the beds had side rails on them. Interview on 3/15/23 at 1:01 p.m. with administrator A revealed the following: *She was not aware of the what the requirements were prior to installing the side rails on the resident's beds. *Since the side rails held the bed controls, there were no other options but to put the rails on the beds. *She agreed the bed controls would have worked without the side rail and they could find another way to have kept the bed control in reach for those residents who had not required a bed rail. Review of the 7/14/21 revised Bed/Side Rails policy and procedure revealed: *Action Steps included: -Residents were to have been assessed for the appropriateness of the side rails including the consideration of alternatives. -Side rails usage would have been minimal, occurring only when there was a medical necessity that was documented. *Residents who had not needed side rails, would have had the rails removed from the bed.

Based on record review, interview, and policy review, the provider failed to ensure the accuracy of current diagnoses and resident events had been captured on the Minimum Data Set (MDS) assessment for two of two sampled residents (7 and 28). Findings include: 1. Review of resident 28's medical record revealed she had been admitted on [DATE] and on 1/6/23, suffered a hip fracture requiring hospitalization after a fall. Review of resident 28's medical record revealed she: *Was admitted on [DATE]. *Had multiple falls at home prior her to admission to the facility. *Had a fall with a hip fracture on 1/6/23 resulting in hospitalization . 2. Review of resident 7's 1/20/23, quarterly MDS assessment revealed diagnoses of sepsis and pneumonia that had been from his 11/29/21, admission and were no longer current. Review of resident 7's medical record revealed he: *Was admitted on [DATE] with diagnoses of sepsis and pneumonia. *He did not have sepsis or pneumonia at the time of the 1/20/23 completion of the quarterly MDS assessment. 3. Interview on 3/14/23 at 12:43 p.m. with MDS coordinator D regarding MDS assessments revealed: *Resident 28's 1/17/23 Admission MDS assessment had not been completed accurately to reflect her history of falls or her fractured hip. *Resident 7 had not had sepsis or pneumonia since admission and should not have been included in the 1/20/23 Quarterly MDS assessment.

Based on observation, interview, record review, job description review, and policy review, the provider failed to: *Ensure infection control precautions had been initiated after an outbreak of vomiting and diarrhea in residents and staff. *Have comprehensive infection control program. *Ensure items that had been used on all residents had been properly cleaned and disinfected. Findings include: 1. Observation on 10/19/21 at 10:22 a.m. revealed resident 11 was lying in her bed. A large amount of vomit was on the blanket in front of her. She stated she felt fine. MDS coordinator E was notified and assisted the resident. Interview on 10/19/21 at 10:28 a.m. with MDS coordinator E revealed: *She was aware that residents and staff are ill with a bug. *She had tested a few of the residents for COVID-19, but they were all negative. *She had not tested any of the staff. *None of the residents have a fever. *No isolation of those residents was necessary. *Did not think any PPE other than gloves and the face masks they wear was necessary. Interview on 10/19/21 at 10:30 a.m. with certified nursing assistant (CNA) K revealed there were some of the residents that had signs and symptoms of the stomach flu. Interview on 10/19/21 at 11:00 a.m. with registered nurse (RN) D and MDS coordinator E revealed: *There were several residents who were having either vomiting or diarrhea or both. *Three CNAs and one RN had called in sick today as there were having the same symptoms. *Had not notified the South Dakota Department of Health (SDDOH) reportable disease department. *Did not feel it was an outbreak of any sort. Interview on 10/19/21 at 11:15 a.m. revealed the maintenance supervisor and the dietary manager were also out with those symptoms. The maintenance supervisor had also been out ill on 10/18/21. Interview on 10/19/21 at 12:12 p.m. with director of nursing (DON) B revealed residents 5, 8, 9, 11, 16, and 21 had either vomiting or diarrhea or both. Observation on 10/19/21 from 1:30 p.m. through 5:00 p.m. revealed: *No other PPE had been put in place for staff when they assisted residents with vomiting, diarrhea, or both. *The DON had ordered tea and toast for those residents for supper. *There were 13 total residents that were having gastrointestinal (GI) upset symptoms. Review of a list of residents given by the DON on 10/20/21 revealed there were five additional residents who had GI upset symptoms. Interview on 10/20/21 at 1:38 p.m. with MDS coordinator E revealed: *She had reported the outbreak of residents ill to the SDDOH yesterday afternoon. *Did not think any other PPE was necessary. *Agreed it had spread to other residents and staff. *There were more staff ill today. Interview on 10/20/21 at 3:30 p.m. with administrator A and DON B revealed: *Medical director F had been notified of the GI outbreak. *He had replied and did not advise to place any residents on precautions. Review of the 10/19/21 facsimile sent at 4:00 p.m. to medical director F revealed: *He had sent it back with his recommendations on 10/20/21 at 9:45 a.m. *The provider had sent the following message: -Please see attached sheet for residents that recently came down with diarrhea and loose stools - What are your recommendations going forward. They are afebrile. *Medical director F replied: -Suspect likely [CONDITION(S)] etiology. Able to keep residents in their rooms that are symptomatic. Continue supportive care. Staff & roommates [unreadable word] to promote good liquid intake/water at bedside. Also able to do sot diet and gradually titrate back to their usual diets as they recover. *Medical director F had not advised on precautions. Review of the provider's revised February 2021 Infection Prevention Precautions policy revealed: *Standard precautions would be used for situations when staff provide care for any resident where there was the potential for contact with bodily fluids or excretions. Those precautions included: -PPE was to be used appropriately when the possibility of contact between bodily fluids of the resident and skin or mucosal membranes of staff was existing. -Gloves for contact with hands, gown for contact with clothing, trunk, or limbs, mask for splatter contact with mouth or nose, and goggles for splatter contact with eyes. *Contact precautions were used for residents with known or suspected infections whose transmission was by direct or indirect contact mechanisms. Those precautions included: -PPE would be provided outside the residents room. PPE provided would be gloves and gowns at a minimum. -A trash container would also be provided near the door for doffed PPE. -A communication card for staff would be provided in the container with the PPE which would list the infection type and procedures to be utilized. Review of the provider's revised February 2021 Initiating and Discontinuing Expanded Precautions policy revealed: *The provider would make every effort to use the least restrictive approach in the management of potentially communicable infections. Those procedures included: -If a resident was suspected of or identified as having a communicable infectious disease, the charge nurse would notify the infection prevention staff, director of nursing, and the resident's attending physician for the appropriate expanded precaution. -When expanded precautions were implemented, the charge nurse would ensure that protective equipment was maintained near the residents room. 2. Interview on 10/20/21 at 2:00 p.m. with MDS coordinator E revealed she: *She used the Centers for Disease Control and Prevention (CDC) guidelines for infection control guidelines. *Had been the infection control nurse for approximately 18 months. *Had taken the infection control preventionist class. *Had the nurses keep track of when a resident was prescribed an antibiotic. *Did not review that list to ensure if a resident had a culture taken, if the antibiotic prescribed was effective, or if the residents infection had resolved. *Did not analyze if there was a trend with residents who had similar infections. *Did not have an antibiotic steward ship program. *Did feel she had been given the time or resources to develop an infection control program. *Did not understand how to monitor and run an infection control program. *There was no infection control plan. Surveyor : 3. Observation and interview on 10/19/21 at 10:08 a.m. with CNA K in the tub room revealed: *She stated the door does not lock unless you turn the knob on the backside of the door. *There had been a silver canister with resident's hairbrushes soaking. *She stated the solution in the silver canister was water from the whirlpool. *The nail clippers were used for all the residents. *Surveyor asked how often she cleans them, she replied: -She tried to clean them once or twice a month. -She cleans them by swishing them around in the bath water. -Surveyor pointed out that they were dirty and still had about five to six various sized nail clippings located inside of them. Surveyor : Interview on 10/20/21 at 3:00 p.m. with administrator A and DON B revealed: *They were not aware there was not an effective infection control program. *It was the job duty of MDS coordinator E to manage the infection control program. Review of provider's 1/15/14 MDS Coordinator job description revealed: *Worked closely with the DON to direct the licensed and non-licensed staff who provided health care and nursing services. *Ensured quality of nursing care on a 24-hour basis. *Assist with planning, organizing, and directing the activities of the nursing department to ensure the delivery of quality nursing care with the goal of facilitating the highest level of functioning and independence for each resident. *Essential duties included: -Oversee, coordinate, and complete the process of MDS, assessment, and care planning. -Improvement of resident assessments. -Complete MDS's per schedule. -Coordinate and direct the care plan team and the care conference process.

Based on observation, interview, record review, and policy review, the provider failed to ensure residents received treatment and care in accordance with professional standards of practice and based on a comprehensive person-centered care plan. Findings include: 1. Noncompliance in the following areas demonstrated the provider's failure to provide residents with care and services necessary to obtain their highest practicable well-being: *Provide accessible contact information for filing a complaint with the state survey agency for all residents and their representatives. Refer to F574. *Document communication with and obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Refer to F578. *Submit online state reports and investigate alleged violations of abuse or neglect for residents who experienced falls, resident to resident altercations, or unsafe exit-seeking. Refer to F609 and F610. *Ensure care plans had measurable goals, current status, and complete interventions and revise as needed to ensure staff provide specific and individualized and care and services to address the person-centered needs of the residents. Refer to F656 and F657. *Develop and provide a comprehensive skin program for the prevention of pressure ulcers. Refer to F686. *Provide adequate supervision and an environment free of avoidable hazards to reduce the risk for injury. Refer to F689. *Provide individualized treatment and services to meet the dementia-related psychosocial needs of the resident. Refer to F744. *Ensure infection control precautions had been initiated after an outbreak of vomiting and diarrhea in residents and staff. Refer to F880. *Develop and implement a comprehensive infection control program. Refer to F880. *Ensure there was an antibiotic stewardship program. This failure placed all residents at risk for potential adverse outcomes, associated with the inappropriate and/or unnecessary use of antibiotics. Refer to F881. *Ensure pneumonia vaccination had been offered, administered, or refused. Refer to F883. *Conduct routine COVID-19 testing for residents and staff. Refer to F886.

Based on observation, interview, record review, and policy review, the facility failed to ensure: *Three of three sampled residents (7, 16, and 28) with facility acquired pressure ulcers *One of one sampled resident (9) with a history of pressure ulcers had ongoing skin assessments to prevent new ulcers from developing or recurring. Findings include: 1. Interview on 10/18/21 at 3:31 p.m. with resident 16 revealed he: *Informed surveyors he had a bleeding area on his buttocks. *Stated he had informed staff about this problem. *Had been provided DynaShield by staff for him to apply to the bleeding area. Interview on 10/18/21 at 3:45 p.m. with minimum data set (MDS) Coordinator E revealed: *They had one resident who had a pressure ulcer in the building and that pressure ulcer was healing. -That resident was identified as resident 1. *Residents 7, 9, 16, and 28 were not the resident that she had mentioned. Further interview on 10/18/21 at 5:15 p.m. with MDS coordinator E regarding the facility matrix revealed: *Resident 28 had been marked for a stage II pressure ulcer. *MDS coordinator E stated the matrix was not accurate as resident 28's pressure ulcer had healed. -She stated it had been healed a couple of weeks ago. *She was going to re-print a corrected facility matrix for the surveyors. Observation on 10/18/21 at 5:41 p.m. of resident 16 and director of nursing (DON) B in conversation revealed: *Resident 16 had been sitting at a table, eating dinner. *DON B was completing medication pass. *He was talking to DON B about the bleeding area on his buttocks. *She replied, well you are putting the Dynashield on it right? *He informed her he had been applying the cream to his buttocks. Observation and interview on 10/19/21 at 11:12 a.m. with resident 16 and certified medication aide/certified nursing aide (CMA/CNA) H revealed: *Resident 16 stated: -The areas on his buttocks was sore and tender. -He had been applying the Dynashield. *The areas on his buttocks were sore and tender. *Surveyor was able view and see the bleeding through the adult brief. -He had two bilateral open areas. *CMA/CNA H applied Dynashield to the two open areas on resident 16. *CMA/CNA H stated he had not observed the open areas on resident 16 before. Review of resident 16's EMR revealed: *He had been admitted on [DATE]. *He never had a skin assessment documented. *DON B documented on 10/19/21: -Resident has redness to his bottom with some bleeding. He is self-sufficient with toileting and personal cares. Will assess bottom and send orders as needed. Will apply protective ointment as needed at this time. *An assessment had not been completed, even after surveyors discussed the wound with DON B, MDS Coordinator E, and RN D. Surveyor : 2. Observation and interview on 10/20/21 at 9:35 a.m. with resident 28 and registered nurse (RN) D revealed: *Surveyor had asked to observe resident 28's heel. *RN D stated that she did not have an open wound on her heel. *RN D lifted resident 28's heel off the pillow it had been lying on. *There was an open area on the resident's left heel that was approximately 1 centimeters (cm) by 2 cm. -It was located on the back of her heel, on the Achilles tendon. *There was green and yellow drainage in the resident's sock. *The heel was not being floated nor did it have a protective boot on. *RN D agreed that the wound was open. *The facility did not have a designated wound nurse. *RN D stated that since resident 28 was on hospice, they do not do anything with her wound care or prevention of wounds. *Surveyor asked how many pressure ulcers were in the building. -RN D stated the same resident that MDS Coordinator E mentioned yesterday. -RN D had not mentioned resident 7, 9, 16, or 28. *Surveyor requested hospice RN's phone number to talk to her about resident 28's heel. *Surveyor asked RN D how often they assess resident's skin once a pressure ulcer or opened area has healed. -RN D stated that the CNAs look at the resident's skin when they get their baths but RNs do not do routine skin assessments. *Any skin assessments would have been documented in the assessment tab on the electronic medical record (EMR). *RN D agreed CNAs do not always know what to look for as far as skin injuries. *Any wounds they have in the facility they treat with [MEDICATION(S)]. Review of resident 28's skin assessments revealed the following documentation: *On 6/22/21: -It had been the first observation of the wound. -They requested [MEDICATION(S)] to treat the blister. -Their preventative measures were leaving her shoes off. -It had been classified as other. *On 6/29/21: -There had been no improvement noted. -Their preventative measures were leaving her shoes off. -They were applying [MEDICATION(S)]. -The wound progress was still marked as first observation. *On 7/6/21: -It had been noted to be improving. - .Hospice nurse sees area several times a week. -Interventions were gripper socks only for the time being and no shoes currently. -Their treatment was [MEDICATION(S)] nightly. *On 7/13/21: -The acquired date was 6/15/21. -She was to be wearing a blue boot in bed. -It was a blister/black eschar. -[MEDICATION(S)] two time per day and wound cleanser. -It was almost healed. * On 7/21/21: -The date acquired was listed as 7/21/21. -It was currently a stage III pressure ulcer. -It was worsening. -Blister came off and foul odor drainage. -They would be receiving an air mattress for resident 28. -Hospice requested that they start using [MEDICATION(S)], [MEDICATION(S)] pad and [MEDICATION(S)], every three days. *On 7/28/21: -The date acquired was still listed as 7/28/21. -Marked as a stage II, healing wound. -Will continue to monitor. *On 8/3/21: -They were using a foam boot as a preventative measure. -It had been marked as other with no staging. -Hospice nurses were completing the treatment every three days. -Almost entirely healed. *The next assessment was on 8/24/21: -Gripper socks only were listed as a preventative measure. -It was listed as acquired on 6/30/21. -It was classified as other. -They were applying [MEDICATION(S)] two times per day. *The next assessment was completed on 9/18/21: -The date acquired was listed as 9/18/21. -Listed as a stage II pressure ulcer. -Noted to be the first observation. -There was no current treatment, they were reaching out to hospice. -This assessment was still marked as wound #1, the same wound as above. *The next assessment was completed on 10/4/21: -They were using an air mattress as a preventative measure. -It was acquired on 9/18/21. -It was a stage II, pressure ulcer. -They changed the treatment order to [MEDICATION(S)]. Review of resident 28's 7/6/21 and 9/29/21 Braden scale assessments revealed she was at moderate risk for skin breakdown. Review of resident 28's hospice notes revealed she had: *Two pressure ulcers. *One had been on the bottom of her heel. *Other one had been located on the back of her heel on the Achilles tendon. *an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident 28's hospice nurses' notes revealed: *On 10/20/21: -Received a call from [RN D's name] requesting wound documentation for pt [patient]. Notified office and documentation were sent prior to arrival to SNF[skilled nursing facility]. Upon arrival to SNF Collab with [RN D's name] regarding [resident 28] . - .[RN D's name] reported wound has reopened with scant amount of drainage noted. [RN D's name] and this HRN [hospice RN] assessed wound. Wound now measuring 0.6cm x [by] 1.5 cm x 0.2 cm depth with red beefy center and scant amount of blooding discharge. Mild pain when assesses depth. PT [patient] moan out and was tense. Call placed to [doctor's name] for new wound care orders verbal orders received for [MEDICATION(S)] and cover with Mepliex. Dressed wound was cleansed and dressed. Hospice ordered wound care supplies to be delivered to SNF. Heel boot applied . -Received a second call from [RN D's name] after HRN left facility regarding stages of wound. Collab with original wound was a DTI [deep tissue injury] but was downgraded to stage when we opened . *On 10/15/21 she was noted by hospice to have a stage II pressure ulcer to her left Achilles tendon. Review of resident 28's progress notes revealed: *Inconsistent documentation related to the wound on her heel. *The stage II pressure injury was identified by hospice on 9/18/21. *The documentation mentioned black eschar but then a few days later the wound was healed. *The orders had always gone back to using [MEDICATION(S)]. *The documentation did not mention location of the wound or which wound was being documented on. Interview on 10/20/21 at 11:23 a.m. with hospice RN L revealed: *It is the facility's responsibility to do assessments, staging, and treatments. *Hospice nurses see the resident's two to three times per week so they need help from the facility's nurse to provide care to the residents. *Surveyor asked about the [MEDICATION(S)] order that the facility had been using. *RN L stated that an RN at the facility had always wanted to use [MEDICATION(S)] on all their wounds. *RN L had obtained orders for various wound treatments and the facility would change those orders back to [MEDICATION(S)]. 3. Review of resident 7's EMR revealed: *He had been admitted on [DATE]. *He had one skin assessment completed on 2/24/21. -This was for his left toe. *He was a paraplegic. *There was a history of a stage four pressure ulcer to his coccyx, before admission. *On 2/15/21: -He had .a .25 circular mostly healed open area. No drainage seen from this. Left buttock has a 1 cm by .75 cm mostly healed open area as well. *On 3/2/21: -resident in on air mattress setting changed to variable. on assessment his abd [abdominal] fold right side has an open chafed area [MEDICATION(S)] applied. rest of abd fold and groin area, thighs cleansed and antifungal applied. posterior peri area is very red chafed by his penis, left buttock. golfball size spongy area on coccyx and on his right posterior medial thigh a and d applied and area rubbed lightly for circulation . *On 3/2/21: -He had a care team meeting and his daughters requested to keep him on protein powder because they wanted to ensure his coccyx continues to heal. *On 3/17/21: - .area cleansed and Dyna Shield applied. noted area above coccyx, muscle flap suture line is pronounced and deeper or starting to open. area is chafed on one side gently cleansed and Dyna shield applied. positioned on right side to keep him off his buttocks. *On 3/29/21 an RD note stated: -Visited with DON. Res [resident] does not have any open areas . *On 4/17/21: -resident was caked with power to open right groin and four open chafed areas on buttocks two were bleeding. cleansed well and powder gently removed thin layer of dynashield applied. [MEDICATION(S)] to one area on buttocks . *On 4/19/21: -Weekend nurses informed RN J to call and schedule an appointment with wound care. -Wound care informed them that they would need a referral from the physician. *On 4/23/21: -There were orders for duoderms to open areas on coccyx, buttocks, and perineum. *On 4/27/21: -There was a note that the perineal and buttocks area is healing well. *On 4/29/21: -He returned from wound care. -Staff were to apply [MEDICATION(S)] and leave coccyx open to air. *On 5/26/21 his care team meeting noted: -There were no open sores on his bottom. *On 5/27/21: -He returned from wound care with orders to cleanse scrotum two times per day and sage wipes. *The next non MDS note that discussed wounds was on 10/20/21. *On 10/20/21 RN D documented: -Coccyx assessed this AM. CNAS to continue with protective cream to the area. Surveyor Observation and interview on 10/19/21 at 11: 00 a.m. with resident 7 being assested by certified nursing assistant (CNA) K and CNA/certified medication aide (CMA) H revealed: *CNA K and CMA/CNA H had been assisting resident 7 with personal cares. *He had two open areas to his buttocks. *CNA K and CMA/CNA H had not noticed those areas before. Interview on 10/20/21 at 2:00 p.m. with RN D revealed: *Her assessment was the above 10/20/21 documented note. *She had not measured the wounds. *Her note did not address: -Details. -Physician notification. -Special equipment or preventative measures. -Pressure ulcer stage. -Type of wound. -Overall impression. -What type of tissue was present. -Drainage. -Odor. -Presence of necrotic tissue. -Measurements. -Tunneling. -Peri-wound tissue. -Wound edges. -Suspected infection. -Changes to treatment plan. Further interview on 10/20/21 at 5:15 p.m. with RN D revealed: *She stated: - There was no further documentation that had been completed regarding the wounds. - We just look at the coccyx and chart we looked at it. Review of resident 7's Braden and skin assessments revealed: *He had been identified as At risk for skin breakdown for three of three completed braden assessments. *He had one weekly skin assessment documented. 4. Review of resident 9's EMR revealed: *He had been admitted to the facility on [DATE]. *He had one skin assessment that had been completed on 9/25/21. *The skin assessment on 9/25/21 stated: -They were asking for orders for DuoDerm for incontinence issues. -The special equipment was reposition tpad w [with] insert to prevent incontinence over area. -It was to his right inner buttock cheek. -It had been marked as a stage II pressure ulcer, present from admission. -Currently marked as a stage III pressure ulcer. --Then marked as unchanged. -Comments: Resident is incontinent. -A scant amount of drainage. -It had white edges and wound was beefy red. *His only Braden assessment was completed at admission and he was identified as at risk for skin breakdown. 5. Interview on 10/20/21 at 3:50 p.m. with administrator A and DON B, and administrator in training P revealed: *Surveyor observed open areas on resident 7 and 16. *There had not been any nursing assessments or documentation completed on the resident's regarding these open areas. *DON stated she had educated staff regarding the wounds. -She stated that she placed a sheet in the staff break room regarding the resident's skin and open areas. 6. Review of the provider's February 2021 Wound Care policy revealed staff were to document: *The type of wound care given. *Any change in the resident's condition. *All assessment dates obtained when inspecting the wound. *Inspection of the wound including: -Wound bed color. -Size. -Drainage. *How the resident tolerated the procedure. *Any complaints made by the resident relating to the procedure. *If the resident refused the treatment and reasons why. *The signature and title of the person recording the data. Review of the provider's November 2002 Nursing Policy and Procedure manual revealed: *The following were established to help prevent pressure ulcers: -Dress chronic wounds using clean sterile technique, since all chronic wounds are contaminated. -Cleanse wounds using a non-toxic agent prior to making wound assessment and applying a new dressing. -Select a dressing that keeps the wound bed moist and the peri-wound skin dry. -Prepare the peri-wound skin with a skin sealant prior to the application of any adhesive dressing or tape. -Reevaluate dressings every shift. -Reevaluate the wounds response to the prescribed treatment. Make recommendations for changes at least every 2 weeks. Inform physician of changes in wound status. -Document all wounds weekly on the pressure ulcer skin flow sheet. -DNS [director of nursing services] should review all wounds weekly. Review of the provider's undated New Pressure Area form revealed staff were to document: *If the pressure area had been new. *If the pressure ulcer was facility acquired or present on admission. *Measurements of the wound. *The beginning of pressure ulcer weekly measurements. *Physician contact for orders and to schedule pain medications. *Notification of the DON. *Notification of the MDS coordinator. *Interventions in the care plan and tasks. *Nurses notes. *Completion of an incident form if acquired in the facility. *Notification of family. *Notification of CNAs, and add to their assignment sheets. *Communication with dietary. Review of the provider's May 2021 standing orders stated, wound care protocol for initial wound care.

Based on observation, record review, interview, and policy review, the provider failed to ensure one of one sampled resident (6) who repeatedly had left the facility without staff knowledge had received adequate supervision to prevent future elopements. Findings include: 1. Random observations from 8/14/17 from 2:30 p.m. through 6:15 p.m., 8/15/17 from 8:00 a.m. through 6:00 p.m. and 8/16/17 from 7:50 a.m. through 2:00 p.m., and interviews with resident 6 revealed he: *Ambulated with a cane, his gait was at times wobbly, and he walked very fast. -He had recently had a series of knee surgeries that had left him laid up for a period of time, showing a large scar over his knee. -He wore a sling supporting his right arm and said he had recently fallen in the bathroom. He reached out for the sink as he was falling but dislocated his shoulder and was then sent to the emergency room . *Was alert and oriented to person, place, and time. *Was a night owl staying up until 3:00 a.m. or 4:00 a.m. watching television. *Had remarkable loss of recall ability and acknowledged his decision making was not always the best, stating Sometimes I just do things without thinking about it. -He said he had an accident when he was very young, and that was why he did those things. -He acknowledged he had recently gotten in trouble for walking downtown at about 1:00 a.m. He walked to the bowling area, but the doors were locked. He knocked on the door but the woman said she was closing up, and he had not gotten in. His knee was very sore and tired at that time. There was no one around town to get a ride back, so he entered an apartment building and sat down on the steps in the entry. He thought he would wait until one of the staff who worked the night shift at the nursing home got off work and came home. He thought they would give him a ride back to the facility. He estimated the bowling alley was about ten blocks from the nursing home. -A staff person woke him up at one point and brought him back to the nursing home. He thought it was light out when he got back. Review of resident 6's 2/10/17 through 8/14/17 nursing progress notes revealed: *On 4/12/17 written at 23:03 (11:03 p.m.): CNA (certified nursing assistant) LS leaving from work and notes resident outdoors wheeling self from facility and over to swimming pool area adjoining loft from here. resident has on only his bathrobe and underpants on. Pitch dark and cold outdoors and no lighting where resident wheeling self across the grass. Sent CNA to bring him back and resident agitated, reminded inappropriate and not allowed to leave facility in dark w/o (without) telling anyone. *On 6/9/17 written at 22:49 (10:49 p.m.) Resident left facility at ? (time unknown) and noted coming back to patio door by CNAs and he told CNAs he went out to get a pop but could not get any so went to another pop machine over by the swimming pool and said he was talking to a guy over there. Returning to facility and at patio door at 2200 (10:00 p.m.). Last seen at 2120 (9:20 p.m.). Resident knows codes for doors. *On 8/3/17 written at 07:23 (7:23 a.m.) Received call from owner of the town bowling alley. She reported she thought a resident was banging on her door when they were closing. 911 called, had a deputy phone here et (and) we explained who the resident was et that he had left without letting any one know. They called back an hour later et said they could not find him. Advised him to check @ (at) an apt (apartment) building by the bowling alley. Did not hear back et called the number the deputy had given me to call. Went to voice mall 2x (twice). Called 911 again et they had another deputy call me et he had been the one to search for him et could not find him. Contacted Adm (administrator) et told him of the situation. He reported if needed we could alert the fire dept (department). Staff member sent to apt. by bowling alley et resident there et brought here. Review of resident 6's 4/19/17 through 7/31/17 mental health counselor progress notes revealed on two occasions the counselor acknowledged the elopements. She did not offer any specific approaches to reduce the risk of an elopement. Interviews on 8/16/17 at 9:00 a.m. and at 10:30 a.m. with the director of nurses and the social worker regarding resident 6 revealed: *They confirmed the above investigations were not thoroughly completed, and there was missing information. *The elopement on 4/12/17 had not been investigated or reported to the SD DOH, because they did not really think that was an elopement. -However they confirmed he had left the building in the dark without staff knowledge. --Staff had not seen him leave but had found him outside that night. *They confirmed they had not put measures in place to ensure no further elopements for resident 6. -They primarily had tried to educate staff about not giving out the code to residents. --For everyone to be careful when putting in the code that residents could not see the numerical sequence. --They had also posted a sign by the door reminding visitors to not give out the code. *He was seen by a mental health counselor. *The resident continued to be at risk for elopement. *They had not completed elopement risk assessments on any resident. Review of resident 6's 7/24/17 care plan revealed: *Focus: The resident is an elopement risk r/t (related to) History of attempts to leave facility unattended, impaired safety awareness. *Goal: The resident's safety will be maintained. The resident will not leave facility unattended. *Interventions: Assess for fall risk. Distract wandering by offering pleasant diversions, structured activities, food, conversation, television, book. -Monitor for fatigue. -Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs , pictures, and memory boxes. *The care plan did not address: -How staff were going to monitor his whereabouts. -He had never left the facility during times when structured activities were being offered. --He left during the nighttime. -He had left the building when he was upset about a misconstrued relationship with a person on staff. --What, if anything, they did to minimize that staff's person's need to have encounters with him. -How they eliminated the risk of the resident knowing the security code to exit the building undetected. Review of the Elopement policy initially given to the surveyor on 8/15/17 at 10:00 a.m. revealed: *The last review was November 2009 and included documentation tools required when they were under other management. *The policy read: Elopement definition: When a resident who needs supervision leaves the premises or a safe area without authorization and/or the necessary supervision to do so. *Policy: The center will be responsible for maintaining a system which clearly defines the mechanisms and procedures for monitoring and managing residents at risk for elopement. These include identifying environmental hazards and resident risks. evaluating/analyzing hazards and risks; implementing interventions; and monitoring/modifying interventions as needed. *All residents will be assessed for risk of elopement through the pre-admission and or admission process and as needed. Each center will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. When an elopement occurs, immediate efforts to locate the resident will be taken. All occurrences will be documented and all follow-up required by state and federal regulations will occur. Review of the provider's undated Accident Prevention and Intervention policy revealed: *The resident's environment will remain as free of accident hazards as is possible. Residents shall receive adequate supervision and assistance devices to prevent accidents. *Social Services staff will monitor residents for unusual physical and/or mental behavior during each program/service. Unusual behaviors shall be reported to the Director of Nursing, or Charge Nurse as possible. *Social service staff shall review incident reports involving residents at least weekly. Staff will attempt to determine if there are a number of accidents or injuries of a specific type or that occur on a specific shift. Recommendations to prevent reoccurrences will be forwarded to the Administrator and QAA committee.

Based on observation, record review, policy review, and interview, the provider failed to: *Implement interventions throughout the facility for all residents to minimize resident's falls. *Report, investigate, and implement fall prevention interventions for eight of eight sampled residents (2, 4, 5, 6, 7, 8, 9, and 10) who had fallen. Findings include: 1. Review of the provider's fall tracking log for the residents revealed: *November 2014 there were nineteen falls. -Resident 2 was listed twice. -Resident 5 was listed four times. -Resident 7 was listed twice. *December 2014 there were twenty-one falls recorded. -Resident 2 was listed twice. -Resident 4 was listed twice. -Resident 5 was listed four times. -Resident 7 was listed twice. *January 2015 there were ten falls recorded. -Resident 4 had one fall. -Resident 5 was listed twice. *February 2015 there were twenty falls or rolled off the bed. -Resident 2 was listed six times for falls or rolling off the bed. -Resident 4 had fallen outside of the facility once and had one fall within the facility. -Resident 5 had one fall. Review of the provider's manager meeting weekly notes from January 5, 2015 to March 6, 2015 revealed they had discussed residents falls. Residents names were listed. No intervention was listed to minimize falls. On 2/13/16 there was the comment "Do we need to assemble a fall prevention committee?" Interview on 3/11/15 at 3:20 p.m. with the director of nursing (DON) revealed: *The incident report was completed for all falls. *No initial or five day report or investigation would be completed for any falls. *Her understanding was falls were not reportable unless the resident had been hospitalized or it was unwitnessed falls. *Review of the SD DOH investigation form indicated the provider had highlighted in the instructions the words "Required nursing facility event reporting." Interview on 3/12/15 at 8:45 a.m. with the administrator revealed: *He was aware of all of the resident falls. *They had a weekly management meeting where they discussed the falls. *They had quality assurance performance improvement (QAPI) meetings were the falls were discussed. *The QAPI committee consisted of the administrator, DON, activity director, and social services designee (SSD). Also included where the following department managers: dietary, housekeeping, business, laundry, and maintenance. *The incident reports were reviewed by the DON, the administrator, and the medical director. *They reviewed how many falls each resident had and discussed what they should do to minimize the falls. *The did not document interventions for the residents during either meetings. *The investigation should have included the who, what, where, when, and why. *They had discussed a fall prevention committee, but that had not been developed. 2. Review of resident 2's 11/2/14 through 2/22/15 nurses notes and incident reports revealed: *11/2/14 at 4:25 p.m.- "Resident's knees buckled when being transferred from recliner to wheelchair by certified nursing assistant (CNA). Lowered to floor." *11/13/14 at 11:15 a.m.- "Attempted to get up on own and fell forward out of chair. Cut on forehead and on 2nd to last finger on right hand." *2/1/15 at 9:32 p.m.- "Staff was assisting resident to bed using the stand aide (lift that requires the resident to be able to bear some weight on their legs). Resident decided not to stand up and lifted his legs leaving him hanging from the stand aide by his arms. Staff assisted to remove him from the stand aide and lowered him to the floor. A total lift (mechanical lift that requires no weight bearing from the resident) was used to help lift him from the floor to his bed." *2/3/15 (no time)- "Resident found lying on the floor on his right side. Skin tear to right elbow." *2/5/15 at 2:25 p.m.- "Resident had his Tabs on (monitor that alarms). In bed in low position. Resident rolled out of bed. Found lying on his comforter." *2/9/15 at 10:15 a.m.- "Found resident laying on pillow between wall and the bed." *2/10/15 at 9:30 a.m.- "Found on floor mat beside low bed. Body pillow with him." *2/19/15 at 12:30 a.m.- "Found laying on left side on floor mat next to bed. Tabs monitor on. No injuries." *2/22/15 at 5:50 a.m.- "CNA came to get resident ready for the day. bed in up position for her to work with the resident. She went to get washcloth and resident rolled out of bed. She had placed body pillow prior to leaving bedside. Skin tear front of forehead, bridge of nose, reopened one on left elbow, pinpoint one 2nd finger right hand, and 3rd finger left hand." Review of resident 2's 2/24/15 fascimile (fax) communication to the physician revealed: *"On 1/28/15 order received to discontinue Aricept (medication for severe dementia (memory loss) and zoloft (antidepressant) per family request." *"On 1/16/15 they requested to have risperdal (antipsychotic medication for mood/behavior)." *"Since that time resident has fallen numerous times." *"In your opinion do you feel the stop of his medications could contribute to his falls?" *The physician responded "No. I think it is his disease process." Interview on 3/12/15 at 10:00 a.m. with the director of nursing (DON) regarding resident 2 revealed: *She had really not investigated any of his falls. *The staff usually had observed him fall or roll out of bed when they entered the room. *They knew he was a high fall risk and had implemented the high/low bed, mat on the floor, and the Tabs monitor (alarm goes off when the resident attempts to get up unassisted). *They had removed the air mattress hospice had put on his bed with the 2/19/15 fall. They had determined that was causing him to roll off the bed. *They attributed his restlessness and increased falls in February 2015 related to the family's request he be taken off all his psychotropic (mood and behavior altering medication) at the end of January 2015. 3. Review of resident 5's incident reports revealed: *On 11/8/14 the resident had tripped carrying a tote. The resident had been taken by an ambulance to the local hospital. *On 11/12/14 at 4:20 a.m. the resident was found on the floor in the bathroom. She had only one gripper sock on. In the section list [DIAGNOSES REDACTED]. *On 11/12/14 at 9:00 a.m. the resident had attempted to get up on her own and fell to the floor. She had been found sitting on the floor. *On 11/18/14 the resident was found sitting on the floor next to the bed and the wheelchair. Appears resident went to the bathroom without asking for assistance. *On 11/27/14 the resident was found sitting on the floor in front of the toilet and was hanging on the rail. *On 1/21/15 the resident was heard yelling. She was found on her knees in the bathroom next to the toilet. The resident had removed the safety alarm monitor and transferred herself. Review of resident 5's nurse's notes revealed on 11/8/14 the resident had fallen and complained of left leg pain. The physician had been notified and orders were received to transfer her to the hospital. She had been transferred to the hospital for a hip fracture. No information had been documented regarding to the events as to why the fall had occurred. Review of the nurse's notes on the above dates for the falls revealed no documentation for an investigation as to why the falls had occurred. Review of resident 5's current care plan revealed: *To encourage the resident to use bell to call for assistance. *For the focus regarding an actual fall with injury the interventions were to continue to use the interventions on the at-risk plan. For no apparent acute injury determine and address causative factors of the fall. *For the focus regarding use of the seat belt was to be used daily. The intervention was to position the resident correctly in the wheelchair. Another intervention listed was the resident was able to release the belt that sounded an alarm to alert the staff of the self-transfer. *There were no interventions on the care plan to direct staff on how to minimize falls for the resident. 4. Review of resident 4's incident reports revealed: *On 12/22/14 the resident reportedly fell to his knees. The resident had stated he had lost his balance. *On 12/23/14 the resident was found sitting on the floor in his room. Resident was confused. *On 1/20/15 the resident was found on his hands and knees on the floor in front of the bed with the wheelchair over him. *On 2/14/15 the resident was found laying on the floor. Review of the nurses notes on the above dates for the fall revealed no documentation for an investigation as to why the falls had occurred. Review of resident 4's progress notes revealed: *On 1/6/15 the SSD documented: -The resident could be found sitting in other resident's wheelchairs in a slumped over position. -"He might go from a sitting to a standing position over a 5 minute period." It will take two to three staff to get him off the floor and dressed or in bed. *On 1/9/15 the DON documented: -The resident required extensive assistance with the majority of his activities of daily living. -He had poor posture and inability to stand straight or ambulate without freezing in position. -He had altered mental status and unsteady gait with huge risk for falls. He had falls prior to admission and since his arrival into the facility. Review of resident 5's current care plan revealed the following interventions: *To encourage the resident to use the bell to call for assistance. *Provide a safe environment: call light in reach, adequate low glare light, bed in lowest position and wheels locked. *For the focus area regarding the resident was high risk for falls related to unawareness of safety needs, poor communication, and Parkinson's Disease with a shuffling gait the interventions were: -Anticipate and meet the resident's needs. -Ensure the call light was in reach and encourage him to use it. -Educate the resident/family/caregivers about safety reminders and what to do if a fall occurred. -Ensure the resident was wearing appropriate footwear when walking or propelling in wheelchair. -Follow facility fall protocol. -The resident needed a safe environment with even floors free from spills and/or clutter: adequate, glare-free light; a working and reachable call light; handrails on walls, and personal items within reach. *There were no interventions on the care plan to direct staff on how to minimize falls for him. 5. Review of resident 6's incident reports revealed: *On 2/2/15 the resident was found lying on the floor in the middle of the room. An approximate twelve inch laceration was on his right forearm. The area was cleaned, and the resident was sent to the emergency room . Review of the nurse's notes indicated the resident had attempted to walk to the bathroom. *On 2/10/15 the resident had been in the bathroom and got up on his own. He was found on his knees with his head over the toilet. He had a laceration on the top of his head. *On 2/23/15 the resident was in bed and had rolled out onto the fall mat located next to the bed. The mobility monitor had sounded to alert the staff. Review of resident 6's current care plan revealed the following interventions: *To encourage the resident to use the bell to call for assistance. *For the focus area the resident was at moderate risk for falls due to unawareness of safety needs, and gait and balance problems. An intervention listed was to review information on past falls and attempt to determine cause of falls. Record possible root causes (why did it happen). Remove any potential causes if possible. Educate resident/family/caregivers as to causes. *There were no interventions on the care plan to direct staff on how to minimize falls for him. 6. Review of resident 7's incident reports revealed: *On 12/7/14 he was found lying next to his bed wrapped in blankets. The resident indicated he had been trying to get to his wheelchair. *On 12/16/14 the resident fell out of bed while leaning over to get to the overbed table. "Because of physical condition, unable to stop/protect self once falling. Hit head against edge of bookcase." Review of resident 7's current care plan revealed no safety interventions or information he had a history of [REDACTED]. 7. Review of resident 8's incident report revealed no date, the fall occurred at 1:30 a.m., the resident was confused, and had been found sitting on the floor at the end of her bed. The overbed table was tipped over. Review of the progress notes for that incident indicated the same information, and they would continue to monitor. Review of resident 8's current care plan revealed she was at moderate risk for falls related to wandering and dementia (impaired memory). Interventions were: *Follow facility fall protocol. *Be sure the call light was within reach and encourage the resident to use it for assistance as needed. *Ensure the resident was wearing appropriate footwear when walking. *There were no interventions on the care plan to direct staff on how to minimize falls for her. *There was no information regarding the fall noted above. 8. Review of resident 9's incident report on 2/16/15 revealed the resident was walking in the hall and attempted to sit in a wheelchair that was in the hall. The resident missed the chair and sat on the floor. There was no information on the incident report if the wheelchair had been locked or unlocked when the resident attempted to sit down. 9. Review of resident 10's incident report dated 1/22/15 revealed when the resident was having physical therapy she had stepped on a bar causing her to fall on her left side hitting her hip and the back of her head. Review of resident 10's nurse's notes revealed documentation on 1/26/15 the resident had a fall in therapy on 1/22/15. No documentation was in the nurses notes regarding the fall until 1/26/15 when the resident complained of a left shoulder, left knee, and left jaw pain. The resident complained of pain level at a six on the pain scale from one to ten with ten being the worst pain. 10. Review of the provider's 7/10/13 Resident Incident policy revealed: *All incident reports would be given to the DON to assess and given to the administrator for review. *The DON would complete a log of all incidents and send reports to SD DOH. *Even reports would be sent to SD DOH if it was determined that the incident/accident resulted from abuse or neglect. The two hour event report and the twenty-four hour event report would be completed by the charge nurse, DON, or social worker. *Incidents that required an event report include: abuse, neglect, serious bodily injury, falls resulting in serious injury or hospitalization , injuries of unknown origin, theft of a resident's items or misappropriation of resident's funds, death (other than natural causes), and missing resident/elopements. Review of the provider's 7/17/14 Falls policy revealed to fill out the "24-Hour Event Reporting" sheet if suspicion of abuse and neglect or if the the fall resulted in a major injury or hospitalization ; fax into the indicated number on the form.

Based on observation, record review, policy review, interview, and job description review, the provider failed to report, investigate, and implement fall prevention interventions for eight of eight sampled residents (2, 4, 5, 6, 7, 8, 9, and 10) who had histories of falls. Findings include: 1. During the survey from 3/11/15 through 3/12/15 the director of nursing and the administrator confirmed a thorough investigation had not been completed for when the above residents had fallen. Only incident reports had been completed. Review of the South Dakota Department of Health Reporting of Injuries of Unknown Source and Reasonable Suspicion of a Crime form specific for falls revealed: *NOT all falls are reportable. Those falls that involve injury of a serious nature should be reported. *If a fall occurs and the provider determines there were no injuries at the time but later there is discovery of an injury and it is not a serious nature, then the fall should be reported. *All falls whether reportable or not should reflect a thorough internal investigation. The investigation should ascertain if there were injuries, appropriate treatment, and a determination if there may have been contributing factors, include any review or revision of individual care plan or facility practices. Review of the provider's 8/5/13 administrator job description revealed: *"Administers, directs, and coordinates all activities of the care center to carry out it's objectives as to the care of the individuals who need nursing care." *"Develops and monitors all departments within the facility to meet the standards put forth by the governing board, management, and state and federal regulations." Review of the 1/15/14 director of nursing (DON) job description revealed: *"Directs the licensed and non-licensed staff who provide health care and nursing services to the residents of the facility." *"The DON's prime responsibility is to ensure the provision of quality nursing care on a 24-hour basis to the residents of the care center in accordance with federal, state, and local standards and regulations." *"Assures there is compliance with the regulations pertaining to care plans and resident assessments." *"Collaborates with outside providers such as hospice, contract therapy, and pharmacy companies to enhance the quality of care for the residents." *"Reviews grievances and must show professional judgement in managing personnel or resident concerns/issues." *"Participates in various committees/meetings for quality review such as falls, skin condition, pharmaceutical and physical/chemical restraining policies and procedures. This position assures that committee recommendations are carried out and reviews and responds to incident reports." Refer to F224, F225, and F323.

Based on record review, interview, and policy review, the provider failed to investigate to determine if abuse or neglect had occurred for one of one sampled resident (2) with a history of falls. Findings include: 1. Review of resident 2's medical record revealed he had been admitted to hospice services at the request of his daughter on 2/6/15 for end stage dementia (memory loss). Review of resident 2's 11/2/14 through 2/22/15 nurses notes and incident reports revealed: *11/2/14 at 4:25 p.m.- "Resident's knees buckled when being transferred from recliner to wheelchair by certified nursing assistant (CNA). Lowered to floor." *11/13/14 at 11:15 a.m.- "Attempted to get up on own and fell forward out of chair. Cut on forehead and on 2nd to last finger on right hand." *2/1/15 at 9:32 p.m.- "Staff was assisting resident to bed using the stand aide (lift that requires the resident to be able to bear some weight on their legs). Resident decided not to stand up and lifted his legs leaving him hanging from the stand aide by his arms. Staff assisted to remove him from the stand aide and lowered him to the floor. A total lift (mechanical lift that requires no weight bearing from the resident) was used to help lift him from the floor to his bed." *2/3/15 (no time)- "Resident found lying on the floor on his right side. Skin tear to right elbow." *2/5/15 at 2:25 p.m.- "Resident had his Tabs on (monitor that alarms). In bed in low position. Resident rolled out of bed. Found lying on his comforter." *2/9/15 at 10:15 a.m.- "Found resident laying on pillow between wall and the bed." *2/10/15 at 9:30 a.m.- "Found on floor mat beside low bed. Body pillow with him." *2/19/15 at 12:30 a.m.- "Found laying on left side on floor mat next to bed. Tabs monitor on. No injuries." *2/22/15 at 5:50 a.m.- "CNA came to get resident ready for the day. bed in up position for her to work with the resident. She went to get washcloth and resident rolled out of bed. She had placed body pillow prior to leaving bedside. Skin tear front of forehead, bridge of nose, reopened one on left elbow, pinpoint one 2nd finger right hand, and 3rd finger left hand." Interview on 3/12/15 at 8:30 a.m. with the director of nursing regarding resident 2's 2/22/15 fall with injuries revealed she: *Had not investigated the incident other than reading the documentation from the nurse and talking to CNA A. It was not an unwitnessed incident as CNA saw him rolling off the bed. *Stated CNA A felt very bad regarding the incident. *Felt it was not necessary for any disciplinary action to be done. *Confirmed CNA A left his bed not in the low position and went into the bathroom to get a washcloth. The CNA had her back turned away from him when she was in the bathroom. *Agreed he had a lot of falls, but the facility had related it to the family having the physician discontinue his [MEDICAL CONDITION] medication (mood and behavior altering) the end of January 2015. Since that time he had become more restless and resistant with care. *Stated the CNA had put the body pillow around him before she went into the bathroom. They had started the body pillow the past month. He had rolled out of bed before, and the body pillow had protected him from serious injury. *Confirmed he got injured during the incident, but he did not need to be sent to the emergency room . Review of resident 2's undated care plan revealed "Resident has high/low bed. Staff will make sure it is in low position when in bed to eliminate risk for falls." Review of the provider's undated Abuse policy revealed: *Mistreatment, neglect, or abuse of residents is prohibited by any individual. *Neglect is failure to provide goods, materials, and services necessary to avoid physical harm, mental anguish, or mental illness. *The investigative team shall generate a written summary based on all discussions, observations, documentation, findings, and conclusions of their investigation of alleged violation. That report shall be maintained in the administrator's office for a minimum of five years.

Based on record review and interview, the provider failed to ensure quality of care during end of life for one of one sampled resident (2). Findings include: 1a. Review of resident 2's 11/2/14 through 2/22/15 nurses notes and incident reports revealed: *Multiple falls and injuries (11/2/14, 11/13/14, 2/1/15, 2/3/15, 2/5/15, 2/9/15, 2/10/15, 2/19/15, and 2/22/15). *None of the above falls had been investigated. Refer to F224, finding 1, and F323, finding 2. b. Review of resident 2's 1/27/15 through 3/9/15 progress notes by the director of nursing (DON), dietary manager, dietitian, activity director, and social services designee (SSD) revealed: *Multiple documentation regarding the family's concern related to his care and medication. *There was no documentation the provider had made any referrals or resolved their concerns. Refer to F250, finding 1. c. Review of resident 2's undated careplan revealed: *There were no specific guidelines for transfers documented for the certified nursing assistants. *There was documentation the high/low bed should be in the low position when he was in bed as he was a high fall risk. On 2/22/15 he rolled out of bed when it was in a high position when the caregiver had left him unattended to get a washcloth in the bathroom. Refer to F280, finding 2. d. Review of resident 2's 2/12/15 through 3/8/15 physician's orders [REDACTED]. Refer to F281, finding 1.