Every finding on record at Dakota Alpha

Based on observation, record review, policy review, and staff interview, the facility failed to provide medication in accordance with professional standards for 1 of 5 residents (Resident #5) observed during medication pass. Failure to ensure the facility's stock medication formulary accommodated physicians' orders and/or staff clarified orders to match the formulary stock medication supply resulted in Resident #5 and possibly other residents receiving an inaccurate medication dose and may result in unintended therapeutic results. Findings include: Review of the facility policy titled Administration of Medications occurred on 07/09/25. This policy, dated 07/01/25, stated, Procedure: Medications are administered . as ordered by the physician . Ensure that the six rights of medication administration are followed: . Right dosage . Review of Resident #5's medical record occurred on 07/08/25. A physician's order, dated 06/01/23, stated, Calcium-Vitamin D Tablet 600-200 MG [milligrams]-UNIT [Calcium 600 mg with Vitamin D 200 units (equivalent to 5 micrograms)] Give 1 tablet by mouth two times a day for OTHER SPECIFIED DISORDERS OF BONE DENSITY AND STRUCTURE. Observation on 07/08/25 at 8:23 a.m. showed a nurse (#1) administered one tablet of Calcium 600 mg with Vitamin D 400 units (equivalent to 10 micrograms) to Resident #5 from the supply of stock medications. The nurse later verified this as the only Calcium with Vitamin D available in the facility's stock supply. During an interview on 07/08/25 at 11:21 a.m., an administrative nurse (#2) stated the facility used the stock Calcium with Vitamin D the consultant pharmacy provided. At 11:55 a.m., the nurse (#2) stated the facility provided stock medications as part of a resident's care and the nurse should have contacted the provider to update the order to match the stock medication available.

Based on observation, record review, professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 1 supplemental resident (Resident #7) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the Centers of Disease Control (CDC) guidance at https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/policy-memos-states-and-cms-locations/enhanced-barrier-precautions-nursing-homes-prevent-spread-multidrug-resistant-organisms-mdros, dated March 20, 2024, titled Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), stated, EBP are indicated for residents with . indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical device examples . feeding tubes . Review of Resident #7's medical record occurred on all days of survey. The care plan identified the resident required EBP. Observation on 07/07/25 at 10:47 a.m. showed a sign on Resident #7's door identifying enhanced barrier precautions. A certified nurse aide (CNA #3) completed hand hygiene, applied gloves, performed perineal cares, and transferred Resident #7 from the toilet to the wheelchair using a mechanical sit to stand lift. The CNA (#3) failed to apply a gown before providing perineal cares. During an interview on 07/08/25 at 4:40 p.m., an administrative nurse (#2) stated she expected staff to wear gowns when providing toileting assistance for residents requiring enhanced barrier precautions.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure food is prepared and stored in a clean and sanitary manner in 1 of 1 kitchen and 1 of 1 kitchenette (Resident Kitchen). Failure to ensure cleanliness of the kitchen, dishware, and food storage areas, to properly store raw and ready-to-eat foods and discard outdated food items has the potential to result in foodborne illness to residents, visitors, and staff. Findings include: Review of the facility policy titled Food Safety Requirements occurred on 05/29/24. This policy, revised 01/31/23, stated, . Food safety practices shall be followed throughout the facility's entire food handling process. Elements of the process include the following: . Storage of food in a manner that helps prevent deterioration or contamination of the food . Preparation of food, including thawing . Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with the food. Practices to maintain safe refrigerated storage include: . storing raw meats on shelves below . ready-to-eat foods so that meat juices do not drip onto these foods . Keeping foods covered or in air tight containers. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. Staff shall follow facility procedures for . cleaning fixed cooking equipment. additional strategies to prevent foodborne illness include . Preventing cross-contamination of foods. Review of the facility policy titled Use and Storage of Food Brought in by Family or Visitors occurred on 05/29/24. This policy, revised 04/16/24, stated, . All food items that are already prepared by the family or visitor brought in must be labeled with the content and dated. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. The prepared food must be consumed by the resident within 3 days. If not consumed within 3 days, food will be thrown away by facility staff. Review of the facility policy titled Dishwashing & [and] Kitchen Sanitation Procedure occurred on 05/29/24. This policy, revised 01/31/23, stated, . All cookware, dishes and eating utensils will be cleaned & sanitized according to regulatory guidelines. Dishwasher Usage & Maintenance . Exterior of dishwasher should be wiped down at a minimum of daily with spot-cleaning throughout the work day [sic]. Assigned staff will descale dishwasher on a weekly basis . Observations on 05/28/24 at 9:05 a.m. showed the following: MAIN KITCHEN COOLER * A covered plate of breakfast food with water on top of the plate cover. The water dripped down onto the plate cover from thawing food containers located on a shelf above. The plate cover had an approximate one-inch diameter opening on its top, which would allow water to drip onto the food. A dietary staff member (#4) stated staff saved the plate in the cooler for resident consumption later. * A large baking sheet with two large rolls of thawing ground beef, a sealed package of sliced, ready-to-eat Canadian bacon, and a zip-lock bag of diced, ready-to-eat ham. CLEANLINESS * A silverware divider located inside a drawer contained dried food substances on the side of the teaspoon divider. * The base of a mini blender sticky with loose food particles on it. * A recently washed container for the mini blender placed upside down on the counter adjacent to the blender base. Part of the container set on top of a sticky dried substance on the counter. * A sticky substance on the controls on the coffee machine. * Burnt, loose, debris under all the grates of the gas cooking stove. * A cupboard containing spices and cooking oils with a layer of dust and spice particles, and random areas with a sticky substance throughout the shelves of the cupboard. * Loose lime-scale debris on top of the dishwasher. RESIDENT KITCHEN * A large clear plastic container of outdated cut pineapple located in the bottom drawer of the refrigerator, labeled with a resident's name, and dated 05/11/24. During an interview on 05/28/24 at 4:11 p.m. a dietary manager (#3) confirmed potential for contamination of the stored breakfast plate with the dripping water, and the thawing raw meat and ready-to-eat meats should be stored separately. The manager (#3) stated the cleanliness of the kitchen is on her list to get the staff to do, and confirmed the pineapple in the kitchenette as outdated and discarded it.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 1 of 2 sampled residents (Resident #11) observed during a dressing change. Failure to place a barrier and establish an area for soiled products has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Clean Dressing Change occurred on 05/30/24. This policy, dated 02/09/23, stated, . Set up clean field with needed supplies for wound cleansing and dressing application: a.) If a table is available, wipe clean before use. b.) Place a disposable cloth or linen saver on the overbed table or available surface. Establish area for soiled products to be placed (Chux [disposable pad] or plastic bag). Observation on 05/29/24 at 11:00 a.m. showed a nurse (#2) placed supplies for a dressing change on Resident #11's bedside table. The nurse donned gloves, removed the dressing from the resident's infected toe, removed her gloves, performed hand hygiene, donned gloves, and used gauze and a wound cleanser to cleanse the infected area. The nurse (#2) placed the soiled gauze on the floor and continued with the dressing change. The nurse failed to clean and place a barrier on the bedside table and establish an area for the soiled products. During an interview on 05/30/24 at 10:35 a.m., an administrative nurse (#1) stated she expected staff to use a barrier on the bedside table for supplies and not place soiled gauze on the floor.

Based on staff interview, the facility failed to ensure 1 of 1 nutrition and food services supervisor (#1) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 07/13/23 at 12:36 p.m., the nutrition and food services supervisor (#1) confirmed they have not completed the necessary courses required for the director of food and nutrition services. The facility failed to ensure the supervisor (#1) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on observation and staff interview, the facility failed to ensure a safe and clean environment for 2 of 3 sampled residents (Resident #8 and #15) and 2 supplemental residents (Resident #4 and #9) with personal fans. Failure to clean personal fans does not provide a safe/clean environment and has the potential to place the residents at risk for illness. Findings include: Observations on 07/11/23 from 9:50 a.m. to 10:05 a.m., showed the following: * Resident #4 lying in bed with a tower fan (visible dust on the outside grate) blowing air directly toward the resident. * Resident #8 lying in bed with an oscillating stand fan (visible dust on the outside grate covering the fan blade) blowing air directly toward the resident. * Resident #9 lying in bed with a tower fan (visible dust on the outside grate) blowing air directly toward the resident. * Resident #15 lying in bed with a tower fan (visible dust on the outside grate) blowing air directly toward the resident. The facility failed to provide a policy related to the cleaning of residents' personal fans. During an interview on 07/13/23 at 12:56 p.m., an administrative staff member (#2) stated staff are expected to clean dirty equipment in residents' rooms.

Based on record review, review of facility policy, and family and staff interviews, the facility failed to provide resident representatives copies of the quarterly financial statements for 2 of 3 residents (Resident #4 and #17) reviewed for personal fund accounts. Failure to provide quarterly statements to the individuals designated by the residents to make financial decisions on their behalf prevented the representatives from verifying transactions and fund balances. Findings include: Review of the facility policy titled Resident Spending Accounts occurred on 07/13/23. This policy, revised 03/09/23, stated, . Dakota Alpha can establish a Resident Spending Account that is separate from Dakota Alpha's operating accounts if the resident chooses. Residents will be given an accounting of their funds held by the Administrative Assistant quarterly, and a copy is placed in their file. Family interviews identified the following: * 07/11/23 at 3:07 p.m., Resident #4's guardian indicated she had not received any quarterly financial statements. * 07/11/23 at 3:18 p.m., Resident #17's family member who manages her finances stated, No, I haven't received one [quarterly statement]. During a staff interview on 07/12/23 at 9:52 a.m., a social services staff member (#8) indicated quarterly financial statements are sent to resident representatives upon request.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 3 of 4 residents (Residents #3, #6, and #16) observed during medication administration. Failure to properly prepare insulin pens (Residents #6 and #16), follow physician orders for blood glucose monitoring (Resident #16), and check gastric tube placement (Resident #3), may result in residents receiving inaccurate doses of insulin, adverse reactions due to high blood glucose levels, and medications not delivered to the stomach. Findings include: INSULIN PENS Review of the facility procedure titled Insulin Pen occurred on 07/13/23. This procedure, dated 06/06/23, stated, . 11. g. Attach safety needle: . iv. Twist open and remove outer cover from the pen needle. h. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Observation on 07/12/23 from 7:53 to 8:09 a.m. showed the nurse (#5) failed to remove the needle covers and held the pens horizontally while priming two insulin pens for Resident #16 and one insulin pen for Resident #6. During an interview on 07/13/23 at 1:00 p.m., an administrative staff member (#2) stated nurses are to hold insulin pens upright with the cover off when priming. 27221 MONITORING BLOOD GLUCOSE Review of the facility procedure titled Blood Glucose Monitoring occurred on 07/13/23. This procedure, reviewed/revised 12/01/22, stated, . It is the procedure of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders. Collect blood sample . Read the digital display to receive blood glucose result. Report critical test results to physician timely. Document the procedure. Review of the facility procedure titled Provision of Physician Ordered Services occurred on 07/13/23. This procedure, reviewed/revised 06/08/23, stated, . Qualified nursing personnel will . review the diagnostic test . and communicate the results to the ordering Physician . per the ordering physician's orders. Review of Resident #16's medical record occurred on all days of survey. The current care plan identified, [Resident #16] has Diabetes Mellitus Type II. He is at risk for diabetes related complications, Accuchecks as needed, Notify MD if needed . The current physician's orders showed Resident #16 receives Lantus insulin, Novolog insulin, and Victoza for his diabetes. An order, dated 10/24/22, identified, Accuchecks if symptomatic. Call MD [medical doctor] if < [less than] 50 [milligrams (mg) per deciliter (dL)] or > [greater than] 500. On 05/10/23, the physician changed the parameters to < 50 or > 400. The blood glucose log identified Resident #16 had a blood glucose level of 502 mg/dL on 04/19/23 and 462 mg/dL on 05/17/23. A progress note, dated 04/21/23, identified, . [Resident 16's] blood sugars have been before meals that [sic] last 3 days. 4/18: 362 before supper 4/19: 377, 502, 378, 4/20: 329, 368, not able to get one before supper 4/21: 314 this morning . Review of the progress notes showed staff failed to document Resident #16's symptoms at the time of the 502 mg/dL and 462 mg/dL readings and failed to notify the physician in a timely manner when Resident #16's blood glucose readings fell outside the set parameters. During an interview on 07/11/23 at 3:45 p.m., an administrative nurse (#2) confirmed staff failed to document Resident #16's symptoms and failed to notify the physician in a timely manner when Resident #16's blood glucose readings fell outside the set parameters. 47896 GASTROSTOMY TUBE Review of the facility procedure titled Verifying Placement of Feeding Tube occurred on 07/12/23. This procedure, dated 06/22/23, stated, . For gastrostomy tubes [surgical opening into the stomach through the abdominal wall], check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube. Measure the pH [a way to measure the acidity level] of the gastric secretions . Review of Resident #3's medical record occurred on all days of survey. The physician orders, dated 09/22/21, stated, Verify placement of feeding tube before beginning a feeding, flushing tube, or administering medications. three times a day Check that enteral retention device is properly approximated to abdominal wall before checking centimeter markings. Gastric fluid usually has a pH of 5 or less (See Verifying Placement of Feeding Tube policy and procedure) Observation on 07/11/23 at 10:00 a.m. showed the nurse (#6) administered medications and feeding via g-tube for Resident #3. The nurse failed to verify placement of the feeding tube. Observation on 07/12/23 at 9:55 a.m. showed the nurse (#5) administered medications and feeding via g-tube for Resident #3. The nurse failed to verify placement of the feeding tube. During an interview on 07/13/23 at 8:59 a.m., an administrative staff nurse (#2) confirmed when verifying placement of feeding tubes staff would be expected to check the measurement on the g-tube and check the pH of the gastric contents if it is present.

Based on record review and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #19) diagnosed with post-traumatic stress disorder (PTSD) received appropriate treatment and services to meet his assessed needs. Failure to provide appropriate person-centered and individualized treatment and services may result in Resident #19's inability to attain his highest practicable mental and psychosocial wellbeing. Findings include: The facility failed to provide a copy of their policy addressing trauma and/or post-traumatic stress disorder (PTSD). Review of Resident #19's medical record occurred on all days of survey. The quarterly Minimum Data Set, dated dated [DATE], identified a diagnosis of PTSD. Current medications included antianxiety, antidepressant, and antipsychotics. During an interview on 07/12/23 at 3:30 p.m., an administrative nurse (#2) stated, We do not have a PTSD assessment. We do have the PHQ-9 assessment [Patient Health Questionnaire 9 - Mental Health Screening for depression]. A Bio-Psychosocial History, dated 05/11/23, identified a history of sexual abuse and past thoughts/plan to self-harm . [Resident #19] reports although he is addressing his issue in counseling, it continues to be an unresolved issue for him, and he believes it always will be. The current care plan failed to address Resident #19's emotional/psychosocial needs related to his trauma/PTSD diagnosis, and failed to include any clinically appropriate and person-centered interventions used to avoid re-traumatization. During an interview on 07/13/23 at 2:30 p.m., an administrative nurse (#2) confirmed Resident #19's care plan failed to address his emotional/psychosocial needs related to his trauma/PTSD diagnosis. The facility failed to: * Ensure Resident #19's assessment identified expressions or indications of distress, identified triggers that may cause re-traumatization, and addressed his preferences, * Develop and implement approaches to care that were both clinically appropriate and person-centered, and * Develop an individualized care plan that addressed Resident #19's assessed emotional/psychosocial needs related to his trauma/PTSD diagnosis.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and/or the State Long Term Care (LTC) Ombudsman a written notice of transfer for 4 of 4 sampled residents (Resident #4, #6, #19 and #20) with a recent hospital transfer. Failure to provide a notice of transfer does not allow the resident and/or their representative to make an informed decision regarding their rights or inform the Ombudsman of the transfers. Findings include: Review of facility policy titled Transfer and Discharge Policy and Procedure occurred on 03/15/22. This policy, dated 12/31/19, stated, . If a resident is to be transferred . , Dakota Alpha will give the resident . written notice . The notice will include the reason for the transfer or discharge, date of the transfer or discharge, location to where the resident is transferred or discharged , the resident's right to appeal the transfer or discharge and the mailing address to which an appeal must be sent. The notice will also include the name, address, and telephone number of the ND [North Dakota] Long Term Care Ombudsperson . - Review of Resident #4's medical record occurred on all days of survey and identified a hospitalization from [DATE]-18, 2021. The record lacked evidence the facility provided the resident and/or the family/legal representative and State LTC Ombudsman written notice of transfer for this hospitalization . - Review of Resident #6's medical record occurred on all days of survey and identified a hospitalization from [DATE]-24, 2021. The record lacked evidence the facility provided the resident and/or the family/legal representative and State LTC Ombudsman written notice of transfer for this hospitalization . - Review of Resident #19's medical record occurred on all days of survey and identified a hospitalization from [DATE]-03, 2021. The record lacked evidence the facility provided the resident and/or the family/legal representative and State LTC Ombudsman written notice of transfer for this hospitalization . - Review of Resident #20's medical record occurred on all days of survey and identified a hospitalization from [DATE]-8, 2021. The record lacked evidence the facility provided the resident and/or the family/legal representative and State LTC Ombudsman written notice of transfer for this hospitalization . During an interview on 03/15/22 at 10:00 a.m., an administrative nurse (#1) confirmed staff failed to complete the notice of transfer and notify the ombudsmen of the residents' transfers to the hospital.

Based on record review, facility policy review, and staff interview, the facility failed to ensure 1 of 1 staff member unvaccinated for COVID-19 met all the requirements for medical exemption (Staff AA). Failure to ensure medical exemptions contained the required information allows staff to remain unvaccinated, placing residents, staff, and visitors at risk for infection with COVID-19. Findings include: Review of the facility policy titled Employee COVID-19 Vaccinations occurred on 03/16/22. This policy, dated 02/16/22, stated, . 'Clinical contraindications'- Conditions or risks that preclude the administration of a treatment or intervention. For COVID-19 vaccines, a vaccine is clinically contraindicated if an individual has a severe allergic reaction (e.g. [MEDICATION(S)]) after a previous dose or to a component of the COVID-19 vaccine or an immediate (within 4 hours of exposure) allergic reaction of any severity to a previous dose or known (diagnosed ) allergy to a component of the vaccine.Vaccination against COVID-19 ensures that employees will provide a safe workplace and decrease the risk of transmission . Review of the facility form titled Employee Medical Exemption Request From the COVID-19 Vaccination Requirement occurred on 03/16/22. This undated form stated, . By attaching your signature below, you are attesting that [sic] following statements are true and accurate: . Your request for a long-term exemption or a temporary delay is based on a medical condition or circumstance that is recognized by the CDC [Centers for Disease Control] in its guidance and is listed in the Emergency Use Authorization [EUA] Fact Sheet for each of the COVID-19 vaccines authorized or approved for use in the United States. Review of Staff AA's Employee Medical Exemption Request From the COVID-19 Vaccination Requirement form and accompanying physician's note occurred on 03/16/22. Staff AA signed the Medical Exemption Request Form on 02/24/22. The physician's note, dated 08/04/21, failed to include which COVID-19 vaccines Staff AA was exempt from and failed to include medical conditions recognized by the CDC or listed in the EUA fact sheets. During an interview on 03/16/22 at 11:53 a.m., an administrative nurse (#2) agreed the physician failed to list the staff member's exempted COVID-19 vaccines and the CDC recognized or EUA listed medical conditions for each vaccine.

Based on record review, policy/procedure review, and staff interview, the facility failed to ensure the medical record and resident Care Card accurately reflected the resident's code status for 1 of 14 (Resident #7) sampled residents. Failure to ensure the resident's medical record and Care Card reflected his/her wishes prevents staff from following the resident's choices in the event of a medical emergency. Findings include: Review of the policy, Advanced Directives Policy and Procedure, dated 12/31/18, stated, An Advance Directive is a written statement of a person's wishes regarding medical treatment, . made to ensure those wishes are carried out should the person be unable to communicate them in a catastrophic event. Dakota alpha will follow the written directions of the Resident or legally assigned agent . Review of Resident #7's medical record occurred on all days of survey and identified Code Status: DNR (do not resuscitate) . physician's orders [REDACTED]. A document in the medical record titled Emergency Care Statement, dated 05/01/20, stated, . I request the following be done for me in the event of a [MEDICAL CONDITION]: .CODE STATUS: LEVEL l - Total Support Provide chest compressions, artificial respiration, and defibrillation. Transfer to the hospital. During an interview on 01/26/21 at 2:11 p.m., a staff nurse (#9) stated she refers to the top page/dashboard of the medical record to determine a resident's code status. The staff nurse (#9) stated the code status is also on the Care Card, which is located in each resident's room on the back of the mirror cabinet. Observation of the Care Card located in Resident #7's room showed a red sticker with DNR for the code status. During an interview on 01/26/21 at 5:30 p.m., an administrative nurse (#1) confirmed staff had not changed the Code Status in the medical record or on the Care Card when Resident #7 signed the Emergency Care Statement on 05/01/20.

Based on observation, record review, review of facility policy, resident and staff interview the facility failed to ensure personal privacy for 1 of 2 sampled residents (Resident #9) who expressed concerns regarding personal privacy. Failure to ensure privacy when using the bathroom/shower is an infringement on residents' rights and may lead to loss of dignity and safety. Findings include: Review of the facility policy titled Promoting/Maintaining Resident Dignity dated May 2020, stated, Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Maintain resident privacy. - During an interview on 01/27/21 at 9:55 a.m., Resident #9 expressed concerns regarding her privacy. She stated the bathroom she shares with a male resident does not have a lock and he could enter her room anytime. Observation of the bathroom doors between the resident rooms and the shared bathroom showed the doors locked in such a way the male resident could still enter Resident #9's room or the shared bathroom anytime. During an interview on 01/27/21 at 10:30 a.m., an administrative staff member (#7) stated Resident #9 had moved closer to the nurse's station due to behaviors. After an observation of Resident #9's room and bathroom, administrative staff members (#7 and #8) confirmed the male resident could enter the shared bathroom and Resident #9's room at any time due to the lack of a door locking mechanism.

Based on observation, professional reference, facility policy review, record review, and staff interview the facility failed to ensure proper positioning for 2 of 2 sampled residents (Residents #3 and #5) observed eating/drinking in an unsafe position. Failure to ensure staff provided proper positioning when giving fluids/enteral feeding/medication, placed Residents (#3 and #5) at risk for aspiration. Findings include: Swigert's The Source for Dysphagia, 3rd ed., Pro-Ed, Inc., Texas, 2007, page 125 and educational handouts, identified, . During the oral intake of . food and/or liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in bed or in a chair. Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue. Review of the facility policy titled Peg Tubes occurred on 01/26/21. The undated policy stated, . The resident should be in at least a 45 degree angle. Residents should remain upright for 30 minutes after the feeding either by having the head of the bed elevated at least 30 degrees or by sitting upright in a chair. - Observation on 01/26/21 at 12:35 p.m., showed Resident (#3) received medication and food bolus via [DEVICE] from staff nurse (#9) as ordered. During medication pass the resident was positioned lying flat. Resident was advised to lie down for a while, after the medication pass, with no elevation of his head. During an interview on 01/27/21 at 4:00 p.m. an administrative nurse (#1) verified that she would expect her staff to follow the facility policy for tube feeding, have the head of the bed at correct level, and have the resident lie at 30 degrees or sit in a upright position as ordered. - Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A speech therapy evaluation, dated 12/11/20, identified, . Currently (Resident #5) does not have his partials due to him taking them out and breaking them. However even without his teeth he is able to eat a mechanical soft texture. He has his food cut up and drinks thin liquids with a straw. The current care plan identified, . Supervision while eating, provide cues . Assist of 1 as needed. Observations showed the following: * 01/25/21 at 1:25 p.m., two certified nursing assistants (CNAs) (#2 and #3) transferred Resident #5 into bed with a full body lift and provide toileting cares. After raising the head of the bed to an approximate 30 degree angle, the CNA (#3) gave Resident #5 a drink of water. * 01/26/21 at 1:44 p.m., two CNAs (#3 and #4) transferred Resident #5 into the bed with a full body lift and provided toileting cares. A certified medication assistant (CMA) (#5) then raised the head of Resident #5's bed to an approximate 45 degree angle and administered his medications with pudding while Resident #5 laid on the bed leaning heavily towards his right side with his head resting on the edge of the mattress. During an interview on 01/27/21 at 3:10 p.m., when asked questions pertaining to positioning, a speech therapy staff member (#6) stated, It is normal for him to lean to the side like that. He should be up higher. I'd be worried. 2. Based on record review, review of a continuous glucose monitoring (CGM) system instruction pamphlet, and resident and staff interview, the facility failed to provide necessary treatment and care for 1 of 1 resident (Resident #19) who used a CGM system. Failure to ensure the facility had a physician order and documentation regarding changing of the CGM system sensor placed the resident at risk for high or low blood sugar and related complications. Findings include: The CGM system instruction pamphlet stated, . insert sensor . attach transmitter . after 10 days sensor session ends . Upon request the facility failed to provide a policy regarding the use of the CGM system. During an interview on 1/25/21 at 10:22 a.m. Resident #19 stated he uses a CGM sensor to check his blood sugars and he changes the sensor every 14 days. Review of Resident #9's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The physician's orders stated, (CGM system) for glucose check right arm 3 times a day. The current care plan stated . has uncontrolled Type 1 Diabetes Mellitus. He has a (CGM) device . Educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections. Monitor blood sugars as ordered and compare with CGM. During an interview on 1/26/21 at 3:45 p.m., an administrative nurse (#1) stated staff are not documenting when Resident #19 changes his sensor as he does this himself. This nurse did not know how often the sensor is changed and directed me to a staff nurse (#9). The staff nurse (#9) did not know how often the Resident #19 changed his CGM sensor and stated ask the resident. The facility failed to develop a policy for the use of a CGM system device, to ensure physician's orders and documentation included how often to change the sensor, and lacked education on the use of a CGM system device.

Based on review of the facility's nursing staff schedule and staff interview, the facility failed to provide the services of a registered nurse (RN) for eight consecutive hours a day, seven days a week, for three days of the 42-day period from 12/13/20 to 01/23/21. Failure to ensure sufficient, qualified nursing staff are available daily has the potential to affect all the residents residing in the facility. Findings Include: The facility provided a copy of the nurse's schedule for the time period of 12/13/20 to 01/23/21. A review of the schedules showed the facility lacked the required RN coverage on 12/13/20, 12/27/20, and 01/23/21. During an interview on 01/27/21 at 8:53 a.m., an administrative nurse (#1) confirmed the facility lacked eight consecutive hours of RN coverage on 12/13/20, 12/27/20, and 01/23/21.

Based on observation, review of facility policy, and staff interview, the facility failed to label 1 of 2 multi-dose insulin pens (long-acting) in 1 of 1 medication cart. Failure to label the multi-dose pens with the date opened and the expiration date, increases the risk of residents receiving outdated medication with reduced efficacy. Findings include: Review of facility policy titled Medications dated 03/23/19, stated, . Insulin: Insulin bottles/pens must be marked with the date the item was opened and initials of staff who opened the pen/bottle at that time . Observation of the medication cart occurred on 01/27/21 at 12:15 p.m. Facility staff failed to label one long-acting multi-dose insulin pen with an open and expiration date. A staff nurse (#10), present at the time of the observation, agreed staff should label the insulin pen with an open and expiration date.

Based on information received from the complainant, observation, record review, resident interview, and staff interview, the facility failed to provide care for 1 of 1 sampled resident (Resident #1) in a manner/environment that maintained, enhanced, and respected the resident's privacy. Failure to ensure the resident's personal dignity resulted in embarrassment, psychosocial harm, and a decreased quality of life. Findings include: Information provided by the complainant indicated facility staff strip searched Resident #1 in the nurses' station on (MONTH) 26, 2019. Review of the document titled Dakota Alpha Compliment, Concern or Grievance Form occurred 12/04/19. This document, dated 11/26/19 stated, .Resident Involved: (Resident #1) . Two staff nurses (#1 and #2) initiated the search in the health station in a private area of the health station. The staff nurse (#2) agree (sic) to the search and proceeded with having Resident #1 remove her shirt and take her pants and underwear down to her knees. During an interview on 12/04/19 at 1:50 p.m., a staff nurse (#1) reported she instructed another staff nurse (#2) to perform a strip search of Resident #1 in the health station on (MONTH) 26, 2019. During an interview on 12/04/19 at 2:23 p.m., Resident #1 reported two staff nurses (#1 and #2) performed a search in the health station after instructing her to remove her top and pull down her pants and underpants. Resident #1 confirmed she stood exposed while the nurses (#1 and #2) performed the search. During an interview on the morning of 12/04/19, an administrative nurse (#3) reported a staff nurse (#2) performed the search of Resident #1 in the health station on (MONTH) 26, 2019 after another staff nurse (#1) instructed her to do so. The administrative nurse (#3) showed this writer exactly where the search took place in the health station. Observation showed wall to wall windows on one side of the health station with frosted glass half way up the window. The search took place in the back room of the health station. From outside the health station, this surveyor could view the back room over the frosted glass. The administrative nurse (#3) confirmed the back room had no door and the windows had no curtains to provide privacy. The facility staff failed to provide Resident #1 with privacy when they performed the search.

Based on information received from the complainant, review of facility policy, record review, resident interview, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #1) remained free from mental abuse. Failure to protect Resident #1 from a humiliating body search resulted in intimidation, shame, agitation, and loss of dignity. Findings include: Information provided by the complainant indicated facility staff strip searched Resident #1 in the nurses' station on 11/26/19. Review of the facility policy titled ABUSE PROHIBITION POLICY occurred 12/04/19. This undated policy stated, Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Willful means the individual deliberately, not that that (sic) the individual must have intended to, inflict injury or harm. Mental abuse includes but is not limited to: humiliation, harassment, or threats of punishment or deprivation. Review of the facility document titled (Resident #1) - Search Protocol occurred 12/04/19. This protocol, dated 07/20/18, stated, For the sake of consistency, please use the follow (sic) guidelines if (searching) (Resident #1) before or after she has left the facility for an outing, appointment, etc. This applies to any time she leaves the facility, with staff or non-staff. Ask her if she has anything she isn't allowed to have, or anything she obtained without permission. Ask her to empty all of her pockets and show you the inside of her socks. Please search her purse (if she's been approved to take it with), camera bag, etc. or basically any other object that items could be in. If an item is visibly bulging from her clothing, ask her to remove it. If she refuses, it will be assumed she has something she shouldn't, and it will be marked on her Behavior Checklist. Review of Resident #1's careplan (used at the time of the incident on 11/26/19) occurred on 12/04/19 and stated, . I have decreased social appropriateness. Anytime I have left the facility, staff will accompany me to the Health Station to be searched by nursing staff according to protocol. Date initiated: 03/14/19. Revision on: 03/14/19 . Review of the document titled Dakota Alpha Compliment, Concern or Grievance Form occurred on 12/04/19. This document, dated 11/26/19, stated, .Resident Involved: (Resident #1) . At 1:30 pm (Resident #1) was asked to step into the health station by (certified nursing assitant #7) (CNA) with (staff nurse #1 and #2) to do (sic) search before (Resident #1) was leaving on an outing. Search protocol for (Resident #1) is to ask her if she has anything she isn't allowed to have, or anything she obtained without permission, ask her to empty her pockets and show the inside of her socks, search her purse, camera bag, etc or basically any other object that items could be in. If an item is visibly building (sic) from her clothing, ask her to remove it. (Staff nurse #1 and #2) initiated the search in the health station in a private area of the health station. (Staff nurse #2) agreed to do the search. (Staff nurse #1) had been previously been (sic) informed by the previous DON (director of nursing), almost a year ago when she lasted (sic) worked, that a strip search would need to be done. (Staff nurse #1) instructed another (staff nurse #2) to do a strip search to include, checking pockets, clothing, skin folds which included bending over to check buttocks area, and any bags. (Staff nurse #2) agree (sic) to the search and proceeded with having (Resident #1) remove her shirt and take her pants and underwear down to her knees. (Staff nurse #1) stepped around to the other area of the health station and sat beside (administrative nurse #3), while the (staff nurse #2) continued the search. (Resident #1) asked (staff nurse #2) why was this search being done and (staff nurse #2) stated that this was what she was instructed to do. During an interview on 12/04/19 at 2:23 p.m., Resident #1 reported the following: * She had to be checked out at the health station before leaving with activity staff to go shopping. Two nurses took her into a small room in the back of the health station and told her to take her shirt off. A nurse (#2) un-snapped her bra and started feeling me inside my bra and she thought that was inappropriate. * The nurse told her to pull her pants and underpants down and to bend over. The resident stated that after it happened, I was in such a tizzy, it took me about 20 minutes to calm down. * She stated she could not sleep that night and was just beside myself. * She spoke to the social worker and the administrator after it happened. I was in such a tizzy, I couldn't even talk, it really bothered me, I couldn't even sleep that night. She stated I felt so terrible when she had me bend down without my pants on. * She stated she is uneasy talking about it and it seemed unnecessary (to remove clothing). * She stated the two nurses (#1 and #2) make me feel uneasy and she does not feel comfortable around them. During an interview on 12/04/19 at 11:20 a.m., a social work staff member (#5) reported she spoke with Resident #1 after staff searched her. The staff member (#5) stated Resident #1 generally isn't one to show a lot of emotion and she questioned why the nurse did that. During an interview on 12/04/19 at 12:00 p.m., an administrative nurse (#3) reported she heard Resident #1 protesting the search. The administrative nurse (#3) stated Resident #1 repeatedly told staff the search had not happened like this before. An interview with an activity staff member (#6) occurred on 12/04/19 at 12:15 p.m. The staff member (#6) reported she and another activity staff member (#7) took Resident #1, along with some other residents, shopping on the afternoon of 11/26/19. Prior to leaving, Resident #1 was very upset, so the other activity staff member (#7) told the resident she needed to go talk to the social worker before they would leave to go shopping. The staff member (#6) stated the resident kept repeating it (the incident) over and over and was told she needed to talk about it with the social worker or the administrator. An interview with another activity staff member (#7) occurred on 12/04/19 at 12:40 p.m. The staff member (#7) reported Resident #1 was upset prior to leaving to go shopping and told her they strip searched me. The activity staff member stated Resident #1 was too upset to shop and was very agitated, so she told the resident to go talk to the social worker. The staff member (#7) reported Resident #1 seemed relieved after talking to the social worker and the administrator. During an interview on 12/04/19 at 1:51 p.m., a staff nurse (#1) stated a staff member told her she needed to search Resident #1 before the resident could leave to go shopping. She reported she had a newly hired nurse (#2) with her, and she told the nurse what to do. The staff nurse (#1) stated when she worked at the facility previously, a nurse told her they needed to do a strip search of Resident #1, so that is what she told the nurse (#2) to do. She reported they took the resident to the back room of the nurses station, and she watched while the other nurse (#2) looked under the resident's bra. The nurse (#1) stated she then left the back room and sat down at the computer at the nurses station while the other nurse (#2) continued her search. An interview with a medication aide (#8) occurred on 12/04/19 at 1:00 p.m. The staff member (#8) reported he/she is the one who does most of the searches on Resident #1 and has never been told to do a strip search. The medication aide (#8) stated he/she has the resident raise her arms up and she checks her pockets and bag. An interview with a charge nurse (#9) occurred on 12/04/19 at 1:41 p.m. The charge nurse (#9) reported he/she occasionally performs searches on Resident #1 and has never heard that staff should do a strip search of the resident.

Based on staff interview, the facility failed to ensure staff received training on abuse, neglect, and exploitation policies for 1 of 1 nurse (#1). Failure to ensure staff receive training may result in staff being unaware of facility policies and put residents at risk for abuse, neglect, and exploitation. Findings include: During an interview on 12/04/19 at 1:50 p.m., a nurse (#1) reported he/she received no training when he/she started in (MONTH) 2019 at Dakota Alpha. During an interview on the afternoon of 12/04/19, two administrative staff (#3 and #4) confirmed the facility had no record of any training for the nurse (#1). The facility failed to provide documentation of training related to abuse, neglect, and exploitation for the nurse (#1).

Based on observation and staff interview, the facility failed to provide care in a manner that maintained or enhanced resident dignity for 1 of 4 sampled residents (Resident #6) requiring staff assistance with toileting. Failure to provide privacy during personal cares does not enhance residents' dignity. Findings include: Observation on 04/16/19 at 9:32 a.m. showed a certified nursing assistant (CNA) (#2) assisted Resident #6 to the bathroom using the stand lift. When resident finished using the restroom, the CNA assisted the resident off the toilet utilizing the stand lift. The CNA then realized there were no clean briefs in the resident's room and called another CNA for assistance. The CNA transferred the resident to his wheelchair with his pants pulled down to his knees. Resident #6 directly faced the door to the hallway. An unidentified CNA knocked on the door and opened it at the same time, exposing the unclothed resident to the hallway. After the unidentified CNA left the resident's room to get a brief, the resident attempted to pull up his pants over his front area. The CNA (#2) did not attempt to cover Resident #6 or pull his pants up. During an interview on the morning of 04/17/19, an administrative nurse (#1) agreed staff should cover residents to provide privacy.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the adequate supervision and necessary interventions to ensure the safety of 1 of 1 sampled resident (Resident #1) identified at risk for elopement and who exited the facility unsupervised. Failure to ensure and maintain resident safety by providing adequate supervision, implementing effective interventions, and monitoring and re-evaluating those interventions resulted in Resident #1 eloping from the facility on five occasions in the past eight months with one elopement resulting in injury/hospitalization . Findings include: Review of the facility policy titled, ELOPEMENT POLICY occurred on 05/17/18. This undated policy stated, . Elopement: When a resident walks away, runs away, or otherwise leaves the facility or environment unsupervised . the management team will develop a plan of care to attempt to prevent elopement specific for each resident at risk . If, at any time, a resident is in the care of (facility) and cannot be located on the grounds . and the staff does not know their whereabouts, the Elopement Response Plan will be immediately implemented. Review of Resident #1's medical record occurred on all days of the survey. A quarterly Minimum Data Set, dated dated [DATE], identified the resident as independent in locomotion on and off the unit. The current care plan stated, . ELOPEMENT I am impulsive and may leave the facility without notifying staff or without a set destination in mind. I have left in the past, sometimes without being dressed for the weather, and cannot find my way back. I need to stay within the building or courtyard for my safety . I eloped on 1/29 which caused me injuries that took me to the ER and a stay overnight in the hospital for observation. An Elopement Risk Assessment, completed on 11/21/17, identified Resident #1 scored a 9. A score of 7 and above on this assessment indicated the resident is at risk for elopement. Nurse's notes identified the following: * 05/01/18 at 4:08 p.m. (Resident #1) was found to be missing roughly at 3pm. After checking the security video footage, it appears that (Resident #1) went out the western door at 3:18 pm. elopement procedures were initiated, including calling the guardians and police. A full scale search took place and a number of staff when (sic) looking in their vehicles. I found (Resident #1) sitting on a hill adjacent to the Wal-Mart holding a few items. I went up to him and asked if he was ok. He stated that he was not hurt. I assisted (Resident #1) into my car and drove him back to Dakota Alpha. When we arrived, the police where there asking questions. We took inventory of the items that he had in his possession. The police noted that they will be taking the items back since they were not paid for. From the best of our knowledge, (Resident #1) took the items through the self-check out. The back door will be locked until further notice per my instructions. * 05/01/18 at 4:27 p.m. Staff began search (3:30 p.m.) and call placed to (resident's mother) at 1538. Call placed to (local) police and notified of missing person at 1545. Aware that he was located by staff at (4:00 p.m.) and called police department (PD), called mother. At 1605 (Resident #1) is out in courtyard talking with (administrative staff) and (Resident #1) went to room with writer for assessment. Bruising and abrasion on left forearm is unchanged, no abrasions or bruising to lower legs and (Resident #1) denies falling. (Resident #1) denies pain. When asked why he left, he tells me that he wanted some pop. Half hour checks initiated for safety. * 03/07/18 at 10:23 a.m. At 10:25 a.m. (Resident #1) was let in the building after he was ringing the bell to the front door. After reviewing the camera in the front lobby it is found that (Resident #1) followed Activities personnel out the door at 10:23 a.m. and stayed in the space between the doors when he turned around and pressed the button to come back in. * 01/29/18 at 8:50 a.m. . Late entry for 1/28/18: I received a telephone call from (name of staff member) CNA, at Dakota Alpha about 8:54 PM stating that (Resident #1), resident of Dakota Alpha had left the building. She stated that (name of nurse), the licensed practical nurse (LPN) was currently talking to a police officer who reported that an ambulance was working on (Resident #1) and would be transporting him to the hospital but was wondering which hospital they should transport him to. I informed her that his hospital of choice was (name of local hospital). When (name of staff member) was finished with the police officer, I spoke to her and she stated that the officer informed her that (Resident #1) was found injured off the grounds of Dakota Alpha and was being transported to the hospital. The staff did not know he was missing; the last time they had seen him was when meds were given at (8:20 p.m.) in the dining room. the nurse was going to notify his mother of his going to the hospitalized and I told her I would notify the guardian. I went to the hospital to check on (Resident #1's) condition and (name of staff member) faxed his med list to the hospital to the number she was given . I reported his condition to (name) and that (Resident #1) would be staying overnight .She had also stated that (Resident #1's) [MEDICATION NAME] time/international normalized ratio (PT/INR) (a lab test used when a resident is on a blood thinner) from the last time he had lab work were pretty high; and that was part of the concern to keep him overnight to re-check for bleeding (with the repeat (computerized tomography (CAT) scan in the morning) after his hitting his head. (Resident #1) had 6-7 stitches above his left eyebrow and a circular punch type the size of an eraser tip on his left hand from an unknown cause which was not bleeding. * 12/08/17 at 4:39 p.m.(Resident #1) was caught trying to leaving the building via the fence this morning. Reports pain to his knee and legs. Felt tired and noted sleeping at AM meal. No bruises noted except left leg still swollen and painful. He is on antibiotics. Afebrile with a temperature of 97.6. * 08/29/17 at 3:03 p.m., .(Resident #1) left via the front door following behind a nursing student. He came back in right away and was found standing between the doors. No injury . He was redirected to his room . No concerns at this time. On 05/16/18 at 3:25 p.m., the survey team was accompanied by an administrative nurse (#2) to the facility courtyard that contained the fence Resident #1 had eloped over. The administrative nurse (#2) stated the facility is in the process of installing steel mesh to the landscape rocks and fence as a preventative measure to deter residents from climbing the wall. Observation showed the project appeared half way completed starting at the most accessible area to residents and working toward the higher area. During an interview on 05/17/18 at 8:10 a.m. with an environmental services staff member (#3), this staff member stated the existing plan is to complete installing the steel mesh on half the length of the wall, (the wall gains height as it moves to the west). He did not have a project completion date. The facility failed to ensure and maintain resident safety by providing adequate supervision, implementing effective interventions, and monitoring and re-evaluating those interventions. This failure resulted in Resident #1 eloping from the facility on five occasions in the past eight months with one elopement resulting in injury/hospitalization .