Every finding on record at Dells Nursing and Rehab Center Inc

Based on observation, interview, and policy review, the provider failed to ensure the staff members followed standard infection prevention practices for:*Storing clean resident use equipment, specifically lift slings, without the slings touching the floor.*Replacing oxygen tubing for one of four sampled residents (35) every 30 days according to the provider's policy.*Personal protective equipment, such as gloves and gowns (PPE), use by one of one observed certified nursing assistant (CNA) D when providing care for one of one sampled resident (15) on enhanced barrier precautions (EBP).Findings include: 1. Observation on 12/9/25 at 10:04 a.m. of the clean linen room revealed more than five lift (a mechanical device used to lift a person's body) slings were touching the floor.2. Interview on 12/11/25 at 1:00 p.m. with infection preventionist (IP)/registered nurse (RN) C revealed that she was not aware that the lift slings were touching the floor. She acknowledged that the floor was not considered a clean surface and that created a potential infection control risk. She then removed the slings that were touching the floor to have them laundered.3. Observation on 12/9/25 at 2:32 p.m. of resident 35's oxygen concentrator revealed that the humidification container and oxygen tubing were dated 11/3/25.4. Interview on 12/11/25 at 1:00 p.m. with infection preventionist (IP)/registered nurse (RN) C revealed that oxygen tubing was expected to be replaced every four weeks by the night shift nurse.5. Review of resident 35's TAR revealed that the task of replacing her oxygen tubing was documented as completed on 11/24/25 by RN I.6. Interview on 12/11/25 at 1:15 p.m. with director of nursing (DON) B revealed that when the oxygen tubing was replaced, the night shift nurse would document that task as completed in the treatment administration record (TAR). She reported that the facility was currently performing audits to ensure oxygen tubing had been replaced on schedule. She expected that if the task was not completed, it would not be documented as completed in the TAR.7. Observation on 12/10/25 at 11:43 a.m. of certified nursing assistant (CNA) D and resident 15 in the shower room revealed CNA D wheeled resident 14 into the shower room and closed the door. CNA D then provided a shower to resident 15 and did not wear a gown or gloves.8. Interview on 12/10/25 at 12:49 with CNA D revealed that she was aware that resident 15 was on enhanced barrier precautions [also called EBP. EBP included the use of PPE to decrease the spread of multi-drug organisms (MDRO)]. She acknowledged that she was not wearing PPE when she assisted resident 15 to undress and when she started the resident's shower. She stated that she did put on a gown and gloves when she realized she forgot to put them on until she had seen the surveyor observe her without them on.9. Interview on 12/11/25 at 1:00 p.m. with IP/RN C revealed that the staff were expected to wear appropriate PPE when providing cares for resident's on EBP.10. Review of the provider's 4/2025 Cleaning of Durable Medical and Therapy Equipment revealed:*8. Oxygen Treatments: 3) Every month, replace cannula [a flexible tube with two prongs that fit into the nostrils to deliver supplemental oxygen or humidified air] or mask, and tubing.11. Review of the provider's 4/1/24 Enhanced Barrier Precautions policy revealed that Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced barrier precautions involve gown and glove use during high contact resident care activities for residents know to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). High-contact resident activities include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube. Wound care: and skin opening requiring a dressing.

Based on observation, interview, record review, and policy review the provider failed to ensure resident choices regarding bedtime requests were being followed for one of one sampled resident (14).Findings include:1. Observation and interview on 12/9/25 at 9:20 a.m. with resident 14 in his room revealed:*He was sitting in his recliner watching television.*He stated there were days when he was tired and wanted to go to bed at 6:00 p.m.*Staff told him he had to wait until 7:00 p.m. before he could go to bed because some residents were still eating supper.2. Interview on12/10/25 at 4:06 p.m. with certified nursing assistant (CNA) E revealed:*If a resident requested to go to bed at 6:00 p.m. she would not have accommodated that request.*She felt that was too early for a resident to go to bed.*She knew resident would request to go to bed early some evenings.*Staff were still helping some residents in the dining room at that time.3. Interview on 12/11/25 at 9:12 a.m. with CNA G revealed:*If a resident wanted to go to bed early, she would talk to the charge nurse.*The charge nurse would normally have the resident try to stay awake until at least 7:00 p.m. 4. Interview on 12/11/25 at 1:03 p.m. with registered nurse (RN) F revealed:*Some residents requested to go to bed early at times.*Staff needed to ensure all the residents were out of the dining room after supper before they started getting residents ready for bed so call lights could get answered.*Some residents finished supper early and then requested to lay down for bed.*She stated those residents would only have to wait 15 or 20 minutes for staff to help them with that.*She agreed it was the residents right to decide when they went to bed at night.5. Interview on12/11.25 at 1:21 p.m. with social services designee (SSD) H revealed:*She knew some residents liked to go to bed early in the evening.*Staff may try to encourage a resident to stay up longer so they were not in bed that long at night.*She confirmed there were not certain hours residents could be awake or asleep. *She agreed it was the resident's right to request to go to bed early.6. Interview on 12/11/25 at 2:10 p.m. with director of nursing (DON) B revealed:*Residents were encouraged to stay up until 7:00 p.m.*Nursing staff were assisting residents in the dining room until 6:30 p.m. or 7:00 p.m.*She agreed it was the residents' right to request to go to bed when they wanted to.*She knew resident 14 requested to go to be early at times.*She was not sure if nursing staff would always accommodate his requests.7. Review of resident 14's electronic medical record (EMR) revealed:*He had a Brief Interview for Mental Status (BIMS) assessment score of 9 which indicated his cognition was moderately impaired.*His 5/8/25 care plan stated he liked to wake up around 7:00 a.m. and go to bed around 8:00 p.m. or whenever he was sleepy.8. Review of the provider's undated Resident's Rights document revealed:*When you leave your home to live in a nursing facility, you take your rights with you.*All residents in nursing facilities have the same rights, although there will be times when there is give and take.*You have the right as a resident of a nursing facility to use all these rights given to you by law, and also to use all the rights you have as a citizen of your State and a citizen of the United States.

Based on record review, interview, job description review, and policy review, the provider failed to ensure blood pressure medications were administered as ordered by the physician for one of one closed resident records (1) by three of three certified medication aides (CMAs) (C, D, and E). These errors in medication administration had the potential to impact the resident's health and well-being. Review of October 2025 closed electronic medical review (EMR) revealed resident 1 was admitted to the facility 10/1/25 and discharged from the facility on 10/27/25 due to an unexpected death. He had primary diagnoses of type 2 diabetes (unstable sugar levels in the blood), orthostatic hypotension (sudden drop in blood pressure when you stand up, which can cause dizziness, lightheadedness, or fainting), and weakness.Upon admission, he had physician orders to take Midodrine 5 milligrams (mg) twice a day for low pressure. This medication was ordered to be held if his systolic blood pressure (SBP) was greater than 135. Also, upon admission, he had physician orders to take Fludrocortisone 0.1mg daily for low blood pressure. This medication was ordered to be held if his SBP was greater than 140.Review of resident 1's October 2025 Medication Administration Record revealed Resident 1 had refused his Fludrocortisone and Midodrine once on 10/11/15.His Midodrine should have been held six times in October 2025 when he had a SBP greater than 135, according to the ordered parameters for the medication. On 10/4/25 his BP was 165/84, on 10/5/25 his BP was 174/98, on 10/9/25 his BP was 139/81, on 10/14/25 his BP was 156/77, on 10/19/25 his BP was 206/60, and on 10/23/25 his BP was 149/74 the medication should have been held according to the ordered parameters, but it was documented as administered.The Midodrine should have been given five times when he had a low blood pressure in October 2025 according to the ordered parameters. On 10/2/25 his BP was 93/62, on 10/4/25 his BP was 66/53, on 10/7/25 his BP was 90/65, on 10/8/25 his BP was 66/63, and on 10/14/25 his BP was 71/62 and the medication was documented as not given but should have been according to the orders. His low blood pressures were not documented as rechecked until the next day for any of the times his Midodrine was held.His Fludrocortisone should have been held twice in October 2025 when he had a SBP greater than 140 according to the ordered parameters. On 10/4/25 his BP was 165/84, and on 10/14/25 his BP was 156/77 and the medication should have been held but was documented as administered.Interview and record review on 10/30/25 at 2:57 p.m. and 4:22 p.m. with director of nursing (DON) A revealed the check mark under the dates, in the row of medications for Midodrine and Fludrocortisone, on resident 1's October 2025 medication administration record (MAR), indicated that the medication was administered to the resident, and the initials indicated which staff administered the medication on those dates. She identified the three staff who administered resident the residents medication when it should have been held were CMAs C, D, and E. She stated, if a resident had blood pressure medication hold parameters ordered, she expected that the blood pressure (BP) would be checked prior to medication administration. If the resident's BP was out of the parameters, she would expect the medication not to be administered by the staff. If the resident's BP was not within parameters, per the policy, she would have expected the resident's physician to be notified each time. DON A confirmed the medication errors and the blood pressure policy had not been followed.Interview and record review on 10/30/25 at 4:25 p.m. with CMA C revealed that, when administering residents' medications that had BP hold parameters, she would check the resident's blood pressure, and if it was out of parameters, she would not administer the medication. If she were to have administered the medication and later noticed that the medication should not have been given, she would have reported it to the nurse. She was not aware she had administered medication twice in October 2025 to resident 1 when it should have been held.When checking the resident's vital signs, and they were not normal for the resident, she would notify the nurse. She was not aware of the facility's Blood Pressure Parameter Policy, and when she should notify the nurse related to blood pressure concerns. Interview on 10/30/25 at 4:33 p.m. with RN B revealed, if she had noticed that a resident's medication was given that should have been held, she would have checked the resident's vital signs and followed the facility's medication error policy and notified the residents physician, the DON, and the resident's family.If a resident's BP was out of parameters, she would recheck the resident's BP after a few minutes, and if it was still out of parameters, she would notify the resident's physician. To know if the vital signs were out of parameters, she would look at the reference sheet that had the parameters listed on it, which was located at the nurses' station. Review of the provider's 8/6/13 medication aide job description revealed the CMA was responsible for observing symptoms and responses to medications and for reporting such to the charge nurse. They were to take and record vital signs, record and report observations and changes in [the] resident's condition to the charge nurse. They were responsible in notifying [the] charge nurse regarding med errors. All entries in [the] resident's chart must be co-signed by [the] charge nurse.Review of the providers' 8/6/13 registered nurses' job description revealed that they were to render professional nursing care to residents, be accountable for demonstrating the ability to identify and utilize quality resident care, observe and report symptoms and conditions of residents, and administer medications as prescribed by the resident's physician. Their essential job duties included to distribute medications accurately and safely.per physician order, participate and facilitate in resident care planning and shift records, maintain records reflecting resident conditions, medication and treatments, and supervise, assign duties, and provide leadership to all nursing staff.Review of the providers' 8/1/24 Blood Pressure and Blood Sugar Parameter Policy revealed the purpose was to ensure adequate blood pressure.parameters are reported and monitored by Physicians. The physician was to be notified when [a] blood pressure is greater than 180/110 or systolic is lower than 85.Review of the providers' 2/1/25 Medication: General Rules Policy revealed the provider expects all employees who administer medications to apply professional standards of care during the process of medication administration. To give medications only upon written orders of a physician. For medication errors, an occurrence report will be filed, the physician, Director of Nursing & POA [power of attorney] will be informed. The resident will be monitored for twenty-four (24) hours following the error. The Director of Nursing will review, follow-up/education and report medication errors at the QA [quality assurance] meeting.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of two certified nursing assistants (CNA) (K) wore appropriate personal protective equipment (PPE) while caring for two sampled residents (22 and 32) who were on enhanced barrier precautions (EBP), which is a type of infection control strategy used in nursing homes to reduce the spread of multidrug-resistant organisms. *One of one CNA (N) practiced appropriate infection control techniques during catheter cares for one of one observed resident (22). *Four of four CNAs (L, M, N, and O) were knowledgeable of the provider's revised catheter care policy and had the skills to implement that policy. *Medical supplies, such as plastic syringes and containers of normal saline found in one of one resident rooms (22) and two of three supply rooms (Rising Sun whirlpool room and the medical supply room), were labeled, stored, and disposed of in an appropriate manner. Findings include: 1. Observation on 6/24/25 at 8:28 a.m. in room [ROOM NUMBER] revealed: *There was a magnet that read EBP at the top of the doorway. *There was PPE hanging on the back of the door. *A poster from the Centers for Disease Control and Prevention (CDC) explaining what EBP was and what direct care staff were required to perform was posted next to the PPE. The poster read: -ENHANCED BARRIER PRECAUTIONS -EVERYONE MUST: --Clean their hands, including before entering and when leaving the room. -PROVIDERS AND STAFF MUST ALSO: --Wear gloves and a gown for the following High-Contact Resident Care Activities. --Dressing --Bathing/Showering --Transferring --Changing Linens --Providing Hygiene --Changing briefs or assisting with toileting --Device care or use: central line, urinary catheter, feeding tube, tracheostomy --Wound Care: any skin opening requiring a dressing. 2. Observation on 6/24/25 at 8:31 a.m. in residents 15 and 22's room revealed: *There was a magnet that read EBP at the top of the doorway. *There was PPE hanging on the back of the door. *There was no EBP poster with instructions for staff as described above. *To the left of the handwashing sink, there was a black plastic trash bag tied to the towel rod. -Approximately three feet of clear plastic tubing was hanging out the trash bag. -There was moisture on the inside of the tubing. -There was a urinary catheter collection bag inside of the trash bag. *To the right of the handwashing sink, there were two black metal storage shelves with personal care products that included: -Two opened containers of normal saline were on each shelf. Neither container was labeled with the date opened or with the resident's initials to identify which resident it belonged to. -One opened plastic package that contained a plastic syringe was on the bottom shelf. Observation on 6/25/25 at 10:23 a.m. in residents 15 and 22's room revealed: *The black plastic trash bag was still tied to the towel rack to the left of the sink. *The catheter tubing was no longer hanging out of the trash bag. *There was moisture buildup on the inside of the catheter collection bag and tubing. Interview on 6/25/25 at 2:50 p.m. with registered nurse (RN) I about resident catheter bags revealed: *He indicated he was a travel nurse and had been working at that facility for four weeks. *Surveyors went with RN I to residents 15 and 22's room to discuss the catheter bag stored there. -It was his understanding that the catheter collection bags should not have been reused. -He indicated that the black plastic trash bag that was tied to the towel rack to the left of the resident's sink contained a urinary catheter collection bag, and it still had traces of urine. -He confirmed that the catheter collection bag was not labeled or dated, and the end of the tube was not capped to protect it from potential contamination. -He confirmed that was not the proper way to store the catheter collection bag. Interview on 6/25/25 at 3:24 p.m. with CNA M about the catheter in residents 15 and 22's room revealed: *CNA M recently passed her CNA certification exam and had been working as a CNA for a couple of weeks. *She confirmed that resident 22 had a suprapubic (SP) catheter and wore a urinary catheter collection bag on her leg (leg bag). *She indicated that she was instructed to keep the leg bag on her leg during the night, rather than switching to a larger bed bag at night. *She confirmed that she also noticed resident 22's urinary catheter collection bag that was in a plastic trash bag and was tied to the towel rack in the resident's room. -She did not know how long that had been stored there like that. Interview on 6/25/25 at 3:35 p.m. with CNA N about catheter care procedures revealed: *Resident 22's leg bag was secured to her right leg during the day. *A bed bag was used to collect urine at night for the resident. *Their normal practice was to rinse and reuse urinary catheter collection bags. -The urinary catheter collection bags were stored in the black plastic garbage bag that was tied to the towel rack in the resident's room. *She explained that a blue solution was used to sanitize the catheter tubing and collection bag. -She did not know what the blue solution was called. -The cleaning solution was supposed to have been stored in the black metal storage shelves located opposite of the towel rack in the resident's room. -She confirmed there was no cleaning solution in resident 22's room. *The blue solution was squeezed through the catheter tubing and into the collection bag. The bag would be filled with about one inch of cleaning solution. -She explained that they allowed the cleaning solution to sit in the collection bag during the day while it was stored in the plastic garbage bag. -The bag was emptied and rinsed with water before switching from one collection bag type to the other. Interview on 6/25/25 at 4:35 p.m. with CNA L about catheter care procedures revealed: *She confirmed that when she helped resident 22 get ready for bed, she would disconnect the resident's leg bag and connect the resident's bed bag for the night. *They stored the bed bag in the black plastic garbage bag that was tied to the towel rack during the day when she was using the leg bag. *The catheter bags they were reusing were cleaned with a liquid in the hopper room (a room where soiled laundry was processed). -She could not find the liquid in the hopper room or in resident 22's room. -She did not know what the liquid was called. -The liquid was bluish-purple in color. Interview on 6/25/25 at 4:48 p.m. with CNA O about catheter care procedures revealed: *She confirmed that residents' urinary catheter leg bags and bed bags were reused. *She would rinse the bags and tubing with water when she changed from one bag to another. -She indicated that she would request other CNAs to clean the catheter tubing and bags because she did not know the procedure for cleaning them. -She had only been a CNA for a few months at the time of the survey. *She did not know what solution was used to clean the catheter tubing and bags. Observation and interview on 6/26/25 at 9:06 a.m. with CNA N while she assisted resident 22 get out of bed revealed: *CNA N confirmed that she and another CNA had assisted the resident to transfer from her bed to her wheelchair. *Resident 22's bed bag was sitting directly on the floor. *CNA N put on a gown, gloves, and a face mask. *CNA N removed a new leg bag from its sterile packaging, uncapped the end of the tubing, and wiped it with an alcohol wipe. -She accidentally touched the resident's leg, the SP catheter tubing, and the bed bag tubing with the end of the new catheter tubing as she struggled to disconnect the bed bag tubing from the SP catheter tubing, potentially contaminating the end of the new catheter tubing. *Once she successfully disconnected the bed bag and connected the leg bag, she brought the bed bag to the bathroom and poured the urine contents into a graduated cylinder (a type of measuring cup) on the floor. She left the graduated cylinder containing urine on the floor in the bathroom, indicating that she would come back after resident 22's shower to clean the cylinder. *She brought the empty bed bag to the sink and said, Where's your garbage bag? -She then grabbed a new black plastic garbage bag and placed the soiled bed bag and tubing inside and tied the garbage bag to the towel rack. *She indicated that she would clean the bed bag after she helped resident 22 take a shower. *She removed her PPE and did not perform hand hygiene before helping resident 22 put her glasses on and brushed her hair out of her face. *She did not perform hand hygiene upon exiting the resident's room. Continued observation and interview on 6/26/25 at 9:46 a.m. with CNA N revealed: *She wanted to correct her comments from the previous day about the catheter cleaning solution. -She learned that the process recently changed to using three parts vinegar to one part water as a cleaning solution. *She went to the medical storage room, grabbed a covered specimen cup and a new plastic syringe, and filled the cup about three-fourths of the way with vinegar. *She brought those supplies to resident 22's room. *Upon entering the room, it was discovered that the graduated cylinder containing urine was no longer there. She stated that someone else must have emptied the cylinder. *She filled the specimen cup of vinegar with water until it was full. *After squeezing the vinegar-water solution through the catheter tubing and into the collection bag, she explained that the new policy was to swish the solution around in the bag and empty it. They were no longer supposed to leave the cleaning solution in the bag throughout the day or overnight. *After pouring the contents of the catheter bag into the toilet, she wiped the end of the catheter tubing with an alcohol wipe and placed it back into the same potentially soiled garbage bag that it had been stored in before she cleaned it. *She stated she sometimes changed the resident's catheter bag to a new one on the resident's bath days, and it was changed at least monthly. Interview on 6/26/25 at 10:39 a.m. with Minimum Data Set (MDS) coordinator/infection preventionist C and director of nursing (DON) B revealed: *It was their expectation that residents' catheter bags should not have been directly on the floor to protect them from potential damage and contamination. *If the insertion tube on a catheter was potentially contaminated by touching other objects, it was their expectation that it should have been sanitized with an alcohol wipe before inserting it into the resident's SP catheter tube. *It was their expectation that staff should have cleaned the SP catheter tube after disconnecting the old collection tube. *They had not used the blue cleaning solution for cleaning catheter bags in a long time. -DON B indicated that she had been working at the facility for one and a half years and they had always used the vinegar solution to clean the catheter bags. *The management team had recently been updating policies and they implemented a new catheter care policy the previous week. -They placed the new policies in the policy binder at the nurse's station on Monday 6/23/25. -They informed staff to review the new policies both verbally and via a sign by the staff's clock-in station. -Once staff reviewed the new policies, they should have signed a piece of paper in the policy binder indicating that they reviewed the policies. *They recently started completing nursing staff competencies in April 2025 by recommendation of their nurse consultant. -Their first nursing staff competency was focused on peri cares (the hygiene and cleaning of the perineal area, which includes the genitals and anal area) due to the high rate of urinary tract infections amongst residents. *They expected staff to drape the catheter bag and tubing over the towel rack to drain and dry and place a bin beneath to catch any liquids draining from the bag. -They indicated that placing the catheter bag into the black plastic garbage bags for storage when not in use was acceptable for dignity purposes, if that still allowed for adequate draining and drying of the catheter bag. *They expected staff to perform hand hygiene before putting on PPE, and after taking off PPE. *Staff should have been dating and labeling the resident's products like the containers of normal saline, and staff should not be reusing plastic syringes. -DON B confirmed that staff used the containers of normal saline to flush the resident's SP catheter. -DON B discarded the opened and unlabeled containers of normal saline and the open syringe package from resident 22's room at that time. *When they were informed that CNA N had made a three-parts vinegar to one-part water solution rather than the three-parts water to one-part vinegar solution as their new policy stated, they did not have any comments. Interview on 6/26/25 at 4:33 p.m. with MDS coordinator/infection preventionist C revealed: *When asked how they ensured staff were aware of and educated on new policies and procedures, she repeated that they placed the policies in the policy binder, staff were to review it and sign it, and if they had questions, they were to find one of the nurse managers. *They review policies at all-staff meetings. Review of resident 22's electronic medical record revealed: *There were no physician's orders describing when the resident's urinary catheter collection bag should have been changed, such as changing the leg bag to a bed bag at night. *She had the following physician's orders: -Flush catheter every night at bedtime and as needed with 60mL [milliliters] saline or sterile water. as needed for catheter [maintenance]. Ordered and started on 3/27/25. -Flush catheter every night at bedtime and as needed with 60mL saline or sterile water. at bedtime for catheter maintenance. Ordered on 3/27/25. Started on 3/28/25. *Her suprapubic catheter was last changed on 6/10/25. *Her care plan did not include directions for when the urinary catheter collection bags should have been changed, such as changing the bed bag to a leg bag during the day. *Her care plan included the following interventions: -EBP are used for high contact cares such as transfers, catheter cares, showers. Initiated on 6/10/25. -Perform catheter cares per facility policy. Initiated on 6/10/25. -Please use enhanced barrier precautions when caring for me. Initiated on 6/1/25. -PPE for enhanced barrier precautions is only necessary for performing high-contact care activities such as transfers, peri cares, dressing, and bathing. Initiated on 6/1/25. Review of the provider's 6/19/25 Changing the Urinary Collection System revealed: *Policy: The urinary collection system shall be changed at the time of a new catheter insertion per provider order or as needed based on clinical assessment (e.g., visible damage, leakage, or malfunction). Aseptic technique must be maintained throughout the procedure to preserve the integrity of the closed urinary drainage system and minimize infection risk. *Required Supplies -Clean non-sterile gloves -Alcohol swabs -Barrier (e.g., disposable pad or paper towel) -Graduated cylinder (for measuring urine) -New sterile urinary drainage bag/system *Procedure -1. Preparation -- .b. Perform hand hygiene. --c. Gather all required supplies and place a barrier on the working surface. -2. Apply Gloves and Empty Current System --a. [NAME] [Put on] clean gloves. --b. Place the graduated cylinder below the drainage spout and empty the contents of the current urinary drainage bag. --c. Record the amount and appearance of the urine per facility protocol. -3. Setup of New System --a. Open packaging of the new sterile urinary drainage bag/system, maintaining sterility of the connection port. -4. Disconnection and Cleaning --a. Clamp the catheter (if applicable per manufacturer guidance) to prevent leakage. --b. Disconnect the old urinary drainage bag from the catheter tubing. --c. Discard the old system appropriately. --d. Using an alcohol swab, cleanse the catheter tubing connection site thoroughly. -5. Connecting New Drainage System --a. Remove the protective cap from the new drainage tubing, being careful not to contaminate it. --b. Immediately connect the sterile tubing to the catheter. --c. Unclamp the catheter to allow drainage to resume. --d. Secure the drainage bag to the bed frame or mobility device, keeping it below the level of the bladder to maintain gravity drainage. Ensure there are no kinks in the tubing. -6. Completion --a. Dispose of gloves and used materials in accordance with facility policy. --b. Perform hand hygiene. -7. Documentation: Document the following in the resident's medical record: --Date and time of the urinary drainage system change --Reason for the change (e.g., routine with catheter replacement, damaged bag) Review of the provider's 6/19/25 Urinary Bag Cleaning & Storage policy revealed: *Policy: Urinary bags to be properly cleaned and stored between use. *Purpose: -1. Maintain asepsis of urinary catheter bags. -2. To prevent introduction of micro-organisms into the urinary drainage system. -3. To prevent urinary tract infections. *Equipment needed: -1. Alcohol Swabs -2. Vinegar solution (3:1 ratio of water to vinegar) - stored in oxygen room -3. Specimen Cup- Stored in the resident room, changed every 3 months with supplies. -4. Graduated cylinder -5. Clean Gloves -6. Paper Towels -for barrier -7. Clean plastic bag- if transport is necessary *Procedure: -1. Preparation -- .Prepare a cleaning solution using three parts water to one part vinegar in a clean specimen cup. - .5. Attach New Bag --Attach a clean urinary drainage bag to the catheter tubing. Label bag with resident initials and room number. -6. Clean Used Bag --Take the used bag to the designated sink. --With the draining port open, flush the bag and tubing thoroughly with the vinegar solution. --Allow excess liquid to drain fully. -7. Hand Hygiene --Remove gloves and perform hand hygiene. *Storage Instructions for Cleaned Urinary Bags -Hang the clean urinary bag on the towel rack near the sink. -Place a basin (labeled with resident initials/room number & urinary drainage basin) below the urinary bag lined with clean paper towels beneath to absorb residual moisture. -Replace paper towels after each cleaning. Review of the provider's Education Signature Sheet that was located at the front of the policy binder at the nurse's station revealed: *Education: Updated Policies/Procedures 6/23/25 *Only two people had signed that they had reviewed the updated policies by the end of the survey on 6/26/25. *CNAs L, M, N, and O had not signed the sheet, indicating they had reviewed the policies. 3. Observation on 6/24/25 at 8:49 a.m. in the whirlpool room on the Rising Sun hallway revealed: *The room appeared to have been used as a storage room. *There was a package of wet wipes that was open to air sitting on the edge of the handwashing sink. It was not labeled with which resident it belonged to. *An opened bottle of barrier cream was sitting on the sink that was not labeled for a specific resident. *There was an unidentified dried brown substance on the faucet handles. *On the shelving unit, there was a bin labeled [hospice provider's name] Hospice Extra Supplies that contained: -One bottle of hand sanitizer that had an expiration date of 08/22. There was an unknown dried brown substance smeared on the bottom of the bottle. -One opened bottle of baby powder that was not labeled for a specific resident. Observation on 6/25/25 at 4:00 p.m. in the medical supply room on the Rising Sun hallway revealed the following expired supply items: *Two Dover brand silicone two-way hemostatic catheters with expiration dates of 1/9/25. *Approximately 25 Cure brand male catheters with expiration dates of 3/28/25. *One package of Tri-Flo Suction Cath-N-Glove catheter kit with an expiration date of 2/8/25. 4. Observation on 6/25/25 at 11:44 a.m. of CNA K assisting resident 32 to transfer from her recliner to her wheelchair revealed CNA K: *Confirmed that resident 32 was on EBP for the opened wounds on her bottom. *Explained that the resident would often remove the bandages from her wounds. *Did not put on a protective gown before helping resident 32 stand up from the recliner and pivot to her wheelchair. *Put on a protective gown before taking the resident to the bathroom. -While in the bathroom, CNA K confirmed the resident had taken her bandage off of the wounds. *Did not offer hand hygiene for resident 32 after she brought her out of the bathroom. Interview on 6/25/25 at 12:00 p.m. with CNA K about the above observation revealed: *She confirmed she was aware of what EBP was and the need for using PPE when assisting those residents with care. *She confirmed she had not put on PPE for transferring resident 32 from her recliner to her wheelchair. -She thought if resident 32 was dry and had not been incontinent, she was not required to put on the protective gown before transferring her. *She indicated that the EBP poster was supposed to be on the back of the resident's door that explained what staff were supposed to do. -She could not find the EBP poster in resident 32's room. -She showed the surveyors the EBP poster in resident room [ROOM NUMBER]. *When she read on the poster that staff were supposed to wear a gown during transfers, she said, My bad. Review of resident 32's care plan revealed she had the following interventions: * .Please use enhanced barrier precautions when caring for me. EBP are used for high contact cares such as transfers, catheter cares, showers. Initiated on 6/8/25. Revised on 6/25/25. *PPE for enhanced barrier precautions is only necessary for performing high-contact care activities such as transfers, peri cares, dressing, and bathing. Initiated on 6/10/25. B. Based on policy review and interview, the provider failed to ensure the infection prevention and control program (IPCP) had policies and procedures that described as required the following areas: -A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility -When and to whom possible incidents of communicable disease or infections should be reported. -The duration of isolation precautions. -A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. -The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. -A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. Findings include: 1. At the start of the survey on 6/23/25, the survey team was provided with a DOH Survey Binder that contained items requested from the entrance conference that was conducted at 8:18 a.m. with administrator A and DON B. *The survey team requested to review the provider's infection prevention and control program policies and procedures. *Three different policies were provided titled Infection Prevention Precautions Policy, Infection Control, and Antibiotic Stewardship Program. 2. Review of the provided policies did not address, describe, or explain the following: *A system of infection surveillance. *A system for recording incidents and the corrective actions taken. *When and whom to report communicable diseases to. *Under what circumstances the facility must prohibit employees with communicable diseases from direct contact with residents or their food. *The duration of isolation precautions. *An explanation that isolation precautions should be the least restrictive possible for residents. 3. Interview on 6/26/25 at 2:36 p.m. with administrator A and DON B revealed: *They confirmed they did not have a policy on reportable diseases. -She explained that they used the South Dakota Department of Health's Reportable Diseases list for that. 4. Interview on 6/26/25 at 4:08 p.m. with MDS coordinator/infection preventionist C revealed: *She confirmed they did not have a policy on reportable diseases. *She indicated that their chosen clinical laboratory was required to report diseases on the Reportable Disease list, so they did not report the required reportable diseases, such as syphilis. *When asked about the missing policies above, she was able to describe actions that addressed the requirements, but confirmed they did not have written policies or procedures for those areas. -For example, when asked about how they identified staff with communicable diseases and prohibited them from direct contact with residents and their food, she indicated that staff would contact their direct supervisor if they did not feel well, and sometimes requested them to come in to be assessed by a nurse or required a doctor's note. 5. Review of the provider's 6/19/25 Infection Prevention Precautions Policy revealed: *The policy described standard precautions, airborne precautions, contact precautions, and droplet precautions. *The policy did not describe the duration of the isolation, depending upon the infectious agent or organism involved, and a requirement that the isolation should be the least restrictive possible for the resident under the circumstances. 6. Review of the provider's 6/19/25 Infection Control policy revealed: *The policy described the following topics: -Standard precautions. -Staff training requirements. -Hand hygiene. -Glove use. -Different types of PPE and when to use each type. -Handling of resident care equipment. -Cleaning of environmental surfaces. -Handling and transporting linens. -Needle safety. -Aseptic techniques when handling injection equipment. 7. Review of the provider's January 2025 Antibiotic Stewardship Program revealed: *There was a section for Reporting and Surveillance that included -a. Report all infections to the Infection Preventionist or designee. -b. Monitor infection rates and trends by surveillance. -c. Investigate outbreaks and take the necessary corrective actions.

Based on record review and interview, the provider failed to ensure the proper Medicare notices were filled out completely and were in the required format for three of three sampled residents (9, 37, and 294) prior to their discharge from Medicare Part A skilled services. Findings include: 1. Review of the Entrance Conference Worksheet completed by the provider on 6/25/25 revealed the list of residents identified as having been discharged from Medicare Part A skilled services included the following: *Two residents (9 and 37) remained in the facility following their discharge from Medicare Part A skilled services. *One resident (294) was discharged to home following his discharge from Medicare Part A skilled services. 2. Review of resident 9's SNF (Skilled Nursing Facility) Beneficiary Notification Review form completed by social services designee (SSD) E revealed: *The resident's Medicare Part A Skilled Services Episode start date was 12/16/24. *Her last covered day on Medicare Part A Service was 1/24/25. Review of resident 9's electronic medical record (EMR) revealed: *She was re-admitted to the facility on [DATE] after a three-day hospital stay with Medicare Part A covering her stay. *On 1/25/25, after her Medicare Part A stay ended, she remained in the facility as indicated on the Entrance Conference Worksheet. *Her 3/9/25 Brief Interview for Mental Status (BIMS) evaluation was scored at seven which indicated she had severe cognitive impairment (a decline in mental abilities including thinking, learning, remembering, and making decisions). 3. Review of resident 294's SNF Beneficiary Notification Review form completed by SSD E revealed: *The resident's Medicare Part A Skilled Services Episode start date was 3/4/25. *His last covered day on Medicare Part A Service was 4/4/25. Review of resident 294's EMR revealed: *He was admitted on [DATE] with Medicare Part A covering his stay. *His 3/6/25 BIMS evaluation was scored at twelve which indicated he was moderately cognitively impaired. *On 4/5/25, after his Medicare Part A stay ended, he was discharged to his home as indicated on the Entrance Conference Worksheet. 4. Review of resident 37's SNF Beneficiary Notification Review form completed by SSD E revealed: *The resident's Medicare Part A Skilled Services Episode start date was 3/26/25. *Her last covered day on Medicare Part A Service was 4/10/25. Review of resident 37's EMR revealed: *She was re-admitted to the facility on [DATE] after a four-day hospital stay with Medicare Part A covering her stay. *On 4/11/25, after her Medicare Part A stay ended, she remained in the facility as indicated on the Entrance Conference Worksheet. *Her 4/11/25 BIMS evaluation was scored at five which indicated she had severe cognitive impairment. 5. Review of the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123, with a revision date of 12/31/11, for residents 9, 37, and 294, completed by SSD E revealed: *The 12/31/11 NOMNC form was outdated and was not the updated form that was required to be used as of 1/1/25, with an expiration date of 11/30/27. *The first bullet point that explained Your Medicare provider . have determined that Medicare probably will not pay for your current {insert type} services . was not completed with the type of services ending. -The type of services ending should have been identified as skilled nursing. *The How to Ask For an Immediate Appeal section was to provide contact information in the fourth bullet point that indicated to Call your QIO [Quality Improvement Organization] at: {insert QIO name and toll-free number of QIO} to appeal, . was not completed with the name and telephone numbers, including TTY (teletypewriter for people with hearing or speech difficulties) of South Dakota's (SD) QIO. *The Additional Information (Optional) section indicated SSD E had spoken by phone with the residents' representatives regarding therapy services ending on the actual date Medicare Part A services would end, the reason why Medicare Part A services were ending, and SSD E's signature. *The form indicated on the Signature of Patient or Representative signature line that the residents' representatives had been contacted verbally by a phone call and the date line indicated the date that phone conversation had taken place. -The information provided had not included all of the information required in the 10/31/24 Medicare Claims Processing Manual's Section 260.3.8 - NOMNC Delivery to Representatives Exceptions to in person notice delivery. Review of the 2018 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 for resident 9 and 37, completed by SSD E revealed: *The 2018 SNF ABN form was outdated and not the updated 2024 form that was required to be used as of 10/31/24. *The forms indicated the notices had been provided verbally during a phone call to the residents' representatives. 6. Interview on 6/26/25 at 5:08 p.m. with SSD E regarding the above NOMNC forms and SNF ABN forms she had completed revealed she: *Was not aware the forms she had used were outdated and that new, updated forms were required to be used. *Agreed that the type of services ending on the NOMNC forms was not clearly identified. *Agreed that the QIO's name and toll-free phone number had not been provided on the NOMNC forms as required. *Was not aware of the information that was required to be documented on the NOMNC form when a resident's representative was contacted by telephone. *Confirmed she had not filled out the forms completely, according to their instructions. 7. Review of the cms.gov website revealed: *On 8/28/2024: With the help of our contractors, we revised the SNF ABN, Form CMS-10055, and the form instructions. -The SNF ABN form and instructions are located in the download section and are available for immediate use, but will be mandatory for use on 10/31/2024. *On 11/18/2024: New NOMNC and DENC for Original Medicare and Medicare Advantage: -The Office of Management and Budget (OMB) has approved a revised Notice of Medicare Non-Coverage (NOMNC / CMS-10123) . -Please note the updated NOMNC .are to be used for both Original Medicare and Medicare advantage . -Providers must use the revised NOMNC beginning January 1, 2025 . Review of the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed: *{Insert type}: Insert the kind of service being terminated, i.e., skilled nursing, home health, comprehensive outpatient rehabilitation service, or hospice. *In the section How to Ask For an Immediate Appeal Insert the name and telephone numbers (including TTY) of the applicable QIO in no less than 12-point type. Review of the 10/31/24 Medicare Claims Processing Manual's Section 260.3.8 - NOMNC Delivery to Representatives Exceptions to in person notice delivery revealed: *The provider must complete the NOMNC as required and telephone the representative at least two days prior to the end of covered services. *The NOMNC must be annotated with the following information on the day that the provider makes telephone contact: -The beneficiary's last day of covered services, and the date when the beneficiary's liability is expected to begin. -The beneficiary's right to appeal a coverage termination decision. -A description of how to request an appeal by a QIO. -The deadline to request a review as well as what to do if the deadline is missed. -The telephone number of the QIO to request the appeal. *Reflect that all of the information indicated above was communicated to the representative. *Note the name of the staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called. *A copy of the annotated NOMNC should be mailed to the representative the day telephone contact is made and a dated copy should be placed in the beneficiary's medical file.

Based on observation, interview, record review, and policy review the provider failed to: * Implement and monitor care planned approaches for one of one sampled resident (25) identified on admission as having potential for pressure ulcer development prior to the development of a heel pressure ulcer. *Implement, monitor and accurately document skin injuries, and care plan approaches for two of two sampled residents (7 and 33) who acquired pressure ulcers after admission. Findings include: 1. Observation and interview on 1/14/25 at 10:36 a.m. with resident 25 while she was sitting in her recliner with her legs elevated revealed she: *Had been admitted to the facility on [DATE] for strengthening due to urinary tract infection. *Had a black spot on her left heel that was not on her heel when she was admitted . *Had edema leggings on her right leg. *Had a wound dressing to her left leg. Observation on 1/15/25 at 9:00 a.m. of resident 25's left heel revealed she had a black area to her left heel with her skin intact and no open areas. Interview on 1/16/25 8:00 a.m. with resident 25 revealed she had not started using the Prevalon boot (for pressure relief) until after she had the sore on her left heel. Interview on 1/16/25 at 8:12 a.m. with certified nursing assistant (CNA) N regarding resident 25's Prevalon boot usage revealed: *The Prevalon boot use had started when her pressure ulcer had been identified. *Resident 25 had not used a sheepskin on her to heels. Interview on 1/16/25 at 8:40 a.m. with RN D regarding resident 25's admission nursing assessment revealed she agreed that assessment did not indicate she had a pressure ulcer to her left heel on admission. Interview on 1/16/25 at 11:30 a.m. with nurse manager C regarding resident 25's interventions for pressure ulcer prevention revealed: *Prevalon boots were on the standing orders for all residents to use for pressure ulcer prevention. *She had not been aware that staff were not using the Prevalon boots or sheepskin for pressure ulcer prevention. *She had been aware that staff were using the Prevalon boot since the identification of the pressure ulcer Review of resident 25's EMR revealed: *She had admitted to the facility on [DATE]. *Her brief interview for mental status (BIMS) assessment that had been completed on 1/6/25 had a score of 15 which indicated her cognition was intact. *Her admission nursing assessment had identified inflammation (redness or swelling) to her lower back that was pink and intact. *No documentation of any skin alteration to her left heel. *On 1/6/25 the skin alteration had been identified. Review of resident's Braden Score for predicting risk of pressure sore development revealed: *On 12/23/24 and 12/30/24 her score was 16.0 indicating she was at risk. *On 1/6/25 and 1/13/25 her score was 17.0 indicating she was at risk. Review of resident 25's care plan initiated on 12/23/24 revealed: *She had been identified for having the potential for pressure ulcer development. *Prevalon boots as needed to prevent heel skin breakdown. *Sheepskin to the end of the bed and chair for skin breakdown prevention as needed. *Administer treatments as ordered and monitor for effectiveness. *Resident 25's care plan had not been revised once her skin alteration had been identified. 51472 2. Observation on 1/14/25 at 8:10 a.m. of resident 7's room revealed: *There was no cushion in her recliner. *She had a standard pressure reduction mattress. Observation and interview on 1/14/24 at 9:02 a.m. with resident 7 revealed: *There were two cushions in her wheelchair. *The top cushion was a waffle cushion that covered the bottom and back of the wheelchair. *The cushion under the waffle cushion was a Roho cushion (air cushion that helps distribute weight evenly to prevent pressure ulcers). *The Roho cushion was not inflated. *Resident 7 transferred herself to her recliner. *There was not a cushion in the recliner. *Resident 7 stated that her daughter brought her the waffle cushion for her comfort. *She did not remember if she had any sores or skin problems. Interview on 1/15/25 at 3:28 p.m. with minimum data set (MDS)/director of nursing (DON) B revealed: *She was responsible for updating resident care plans. *Care plan interventions were to be updated when there were changes in resident care. *She agreed that resident 7's care plan was not updated to include her facility-acquired pressure ulcer. *It was her expectation that someone was checking the ROHO cushions to ensure they did not go flat. *She stated that therapy would be providing education on the ROHO cushions. Interview on 1/16/25 at 8:34 a.m. with nurse manager C revealed: *It was her expectation that staff reposition residents every two hours, the cushions in the wheelchairs were properly placed, heel boots were on the residents per information provided in the electronic medical record (EMR). *MDS/DON B was responsible for updating resident care plans. *She expected resident care plans to be updated to include pressure-reduction devices. *She believed that the staff knew how to access resident care plans. *ROHO cushions were managed by therapy (physical and occupational) but it was everyone's responsibility to monitor the filling and maintenance of the ROHO cushions. *She did not know if staff had received training on filling and use of the ROHO cushions. Interview on 1/16/25 at 10:50 a.m. with certified nursing assistant (CNA) G revealed: *She did not have access to resident care plans. *She did not know what a ROHO cushion was. *She stated that the cushions were managed by therapy. *She was unable to identify pressure reduction interventions that were being utilized for resident 7. Review of resident 7's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 12/7/24 brief interview for mental status (BIMS) assessment was 12, which indicated moderate cognitive impairment. *Her diagnoses included dementia, repeated falls, and weakness. *She had had a stage II pressure ulcer (a shallow open ulcer that resulted due to pressure) on her left hip identified on 11/16/24. -The stage II pressure was documented as healed on 12/6/24. *The record lacked ongoing documentation of assessment, measurements and size of the pressure ulcer as it progressed to being healed. *Skin observation tool documentation reflected: -Bruising to left elbow. -Red coccyx area noted, 2-3 small open areas noted. Fax MD [medical doctor] for tx [treatment]. Barrier cream applied. Small area noted on outer left elbow bruised with scab noted over the bony area. Area intact. Review of resident 7's 1/14/25 care plan revealed: *A focus area of I have the potential to have impairment to skin integrity which was initiated on 5/30/24 and updated on 6/3/24. *The use of the ROHO cushion or the waffle cushion was not included in the care plan. *A focus area of I have a potential nutritional problem r/t [related to] hx [history] of CHF [congestive heart failure]; COPD [chronic obstructive pulmonary disease] and recent hip fracture with repair initiated on 7/8/24 included an intervention of Resident with stage II wound to left hip. Dislikes supplements. Will offer extra 1 oz [ounce] of protein with meals to aid in wound healing initiated on 12/6/24. 3. Observation on 1/15/25 at 9:35 a.m. of resident 33's while in the shower room with certified nursing assistant (CNA) I revealed: *Resident 33 reported that his butt hurt. *CNA I radioed for registered nurse (RN) D to come to the shower room for a skin check. *When RN D came into the shower room, CNA I reported that resident 33 had sores on his butt. *A scabbed area was present on his left middle buttock and two open areas were present on his right middle buttock. *RN D stated that resident 33's buttocks had open areas on them and instructed CNA I to apply a barrier cream. *RN D indicated she would fax the doctor for orders. *CNA I applied barrier cream to resident 33's buttocks. Observation on 1/16/25 at 10:25 a.m. of resident 33 in the common area by the nurses' stations revealed: *He walked with a walker. Observation on 1/16/25 at 12:08 p.m. of resident 33's room revealed: *There was no pressure reduction cushion on his recliner. *His mattress was a standard pressure reduction mattress. Interview on 1/16/25 at 10:21 a.m. with registered nurse (RN) D revealed: *She had access to view resident care plans. *She was not able to edit the care plans. *She indicated ways to implement pressure reduction included: -Repositioning the resident every two hours. -Application of heel boots. -An air mattress placed on the bed. -Cushions in the residents' chairs *Therapy was to be initiated for residents with pressure ulcers. *The therapists were not employed by the provider. *Therapy placed the ROHO cushions in resident chairs and then notified MDS/DON B to update the care plan. *She did not know who was responsible for monitoring and filling the ROHO cushions. *She had not received training on the care and maintenance of the ROHO cushions. *Wounds were monitored by the charge nurse within the treatment administration record (TAR). *Wounds were not measured by the charge nurse. *Wounds were measured by MDS/DON B if the resident was referred to the wound clinic. *She did not believe that resident 33 had a cushion in his recliner in his room. *She stated that she knew he did not have a cushion in the chair he frequently sat in in the common area by the nurses' station. Review of resident 33's EMR revealed: *He was admitted on [DATE]. *His 12/19/24 BIMS assessment was 5, which indicated severe cognitive impairment. *His diagnoses included: diabetes, dementia with behavioral disturbance, and muscle weakness. *He had an order for calmoseptine ointment to be applied twice daily to open areas on his buttocks that was ordered on 1/15/25. *The 1/15/25 Skin Observation Tool documented a site of Coccyx, type as Pressure and stage as II. There was no documentation of size, number of open areas, specific locations, drainage, appearance of wound bed, or interventions. *Per standard of practice there was no weekly documentation of the pressure ulcer. Review of resident 33's 1/16/25 care plan revealed: *A focus area of I have potential to have impairment to skin integrity which was initiated on 6/10/24 and revised on 6/17/24. *The interventions for that focus area included: -Encourage good nutrition and hydration to promote healthier skin. -I have a pressure reduction mattress on my bed and in my wheelchair. --This intervention was initiated on 6/10/24 and revised on 6/17/24. -Identify/document potential causative factors and eliminate/resolve where possible. Review of the provider's 8/2024 PRESSURE ULCER (PREVENTION) policy revealed: *Resident care plans reflect any specific skin care needs. *Protect boney prominences with cushions and pads. *Document all wounds weekly and the pressure ulcer skin flow sheet.

Based on observation, interview, record review, and policy review the provider failed to: *Accurately identify and implement enhanced barrier precautions (EBP) for three of three sampled residents (4, 20, and 24) who had care concerns requiring personal protective equipment (PPE). *Utilize appropriate hand hygiene and gloves during cares by one of one staff (certified nursing assistant (CNA) I with one of one resident (33). *Appropriately maintain and dispose of resident care items in two of two hopper rooms, one of one shower room, and one of one beauty shop. Findings include: 1. Observation on 1/14/25 at 8:15 a.m. of the Garden Terrace hallway revealed there was no PPE in the hallway or residents' rooms. Observation on 1/14/25 at 9:09 a.m. of resident 4 in the dining room revealed: *She was seated in her wheelchair. *She had her right lower extremity (RLE) wrapped in a dressing. *She was touching what appeared to be a wound on her RLE that was not covered and was open and red. 2. Observation on 1/14/25 at 9:36 a.m. of resident 4's room revealed: *There was no sign indicating a need for EBP. *There was no personal protective equipment (PPE) outside or inside her room. *She shared a room with resident 9. *The room and an adjoining bathroom with the room next door. Review of resident 4's electronic medical record (EMR) revealed: *She was admitted on [DATE] *She had a Brief Interview of Mental Status (BIMS) assessment score of 8, which indicated she was moderately cognitively impaired. *Her diagnoses included cellulitis, dementia, and bulbous pemphigoid (autoimmune disease that causes skin blisters) *She had an order for wound care to her RLE. *She was not on enhanced barrier precautions. Interview on 1/15/25 at 9:22 a.m. with registered nurse (RN) D regarding how she performed resident 4's RLE dressing change revealed: *She performed hand hygiene before putting on gloves. *She removed the dirty wound dressing and threw it away in the garbage can. *She performed hand hygiene before putting on a clean pair of gloves. *She applied clean dressings to the wound. *She confirmed she would only wear gloves for PPE for resident 4's dressing change of her wound. Interview on 1/15/25 at 12:09 p.m. with minimum data set (MDS)/ director of nursing (DON) regarding their enhanced barrier precautions (EBP) protocol revealed: *She believed the statement in the policy that read, CMS [Center for Medicare and Medicaid Services] notes facilities have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents came from the CDC (Center for Disease Control) website. *She did not produce where that portion of the policy was referenced from as requested. Interview on 1/16/25 at 10:21 a.m. with RN D about EBP revealed: *Anyone with a urinary catheter was on EBP. -She listed three residents who had a urinary catheter. *She indicated that residents who had MRSA (methicillin-resistant Staphylococcus aureus) or VRE (Vancomycin resistant enterococcus) would also be on EBP. -There were no residents in the facility that currently had either of these. 3. Observation on 1/14/25 at 8:15 a.m. of Garden Terrace hallway revealed: *There was one wall hanging alcohol-based hand sanitizer (ABHS) in the hallway. -It was in the middle of the hallway. *Each resident room had a wall hanging ABHS near the bathroom door. 4. Observation on 1/14/25 at 8:36 a.m. of the Garden Terrace hopper room revealed: *The cabinet under the sink contained: -A spray bottle labeled 75% Ethyl Alcohol with a broken spray top. -A spray bottle labeled C-Diff [clostridium difficile] solution tablets. -Multiple glass containers. -A plastic basin. -Empty plastic ice cream buckets. -A short white extension cord. -A bottle of toilet bowl clearer with a brush in a plastic white bucket. The bottom of the bucket had multiple black flecks of an unknown substance and a yellow crusty unknown substance. *There was no ABHS available in or outside the door of the hopper room. *Soap and water were available at the sink. *Two unidentified staff opened the door, threw trash in the garbage and exited the room without washing their hands. 5. Observation on 1/14/25 at 8:56 a.m. in Garden Terrace hallway revealed: *A covered cart was parked in the hallway. *On top of the cart were two fabric soaker pads and a bed sheet. *The linen was not covered. *There were two full body mechanical lifts parked in the hallway. *Neither lift had a container of disinfectant wipes. 6. Observation on 1/14/25 at 9:29 a.m. of the Happy Trails hopper room revealed: *There was no ABHS available in or outside the door of the hopper room. *Soap and water were available at the sink. *The cabinet under the sink contained: -One teal plastic bedpan and two gray plastic bed pans. -A can of Spectracide wasp and hornet killer. -A white basin. -Two plastic buckets. -A clear Sterlite four-quart plastic container with brown paper towels. On top of the paper towels was a rectangular silver metal cover with green corrosion on it. Inside the clear container along the paper towels was cobwebs and brown flakes of an unknown substance. -An empty spray bottle labeled PH7Q Dual disinfectant. -A partial bottle of tearless Shampoo & Body Wash. -An open container of Super Sani-Cloths. - Two round pink basins. -Two bundles of brown paper towels and two rolls of toilet paper. -An empty bottle labeled Isopropyl Rubbing Alcohol 70% that had outdated on 6/17. *The cabinet between the hopper and the sink contained: -A partial bottle of Dermal Wound Cleanser that was outdated on 4/22. -A partial bottle of hand sanitizer that was outdated on 8/22. -A cardboard box that contained red bags with moisture damage present to the box. *Two unidentified individuals opened the door, threw garbage into the hamper and did not wash their hands. 7. Observation on 1/14/25 at 1:36 p.m. of the beauty shop revealed: *A wooden cabinet around the stationary hair dryer. *The wooden cabinet contained: -A partial bottle of hand sanitizer that was expired on 7/22. -Nail polish remover that was expired on 4/19. -A bottle of Tresemme conditioner that had a name on it that was not a current resident. -A partial container of disinfectant wipes that was expired on 2/21. *The counter beside the hair washing sink contained: -A dry container of disinfectant wipes. -A bottle of ABHS that was outdated on 9/23. -A bottle of Biolage Antidandruff shampoo that was outdated on 10/24. -A white bucket that contained hair curlers with no resident identifier on the bucket. -The curlers contained strands of gray and white hair. -A clear container of pins to secure the curlers with no resident identifier. *The filter on the back of the stationary hair dryer had a thick coating of dust and gray and tan particles. Interview on 1/14/25 at 1:56 p.m. with RN D revealed: *Staff use the beauty shop for the residents. *Bath aides use the curlers to set residents' hair. *Local beauticians use the beauty shop to cut residents' hair. 8. Observation on 1/15/25 at 8:43 a.m. of the shower room revealed: *There were tiles missing on the shower floor. *In a plastic three-drawer cabinet were: -Two electric razors that were filled with white and gray hair. -Two different sized curling irons with an unknown crusted white substance and long white hairs on the barrels. *On the floor near the sink were two blue squares of non-stick rubber-like material that had hairs and other unknown white particles on them. *On the wooden shelves between the cabinet and the sink there were: -Multiple bags of open incontinent products without any resident identifiers. -An open container of disposable skin wipes with an unknown brown substance on the container. --There was no resident identifier on the container. -Twelve uncovered towels. -A gray basin with black garbage bags and two unrolled gait belts with a brown substance on one of the gait belts. *On the outside of the white cabinet was a piece of paper titled Bath Aide. -A list of the bath aide duties was on the piece of paper. -Under the duties there was a portion labeled Infection Control. --Use 1/3 cup or less Virex Cleaner in spray bottle fill with water. Spray down shower chair/bath in between resident use. --Use alcohol spray for all other reusable items between uses. Combs Nail clippers Tweezers Shave Parts. *A towel was covering an over-the-bed table by the window. *On the towel was a plastic gray basin that contained two black electric razors filled with gray hair, a temporal thermometer (thermometer that takes temperature on the forehead), a wrist blood pressure cuff, and a white coffee cup. *The coffee cup contained: -Eight pens, two black combs, one purple pick, one silver scissors, one black handles scissors, two nail clippers, a spray bottle with a handwritten label For reusable items combs tweezers, razor parts. Alcohol Spray 05/25, and a bottle of alcohol-based hand sanitizer (ABHS). *A towel was covering an over-the-bed table near the shower. *On the towel was five wash cloths and two pump bottles labeled conditioner and shampoo and body wash. 9. Observation and interview on 1/15/25 at 9:09 a.m. of CNA I as she removed hair rollers from a resident in the beauty shop revealed: *She removed the rollers from the resident's hair and placed them in a white bucket with other rollers. *She did not clean the rollers, or the pins used to hold the rollers in place. *She stated that this was the only resident she set hair for. *She had not been trained on the use of rollers or how to clean them. *She reused the rollers and pins without them being cleaned. 10. Observation and interview on 1/15/25 at 9:35 a.m. of CNA I during a resident shower revealed: *Applied gloves without prior hand hygiene. *She undressed the resident. *Took the resident's blood pressure and temperature and did not cleanse the equipment after use. *Shaved the resident's face with the electric razor from the over-the-bed table. *Sprayed the outside of the razor with the bottle labeled alcohol with three sprays and placed it on a paper towel. *She did not empty the facial hair from the razor. *Pushed the resident on the shower chair into the shower and pumped the shampoo and body wash into a washcloth she removed from the over-the-bed table near the shower. *After the shower she used a towel from the wooden shelves to dry off the resident. *She changed gloves without hand hygiene. *She placed the two blue squares of non-stick rubber-like material under the resident's bare feet for the resident to stand on while she observed and dried his skin. *She used a pump lotion bottle, without a resident identifier on it, multiple times to dispense lotion and apply it on the resident. *Used spray deodorant and dressed the resident. *She changed her gloves without performing hand hygiene. *She assisted the resident in putting on his clothing. *Cleaned under the resident's fingernails with a wood stick. *Applied after shave, without a resident identifier on it, to the resident. *Changed her gloves without performing hand hygiene. *Applied skin protectant cream to the resident's buttocks from a tube that was dated 7/20/24 with no resident identifier on it. *She removed her gloves without performing hand hygiene. *She placed the aftershave, skin protectant cream, and deodorant into the white cabinet without disinfecting after resident use. *She did not disinfect the lotion after use and left it on the over-the-bed table. *She stated that some residents have their own products, but others used shared products. *The shared products should be wiped with a disinfectant wipe after each resident's use. *The end of the razor was sprayed with the alcohol after each use and the razors were emptied at the end of the day. *Nail clippers and combs were also sprayed with alcohol after each resident use. *She sprayed the shower chair with the bottle labeled Virex. *She did not spray the floor or the walls of the shower. *She indicated she would let the chair sit for a couple minutes. *She washed her hands with soap and water. 11. Interview on 1/15/25 at 4:30 p.m. with MDS/DON B revealed: *She was unaware there was outdated products in the beauty shop and both hopper rooms. *She was unaware there was a filter in the back of the stationary hair dryer that needed to be cleaned. *She did not know how the hair rollers were supposed to be cleaned. *She stated the provider had been told during a previous survey that items could not be stored under the sink, and she thought the items had been removed. *She was unaware how the nail clippers, razors, and combs were being cleaned. *She verified the electric razors in the shower room had not been emptied and were filled with white and gray hair. *She did not know the linen in the shower room needed to be covered. *It was her expectation staff performed hand hygiene after bringing soiled materials into the hopper rooms. *It was her expectation that hand hygiene be performed prior to applying gloves and after removing gloves. 12. Interview on 1/15/25 at 5:00 p.m. with administrator A revealed: *The provider did not have a policy for cleaning of hair rollers, nail clippers, and hair combs. *The provider did not have a policy on expired products. 13. Interview on 1/16/25 at 8:34 a.m. with nurse manager C revealed: *Razors should be cleaned between each resident, per facility policy. *She did not know how the razors were currently being cleaned. *She expected that the facial hair be brushed out, the parts were taken out, and the parts were sprayed with alcohol. *She thought the instructions were on the rubbing alcohol bottle that told staff [NAME] to mix the spray bottle, but the manufacturer's instructions were to be followed when mixing. *She believed that environmental service manager J had told the nursing staff the process of dilution. *Linen should be covered when in the hallway and the towels in the shower room be in a covered cart. *Nothing was to be stored under the sinks. *There was not a person assigned to check outdates. *She felt that there should be someone responsible for this. 14. Interview on 1/16/25 at 9:09 a.m. with environmental service manager J revealed: *She had not provided training to the nursing staff about mixing chemicals. *She was not aware that nursing staff was using alcohol. Interview on 1/16/25 at 10:21 a.m. with RN D regarding expired products revealed: *She was not sure who oversaw checking for expired products. *She checked the expiration dates of products as she used them. *She indicated that nurse manager C completed audits of the medication carts for expired medications and products. 45683 15. Observation and interview on 1/15/25 at 9:41 a.m. with CNA G regarding resident 20 and enhanced barrier precautions (EBP) revealed: *There was a small magnetic sign on the top of the door frame titled EBP. *CNA G entered resident 20's room and sanitized her hands. -Put gloves on. -Put paper towels on the floor as a barrier. -Put a plastic cylinder on the paper towels. -Emptied the urine from the catheter bag into the cylinder. -Emptied the container of urine into the toilet. -Rinsed the cylinder in the sink and emptied it into the toilet. -Put the cylinder back on a shelf. -Removed her gloves and sanitized her hands. *She confirmed this was how she normally emptied catheter bags. *She was not sure what the EBP sign at the top of the door frame meant. Review of resident 20's electronic medical record (EMR) regarding her catheter revealed: *She had an order for a suprapubic catheter due to urine retention. *Her revised 7/1/24 care plan directed staff to: -Check tubing for kinks each shift. -Encourage fluid intake. -Monitor and document output as per facility policy. -Monitor/document for pain/discomfort due to catheter. *She was dependent on one staff for toileting. *The care plan had no guidance for enhanced barrier precautions. 45383 16. Interview on 1/14/25 at 3:50 p.m. with certified nursing assistant (CNA) H regarding enhanced barrier precautions revealed he had been unsure what that had been and asked other nurses to help him. Interview on 1/14/25 at 3:25 p.m. with Minimum Data Set (MDS)/ director of nursing (DON)/ infection preventionist (IP) B regarding enhanced barrier precaution revealed: *It had been used for wounds, catheters, and anything that could transmit bacteria. *PPE had been stored in the medication storage room. *It would have been the facility's discretion if PPE was required with enhanced barrier precautions. Interview on 1/15/25 at 2:00 p.m. with medical director U regarding residents placed on enhanced barrier precautions and urinalysis collection revealed: *He had not been aware of enhanced barrier precautions and the criteria for residents to place on precautions. *He would not want residents to be isolated if there were on precautions. *If a resident has had multiple urinary tract infection, he would prefer a catheter urinalysis to be collected. *He would prefer more infection symptoms to be exhibited by the resident before a u/a is collected. *He does participate in the antibiotic stewardship and other providers have access to the facilities program. 51370 17. Observation on 1/14/25 at 1:40 p.m. revealed a 1.5 x 3 inch magnet with EBP written on it stuck to the top of the door frame to resident 24's room. -No personal protective equipment (PPE) was present in the hall or in resident 24's room. Interview on 1/14/25 at 1:57 p.m. with certified nursing aide (CNA) Q revealed: -She wasn't sure what the EBP tag meant. -She thought it had something to do with the floor mat. -She stated I should know since I get her up. -She went to the nurse's station and returned, saying that the EBP had to do with blood sugars. -She did not know what enhanced barrier precautions meant. -She did not wear any PPE when working with resident 24. Record review on 1/14/25 revealed resident 24 had an indwelling catheter since prior to admission on 5/8/24. -The care plan had no guidance for enhanced barrier precautions. Review of the provider's 6/23/23 Cleaning of Durable Medical and Therapy Equipment policy revealed: *To provide residents with clean, sanitary equipment and prevent the spread of infection. *The policy did not address items such as thermometers or blood pressure cuffs. Review of the provider's Hand Hygiene policy revealed: *Cleaning hands promptly and thoroughly between resident contact and after contact with blood, body fluids, secretions, excretions, equipment and potentially contaminated surfaces is an important strategy for preventing healthcare associated infections. Hand hygiene should be performed: After removing gloves, After handling equipment supplies, or linen contaminated with body substances, and When moving from contaminated to clean body sites. Review of the provider's Infection Control and Prevention policy revealed: *Using Standard and Transmission based Precautions appropriately and correctly, you will keep yourself and your residents safe from acquiring infection while in the healthcare setting. *Standard Precautions include Hand washing single most effective way to prevent the transmission of disease. Review of the provider's April 2024 Enhanced Barrier Precautions policy revealed: *It is a policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms (MDRO). *Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) in nursing homes. Enhanced barrier precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisitions (e,g ,residents with wounds or indwelling medical devices ).

Based on Payroll Based Journal (PBJ) record review, employee timecard review, staffing schedules, and electronic medical record (EMR) review, the provider failed to submit PBJ data accurately for one of one federal fiscal quarter (Quarter 4, 2024). Findings include: 1. Review of PBJ records submitted to the Center for Medicaid and Medicare Service (CMS) revealed the provider submitted no licensed nursing coverage 24 hours per day for quarter 4, 2024: 9/15/24, 9/17/24, 9/19/24, and 9/21/24. Review of the provider's employee timecards, staffing schedules, and residents' EMR records documentation revealed the provider had licensed nursing coverage 24 hours per day for the period referenced above. Interview on 1/15/25 at 3:03 p.m. with administrator A and nurse manager C revealed: *Nurse manager C made the nursing schedule. *She did not participate in PBJ submission. *Administrator A submitted the records to PBJ. *The information was automatically obtained from the individual staff timecards by their electronic payroll system. *She entered the agency staff manually. *She was not aware the PBJ reports indicated the provider did not have licensed nursing coverage 24 hours per day in quarter 4, 2024. *She did not know where to find the PBJ reports. *She thought the missed information could have been due to her manually entering agency staff hours. *She reviewed the September 2024 nurse schedule and indicated that some of the days of missing coverage in the report were not staffed by agency staff. *She did not know how the hours were incorrectly reported to PBJ.

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 (4, 9 and 34) who had fallen. *One of one sampled resident (7) who had a facility acquired pressure ulcer. *One of one sampled resident (10) who had a history of urinary tract infections. *One of one sampled resident (11) who developed a facility acquired pressure sore. *One of one sampled resident (29) who had attempted to leave the facility without staff knowledge. Findings include: 1. Review of resident 34's electronic medical record (EMR) revealed: *She had fallen on 8/25/24, 10/12/24, and 12/28/24. *On 12/28/24 resident 34 had an injury after her she fell and required a laceration repair above her left eye in the emergency room . *On 8/14/24 the care plan had identified her as at risk for falls. Interventions on the 8/14/24 initiated care plan included a physical therapy evaluation to treat as needed and to follow the facility's fall protocol. Interview on 1/15/25 at 2:00 p.m. with Minimum Data Set (MDS)/director of nursing (DON) B regarding interventions for resident 34 due to her falls revealed: *She had an intervention for physical therapy (PT) to evaluate and treat as ordered initiated on 8/14/24. *MDS/DON B stated that the facility's fall protocol was the same as their fall policy. 45683 2. Observation and interview on 1/14/25 at 8:26 a.m. of resident 10 while in her room revealed: *She was sitting in her recliner working with an occupational therapist. *Her goal was to get stronger and go to assisted living. *She had been in the hospital recently for an infection. Review of resident 10's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included: -Chronic kidney disease, stage four. -Type two diabetes mellitus without complications. -Retention of urine, unspecified. -History of urinary tract infection. *Her 1/14/25 revised care plan had an intervention to monitor for signs and symptoms of infection, UTI (urinary tract infection) initiated on 3/27/24. *She had orders for antibiotics to treat a UTI on 8/20/24, 8/21/24, 9/9/24, 10/21/24, 11/19/24, 12/6/24, and 12/16/24. *No updates to the care plan were implemented regarding resident 10's UTIs since 3/27/24. Interview on 1/16/25 at 10:05 a.m. with CNA G regarding resident 10's UTIs revealed: *She had been instructed to watch for changes in her behavior that would indicate a UTI. *She would report any changes to the charge nurse. *If a UTI was suspected they would put a hat in her toilet to collect a urine sample. *She did not have access to the residents' care plans. Interview on 1/16/25 at 1:05 p.m. with MDS/DON B regarding resident 10's care plan revealed: *The interdisciplinary team would review resident care plans and make changes as needed. *If changes were made that information was communicated to staff in the pocket care plans (a print out of residents' basic needs for staff to follow). *It was her expectation the care plans would be updated with any significant health issues that would arise. *She agreed resident 10's care plan should have been updated to reflect her care needs related to UTIs. 50015 3. Review of resident 29's electronic medical record (EMR) revealed: *She had opened the front door and started to exit the facility on 12/14/24 at 3:35 p.m. -Alarms sounded and alerted the staff. -She was observed by registered nurse (RN) D standing in the doorway with her walker. -She had been assisted back into the building by RN D. -Her vital signs were taken, were within normal limit, and were documented. *The incident was documented in her chart. -Her family, provider, nurse manager C, and administrator A were notified. *The Elopement Risk Tool completed by RN D on 12/14/24 at 3:50 p.m. -Identified resident 29 was at risk for elopement *Her diagnoses included: -Vascular dementia (brain damage caused by multiple strokes) with psychotic disturbance. -Adjustment disorder. -Weakness. -Hypertension. *She had a Brief Interview for Mental Status (BIMS) assessment score of 12 which indicated she had moderate cognitive impairment. -There was an order dated 12/31/24 to switch out monitors twice daily to recharge for safety monitoring. *Her care plan did not indicate she was at risk for elopement. -No interventions were indicated on her care plan following the above attempted elopement incident on 12/14/24. Interview on 1/15/25 at 2:17 p.m. with registered nurse D revealed: *She had started 30-minute visual checks on resident 29 following the above attempted elopement. -They continued those checks for 24 hours. -Then hourly visual checks were completed during the day. -From 8:00 p.m. to 8:00 a.m. she would have been on 30-minute visual checks. *She completed the Elopement Risk Tool on 12/14/24. -That identified resident 29 as at risk for elopement. *Care plans were to be updated by MDS/DON B. *She was unsure if a tile alarm device was used on resident 29 following the incident. Interview on 1/15/25 at 3:00 p.m. with MDS/DON B revealed: *Regarding resident 29's elopement risk they would have considered her behaviors not the score on the assessment. *On 10/18/24 her elopement risk score was 10, and she was not considered an elopement risk at that time. *The elopement risk assessment score of 25 completed on 12/14/24, identified her as at risk for elopement. *She agreed resident 29's care plan should have been updated after interventions were initiated. *Nurse manager C and administrator A would decide on the use of tile device alarms. As an elopement prevention intervention. *She agreed resident 29's care plan had not been updated to following the above attempted elopement or any interventions put in place. Interview on 1/15/25 at 3:00 p.m. with administrator A and nurse manager C revealed: *Resident 29 had used a tile device following the above incident on 12/14/24. -Her family had approved and consented to the use of the device. *They would have expected the care plan to have been updated following the elopement. *Elopement education was provided to staff following resident 29's elopement on 12/14/24. *Behavioral health had recommended memory care placement for resident 29. 50916 4. Observation on 1/14/24 at 9:09 a.m. with resident 4 in the dining room revealed: *She was seated in her wheelchair. *She had an electronic monitoring device on her wrist. Review of resident 4's electronic medical record (EMR) revealed: *She was admitted on [DATE] *She had a Brief Interview of Mental Status (BIMS) assessment score of 8, which indicated she was moderately cognitively impaired. *Her diagnoses included cellulitis, dementia, and bulbous pemphigoid (an autoimmune disease that causes skin blisters). *She had fallen on 8/9/24, 8/13/24, 8/14/24, 8/15/24, 8/28/24, 9/9/24, 10/10/24, 10/11/24, 10/13/24, and 12/18/24. *She had an electronic monitoring device on her wrist that would alarm to alert staff of position changes as a fall prevention. *There was no documentation of interventions in her care plan that addressed fall prevention since her admitted on 5/23/24. 5. Observation and interview on 1/14/24 at 10:35 a.m. with resident 9 in her room revealed: *She was seated in her wheelchair listening to an audiobook. *She had a full body mechanical lift sling underneath her. *She had recently fallen. *She used her walker for transfer assistance before she had fractured her ankle. *She was transferred with the use of a full body mechanical lift and the assistance of two staff. Review of resident 9's EMR revealed: *She was admitted on [DATE]. *She had a BIMS assessment score of 11, which indicated she was moderately cognitively impaired. *Her diagnoses included chronic obstructive pulmonary disease, Parkinson's disease, and hypertension. *She had fallen on 10/27/24, 10/28/24, 11/3/24, 12/9/24, 12/19/24, 12/20/24, and 12/22/24. *There was no documentation of interventions in her care plan that addressed fall prevention since her admitted on 2/14/24. Interview on 1/15/25 at 1:01 p.m. with registered nurse (RN) D revealed: *MDS/DON B updated the residents' care plans and the pocket care plans. *Hired agency workers and staff referred to the pocket care plans to help care for residents' needs. Interview on 1/15/25 at 3:28 p.m. with MDS/DON B regarding resident care plans revealed: *She updated the resident's care plans and pocket care plans. *She stated the care plans should be updated when a new intervention was added for a resident. *She confirmed that residents 4 and 9 did not have new interventions documented on their care plans after their fall incidents. *She confirmed the care plans should be updated to provide appropriate care for the residents' needs. Interview on 1/16/25 at 8:32 a.m. with nurse manager C regarding resident care plans revealed: *DON B was responsible for updating residents care plans. *The interdisciplinary team (IDT) would meet daily at 10 a.m. to review resident falls that occurred during the night and discuss interventions to implement. *Her expectation was that DON B would update and document the interventions in the residents' care plans after the IDT meetings. *She was not aware that fall interventions were not documented for residents 4 and 9 in their care plans. *She had the capability to update the pocket care plans if it was needed. 51472 6. Observation and interview on 1/14/24 at 9:02 a.m. with resident 7 revealed: *There were two cushions in her wheelchair. *The top cushion was a waffle cushion that covered the bottom and back of the wheelchair. *The cushion under the waffle cushion was a Roho cushion (air cushion that helps distribute weight evenly to prevent pressure ulcers). *The Roho cushion was not inflated. *Resident 7 transferred herself to her recliner. *There was no cushion in the recliner. *Resident 7 stated that her daughter brought her the waffle cushion for her comfort. *She did not remember if she had any sores or skin problems. Review of resident 7's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 12/7/24 brief interview for mental status (BIMS) assessment was 12, which indicated moderate cognitive impairment. *Her diagnoses included dementia, repeated falls, and weakness. *She had a stage II pressure ulcer (a shallow open ulcer that resulted due to pressure) identified on 11/16/24. *The stage II pressure was documented as healed on 12/6/24. *She was prescribed mirtazapine with an Indication for Use: antidepressant. *She did not have a diagnosis of depression. Review of resident 7's 1/14/25 care plan revealed: *She had a focus area of I have the potential to have impairment to skin integrity which was initiated on 5/30/24 and updated on 6/3/24. *The use of the ROHO cushion or the waffle cushion was not included in the care plan. *A focus area of I have a potential nutritional problem r/t [related to] hx [history] of CHF [congestive heart failure]; COPD [chronic obstructive pulmonary disease] and recent hip fracture with repair initiated on 7/8/24 included an intervention of Resident with stage II wound to left hip. Dislikes supplements. Will offer extra 1 oz [ounce] of protein with meals to aid in wound healing that was initiated on 12/6/24. *A focus area of, I use antidepressant medication (mirtazapine) and interventions to: -Administer ANTIDEPRESSANT medication as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. -Monitor/document/report PRN [as needed] adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activities of daily living] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs [problems], movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea/vomiting], dry mouth, dry eyes 7. Observation and interview on 1/14/25 at 9:20 a.m. with resident 11 revealed: *She was admitted to the facility after she fell and broke her hip. *She stated she was mixed up. *During the conversation resident 11 spoke with her eyes closed. Review of resident 11's EMR revealed: *She was admitted on [DATE]. *Her 10/7/24 BIMS assessment was 10, which indicated moderate cognitive impairment. *Her diagnoses included: weakness, hallucinations, generalized anxiety, and dementia with psychotic disturbance. *She was prescribed: -lorazepam 0.5 mg (milligrams) every four hours as needed for anxiety or restlessness. -olanzapine 5 mg two times per day related to dementia with psychotic disturbance. Review of resident 11's care plan revealed: *A focus area of, I use psychotropic medications (olanzapine) with interventions to: -Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. -Monitor/document/report PRN adverse reactions to PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. *Lorazepam or interventions to monitor for adverse effects was not referenced in resident 11's care plan. *Non-phamalogical interventions relating to her hallucinations, anxiety, or psychotic disturbance, was not addressed in resident 11's care plan. Interview on 1/15/25 at 3:28 p.m. with MDS/DON B revealed: *She expected staff to follow the interventions on the residents' care plans. *She was responsible for updating resident care plans. *Care plan were to be updated when there were changes in resident care. *She agreed that resident 7's care plan was not updated to include her facility-acquired pressure ulcer. Interview on 1/16/25 at 8:34 a.m. with nurse manager C revealed: *She expected resident care plans to be updated to include pressure-reduction devices. *She believed that the staff knew how to access resident care plans. Interview on 1/16/25 at 10:21 a.m. with registered nurse (RN) D revealed: *She had access to view resident care plans. *She was not able to edit the care plans. *Therapy [physical and occupational] was to be initiated for residents with pressure ulcers. *If therapy placed ROHO cushions in residents' chairs they were to inform MDS/DON B to update the care plans. *Nurse manager C worked with the pharmacist on the psychotropic medications. *The charge nurse did not chart the side effects and effectiveness of the psychotropic and antidepressant medications. Review of provider's 3/2024 Care Planning Process Policy revealed: *Using an intradisciplinary approach, each resident will have an individualized plan of care which addresses the resident's needs and severity of condition, impairment, disability, or disease and based on the universal care standards identified by the DNRC staff as the minimum standards for all residents. *It is the responsibility of the IDT members to access the resident, individualize the plan of care, evaluate the effectiveness and the plan of care, revise the plan of care as the resident's needs change and attend care conferences. Review of the provider's undated Fall Policy revealed: *A licensed nurse will update the care plan to reflect interventions instituted to prevent further falls. *The resident's fall will be discussed with interdisciplinary team as soon as possible after the falls to determine new interventions to try.

Based on record review and interview the provider failed to ensure four sampled residents (11, 29, 33, and 34) had received the wrong medication administered by four of four of staff, registered nurse (RN) (D and F) and certified medication aide (CMA) (O and P). Findings include: 1. Record review of resident 33's electronic medical record (EMR) revealed: *On 12/8/2024 at 1:09 a.m. a nursing progress note had been entered that resident 33 had been given another resident's medications by CMA O. *Resident 33 was given the following medications: -Tylenol 1000 milligrams (mg) (pain reliever), -Olanzapine 5mg (antipsychotic), -Celecoxib 100mg (pain reliever). -Tamsulosin 4mg (to treat an enlarged prostate). 2. Record review of resident 34's EMR revealed: *On 9/14/24 at 5:00 p.m. resident 34 had been administered: -Carbidopa/Levodopa 25/100 mg (treat symptoms for Parkinson's disease) by CMA P. -This medication had not been ordered based on review of the physician orders. *Poison control had been notified and guided to monitor for adverse reactions including agitation and stomach pain. 51472 3. Review of resident 11's EMR revealed: *She was not a diabetic. *On 12/13/24 at 2:30 p.m. a progress note that stated, Resident 11 was mistaken for a different resident. At 1200 [12:00 p.m.], her blood sugar was taken and found to be 172. 7 units NovoLog insulin (a fast acting insulin) given by mistake at that time, and resident ate a good lunch. Primary MD [medical doctor] and resident's daughter were both notified. Will continue to monitor for hypoglycemia. Re-check BS [blood sugar] 1400 [2:00 p.m.] =145. *There were no further blood glucose checks documented in resident 11's EMR. *On the 12/13/24 at 1:54 p.m. fax that was sent to the provider that notified him of the medication error, the provider replied, OK: Noted- Continue to monitor for signs of hypoglycemia [low blood sugar] for 8-12 hrs [hours] from injection. Review of the provider's 12/13/24 Medication Error Incident Audit Report for resident 11 revealed: *The Medication Error Incident Audit Report was completed by registered nurse (RN) F on 12/13/24 at 5:20 p.m. *Resident 11 was mistaken for a different resident. Her blood sugar was taken and found to be 172. 7 units of NovoLog insulin given by mistake. Resident ate a good lunch. *Resident 11's description was documented as Oh, okay. *The Description of Action Taken was, Primary MD and resident's daughter were notified. Will Continue to monitor for hypoglycemia over the next 6-8 hours. Will recheck BS at 1400. Interview on 1/15/25 at 2:16 p.m. with nurse manager C regarding resident 11's medication error revealed: *She was not sure if education was provided or if a review of the medication error had been completed. *She stated she would have to look if there was anything completed because she was not available at the facility at the time of the medication error. Interview on 1/16/25 at 8:34 a.m. with nurse manager C about medication errors revealed: *An agency staff member made resident 11's medication error. *The company that the agency staff work for is responsible for the education and competencies of all agency staff. *Agency staff was not provided training by the provider. *When she reached out to the travel agency to request agency staff receive education on something she expected the travel agency to complete the education. *She did not follow up with the travel agency to be sure the education was completed. *She expected agency staff to work on the floor on the first day of hire after being given a facility tour. 4. Review of resident 29's EMR revealed: *She was admitted on [DATE]. *Her 7/26/24 BIMS was 12, which indicated moderate cognitive impairment. *On 12/29/24 at 2:36 p.m. an incident/fall progress note indicated, This writer had just counted controlled medications with med aide today and counted Lorazepam [Ativan] for resident. Reviewed paper order in the Narcotic book and gave 1 tablet of 5mg [milligram] Lorazepam. When this nurse went to chart in the EMR, realized medication had been discontinued but not removed from the narcotic drawer of the medication cart. Contacted Nurse Manager C. Contacted resident 29's next of kin regarding medication given with no [current] order. Review of the provider's 12/30/24 Medication Error Report Sheet for resident 29 revealed: *On 12/29/24 at 1:31 p.m. RN D administered Ativan (an anti-anxiety medication) 5mg by mouth to resident 29. *The order for Ativan for resident 29 was discontinued on 11/11/24. *Steps taken to correct the error were, Medication was removed from cart. Education provided on 5 rights of med administration. PCP [primary care provider] faxed, vitals taken. *The cause of the error was identified as Medication was not verified in the EMAR [electronic medication administration record] prior to administration. *The action taken to prevent the error from reoccurring was, Always use 5 rights of med administration, when medications are discontinued pull medications @that time. Review of the provider's Medication Error policy revealed: *The policy was Guidelines designed to prevent, identify, report and address errors related to administration of medications. *The policy outlines responsibilities, steps of reporting errors, and corrective actions to be taken. *To ensure patient safety by minimizing the risks associated with medication administration. *The procedure included: Obtain Vital Signs, Fax Provider. If after clinic hours or during weekend call the on-call provider., Create Incident in Risk Management., and Notify Nurse Manager/DON to initiate Medication Error Report Sheet. *The Medication Error Report Sheet included details about the medication error as well as, Type of Medication Error, Steps taken to correct error, Was Physician notified, Describe exactly what caused error to occur, and Actions taken to prevent error from reoccurring.

Based on observation, interview, and policy review the provider failed to ensure chemicals had not been stored under sinks in four of four rooms and were secured per their written instructions. Findings include: 1. Observation on 1/14/25 at 8:36 a.m. of the Garden Terrace hopper room revealed: *The Garden Terrace hopper room was not locked. *Under the sink was a brown wood cabinet with a lock present on the door. *The door was not locked. *This cabinet contained: -A spray bottle with a broken top labeled 75% Ethyl Alcohol. -A spray bottle labeled C-Diff Solution Tablets. -A bottle of Betco Kling toilet bowl cleaner. *On the wall above the sink was a sign that said, Keep all chemicals in LOCKED Cupboard and securely locked when not in use. 2. Observation on 1/14/25 at 9:29 a.m. of the Happy Trails hopper room revealed: *The Happy Trails hopper room was not locked. *The cupboard and under the sink was: -An aerosol spray can of Spectracide wasp and hornet killer. -An empty spray bottle with a handwritten label PH7Q Dual disinfectant Do not throw away. -An empty bottle labeled Isopropyl Rubbing Alcohol 70% that was outdated on 6/17. *In a cupboard between the sink and the hopper was: -A partially full bottle of Dermal Wound Cleanser that did not have a resident name or date of opening on the bottle. -An aerosol bottle of [NAME]-Mist furniture polish. 3. Observation on 1/14/25 at 1:36 p.m. of the beauty shop revealed: *The beauty shop door was open. *There was a wooden cabinet beside the stationary hair dryer with a lock on it. *The cabinet was not locked. *In the cabinet was: -A spray bottle with a white label that did not have a chemical name on it. --The label was identified as a Drug Facts Label with the main ingredient on the label identified as Ethyl Alcohol 75%. --The label also included Uses: Hand sanitizer to help reduce bacteria that potentially can cause disease. --The label was dated 4/17/20. -A bottle of Brush Delite. --The label indicated Use rubber or plastic gloves. NEVER bare hands. -Nail polish remover that was outdated on 4/19. -A partial bottle of BETCO odor eliminator. *On the counter was a blue-green bottle with a clear liquid in the bottle that was one-third full. This bottle did not contain an identifier of what was in the bottle. 4. Observation on 1/15/25 at 8:43 a.m. of the shower room revealed: *The door to the shower room was not locked. *There was no staff present in the shower room. *On an over-the-bed table near the window was a spray bottle with a clear liquid that was almost empty. -Handwritten on the spray bottle was, For reusable items combs tweezers razor parts. Use new label for each bottle of alcohol label w/ [with] exp [expiration]. The adhesive label attached to the bottle reads Alcohol Spray 05/25. *A tall white cabinet had a padlock with a key hanging from the padlock and the door was open. *On the bottom shelf of the white cabinet was a spray bottle that contained a blue liquid. -Virex II 256 Disinfectant cleaner was handwritten on the spray bottle. *Between the toilet and the wall was a white basin that held a toilet plunger, two toilet brushes, and a white bottle of blue liquid. -The bottle was labeled Kling Toilet Cleaner on a manufacturer's label. 5. Interview on 1/15/25 at 9:35 a.m. with certified nursing assistant (CNA) I revealed: *The shower room door was not locked. *The white cabinet was supposed to be locked when staff were not present. *The key for the cabinet was stored on the top of the cabinet. 6. Interview on 1/15/25 at 11:08 a.m. with housekeeping L revealed: *Chemicals were to be stored in a closet or storage room. *All chemicals were to be in a locked area. *Chemicals were to be stored away from residents. 7. Interview on 1/15/25 at 4:30 p.m. with minimum data set (MDS)/director of nursing (DON) B revealed: *She was unaware that the cabinet in the beauty shop was unlocked. *It was her expectation that the beauty shop cabinet was locked. *She had been told that items could not be stored under the sinks. *She confirmed there were items stored under the sinks in the hopper rooms and some were chemicals. *She was unaware that chemicals needed to be labeled with manufacturer's labels. *She expected the toilet bowl cleaner to be in a locked cabinet and not accessible to the residents. 8. Interview on 1/16/25 at 8:34 a.m. with nurse manager C about chemical storage revealed: *It was her expectation that chemicals were not stored under the sink. *The provider was previously told that products could not be stored under the sink. *She believed that the cupboards under the sink had been cleaned out. *Chemicals were to be kept out of access from the residents. *Chemicals were to be stored in locked cabinets and not left unattended. *Indicated that the toilet bowl cleaner stored in the shower room beside the toilet was accessible to residents due to the door not being locked. 9. Interview on 1/16/25 at 10:50 a.m. with CNA G revealed: *She did not handle chemicals. *She stated it was the responsibility of housekeeping and maintenance. 10. Review of the provider's 2/24 Chemical Safety policy revealed: *Promote safe use and storage of chemicals. *Toxic items such as detergents and polishes will be properly stored, labeled, and used in a way that will not contaminate food. *This policy, presented by the provider as the chemical storage policy, referred to dietary staff and chemical use and storage related to food contamination.

Based on interview, record review, policy review, and review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), the provider failed to ensure a controlled medication (medication with potential for abuse and addiction) for one of one sampled resident (41) had remained secured and was accounted for. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Interview on 1/16/25 at 8:40 a.m. with registered nurse (RN) D regarding resident narcotic medication counting at the end of her shift revealed: *She had counted the resident narcotics when she had arrived to begin her shift on 11/23/24 6:00 a.m. with no discrepancy identified. *RN D did not count the resident narcotics with licensed practical nurse (LPN) R at the end of her shift on 11/23/24 at 6:30 p.m. *RN D had not left her shift and not counted resident narcotics before 11/23/24 at 6:30 p.m. *LPN R refused to do the narc count until RN D insisted on it. *She had been notified on 11/24/24 at 6:25 a.m. by administrator A to return to work and help locate the morphine sulfate (a controlled pain medication) liquid that had been missing. *RN D had called LPN R on 11/24/24 at 7:00 a.m. and LPN R had already left the facility without locating the missing medication. 2. Interview on 1/16/25 at 10:30 a.m. with nurse manager C regarding the missing morphine sulfate revealed: *She had been notified on 11/24/24 that six milliliters (ml) of morphine sulfate liquid had not been accounted for. *Nurse manager C had been working with the pharmacy to complete the investigation of the missing medication and staff education that had been completed on 12/19/24. *LPN R had been instructed to stay at the facility until RN D arrived to help locate the missing medication. *She had not thought that the missing medication would have been considered theft until the pharmacy had informed her that the missing medication was theft. 3. Interview on 1/16/25 at 11:50 a.m. with pharmacist T regarding the missing medication revealed: *He had been informed on 11/24/24 of the missing six ml of morphine sulfate. *Pharmacist T had been involved with the investigation of the missing medication. *He had helped with providing education to staff regarding medication safety, procedures and regulations. 4. Review of the controlled drug receipt/record/disposition form for resident 41's liquid morphine sulfate revealed the last dose of morphine sulfate had been administered on 11/16/24 at 5:00 a.m. with six ml remaining in the bottle. 5. Review of the provider's undated Narcotic Count Policy revealed: *Narcotics will be counted by licensed nursing personnel to assure they are properly accounted for at the beginning and ending of each shift. *The ongoing and off going nurse at shift change will perform a physical count of the narcotic drawer. 6. The provider implemented changes to ensure the deficient practice does not recur was confirmed on 1/16/25 after record review revealed the facility had followed their quality assurance process, education was provided to all staff who were approved to administer medication regarding the regulations for controlled substances, that a system to account for controlled medication is in place and followed, receipt and disposition of medication, a shift-to-shift controlled medication count is completed by the appropriate staff to ensure accurate reconciliation of medications on hand, interviews revealed staff understood the education provided regarding those topics, and observation of controlled medication count compared to the medication supply on hand was accurate. Based on the above information, non-compliance at F602 occurred on 11/24/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 1/16/25, the non-compliance is considered past non-compliance. Review of education provided on 12/19/24 to all staff that administer medication revealed: *Regulations for controlled substances require facilities have a system to account for controlled medication, receipt and disposition in sufficient detail to ensure accurate reconciliation. *A shift-to-shift count is required to pass responsibility and accountability of controlled medication. Education was provided on 12/19/24 to all staff that administer medication regarding controlled medication regulations and accountability of those medications, including liquid medications. 7. Education was provided on 12/19/24 to all staff that administer medication regarding controlled medication regulations and accountability of those medications, including liquid medications.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review the provider failed to report the missing controlled medication (medications with potential for abuse and addiction) had been reported timely to SD DOH. Findings include: 1. Review of the provider's 12/4/24 SD DOH FRI revealed on 11/24/24 six milliliters (ml) of morphine sulfate (a controlled pain medication) had been unaccounted for. 2. Interview on 1/16/25 at 11:28 a.m. with nurse manager C regarding the reporting the missing controlled medication revealed: *She had not known the timeline requirement for reporting the missing controlled medication to SD DOH. *She had not known that the missing medication could be considered theft of personal belongings. *She had known that she had not followed the facility's policy for reporting the potential diversion of a controlled substance. *On 11/25/24 she had begun the paperwork the pharmacy had provided her for drug diversion. *The pharmacy had informed her that it was a misappropriation of a personal item on 12/4/24. 3. Interview on 1/16/25 at 12:16 p.m. with administrator A regarding the reporting of the missing controlled medication revealed: *She had not been aware of the timeline for reporting missing medication to the SD DOH. *Administrator A agreed that she had not followed their policy for reporting the potential diversion of a controlled substance. Review of the provider's undated Reporting and Investigating Diversion of Controlled Substances Policy revealed: *The investigation will be conducted with the assistance of human resources and will be completed within 48 hours of the incident's discovery. *Severity of the theft or loss must be evaluated when considering reporting. *Agencies to whom narcotic thefts may be reported include local office of [NAME] licensing.

Based on observation, interview, and record review the provider failed to ensure one of one sampled resident (24) had been monitored for consistent weight loss. Findings include: 1. Observation on 1/15/24 from 12:00 p.m. through 12:35 p.m. of the lunch meal service revealed: *Resident 24 was seated in her wheelchair at a table. *An empty chair was between her and another resident. *Certified Nursing Assistant (CNA) G sat in the chair and assisted to resident to her left. *At 12:02 p.m. CNA Q brought her meal, and cut her burger in half, told the resident she had a cheeseburger and fries. *Resident 24 did not respond to the CNA. *At 12:06 p.m. CNA G reminded the resident that she had a burger and fries. *She made several attempts to pick up her burger and was able to take a small bite. *CNA G assisted her in eating several bites of fruit fluff. *At 12:25 p.m. CNA G left the table and began helping other residents leave the dining room. *At 12:33 p.m. CNA H walked up to the table and said [resident's name], are you awake? -CNA H did not encourage her to eat or assist her with eating. *At 12:35 p.m. the resident pushed herself away from the table. -She consumed approximately one-quarter of the cheeseburger, no fries, approximately 3 oz. of fruit fluff, and 2 oz. of the red liquid which was identified by CNA G as Boost. [supplement] -No documentation of her consumption was made in the EMR. 2. Interview on 1/16/25 at 10:30 a.m. with CNA G revealed that resident 24 had refused breakfast. *Interview on 1/16/25 at 10:50 a.m. with Nurse Manager C revealed: *She agreed that nutrition was addressed in multiple places in the resident's care plan. -She would expect all meal consumption for resident 24 to be documented. -She was unaware that there was no documentation for many meals. _She was unaware that there was no documentation for any evening meals this month. -The residents' meal percentage consumed should be recorded by dietary staff if the resident eats in the dining room and by CNA if the resident eats in their room. -The resident had been sleeping a lot in the last few months and missing a lot of meals in the dining room. *She was unaware that meal consumption was not being regularly recorded for resident 24. *The management team would meet every morning at 10:00 a.m. and discusses resident information including weight. -Weights were to be obtained weekly on bath day. -Weight loss should have been brought to the attention of the charge nurse. -She was unaware that resident 24 had flagged for weight loss on her past seven of the past weekly weights. -She stated that they had a hard time with CNAs obtaining accurate weights. 3. Review of resident 24's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. -She has an indwelling catheter that was present on her admission. *She had a Brief Interview for Mental Status (BIMS) assessment score of 7 on 11/13/24, indicating severe cognitive impairment. *Was to receive a regular diet. *Her current care plan included: -She needed supervision or touching assistance by 1 staff member when eating. -A 5/8/24 initiated and 1/14/25 revised focus area that indicated she had a functional abilities performance deficit. -EATING: I need supervision or touching assistance by 1 staff member for eating. *An initiated 5/8/24 focus area of congestive heart failure, Encourage adequate nutrition. Offer small frequent feedings. -Monitor/document for s/sx [signs/symptoms] of malnutrition. Do not force me to eat. Offer small frequent feedings. Monitor/document food preferences. -An initiated 5/8/24, revised 5/17/24, focus area of I have peripheral vascular disease, Encourage good nutrition and hydration. -An initiated 5/10/24, revised 8/7/24, focus area of I have a potential nutritional problem r/t hx (related to history] of dementia and CHF [congestive heart failure]. -Initiated 5/8/24, revised 5/17/24, focus area of I have potential to have impairment of skin integrity, Encourage good nutrition and hydration in order to promote healthier skin. *On 1/6/25, Registered Dietician Licensed Nutritionist (RDLN) S entered a nutrition note in the EMR that indicated: -Weight down 5# x 1 mo. (4%). -down 13# x 3 mo. (10.8%). -down 10# x 6 mo. (8.3:%). -Indicates a significant weight loss over past 3 months. -Resident is assisted with meals. -Consider need for appetite stimulant. -Encourage meal intake. *Resident 24's meal documentation was incomplete in the EMR (electronic medical record): -From 1/3/25 to 1/15/25, there were 39 meals served. -A total of 25 meals showed documentation. -There was no documentation of any evening meal consumed. -7 of 25 meals were marked as 0-25% of meal eaten. -Her meal consumption recorded on 1/15/2025 at 10:05 a.m. was 51-75%. -According to the task list report in the EMR, the schedule for nutrition recording was every day at 09:00 a.m., 13:00 p.m., and 18:00 p.m. -The CNAs and Dietary Aides were responsible for the nutrition recording. *No hydration documentation was recorded in the EMR. -A task to record supplemental fluids was added to the EMR on 1/15/24, to be completed three times a day by a dietary aide or a CNA. *No update to the care plan had been made addressing resident's weight loss of greater that 10%.

Based on observation, record review, interview, and policy review the provider failed to adequately implement and monitor an effective antibiotic stewardship program. Findings include: 1. Observation and interview on 1/14/25 at 8:26 a.m. of resident 10 in room [ROOM NUMBER] revealed: *She was sitting in her recliner working with an occupational therapist. *Her goal was to get stronger and go to assisted living. *She had been in the hospital recently for an infection. Review of resident 10's EMR revealed: *She was admitted on [DATE]. *Her diagnoses were: -Chronic kidney disease, stage four. -Type two diabetes mellitus without complications. -Retention of urine, unspecified. -History of urinary tract infection. *Her 1/14/25 revised care plan had an intervention to monitor for signs and symptoms of infection, UTI (urinary tract infection) initiated on 3/27/24. *She had orders for antibiotics to treat a UTI on 8/20/24, 8/21/24, 9/9/24, 10/21/24, 11/19/24, 12/6/24, and 12/16/24. Interview on 1/15/25 at 3:29 p.m. with minimum data set (MDS)/director of nursing (DON) B revealed: *She is the infection preventionist. *She presented a spreadsheet of the infections in the facility as her antibiotic stewardship tracking. *She stated that the infections each month are discussed at QAPI (quality assurance and performance improvement). *A PIP (performance improvement plan) has been developed related to urinary tract infections in the facility. *Management was auditing resident fluid intake, staff rounding on residents every two hours, and wiping from front to back when staff was performing genital hygiene. *Management had done hand hygiene audits in the past. *Staff was not obtaining an order each time a urine dip was completed. *It was her expectation that staff document the reason for completing a urine dip or getting a UA. *She expected a nurse's note to be entered into the resident's EMR that indicated what the staff was doing and why. *She did not believe that staff were using a form, such as a SBAR (situation, background, assessment, recommendation) to determine if a urine dip or UA is indicated. *She believed that there was an SBAR form available on the computer. -The SBAR form she located was for Skin/Soft Tissue. *She indicated she believed a form such as an SBAR form would be helpful in the decision-making process for the nurses. *She is responsible for follow-up of UA and urine culture (UC) results. *After the urine culture is resulted, she waits for the provider to either write an order to continue the antibiotic or stop the antibiotic. *Lab sends the results of the UA and UC to the facility and the results are scanned into the resident EMR. *She was unable to locate a UC result in resident 11's EMR for a UTI diagnosis and treatment on 1/16/24. *The provider does not get results of chest x-rays when residents go to the clinic and are diagnosed with pneumonia. Interview on 1/16/25 at 10:05 a.m. with CNA G regarding resident 10's chronic UTIs revealed: *She had been instructed to watch for changes in her behavior that would indicate a UTI. *She would report any changes to the charge nurse. *If a UTI was suspected they would put a hat in her toilet to collect a urine sample. Interview on 1/16/25 at 10:21 a.m. with registered nurse (RN) D revealed: *If the nurse suspected a resident had a urinary tract infection (UTI) the nurse would complete a urine dip test. *If the urine dip was positive the primary care provider would be faxed with the resident's signs and symptoms and a request to collect a urine sample for a urinalysis. *The urine would then be sent to lab for evaluation. *The lab would send the results of the urinalysis to the facility and the primary care provider would decide if treatment was necessary. *An order for the urine dip was not obtained prior to completing the urine dip test. *She was under the understanding since she was hired that there was an understanding with medical director U that a urine dip test could be performed with any signs and symptoms of a UTI. *Symptoms she would consider to be signs of a UTI included: urine with a strong odor, frequency of urination, pain, burning with urination, and with certain residents behavior changes. *She did not enter a progress note in a resident's chart if she completed a urine dip test or the reasoning the urine dip test was completed. *She would enter a progress note in the resident's chart when she faxed for the UA, the results are returned, and when the family was notified of the treatment. *When asked about documentation of the urinalysis completed on resident 11 in January 2025. RN D stated she was asked by resident 11's family to contact hospice to obtain a UA order. She agreed there was no documentation in the resident's chart that indicated the family requested the UA and any communication with hospice or the reason the UA was requested by family. Review of resident 11's hospice note revealed a UA was being obtained by SNF (skilled nursing facility) for symptoms if a UTI. Review of the Infection Prevention spread sheets revealed: *There were five UTIs (four residents) and two cellulitis (skin infection) (one resident) treated in August 2024. *There were seven UTIs (five residents) treated in September 2024. *There were six UTIs (four residents) and two cellulitis treated in October 2024. *There were two UTIs, two cellulitis, and two respiratory infections treated in November 2024. *There were three UTIs, and four pneumonias (three residents) treated in December 2024. *From August through December there were six residents that were prescribed antibiotics more than one time. Review of the provider's 2024 Infection Control and Prevention policy revealed: *The infection preventionist is responsible for Systemic data collection to identify, trend and track infection in residents. *The facility will work to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. *Antibiotic use will be tracked and reported monthly. -Number of resident prescribed antibiotics. -Number and type of infections---trends and outbreak control if applicable. -Number of lab proof of infections versus those without. -Number of residents with C. [Clostridium] Difficile, antibiotic resistant organisms or adverse drug events.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, and record review the provider failed to ensure the safety of one of one sampled resident (1) identified at risk for elopement, who had eloped (left the facility without staff knowledge) after staff turned a door alarm off. Failure of staff to ensure the door alarm was reactivated resulted in the resident's elopement and put her at risk for physical injury or serious harm. This citation is considered past non-compliance based on the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 11/20/24 SD DOH FRI revealed:*On 11/20/24 at 1:00 p.m. certified nursing assistant (CNA) G reported to licensed practical nurse (LPN) H the fire exit door in the living room was cracked open. *The alarm did not sound. *Resident 1 was standing on the sidewalk by the door. -She was last seen prior to that eating lunch in the dining room. -She stated she was going to get hot chocolate. *Resident 1 was immediately put on one-to-one observation with activities assistant F. *Her vital signs were taken and were within normal limits. *No injuries were noted at the time of the incident. *She was wearing a Tile tracking device and a watch with the capability to track her location. *The charge nurse notified administrator A, director of nursing (DON) B, the physician, and resident 1's son of the incident. *The door alarm system was immediately checked, and the alarm for that door was noted to be turned off. *The door alarm was turned back on and noted to be working. Observation on 11/26/24 at 9:30 a.m. at the nurse's station revealed: *The door alarm system was on. *New education for staff was posted directly under the panel. *Observation and interview on 11//26/24 at 10:30 a.m. with resident 1 in her room revealed she was watching TV in her room with her husband and had no concerns at this time. *Interview on 11/26/24 at 10:47 a.m. in the dining room with activities assistant F regarding the elopement process revealed she: *Would retrieve the resident from outside. *Ensure they were ok, bring them inside, and get them a cup of coffee. *Notify the charge nurse or her supervisor. Interview on 11/26/24 at 10:52 a.m. with housekeeping assistant E regarding elopement revealed: *She would notify her supervisor and help look for the resident. *If she found the resident, she would call 911 so they could do an assessment. *She would notify her supervisor that the resident was found. Interview on 11/26/24 at 11:05 a.m. with CNA D regarding the elopement process revealed she: *Would retrieve the resident if they got outside. *Would make sure they were ok. *Bring them inside and notify the charge nurse so they could do an assessment. Interview on 11/26/24 at 11:39 a.m. with registered nurse (RN) C regarding education provided after the elopement revealed: *Staff were provided education in a binder regarding elopements. *They were required to read and sign before the next shift worked. *The nurses were now documenting door alarm checks completed each shift in the treatment administration record (TAR) and in paper narcotics count book, the alarm checks on each shift. *The nursing staff continued to monitor resident 1 hourly while she had her watch on, and every 30 minutes once it was removed to be charged. The staff had participated in monthly elopement drills. Interview on 11/26/24 at 1:10 p.m. with administrator A regarding resident 1's elopement revealed: *The door resident 1 exited through did have an alarm on it. *That door was the only one that did not have a key pad to code out on. *She was placed on 15-minute checks immediately after the incident. *They had provided education for staff regarding which doors were appropriate to use to exit the building, as well as monitoring residents who wandered. *She was auditing the door alarms daily for one week, then she planned to complete weekly audits for four weeks. *Maintenance staff used the living room door to complete maintenance tasks outside. *The process for resetting the door alarms was to silence the alarm button, push the reset button, turn off the alarm switch and then turn it back on. *She thought someone missed the last step and did not turn the alarm back on. *She could not determine which staff member shut off the alarm, so education had been provided to all staff members. *She had ordered a new keypad for the fire exit door in the living room so staff would have to enter a code to exit the building along with the door being alarmed. *The keypad was scheduled to arrive on 11/27/24 and maintenance would install it the day it arrived. *Resident 1 wore a watch that was used with a provider-owned cell phone to track her location. *Resident 1 also wore a Tile tracking device that would show her location if she left the property. *Staff were also educated to do physical checks on resident 1 hourly during the day and every half hour at night. Interview on 11/26/24 at 1:25 p.m. with DON B regarding the interventions put in place after resident 1's elopement revealed: *She was moved to a different table in the dining room for the exit door to not be in her immediate line of sight. *Immediately after the elopement resident 1 was placed on one-to-one observations with the activity assistant and was taken to Bingo for close monitoring. *She was checked for a urinary tract infection (UTI), as they had discovered that had elevated her exit seeking in the past. *The administrator was in the process of obtaining a door alarm bracelet system for her. *A coded pad has been ordered for the fire door that the resident eloped from. *Alarm checks were added to the TAR and the narcotis countc book for the nurses to check and document. *Resident 1's care plan was reviewed, and the table change intervention was added. Review of resident 1's electronic medical record (EMR) revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was 10 which indicated she had moderate cognitive impairment. *She was monitored one-to-one by activities assistant F immediately after the elopement on 11/20/24. *Staff had documented the 15-minute checks in the TAR. *Her care plan was updated to ensure she was seated in the dining room so the living room exit door was not in her line of sight. The provider implemented changes to ensure the deficient practice does not recur was confirmed after record review revealed the facility had followed their quality assurance process, education was provided to staff regarding the door alarming process and the new interventions that were added to resident 1's care plan, observations and interviews revealed staff understood the education provided and had implemented those interventions, the door alarms were on and monitored, and the process was being audited ongoing to assist in deterring resident elopement. Based on the above information, non-compliance at F689 occurred on 11/20/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 11/26/24, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to report one of one sampled resident's (12) bruises of unknown origin to the nurse manager C and director of nursing (DON) B for further investigation. Findings include: 1. Observation and Interview on 8/06/24 at 8:32 a.m. with resident 12 revealed: *She had a bruise on her forehead above her right eye and stated she didn't know how she had gotten it. *The bruise measured 11/4 inch x 1/4 inch and was dark purple with light yellow around the edge. 2. Interview on 8/7/24 at 10:36 a.m. with certified nursing assistant (CNA) K revealed she did not know how or when resident 12 got the bruise above her right eye. 3. Interview on 8/7/24 at 10:38 a.m. with licensed practical nurse (LPN) G revealed: *She had spoke to resident 12's daughter whom stated she had dropped her phone while they were visiting, and may have bumped her head while getting the phone. *She stated, or she may have bumped on the bed rail. *She had not documented this but had said she would. 4. Phone interview on 8/7/24 at 3:00 p.m. with resident 12's daughters revealed: *They were not aware of the bruise above resident 12's right eye. *She had been contacted about a week ago in regards to her pneumonia vaccine but nothing about the bruise. *They had seen her mother last Friday during the facility picnic and she did not have a bruise then. *Their mother did not mention dropping her phone during any phone conversations. *Their mother said she was sitting in her chair during their conversations. 5. Interview on 8/7/24 at 3:15 p.m. with LPN G revealed: *She had mixed up the dates the bruise was found. *She had received report of the bruise on 8/5/24 at 8:00 a.m. *She stated she should have called the family that morning but she didn't. *She had talked to resident 12's daughter when she called in the afternoon and reported it to her then *She would have expected a progress note and pain assessment. *She should have faxed the doctor but did not. *She agreed she should have reported it to the charge nurse or director of nursing (DON) for an investigation but she did not. *The skin assessment would flag the MDS coordinator to investigate. *She agreed it was an injury of unknown origin and should have been investigated to rule out abuse and neglect. 6. Interview on 8/7/24 at 3:38 p.m. with DON B revealed: *She was aware of the bruise above resident 12's right eye. *She said an investigation with other staff to see if they noticed the bruise should have been completed. *She stated the family and doctor should have been notified. *She agreed the bruise should have been investigated from the beginning. *A skin assessment to monitor the color of the bruise for healing progression should have been placed on the medication administration record (MAR). *She stated there was a bruise policy that would direct the process when a bruise occurred and if the resident could not explain how it happened. 7. Interview on 8/7/24 at 4:04 p.m. and 4:30 p.m. with administrator A revealed: *She was aware of the bruise above resident 12's right eye and it had not been investigated, nor had it been reported to the department of health (DOH) per policy. *She reported at 4:30 p.m. that the bruise had been investigated and she thought the bruise was from dropping her phone and it had hit her. -She stated the bruise was not reported to DOH because of the investigated findings. -The DOH complaints department confirmed this was not reported. 8. Interview on 8/08/24 at 1:32 p.m. LPN G revealed: *She stated it should have flagged from the skin assessment to DON for an investigation. *Resident 12's bruise should have been put on the medication administration record (MAR) so it could be monitored daily but she did not do this stating, if it's not charted, it's not done. 9. Interview on 8/08/24 at 1:40 p.m. with DON B revealed: *Skin assessments do not flag the minimum data set coordinator and DON for further investigations. *She agreed LPN G should have known that the skin assessment would not flag or notify the MDS/DON. *She agreed that LPN G knew she should have reported a bruise of unknown origin to the nurse manager. 10. Interview on 8/08/24 at 2:13 p.m. with CNA L revealed: *She would complete a resident bath or shower and get the nurse to do their skin assessment. *She would report any new bruises or skin concerns to the charge nurse, nurse manager, or DON. *She was not aware that bruises were investigated. 11. Interview on 8/08/24 at 2:21 p.m. with administrator A revealed: *She stated a bruise of unknown origin would be investigated by DON B and nurse manager C. She agreed the process for reporting the bruises for further investigation was broken. *She had been monitoring this process for a few months but had recently stopped because they were doing a good job' -She stated, clearly it had fallen back to the old ways. 12. Record review of resident 12's electronic medical record (EMR) revealed. *The bruise located above her right eye was not documented on the MAR. *The family was not notified of the bruise. *The charge nurse and DON were not notified of the bruise to initiate the investigation. 13. The provider's bruise policy dated October 2023 revealed: *The purpose was,to detect and monitor bruises early. *Identified bruises would be evaluated by nursing. *The bruise would be placed on the MAR for daily monitoring until resolved. *The color of the bruise, mechanism of injury if known and contributing factors if applicable, and notification of family and physician would be documented in the nurse's notes.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one dishwasher was adequately cleaned and delimed on a regular basis to prevent food scum and limescale buildup. Findings include: 1. Initial kitchen observation on 8/6/4 from 8:24 a.m. to 8:35 a.m. revealed: *The dishwasher was in use to clean dishes from breakfast. *There was a line of limescale buildup on the outside of the door where water was spraying out of a seam. *There was a buildup of food scum on the outside borders and inside seams of the dishwasher doors. *Limescale buildup was present on the wash arms and piping inside the dishwasher. 2. Interview on 8/8/24 at 11:57 a.m. with cook I and dietary aide J about the dishwasher revealed: *They did not know when the dishwasher was cleaned or how often. *Dietary aide J had never cleaned or delimed the dishwasher before. *Cook I had not been tasked with cleaning or deliming the dishwasher in a long time. *The night shift was responsible for cleaning and deliming the dishwasher. 3. Interview on 8/8/24 at 2:55 p.m. with administrator A about the dishwasher revealed: *She thought the dishwasher was supposed to have been delimed once per week. *The instructions and deliming schedule were hanging on the wall across from the dishwasher. *She confirmed the night shift was responsible for cleaning and deliming the dishwasher. *She was not aware of the state of the dishwasher. 4. Review of the dishwasher deliming schedule revealed the last time it was recorded that the dishwasher was delimed was on 6/12/24, about two months ago. 5. Review of the provider's 3/23 Dishwashing policy revealed: *Policy: Dietary staff will ensure that food preparation equipment, dishes, and utensils are [effectively] cleaned and sanitized to destroy potential disease carrying organisms, and ensure equipment is stored in a protective manner. *Procedure: -1. Follow the manufacturer's instructions for operation. .14. The [dietary manager] will monitor completion of tasks and accuracy of records.

A. Based on record review, interview, and policy review, the provider failed to report one of one sampled resident's 8 blood sugars that were out of parameter to the doctor per the doctor's order. Findings include: 1. Record review on 8/7/24 of resident 8's electronic medical record (EMR) revealed: *There was an order from his doctor on 3/21/24 to check his blood sugar four times daily and to call the provider if his blood sugar is less than 60 or greater than 500. *He had a blood sugar on 5/14/24 at 7:04 p.m. that was 542 and again on 5/25/24 at 7:01 p.m. that was 517 -There was no documentation in his EMR that the doctor was notified on the high blood sugars. 2. Interview on 8/8/24 9:41 a.m. with licensed practical nurse (LPN) G revealed she: *Agreed the high blood sugars were not reported to the doctor. *Would have been expected that the doctor to have been notified. 3. Interview on 8/8/24 at 10:37 a.m. with nurse manager C revealed: *She stated they had a new blood sugar parameter reporting policy as of 8/1/24 with the medical director. *She agreed resident 8's blood sugars had not been reported to his doctor and should have been faxed per the physicians orders. 4. Interview on 8/8/24 at 2:47 p.m. with administrator A regarding resident 8 revealed: *She had been auditing the staff to ensure they had been reporting abnormal blood sugars. *She had not been aware they were not reporting resident 8's abnormal blood sugar tests per physician's orders. 5. The provider's blood sugar parameter policy dated 8/1/24 revealed: *The purpose was to ensure adequate blood sugar parameters are reported and monitored by physicians. 46453 B. Based on observation, interview, record review, and policy review, the provider failed to follow their policy regarding storage of resident prescriptions for one of one sampled resident (27) who had prescription ointment on her bedside table. Findings include: 1. Observation on 8/6/24 at 2:25 p.m. in resident 27's room revealed there was a green tin of Bag Balm with a prescription label attached to it on the resident's bedside table. 2. Interview on 8/7/24 at 3:58 p.m. with licensed practical nurse (LPN) G about storing prescription medications in a resident's room revealed: *A resident must have a physician's order for a medication to be kept at their bedside. *The resident must also be assessed for competencies regarding what medication it was, how to use it, how much to use, and when to use it. 3. Continued interview on 8/8/24 at 9:29 a.m. with LPN G about resident 27's prescription ointment revealed: *She confirmed there was no physician's order for resident 27's Bag Balm to have been kept at her bedside. *Resident 27 was not able to open the tin of ointment by herself. *The ointment was probably there for staff to use when they were performing perineal cares. *It should have been stored in the medication room. 4. Interview on 8/8/24 at 10:02 a.m. with director of nursing (DON) B about resident 27's prescription ointment revealed: *She indicated it was acceptable for resident 27 to have the Bag Balm at her bedside for the staff to use. *She confirmed that resident 27 was not able to use the ointment by herself. 5. Review of resident 27's electronic medical record revealed: *There was no physician's order for the Bag Balm to have been stored at resident 27's bedside. *There were no medication self-administration assessments. *Resident 27 was admitted on [DATE] and had a Brief Interview for Mental Status score of 7, which suggested severe cognitive impairment. *There was a physician's order for Bag Balm Ointment APPLY TOPICALLY TO PERI AREA AS DIRECTED that started on 7/19/24. *The resident's care plan did not indicate anything about Bag Balm being stored at her bedside. 6. Review of the provider's 6/15/24 Bedside Medication Storage policy revealed: *Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. *Procedures: -A. A written order for the bedside storage of medication is present in the resident's medical record. -B. Bedside storage of medications is indicated on the resident medication administration record (MAR) and in the care plan for the appropriate medication. 7. Review of the provider's 6/15/24 Storage of Medications policy revealed: *Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. *The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on menu review, observation, and interview, the provider failed to ensure adequate portions were served according to the menu for one of one observed meal. This had the potential to affect all residents receiving the main menu in the facility. Findings include: 1. Review of the provider's menu for lunch on 8/8/24 revealed the following main menu items: *One cup of taco bake. *The pureed portion size was 2/3 cup. 2. Observation on 8/8/24 from 11:43 a.m. to 12:11 p.m. in the kitchen for lunch service revealed: *Cook H set up the steam tables, placed pans of food into the steam table, and placed the serving scoops next to each pan of food. *She used a 1/2 cup scoop for the taco bake, and another 1/2 cup scoop for the pureed taco bake. -1/2 cup of taco bake was 50% less than what the menu called for. -1/2 cup of pureed taco bake was about 33.33% less than what the menu called for. 3. Interview at that time with cooks H and I about the menu revealed: *Cook H had been working at that facility for about three weeks. *She had not made that recipe before. *Neither [NAME] H nor [NAME] I were aware that the serving size for the regular taco bake was one cup, and the serving size for the pureed taco bake was 2/3 cup. *Cook H indicated that she was trained to use the 1/2 cup scoop for every recipe. *When asked if cook H was aware how to verify the correct serving size, she looked at the posted menu with each diet listed and the serving sizes, but said, No I was not aware of that. *Cook H continued to use the incorrect scoop sizes for the remainder of the meal service. 4. Interview on 8/8/24 at 2:55 p.m. with administrator A about the above observations revealed: *She was not aware that the dietary staff served the wrong portion sizes for lunch that day. *She was the acting dietary manager as the previous one had ended their employment the previous week.

Based on record review, interview, observation, and policy review, the provider failed to implement adequate monitoring and supervision for one of one sampled resident (39) who had a history of unsafe wandering and elopement, which resulted in two separate incidents of successful elopement that the facility staff were not aware of until the resident had already left the building. Findings include: 1. IMMEDIATE JEOPARDY According to resident 39's electronic medical record, there were two instances since the previous recertification survey (exit date 8/31/23) where she left the building without the staff's knowledge. On 10/19/23 at around 5:30 p.m., the facility experienced a blackout in electricity for approximately two to three minutes according to their report submitted to the South Dakota Department of Health. During that time, the generator failed to initiate emergency electricity within the required 10 seconds. Due to that lapse in electricity, the door alarms were not active. Resident 39 was able to exit the facility without anyone's knowledge. Staff noticed her wandering around in the employee parking lot through the dining room windows. On 1/3/24 at around 1:00 p.m., a housekeeper had finished her shift and walked out of the building into the employee parking lot. She happened to notice resident 39 wandering around in the employee parking lot, approximately 45 yards from any of the building's exit doors. She assisted the resident partway back to the building when the charge nurse responded to the door alarm. In both instances, the resident was immediately placed on 15-minute checks for 24 hours, then 30-minute checks for the next 24 hours, then returned to the normal 60-minute checks as noted in her care plan. She was wearing her Tile brand tracking device on both instances, a device that tracked GPS location. That device was implemented in June of 2023 after the resident eloped and was found about a mile away from the facility near the grocery store by a citizen in the community. The device was used solely for tracking purposes and did not alarm if the resident left the building. The provider failed to reassess their interventions after both elopement incidences to further prevent her from eloping. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing to administrator A, director of nursing B, and nurse manager C on 2/8/24 at 3:17 p.m. IMMEDIATE JEOPARDY REMOVAL PLAN On 2/12/24 at 7:31 a.m., administrator A provided a final written immediate jeopardy removal plan. The removal plan was approved by the survey team on 2/12/24 at 8:35 a.m. with guidance from the long-term care advisor for the South Dakota Department of Health. The provider gave the following acceptable immediate jeopardy removal plan: Interventions were put into place following [resident's] last elopement on 1/3/24. The interventions put in place on 1/3/24 included 15-minute checks, which graduated to [30-minute] checks followed by [60-minute] checks until resident was determined safe. Hourly checks have continued for resident to ensure resident is safe from falls and elopement. Removable stop sign Velcro barrier put on door resident exited. Once interventions put in place, resident has not since eloped. Resident does wander facility hallways and look out windows, but does not attempt to exit. On 2/1, UTI [urinary tract infection] PIP [performance improvement plan] was put in place as resident begins displaying wandering behaviors when UTI is present. In addition to those the following interventions have been put in place: Resident has been put on 15-minute checks immediately to ensure resident is in the facility and safe. Nurses and oncoming staff to be educated for resident on 15-minute checks. Nurse is responsible for 15 minute checks, and can delegate to staff on duty as needed. Checks will be documented on daily shift sheets with resident's name, date, time, initial, and what resident was doing at time of check. Once determined wandering has reduced, IDT [interdisciplinary team] will determine whether to change frequency of resident checks. All oncoming nursing staff educated on correct charting for 15-minute checks. Staff educated prior to next scheduled shift on high-risk elopement residents. Elopement policy updated on 2/8/2024. Elopement policy to be reviewed and discussed with any further updates at all staff meeting on 2/16/24. An alerting device has been put into place in addition to the tile tracker to set boundaries for alarms to go off on facility phone if resident leaves facility boundary. Charge nurse will carry facility phone with them at all times throughout shift. Resident care plan updated to include interventions. All staff meeting on 2/16 to provide all staff about high-risk elopement patients. Elopement drill scheduled monthly going forward. The generator company visited the facility on 2/8/24 to ensure proper operation of generator. The company is putting a report together regarding proper operation of generator. The immediate jeopardy was removed on 2/12/24 at 11:30 a.m. after verification that the provider had implemented the removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was D. 2. Review of resident 39's electronic medical record (EMR) revealed: *On 10/18/23, staff witnessed the resident leave the building. *She continued to display anxious behaviors of wandering and attempting to transfer her husband from surface to surface throughout the night on 10/18/23 and into the morning of 10/19/23. *On 10/19/23, staff were not aware the resident had left the building and saw her in the parking lot through the dining room windows. -The following incident note was entered at 6:20 p.m.: This nurse witnessed CNA's [certified nurse assistants] running out the front door of building after the facility experienced a black out. The black out [blackout] of electricity was approximately 2 minutes. This nurse went to the front door to investigate. CNA's were bringing resident back in through the front door by the time this nurse got to the door. CNA's stated that they saw the resident walking around the side of the building through the dining room windows and went outside to get resident. Resident stated that she was looking for a donut. Resident brought back in to the facility and sat by the nurses station. CNA was able to get a donut from the kitchen and resident stated that was good. Vital signs 116/75, 88 bpm, 18 respirations, 94% O2 on room air, no complaints of pain. DON contacted, Faxed MD [medical doctor] office with notes and spoke [with] family member regarding elopement. *It was noted on 10/20/23 that resident 39 was removing the Tile brand tracking device multiple times during the day. *She was started on an antibiotic on 10/23/24 due to a positive UTI result. *On 12/6/23, her physician added gabapentin 100mg twice per day as needed for anxiety. *On 12/12/23, she attempted to exit the building through the emergency exit door in the dining room TV area. The following behavior note was entered into her record: -Pt [Patient/resident] stood up from dining table and walked to TV area. Pt opened the south side door in the TV area by the dining room. Alarm went off and pt did not exit the building. Pt redirected, and then requested staff to open up restroom in dining hall. When asked where pt was going when she pushed open the door, the pt giggled and said, I don't like to go out that door because of the alarm. *On 1/2/24, she attempted to exit the building again at the East Door. Staff witnessed her exit the building and guided her back inside. *On 1/3/24, staff were not aware the resident left the building. A housekeeping staff had just clocked out and went to the parking lot. She saw the resident wandering around in the parking lot. The following incident note was entered into her record at 1:52 p.m.: -Data: Resident was found in the back parking lot by housekeeping staff [housekeeper L] and walked back to the building. Nursing staff [registered nurse G] was able to meet housekeeping staff in back lot and resident brought back in. Alarm to the living room emergency exit was alerting. Resident walked out the living room emergency exit and was walking very quickly in the back parking lot. Housekeeping staff stated that she had to run to catch up to her in the lot. Resident brought immediately back into facility. Resident approximately out of the facility for 1-2minutes max. Action: Resident assessed when returned to facility. No signs/symptoms of distress noticed. Resident alert and oriented x1. Resident was then found to have a coat on and looking for a hat. Staff redirect to remove coat and sit in the recliner. Staff sitting with resident for about 10 minutes to redirect from trying to leave again. Gabapentin 100mg administered. Resident currently sitting with two other staff members. [15-minute] safety checks were started immediately. Response: Continuing to monitor for resident safety. *The resident was found to have been positive for a UTI on 1/5/24 and was started on an antibiotic. *On 1/20/24 and 2/4/24, she was witnessed attempting to exit the same emergency exit door in the dining room TV area. -On both occasions, she said she was looking for her room. -On 2/4/24 at 6:57 p.m., a behavior note entered into her record read, After dinner pt walked to door to the right of the TV and pushed it open. Staff followed pt and asked [Resident 39], where are you going? Pt states she is going to her room. Pt followed staff back into the dining room and laughed, asking if the alarm went off. [Administrator A] notified, Son notified via phone. 3. Interview on 2/7/24 at 12:25 p.m. with licensed practical nurse (LPN) F and nurse manager C revealed: *Resident 39 wore a Tile brand tracking device that tracked her GPS location. *They had an application (app) on the facility's iPad to see the location of the Tile brand tracking device. *They confirmed the device did not alarm or alert staff if the resident left the building. *They indicated that resident 39 had a tendency to remove the Tile brand tracking device and would hide it in her dresser drawers. -They speculated that the resident knew what the device was used for. *If they noticed that resident 39 was anxious or was displaying wandering behaviors, their interventions were to: -Ask her if she needed help with anything. -Offer an alternative activity, such as coloring. -Offer a snack or a beverage. Continued interview on 2/7/24 at 2:05 p.m. and 4:25 p.m. with LPN F revealed: *There was a physician's order that prompted the nurse twice per day to check the placement of the Tile brand tracking device. *They kept the device on a string and the resident wore it as a necklace. *Resident 39 was on hourly checks. -There were several residents on hourly checks for fall and elopement risks. -She walked the halls each hour to lay eyes on each resident during the hourly checks. *With the elopement on 10/19/23, the power went out for approximately two to three minutes. *Resident 39's room was situated in between two fire doors. The employee door was across the hall from her room, giving her a direct route outside to the employee parking lot. -The fire doors automatically shut when the electricity went out. -Resident 39 happened to have been in the hallway when the electricity went out and the fire doors closed. -Resident 39 was able to exit the building without the door alarms sounding. *Some of the CNAs in the dining room had seen resident 39 in the parking lot through the dining room windows. -They informed LPN F immediately. *If they found resident 39 displaying unsafe wandering behaviors, the protocol was to put her on 15-minute checks for 24 hours, then 30-minute checks for the next 24 hours, then back to the regular 60-minute checks. *She tried to complete the hourly checks at the top of each hour. 4. Interview on 2/7/24 at 5:23 p.m. with director of nursing B revealed: *She completed a wandering assessment upon admission, 72 hours after admission, one month after admission, and then quarterly thereafter. *She confirmed the door alarms did not sound when resident 39 eloped on 10/19/23. *She confirmed the door alarms did sound when resident 39 eloped on 1/3/24. -The emergency exit door in the dining room TV area only alarmed at the nurse's station, not in the dining room itself. *They noticed a trend that resident 39 would usually have a positive UTI if her wandering and eloping behaviors increased. *The resident currently had a UTI. Interview on 2/7/24 at 5:45 p.m. and again on 2/8/24 at 9:18 a.m. with administrator A revealed: *The power outage on 10/19/23 didn't last very long. *During a power outage, she expected staff to have completed a head count to ensure all residents and staff were accounted for. *A record of the head count was requested from when the power went out on 10/19/23. -She said, As far as a head count, there's no formal check sheet for a head count. It would be in the charting. *When asked where in the charting it would have been located at, administrator A said she did not know. *When asked in the event of an elopement, did they perform a head count to see if everyone was accounted for, she said, I'm not sure, I would have to look at the policy. 5. Random observations throughout the survey revealed that resident 39 would wander towards the exit doors several times per day. Each time, a staff member successfully intervened and redirected her towards her room. 6. Interview on 2/8/24 at 11:16 a.m. with director of nursing B revealed: *The Tile brand tracking device was implemented after she eloped in June 2023. -Someone in the community found her near the grocery store in town and brought her back to the facility. -The grocery store was about a mile away from the facility. *She had been on hourly checks since that incident. *All staff were aware they needed to monitor resident 39 closely due to her wandering behaviors. 7. Interview on 2/8/24 at 11:25 a.m. with activities director Q revealed: *They had a variety of activities for resident 39 if she displayed unsafe wandering behaviors. *They first invited her to the group activities if there was one going on. *Staff invited her to have a cup of coffee. *Other activities that resident 39 enjoyed included coloring, folding laundry, reading the paper, and watching certain TV shows. *There was usually an activity aide in the building until 7:30 p.m. which helped the resident to keep busy. 8. Interview on 2/8/24 at 11:59 a.m. with certified medication aide K revealed: *During meals if they could not find resident 39, they first checked her room. *She usually tried the exit doors because she was looking for her room. *Resident 39 and her husband sat at a dining room table by themselves. -Her husband learned to sit and wait for his wife to finish her meal rather than going back to their room after he finished eating because much of resident 39's anxiety came from not being able to find her husband. *She confirmed that resident 39 had a PRN medication to help with anxiety. 9. Interview on 2/8/24 at 12:15 p.m. and again on 2/12/24 at 9:30 a.m. with housekeeper L revealed: *On 1/3/24, she had just clocked out for the day and exited the employee door into the parking lot. *She saw resident 39 with her walker wandering around in the parking lot. -The resident was walking very quickly away from the building. -She had to run to catch up to resident 39. *The resident was about 45 yards from the exit door. *When she ran to catch up with resident 39, she said to the resident, Oh [resident 39], you're not supposed to be out here! The resident responded with, No I'm not. *She started walking with the resident back to the building. -At that time, RN G came out to the parking lot and assisted the resident back inside. *She did not know how long the resident was outside. 10. Interview on 2/8/24 at 12:24 p.m. with RN G revealed: *On 1/3/24, the resident walked out of the emergency exit door in the dining room TV area. *The alarm sounded at the nurse's station. *She ran out the employee exit door into the parking lot. *She saw resident 39 walking with housekeeper L. *She assisted the resident back inside and assessed her for injuries. *Resident 39's physician and family were notified, along with the facility's leadership team. *She was placed on 15-minute checks for 24 hours, then 30-minute checks for the next 24 hours, then back to the regularly scheduled hourly checks. 11. Review of resident 39's Treatment Administration Record at approximately 3:25 p.m. on 2/8/24 revealed that the hourly check for 4:00 p.m. had already been checked as having been completed. 12. Review of the resident 39's care plan on 2/8/24 revealed: *She was admitted on [DATE]. *Under the activities section, there was an intervention that read, I will go to the activity room to read the paper. I will Walk the halls, sometimes I get confused where my room is and staff help remind me where it is. Initiated on 11/28/23. *There was a focus area that read, I am an elopement risk/wanderer r/t [related to] disoriented to place and wanders aimlessly. Initiated on 6/7/23, revised on 9/13/23. *The associated interventions included the following: -Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Initiated on 6/7/23, revised on 9/13/23. -Elopement 6/11. One to one care until 0600 6/12, then 10minute checks of resident [until] 0600 6/13, then as long as no exit seeking has been demonstrated, then advance to 30minute checks of the resident until 0600 6/14, then resume hourly checks starting 0600 on 6/14 as long as no exit seeking is still demonstrated. -6/14 [resident 39] seen pacing by front door carrying purse waiting for daughter so she can leave. Redirected [resident 39] successfully. Call made out to family to verify if they are coming to get her or not. Will continue to do 30 min checks on [resident 39] until no exit seeking has been observed. Initiated on 6/12/23, revised on 6/14/23. -I am on hourly checks for fall prevention and elopement risk. Initiated on 6/7/23, revised on 9/13/23. -I wear a tile device that tracks location for safety. Staff are to check placement 4 times a day. Initiated on 6/23/23, revised on 9/13/23. -I will have 15min check for the first 24hrs and then 30min for 24hrs then hourly unless determined a need for change, d/t [due to] elopement attempt on 10/19/23. Initiated on 10/20/23, revised on 10/25/23. -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Initiated on 6/7/23. -My triggers for wandering/eloping are phone calls from family members or visitations from family members. My behaviors are de-escalated by redirection. Initiated on 6/7/23, revised on 9/13/23. *Her care plan had not included the elopement from 1/3/24. 13. Review of the provider's December 2021 Missing Resident policy revealed: *The policy came from their Emergency Preparedness binder. *There was a handwritten Elopement at the top of the policy. *Missing Resident (Elopement) is defined as: Elopement is when a resident leaves the nursing facility unattended without the facility's knowledge. *1. The person discovering the absence of a resident will immediately notify the Charge Nurse/Personal Care Aide/LPN in charge and Nursing Supervisor/LPN of the areas where the person resides. Staff should provide the time and location of when the resident was last seen as well as the clothing the resident was wearing when last seen. *2. Unit staff will immediately check the resident's chart and the unit sign-out book to determine if the resident in in fact on an authorized absence. Ask other staff for any information about the resident's location or possible activities, including possible destinations. *8. After receiving information about the missing resident, all staff should quickly proceed to their designated search zone and begin a thorough search process, including closets, under beds, utility rooms, bathrooms, showers, tub rooms (in the bathtub), behind [NAME], in corners, in and under automobiles, etc. The designated search zones for each department are listed at the end of this section. After a room is searched the magnet on the inside of the door frame will be moved to the corridor side of the frame indicating the room has been searched. -The policy did not list the designated search zones for each department. -There were no magnets on the inside of door frames in the building.

Based on observation, interview, record review, and policy review, the provider failed to ensure appropriate infection control precautions had been followed with: *Certified nursing assistants (CNA)s F, G, O, U and W had not performed hand hygiene after care of residents. *Two of two observed dressing changes by interim director of nursing (DON) M. *COVID-19 precautions were not taken with residents exposed to someone who had tested positive for COVID-19. *Lifts had not been disinfected in between residents (4 and 8). *CNA T had not followed appropriate putting on and removal of personal protective equipment (PPE) when for caring for a resident who was presumed positive with COVID-19. *Two of two observed visitors had not been screened for COVID-19. *No screening residents for COVID-19 signs and/or symptoms. *Environmental Services staff Z while cleaning resident 41's room. Findings include: These failures have a potential to expose all residents, staff, and visiting essential personnel to COVID-19, a [CONDITION(S)] infection that could lead to serious harm or death. NOTICE: On 11/4/21 at 11:00 a.m. an Immediate Jeopardy was identified after the Centers for Medicare and Medicaid Services (CMS) Regional Office review of the 9/27/21 Recertification Survey Form CMS-2567. The facility failed to implement CMS and CDC recommended practices to prepare for COVID-19. On 11/4/21 at 3:52 p.m. a copy of the immediate jeopardy template was emailed to the provider for review. Notice of immediate jeopardy was given verbally, via telephone to the administrator. Specifically, the provider failed to ensure: *CDC guidelines were followed for proper PPE usage to prevent the spread of COVID-19. *Unvaccinated residents who had been exposed to a staff member who had been positive with COVID-19 remained quarantined from the remaining resident population. *Staff who care for quarantined residents were wearing appropriate PPE. *One of one CNAs followed proper infection control practices after leaving one of three quarantined rooms. *Two of two observed visitors had been screened for the potential of COVID-19 illness. *Residents had been screened for signs and symptoms of COVID-19. PLAN: On 9/27/21 at 5:00 p.m. surveyors were able to verified that the Immediate Jeopardy had been removed while the survey team had been onsite. The Immediate Jeopardy was removed after the provider educated all staff, quarantined COVID-19 exposed residents, implemented infection control practices to prevent the spread of COVID-19, and screened all staff and visitors. Immediate Jeopardy was removed on 9/27/21 at 5:00 p.m. after the removal plan had been verified by the survey team. After removal of the Immediate Jeopardy, the scope/severity of this citation is level F. 1. Observation on 9/26/21 at 10:35 a.m. with CNA O revealed she: *Was grabbing a bag of trash out of a resident 16's room. *Tied the bag with bare hands and took the trash down the hall to the soiled utility room. *Had not performed hand hygiene after doing this. *Then went back in resident 16's room to make her bed. Observation on 9/26/21 at 10:52 a.m. of the facility's front entrance revealed: *Two visitors walked into the facility, through the front door. *No one had asked them if they had screened themselves. *No one had inquired about their COVID-19 status/exposure. Observation on 9/26/21 at 11:35 a.m. with CNA Q revealed She had: *Been taking a bag of trash to the soiled utility room. *Not sanitized her hands and went into resident 30's room. *Grabbed resident 30's trash and dropped it off in the soiled utility room. *Not sanitized her hands and went into resident 22 and 28's room. *Grabbed resident 22 and 28's trash and brought it to the soiled utility room. *Not sanitized her hands when leaving. 2. Observation and interview on 9/27/21 at 7:47 a.m. with interim DON M revealed she: *Went into resident 16's room and put her clean gloves on top of the resident's dresser. *Put on gloves to check resident 16's wound. *Removed the gloves, did not sanitize hands. *Went back into the hallway to get an alcohol pad. *Came back in the room and put on a new pair of gloves. -That pair of gloves had also been laying on the resident's dresser with her personal belongings. Interview on 9/27/21 at 9:49 a.m. with administrator A and business manager B revealed: *Had not been aware they needed to test all unvaccinated staff per their county level positivity rate. Refer to F886. *Employees are self-screening themselves. *Employees walk through the building to screen themselves at the nurses' station. *They were unable to say who monitored those screening forms. *They did not have a list of employees that had been fit-tested . *Interim DON M was fit-testing staff. *They had not been aware they should still be monitoring residents for signs and symptoms of COVID-19. *They had not put unvaccinated residents who had been exposed to positive staff CNA/MA H in quarantine. *They had not implemented any precautions for isolation. Observation and interview on 9/27/21 at 10:57 a.m. with interim DON M revealed she: *Was going to change resident 4's dressing. *Laid her clean gloves on the resident's blanket. *Sanitized her hands and put the gloves that had been on the blanket. *Had braced herself with one gloved hand on the floor. *With that same glove that was on the floor she assessed the resident's foot wounds. *With the same soiled gloves, she touched the wound with she had reached into resident 4's treatment box to grab supplies. *While wearing soiled gloves she applied ointment by using her finger to obtain and apply the ointment. Observation and interview on 9/27/21 at 11:31 a.m. with environmental services staff Z revealed she: *Had walked into resident 41's room. *Stated resident 41 had been sick and not feeling well. -Resident 41 had vomit on down her clothing protector, and piled on her left hand. *Started cleaning resident 41's room. *Sprayed the doorknobs with a cleaner. *Had no idea of a contact time for the cleaner. *Then swept the room and mopped the room. *Had not cleaned any bedside tables, remotes, or rails in the resident's room. *Stated she usually does not clean those items because they have residents' things on them. Observation on 9/27/21 at 11:37 a.m. of CNA T revealed she brought a lift out of resident 8's room and did not disinfect it. Observation and interview on 9/28/21 at 8:44 a.m. with CNA T revealed she: *Been coming out of a COVID-19 quarantine room. *Was not wearing a face shield. *Was not wearing an N95 mask. *Had not changed her surgical mask upon leaving the quarantine room. *Did not believe she needed to wear an N95 mask or a face shield since the resident was just on precautions. *Surveyor informed her that the resident was on quarantine because they could be positive with COVID-19. 3. Observation on 9/28/21 at 8:38 a.m. with CNAs G and W assisting resident 4 revealed: *Resident 4 had been sitting in his wheelchair in his room and requested assistance to use the restroom. *CNA G washed her hands and put on gloves. *CNA W brought the mechanical stand aid into the room and closed the door then put on gloves without performing hand hygiene. *CNA G moved the wheelchair foot pedals to the side, placed resident 4's feet on the floor and then removed the foot pedals and placed them to the side. *CNA W rolled the mechanical stand aid into position next to the toilet. *CNA G attempted to move him to the restroom but the oxygen tubing was not long enough to reach. *Using the same gloved hands, she removed the nasal cannula from his nose, attached the tubing to the oxygen tank on the back of his wheelchair, rearranged the resident, turned the oxygen on and then placed the nasal cannula back into his nostrils. *CNA G rolled him into the restroom into position by the stand aid, placed the back brace around him and attached the straps. *CNA W removed the nasal cannula to untangle it, then put it back into his nostrils. *CNA W placed the leg strap around the resident's legs, raised the resident into position and lowered him onto the toilet after removing his adult brief. *Both CNAs removed their gloves. *CNA G left the room. *When finished assisting the resident, the mechanical stand aid had been parked in the hallway by CNA W and had not been sanitized. Interview on 9/28/21 at 8:47 p.m. with CNA W revealed: *She had been a CNA for 7 years. *She recognized they had missed opportunities for hand hygiene and glove changes while assisting resident 4. *She agreed the lift should have been sanitized after being used. Review of the undated electric lift cleaning policy revealed: *Purpose: To provide clean equipment for resident care. To prevent growth of bacteria. *At the end of each shift each item used will be cleansed with the Vindicator solution. *Equipment will be cleansed ant [at] the time of soil age [soilage]. 4. Observation on 9/27/21 at 8:57 a.m. of CNA F assist CNA G to get resident 32 up from bed revealed CNA F failed to follow proper procedures for hand hygiene and glove use. *She did not wash or sanitize her hands before putting on the gloves. *CNA F was on the left side and in front of resident 32 as she and CNA G positioned the resident in the stand aid sling and stood her up from the edge of the bed. *Once resident 32 was standing, CNA F removed the resident's brief and placed it into the trash can. There was an odor of bowel at that time. *Without wiping resident 32's bottom, CNAs F and G positioned resident 32 on a bedside toilet commode with wheels. *While wearing the same gloves she used to remove resident 32's brief, CNA F proceeded to strip the linens off resident 32's bed, placing them in the linen cart, and picking up the pillows and blankets to the head end of the mattress. *CNA F pushed the linen cart into the hallway, removed her gloves, placed them into a cart, then sanitized her hands. Interview with CNA F on 9/28/21 at 8:41 a.m. revealed she was taught to wear gloves whenever we are handling residents, and to sanitize hands before and after. Surveyor : Review of the provider's undated COVID-19 Prevention and Control Guidance policy revealed: *The Infection Control Preventionist will track how many and which residents were isolated and/or quarantined. *A list of which residents are isolated and/or quarantined will be posted each day on the [electronic charting software] dashboard so that staff are aware. Review of the provider's undated Hand Washing policy revealed: *The purpose of hand washing was to: -Medical asepsis [the absence of viruses, bacteria, and other organisms] to control infection. -To reduce transmission of organisms from resident to resident. -To reduce transmission of organisms from nursing staff to resident. -To reduce transmission of organisms from resident to nursing staff. Review of the provider's undated Hoyer Lifts, [NAME], Electric Lift Cleaning policy revealed: *Hoyer lifts, [NAME], and Electric lifts were to be cleaned: -At the end of each shift each item used will be cleansed with [cleaner's name] solution. -Equipment will be cleansed ant [at] the time of soil age. Review of the provider's Infection Control and Prevention Policy revealed: *Staff were to use standard and transmission-based precautions to keep the residents safe as well as themselves from infection. *Standard precautions included: -Hand washing. -Use of PPE. *Transmission-based precautions included: -Droplet. -Airborne. -Contact. * .If eye protection is indicated, wear goggles or a face shield during ALL contact with the individual, not just when splashes or sprays are anticipated, as well standard precaution.

Based on observation, interview, record review, and reference source review, the provider failed to follow outbreak and county level testing procedures for staff and residents in their building. Findings include: These failures have a potential to expose all residents, staff, and visiting essential personnel to COVID-19, a [CONDITION(S)] infection that could lead to serious harm or death. NOTICE: On 11/4/21 at 11:00 a.m. an Immediate Jeopardy was identified after the Centers for Medicare and Medicaid Services (CMS) Regional Office review of the 9/27/21 Recertification Survey Form CMS-2567. The facility failed to implement CMS and CDC recommended practices to prepare for COVID-19. On 11/4/21 at 3:52 p.m. a copy of the immediate jeopardy template was emailed to the provider for review. Notice of immediate jeopardy was given verbally, via telephone to the administrator. Specifically, the provider failed to ensure: *Unvaccinated staff had been tested for COVID-19 according to the provider's county level positivity rate. *Perform outbreak testing when a staff member had tested positive for COVID-19. PLAN: On 9/27/21 at 5:00 p.m. surveyors were able to verified that the Immediate Jeopardy had been removed while the survey team had been onsite. The Immediate Jeopardy was removed after the provider educated all staff and tested all residents and staff in the building to identify COVID-19 infections within the building. Immediate Jeopardy was removed on 9/27/21 at 5:00 p.m. after the removal plan had been verified by the survey team. After removal of the Immediate Jeopardy, the scope/severity of this citation is level F. 1. Observation on 9/26/21 at 10:00 a.m. of the facility's main entrance revealed: *Surveyors had walked through the entrance. *An unidentified staff member was talking to a resident with a mask under her chin. *Surveyors introduced themselves, they had not been: -Asked any questions regarding COVID-19 status. -Screened for the potential of having COVID-19. -Given any instructions to prevent the spread of COVID-19. 2. Interviews, observations, record reviews, and policy reviews, throughout the survey revealed the facility was not testing all residents and staff every three to seven days since being in outbreak status starting on 9/22/21. 3. The facility had not been testing all unvaccinated staff per their county level positivity rate to detect COVID-19 in staff members. Review of the facility's COVID-19 testing documentation revealed they had: *A symptomatic staff member test positive on 9/22/21. *Not performed outbreak testing for their residents or staff. *Had not been testing unvaccinated staff per their county level positivity rate. Interview on 9/27/21 at 9:40 a.m. with administrator A and business office manager B revealed: *Business office manager B had been the previous administrator and was keeping track of COVID-19 testing. *Business office manager B not been aware they should have been: -Testing every three to seven days during outbreak status. -Testing two times per week since their county was of high transmission status. Review of the provider's undated COVID-19 Prevention and Control Guidance policy revealed: *To ensure the health and safety of [facility name]'s residents and staff by enforcing the standards required to help each resident maintain their highest level of well-being due to the virus that causes coronavirus disease (COVID-19). Review of Centers for Disease Control and Prevention's (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 [COVID-19] Spread in Nursing homes <www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html> 9/10/21 guidance revealed: *Unvaccinated staff were to be tested based off county level positivity rates. *Healthcare personal (HCP), residents and families were to be notified of an outbreak in the facility. *An outbreak consisted of: -One resident or HCP *A person should be designated as the infection control person to oversee the COVID-19 effort and management of infection control program. Review of the provider's undated Infection Control and Prevention Policy revealed: *LTC [long-term care] facilities must test residents and staff, including volunteers and/or contracted service providers for Covid-19 based upon the following parameters. *Those parameters included: -Symptoms. -An outbreak, which was any new case in the facility. -County-level positivity testing.

Based on observation, interview, record review, and policy review, the facility failed to report incidents of alleged abuse and neglect to the state for: *Three of three residents (6, 8, and 31) related to neglect and verbal abuse from certified nursing assistant/medication aide (CNA/MA) H. *One of one resident (3) related to neglect from delayed care and services. *One of one resident (16) who had a hematoma that had resulted from a fall. *One of one resident (29) with [CONDITION(S)] from hot tea. Findings include: 1. Interview with resident 6 on 9/27/21 at 10:45 a.m. and review of resident 6's record revealed: *CNA/MA H had disregarded his ongoing concern regarding the temperature of his room. (Refer also to F600, finding 1.) *On 7/22/21 at 8:12 a.m. by CNA/MA H when she turned on and kept his air conditioner on while she got him ready for the day despite his verbal and physical objections. *On 7/22/21 at 9:10 a.m. by director of nursing (DON) X when she spoke with resident 6 and counseled CNA/MA H about respecting resident 6's personal space as his home. 2. Interviews with two separate staff members who wished to remain anonymous on 9/28/21 at 10:15 a.m. and 3:07 p.m. respectively reported witnessing alleged verbal abuse and neglect by CNA/MA H towards one unnamed resident, resident 8, and resident 31. (Refer also to F600, finding 2). Interview on 9/29/21 at 3:46 p.m. with administrator A, business manager B, and interim director of nursing M revealed: *They were not aware of the allegations related to CNA/MA H despite the documented progress note for resident 6 and the anonymous staff member who reported witnessing alleged verbal abuse by CNA/MA H. *All staff are mandatory reporters when a grievance involves abuse or neglect. *Grievances related to abuse and neglect need to be reported to the state. *They had not reported these allegations to the state. 3. Review of resident 3's interdisciplinary progress notes revealed: *On 9/12/21 at 3:47 p.m. Pt. [resident] insistent that staff and peers are her family member. Staff attempts to redirect pt, but continues. Pt noted to go into peers room, grab peers arms bilaterally and yell at them. *On 9/16/21 at 5:22 p.m. registered nurse (RN)/interim DON M documented the following: -Data: RN found patient [resident] on toilet. RN called CNA on that hallway to come to the patient's room. The patient was found sleeping against the wall still hooked up to the EZ stand. DON [director of nursing] called to patient's room. Pt's [resident] buttocks was bright red/purple. DON and RN got patient off of the toilet and into the wheelchair to go to supper. Expected time that resident was left on toilet in EZ stand was 20-25 min. [[minutes]. -Action: Pt was taken off toilet via RN and DON. Both nurses aides were called to the room to tell their side of the situation. -Response: DON followed up with both nurses aides. *On 9/18/21 at 7:39 a.m. Pt is noted to approach peers and staff by the hands/arm and note [not] letting go. Staff attempts to intervene, pt becomes agitated and refused to release grip on peer. Pt states she is healing peer. Pt given therapeutic toy cat to hold. Pt in dining room, again grabbing at peers, hold their hands/arms and stopping them from eating. Gripping them firmly. *On 9/19/21 at 5:30 p.m. Pt is grabbing peers with her hands aggressively and not letting go, stating they are her family members. Staff physically having to remove pt hands from hurting peers. Peers are becoming agitated with pt having poor personal boundaries. *On 9/21/21 at 7:46 a.m. Resident seen going up to other residents and grabbing their arms, resident brought to nurses station, given a baby doll, resident doing better, will continue to monitor. *On 9/25/21 at 6:00 p.m. Resident was wheeling herself around dining room and near nurses station and was grabbing at other residents legs, arms. Interview on 9/28/21 at 3:30 p.m. with interim DON M revealed: *She had been the RN who had found resident 3 on the toilet. *The other nurse was licensed practical nurse (LPN) N, who had just started her shift. *The two CNAs were CNA O and CNA P. *She agreed CNAs O and P had neglected to assist resident 3 off of the toilet in a timely manner. *She had not completed any other investigation or documentation of this incident. *She was aware of resident 3's behaviors of grabbing other residents. -A recent reduction in her anti-psychotic medication had occurred and those behaviors started. -There had been no incident reports to indicate who the other residents were, if they had been injured physically or emotionally, family notifications, and physician notifications. 4. Interview on 9/28/21 at 3:45 p.m. with administrator A, business manager B and interim director of nursing (DON) M revealed: *They agreed the incidents involving residents 16 and 29 should have been reported. (Refer to F600, findings 6 and 7.) *They had not realized that their facility had not submitted any incident reports to the South Dakota Department of Health during a six month time period.

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. Findings include: 1. Observations, interviews, record reviews, and policy reviews revealed a failure to ensure residents received care to obtain their highest practicable wellbeing. *Routine COVID-19 testing for residents and staff. Refer to F886. *COVID-19 testing of all residents who had contact with a staff member who had tested positive. Refer to F886. *Ensure staff had competencies and training to provide the care that residents needed. Refer to F726. *Ensure the facility had registered nurse coverage to oversee the care of residents. Refer to F727. *Ensure investigations and reports had been completed of residents who had experienced falls or accidents. Refer to F600, F609, and F610. *Ensure all allegations of abuse and/or neglect have been investigated. Refer to F600. *Ensure a comprehensive skin program had been developed for the prevention of pressure ulcers. Refer to F686. *Ensure the bowel management program was followed for residents. Refer to F690, findings 2, 3, 4, 5, and 6. *One of one resident (4) who had an in-dwelling foley catheter had been reassessed for its continued use. Refer to F690 finding 1.

Based on observation, interview, record review, and policy review, the facility failed to investigate incidents of alleged abuse and neglect for: *Three of three residents (6, 8, and 31) related to neglect and verbal abuse from certified nursing assistant/medication aide (CNA/MA) H. *One of one resident (3) related to neglect from delayed care and services. *One of one resident (95) who had a fall and passed away unexpectedly. *One of one resident (16) who had a hematoma that had resulted from a fall. *One of one resident (29) with [CONDITION(S)] from hot tea. Findings include: 1. Interview with resident 6 on 9/27/21 at 10:45 a.m. and review of resident 6's electronic medical record (EMR) revealed: *CNA/MA H had disregarded his ongoing concern regarding the temperature of his room. (Refer to F600, finding 1.) *On 7/22/21 at 8:12 a.m. by CNA/MA H when she turned on and kept his air conditioner on while she got him ready for the day despite his verbal and physical objections. *On 7/22/21 at 9:10 a.m. by director of nursing (DON) X when she spoke with resident 6 and counseled CNA/MA H about respecting resident 6's personal space as his home. 2. Interviews with two separate staff members who wished to remain anonymous on 9/28/21 at 10:15 a.m. and 3:07 p.m. respectively reported witnessing alleged verbal abuse and neglect by CNA/MA H towards one unnamed resident, resident 8, and resident 31. (Refer also to F600, finding 2). Interview on 9/29/21 at 3:46 p.m. with administrator A, business manager B, and interim director of nursing M revealed: *They were not aware of the allegations related to CNA/MA H despite the documented progress note for resident 6 and the anonymous staff member who reported witnessing alleged verbal abuse by CNA/MA H. *Grievances related to abuse and neglect need to be reported to the state. *They did not investigate these allegations but will investigate them right away. 3. Review of resident 3's interdisciplinary progress notes revealed: *On 9/12/21 at 3:47 p.m. Pt. [resident] insistent that staff and peers are her family member. Staff attempts to redirect pt, but continues. Pt noted to go into peers room, grab peers arms bilaterally and yell at them. *On 9/16/21 at 5:22 p.m. registered nurse (RN)/interim DON M documented the following: -Data: RN found patient [resident] on toilet. RN called CNA [certified nursing assistant] on that hallway to come to the patient's room. The patient was found sleeping against the wall still hooked up to the EZ stand. DON [director of nursing] called to patient's room. Pt's [resident] buttocks was bright red/purple. DON and RN got patient off of the toilet and into the wheelchair to go to supper. Expected time that resident was left on toilet in EZ stand was 20-25 min. [[minutes]. -Action: Pt was taken off toilet via RN and DON. Both nurses aides were called to the room to tell their side of the situation. -Response: DON followed up with both nurses aides. *On 9/18/21 at 7:39 a.m. Pt is noted to approach peers and staff by the hands/arm and note [not] letting go. Staff attempts to intervene, pt becomes agitated and refused to release grip on peer. Pt states she is healing peer. Pt given therapeutic toy cat to hold. Pt in dining room, again grabbing at peers, hold their hands/arms and stopping them from eating. Gripping them firmly. *On 9/19/21 at 5:30 p.m. Pt is grabbing peers with her hands aggressively and not letting go, stating they are her family members. Staff physically having to remove pt hands from hurting peers. Peers are becoming agitated with pt having poor personal boundaries. *On 9/21/21 at 7:46 a.m. Resident seen going up to other residents and grabbing their arms, resident brought to nurses station, given a baby doll, resident doing better, will continue to monitor. *On 9/25/21 at 6:00 p.m. Resident was wheeling herself around dining room and near nurses station and was grabbing at other residents legs, arms. Interview on 9/28/21 at 3:30 p.m. with interim DON M revealed: *She had been the RN who had found resident 3 on the toilet. *The other nurse was licensed practical nurse N, who had just started her shift. *The two CNAs were CNA O and CNA P. *She agreed CNAs O and P had neglected to assist resident 3 off of the toilet in a timely manner. *She had not completed any other investigation or documentation of this incident. *She was aware of resident 3's behaviors of grabbing other residents. -A recent reduction in her anti-psychotic medication had occurred and those behaviors started. -There had been no incident reports to indicate who the other residents were and if they had been injured physically or emotionally, family notifications, and physician notifications. 4. Interview on 9/28/21 at 3:45 p.m. with administrator A, business manager B and interim DON M revealed: *They agreed the incidents involving residents 95, 16, and 29 needed to be investigated and should have been investigated. (Refer to F600, findings 5, 6, and 7.) *They had been unable to provide surveyors with documentation related to the investigations.

Based on observation, interview, record review, and policy review, the facility failed to ensure: *Three of three residents (6, 8, and 31) had been free from neglect and verbal abuse from certified nursing assistant/medication aide (CNA/MA) H. *Two of two residents (3 and 41) were free from neglect related to delayed care and services. *Facility interventions related to an unexpected death of resident (95) were followed. *One of one resident (16) with a hematoma which had resulted from a fall. *One of one resident (29) was free from [CONDITION(S)] related to hot tea. Findings include: 1. Interview with resident 6 on 9/27/21 at 10:45 a.m. revealed he had concerns about his room being too cold at night and nothing had been done to fix it. (Refer also to F585, finding 2.) Review of resident 6's electronic medical record (EMR) revealed: *He had reported his concern and it had been documented as behavior notes: *On 9/23/20 at 10:18 a.m. by registered nurse Y: -CNA/MA H responded to the resident's call light. -The resident shouted, 'It's freezing in my room and I haven't been able to get any sleep.' -CNA/MA H told the resident she would get him a blanket and let maintenance know that room is cold. *On 7/22/21 at 8:12 a.m. by CNA/MA H: -Went into the resident's room to get him up and dressed. -Turned on the air conditioner because it was so hot in there. -Resident 6 called the aid a [OBSCENITY] for turning his air on. -CNA/MA H told resident she will turn it off in a [minute] that we need to finish getting ready. -The resident stood up and swung at CNA and kept calling her a [OBSCENITY] . -The resident then shoved CNA out of the way and punched her to get to the [air conditioner]. *On 7/22/21 at 9:10 a.m. by the director of nursing (DON) X: -Resident 6 said to DON, 'This is my house. They can't do whatever they want.' -Discussed with CNA/MA H and reminded this is the resident's home. 2. Interview on [date and time withheld due to anonymity] with a staff member who wished to remain anonymous reported: *CNA/MA H is mean to residents. *The staff member heard CNA/MA H tell a resident to go in his pants because she was not going to toilet him again. *The staff member reported the concerns to management and they replied that she is too reliable to reprimand or let go. Interview on [date and time withheld due to anonymity] with another staff member who wished to remain anonymous reported witnessing two specific incidents: * Resident 8's call light was on. -CNA/MA H said, I'm not going back in there; I just took her to the bathroom. -The staff member reminded her that resident 8 was just diagnosed with a urinary infection resulting in the need for more frequent and urgent toileting. -CNA/MA H was observed to walk away and not take care of resident 8. *Resident 31's wife called the staff member while the resident was in the room waiting for someone to respond to his call light. -The staff member observed that no other call lights were on at the time and all the CNAs were at the nurses station. -CNA/MA H was heard saying, I'll will be there when I can be there. -As CNA/MA H walked out of the room, after taking care of resident 31, she said, Please and thank you would be appreciated. -When resident 31's light came on again, CNA/MA H entered the room, turned off the call light, and said, I just took care of you. -The staff member explained that the resident was having problems with loose bowel movements at the time. Surveyor : Review of CNA/MA H's employee file revealed she had instances of written warnings in the past regarding residents and her behavior with them. Surveyor : Interview on 9/29/21 at 3:46 p.m. with administrator A, business manager B, and interim DON M revealed: *They were not aware of the allegations related to CNA/MA H. *Administrator B said the allegations would be neglect. *All staff are mandatory reporters when a grievance involves abuse or neglect. *Grievances related to abuse and neglect need to be reported to the state. *They will investigate the allegations right away. Surveyor : Interview on [date and time withheld due to anonymity] with anonymous staff member revealed: *CNA/MA H would turn on residents' air conditioners. *Residents would complain that they were cold or want them turned off. *CNA/MA H would refuse to take care of the residents or help them unless she was comfortable. *This allegation coincided with CNA/MA H's documentation in finding 1. 3. Review of resident 3's interdisciplinary progress notes revealed: *On 9/12/21 at 3:47 p.m. Pt. [resident] insistent that staff and peers are her family member. Staff attempts to redirect pt, but continues. Pt noted to go into peers room, grab peers arms bilaterally and yell at them. *On 9/16/21 at 5:22 p.m. registered nurse (RN)/interim director of nursing (DON) M documented the following: -Data: RN found patient [resident] on toilet. RN called CNA [certified nursing assistant] on that hallway to come to the patient's room. The patient was found sleeping against the wall still hooked up to the EZ stand. DON [director of nursing] called to patient's room. Pt's [resident] buttocks was bright red/purple. DON and RN got patient off of the toilet and into the wheelchair to go to supper. Expected time that resident was left on toilet in EZ stand was 20-25 min. [[minutes]. -Action: Pt was taken off toilet via RN and DON. Both nurses aides were called to the room to tell their side of the situation. -Response: DON followed up with both nurses aides. *On 9/18/21 at 7:39 a.m. Pt is noted to approach peers and staff by the hands/arm and note [not] letting go. Staff attempts to intervene, pt becomes agitated and refused to release grip on peer. Pt states she is healing peer. Pt given therapeutic toy cat to hold. Pt in dining room, again grabbing at peers, hold their hands/arms and stopping them from eating. Gripping them firmly. *On 9/19/21 at 5:30 p.m. Pt is grabbing peers with her hands aggressively and not letting go, stating they are her family members. Staff physically having to remove pt hands from hurting peers. Peers are becoming agitated with pt having poor personal boundaries. *On 9/21/21 at 7:46 a.m. Resident seen going up to other residents and grabbing their arms, resident brought to nurses station, given a baby doll, resident doing better, will continue to monitor. *On 9/25/21 at 6:00 p.m. Resident was wheeling herself around dining room and near nurses station and was grabbing at other residents legs, arms. Interview on 9/28/21 at 3:30 p.m. with interim DON M revealed: *She had been the RN who had found resident 3 on the toilet. *The other nurse was licensed practical nurse N, who had just started her shift. *The two CNAs were CNA O and CNA P. *She agreed CNAs O and P had neglected to assist resident 3 off the toilet in a timely manner. *She had not completed any other investigation or documentation of this incident. *She was aware of resident 3's behaviors of grabbing other residents. -A recent reduction in her anti-psychotic medication had occurred and those behaviors started. -There had been no incident reports to indicate who the other residents were if they had been injured physically or emotionally, family notifications, and physician notifications. 4. Observation on 9/27/21 at 10:18 a.m. of resident 41 revealed: *She had been in her room seated in her recliner. *Her eyes had been closed and appeared to be sleeping. *She was wearing a clothing protector. *There was vomit down her front chest area and on her left hand. *The call light was on the arm of the recliner next to her. *The call light had not been triggered. Interview on 9/27/21 at 10:20 a.m. with activity director (AD) S regarding resident 41 revealed: *AD S had been in the hallway near her office and next to resident 41's room and stated: -She had Alzheimer's and used a wheelchair. -She had vomited earlier and had not been feeling well. -Normally she would have been up and out of her room wandering around the facility with her wheelchair. *Refer to F690, finding 1. Observation at the following times revealed the resident in the same condition with vomit still on her: *9/27/21 at 10:43 a.m. *9/27/21 at 11:00 a.m. Observation on 9/27/21 at 11:29 a.m. of housekeeper/laundry worker Z revealed: *She had entered resident 41's room and cleaned it and exited. *Resident 41 still had vomit on her front chest area and on her hand when she left the room. 5. Review of facility reported incident regarding resident 95 revealed he had: *Been admitted to the facility 3/9/20. *Been admitted to the facility for rehabilitation. *The facility had identified that resident 95 had missed 10 doses of his [MEDICATION(S)] medication. *In a response to the incident the facility put the following in place: -A cheat sheet for ordering and reordering medications. -A physician will be notified any time a resident falls or early the next morning. -When a resident has a fall, they will be checked at least once per shift for 24 hours. -An audit of medication fill times will be reported to quality assurance preformance improvement (QAPI) committee for three months. -Medication error will be reported at QAPI in May 2020. -Education was provided to medication aides involved, including CNA/MA H. *Refer to F865, finding 1. Review of resident 95's EMR revealed: *He had experienced three falls during his short stay at the facility. *On 4/11/20 he had a fall with a note stating: -At 0105 [1:05 a.m.] Resident placed his call light on, CNA answered call light, CNA summoned Nurse/writer to the room as resident appeared to be lying on the floor next to his bed with his blankets underneath him, attends 1/2 ways down & and resident was slightly incontinent. Resident's bed appeared to be in its lowest position to the floor. Nurse/Writer asked resident if he could recall what happened. Resident stated he thinks he slid out of bed, resident denies hitting his head, no visible injuries noted with no appearance of redness or bruising at this time. Resident denies hitting his head. Resident reports soreness to his left hip rating pain at 4 . *Vital signs were checked at that time. *At 9:59 a.m. he was noted to be: - .Resident increasingly tired and pale, complaining of chills. *The next note at 6:00 p.m. stated: -Nurse called to resident's room. Resident is sitting in his wheelchair hunched over unresponsive to staff. Face purple. Resident was placed in bed and Nurse listened for lung sounds and heart sounds. None present. 1750[5:50 p.m.] family notified. On-Call doctor notified will be calling back. *His physician had not been notified of the fall. *His family had not been notified of the fall. *Follow-up vitals had not been completed, even when he was noted to be pale. 6. Observation and interview on 9/27/21 at 7:47 a.m. with interim DON M and resident 16 revealed: *DON M was doing a dressing change to resident 16's head. *Resident 16 had fallen a couple of weeks ago and had a large hematoma on the back of her head. *The hematoma had split open a couple of days ago. *Resident 16 had to go to the emergency department (ED) to get stitches to close the hematoma. Review of resident 16's EMR revealed: *She had been admitted to hospice in June of 2021. *On 9/1/21: -Head pain d/t [due to] fall/'goose egg'. *On 9/2/21: - .Hematoma noted to left back of head . *On 9/3/21: -Post fall. Resident fell ,d+[DATE]. Has an abrasion to the back of the head . *On 9/8/21: - .Bruising noted on neck and head from previous fall *On 9/8/21 the minimum data set (MDS) nurse and charge nurse evaluated resident from the fall she had on 9/1/21. *That documentation stated: -MDS nurse and charge nurse evaluated resident at this time post fall, resident continues to present with large hematoma on the left back of [NAME] [sp] with bruising going from the back of her neck down to the left front shoulder, resident also has a bruise on her left buttock and a bruise on her right buttock . *It was not until 9/8/21 of documentation that the family had been notified. *On 9/9/21 there had been documentation that the Physician had been updated. *On 9/25/21 she was transferred to the ED because resident 16 was noted to have bloody Kleenex in her hands. The nurse's observations stated: - .upon observation of the back of resident's left side of head; noticed that the skin to her hematoma was not intact and was an opened area measuring 2.5 inches by 2.2 inches. Resident had a fall on 9/8 that left behind this hematoma . *There had been inconsistancies on the date in which the fall occurred. *There had been no investigation of this fall. *There had been no report submitted to the South Dakota Department of Health regarding this fall. 7. Review of resident 29's EMR revealed: *She had received [CONDITION(S)] on her inner thighs in June of 2021. *On 6/8/21: -Resident grabbed another residents Hot Tea from the table and spilt it [spilled] between her legs, back of left leg is red, no blistering noted at this time, lotion applied. Nursing will continue to monitor. *On 6/10/21: -Follow up to her burn. She had three blisters, one intact and two had opened. *On 6/12/21: -Documentation of a large intact blister. *On 6/13/21: -The area was reddened/ pink, with no intact blisters. *There had been no documentation that the Physician had been notified or her family.

Based on observation, interview, record review, and policy review, for two of two residents (3 and 4) with facility-acquired pressure ulcers the provider failed to: *Develop a comprehensive preventative skin program. *Identify and document pressure ulcer stage and size. *Update the care plan to include interventions. Findings include: Surveyor: 1. Interview and observation on 9/26/21 at 11:21 a.m. with resident 4 revealed he: *Was seated in a wheelchair in his room. *Had a gauze dressing on his left foot. *Was not wearing boot protectors. *Stated he had blisters on his left foot. *Had the sores since a fall in June when he broke his left leg. Surveyor: Observation and interview on 9/27/21 at 10:57 a.m. with interim DON M while completing a dressing change for resident 4 revealed: *There were two open wounds on the left lateral side of his foot. *There had been a pressure ulcer wound on his left backside of his heel. -The wound was in the spot where his heel made contact when the recliner. *Surveyor asked what stage the interim DON would stage the wounds at. *She stated the two on his left lateral side were both stage four wounds. *The pressure on his heel would be a stage III pressure ulcer. Surveyor: Observation and interview on 9/27/21 at 11:36 a.m. with resident 4 revealed he: *Had not been wearing his boot protectors. *Had been seated in his recliner. *Was not sure where his boot protectors were. *Thought the staff had forgotten to put them back on him after he had his dressing change and physical therapy. *Knew he was to always wear the protectors. Observation on 9/28/21 at 10:45 a.m. of resident 4 revealed: *He was in his room seated in his recliner with his feet elevated and without boot protectors. Review of resident 4's electronic medical record (EMR) revealed: *A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *He had a brief interview for mental status (BIMS) score of 15 which indicated he was cognitively intact. *He fell and broke his left tibia on 6/17/21, was hospitalized , and had surgery to repair it and returned to the facility on [DATE]. Review of resident 4's 6/25/21 re-admission assessments revealed: *A re-admission skin observation tool had identified an open left heel blister 3.5 centimeters (cm) x 3 cm. *A nursing admission screening history revealed a left heel blister with no measurements completed. -Those assessments had been completed by two different staff. Review of resident 4's Braden Scale assessments for predicting pressure sore risk revealed: *His 3/15/21 quarterly assessment: he had a score of 21 that indicated he was at no risk for pressure ulcers. *His 6/9/21 quarterly assessment: he had a score of 20 that indicated he was at no risk for pressure ulcers. *His 6/25/21 re-admission assessment and 9/21/21 quarterly assessment: he had a score of 17 that indicated he was at risk for pressure ulcers. -The score changed due to his being chairfast, having extremely limited mobility and a potential problem with friction and shearing. Further review of resident 4's EMR revealed: *A 7/2/21 fax that stated: -Open blister to back of left heel, superficial. May we have the following order: Left heel cleanse and apply Opti foam daily and prn [as needed]. *A 7/29/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident 4's weekly wound assessments revealed: *There had been three wound assessments completed on each of the following days, one for each pressure ulcer. *On 7/29/21: -A stage two heel ulcer measured 35 millimeters (mms) x 24 mms with a depth of 1 mm. -A stage two upper lateral pressure ulcer measured 18 mms x 17 mms with a depth of 5 mms. -A stage two lower lateral pressure ulcer measured 10 mms x 10 mms with a depth of 2 mms. -Special preventative measures/equipment: alternating air mattress, a pressure relief cushion in chair, Prevalon boots to both feet. -No inflammation was noted. *On 8/12/21: -A stage two heel ulcer measured 20 mms x 28 mms with a depth of 3 mms. -A stage two upper lateral pressure ulcer measured 15 mms x 20 mms with a depth of 1 mm. -A stage two lower lateral pressure ulcer measured 20 mms x 25 mms with a depth of 3 mms. -Special preventative measures/equipment: Intermittent pressure exchange air mattress, Prevalon boots, heel cradle. -No inflammation was noted. *On 8/24/21: -A stage two heel ulcer measured 20 mms x 25 mms with a depth of 3 mms. -A stage two upper lateral pressure ulcer measured 20 mms by 25 mms with a depth of 3 mms. -A stage two lower lateral pressure ulcer measured 20 mms x 14 mms with a depth of 3 mms. -Special preventative measures/equipment: No changes from the previous assessment. -No inflammation or symptoms of infection were noted. *After the initial wound on his heel had been discovered, the initial wound assessment was not completed for another 27 days. -This was after wound care had identified the two additional sores on his left lateral foot. Review of resident 4's September 2021 treatment administration record (TAR) revealed: *Missing documentation on 9/9/21 of Endoform and [MEDICATION(S)] placement one time a day every other day for left heel wound. *Missing documentation on 9/9/21 and 9/15/21 for triad paste, gauze and kerlix daily for left later foot ulcers. Review of resident 4's revised 9/23/21 care plan revealed: *His care plan had not been revised to include: -The two additional lateral pressure ulcers he had developed. -His boot protectors were to be worn at all times. -Any changes with his wounds. *His care plan stated: -Wounds were to be documented weekly which were to include: -Measurement of each area. -Breakdown's width. -Length. -Depth. -Type of tissue and exudate. -Any other notable changes or observations. *They had missed a total of 10 weeks of wound assessments. Interview on 9/28/21 at 2:30 p.m. with interim DON M revealed: *She was familiar with resident 4. *Wound assessments were to be completed weekly for his pressure ulcers. *He had been going to the wound clinic weekly for the care of his pressure ulcers. *He was to wear boot protectors at all times. *She had not been aware he was observed not wearing them. *Confirmed there had been no further wound assessments completed since 8/24/21. *She would expect them to be done and for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor: 2. Review of resident 3's medical record revealed: *On 6/4/21 documentation on the provider's skin observation tool revealed Resident skin clear and intact, no skin issues noted at this time. *A 7/1/21 at 9:10 a.m. skin/wound note Resident in bath today and skin assessment completed. Right outer ankle has stage 2 pressure wound. Cleansed and dressed with [MEDICATION(S)]. Nursing order for Prevalon boots at HS {hour of sleep]. *A 7/1/21 facsimile to resident 3's physician. Today I noted a stage 2 pressure ulcer to [resident] R [right] outer ankle lateral malleolus. OK for dressings daily & PRN [as needed] til [until] healed? Prevalon padded booties on @ HS [hour of sleep] for padding & protection bilat. [bilateral]? *A 7/2/21 at 12:19 p.m. skin/wound note Dressing change to PU [pressure ulcer] of the R outer ankle; redness-scant drainage on the old dressing. Area cleansed and new [MEDICATION(S)] applied. *A 7/8/21 at 2:19 p.m. skin/wound note Skin assessed during bath, no new skin issues noted at this time, dressing change to R out ankle. *A 7/15/21 at 1:45 p.m. skin/wound note Skin assessed during shower, R ankle continues to be dressed per TAR [treatment administration record] for protection, see TAR [treatment administration record], tops of toes continue to be red, res [resident] has not complaints at this time, no other new skin issues noted at this time. *A 7/19/21 facsimile to resident 3's physician. [Resident] R [right] lateral ankle wound is resolved. May we discontinue dressing change? *A 7/29/21 at 1:54 p.m. skin/wound note Skin assessed during residents shower. Resident has healed are to right ankle, area is pink, boney prominence, but no concerns at that time. No new skin issues. *An 8/5/21 at 10:20 a.m. skin/wound note Skin assessed during shower, resident continues to have reddened R outer ankle, not new skin issues noted at this time. *An 8/12/21 at 10:19 a.m. skin/wound note Resident skin assessed during shower. R outer ankle continues to be reddened on the bony prominence, denies pain, resident does wear prevalon boots at HS, will continue to monitor. *A 9/2/21 at 6:29 p.m. skin/wound note Skin is clean/dry/intact with no new open areas or bruising noted. *A 9/9/21 at 8:54 a.m. skin/wound note [MEDICATION(S)] intact to right ankle. No new skin issues notes [[noted]. *A 9/11/21 at 3:14 p.m. health status note included: Pt. [resident] refused to let RN [registered nurse] change dressing to R outer ankle. Pt did allow dsg [dressing] to be changed later in the afternoon. *A 9/16/21 at 1:29 p.m. skin/wound note included no new skin issues noted. *There had been no measurements when the pressure ulcer had been discovered and subsequently. *The dietician had not been made aware of the pressure ulcer. She had listed resident 3's skin as being intact on her 7/1/21 and 9/20/21 nutrition progress note. Review of resident 3's TARs revealed: *July 2021: -Daily and prn dressing change to lateral right ankle for stage two pressure ulcer. This treatment was started on 7/1/21 and was discontinued on 7/19/21. -Prevalon boots on at HS both feet for stage two pressure ulcer right ankle. This was started on 7/1/21. *August 2021: --Prevalon boots on at HS both feet for stage two pressure ulcer right ankle. *September 2021: -Apply corn cushion to outer right ankle for protection. This was started on 9/1/21 and discontinued on 9/8/21. -Apply [MEDICATION(S)] to right outer ankle every 3 days for protection. This was started on 9/9/21. Review of resident 3's revised 1/18/21 care plan revealed: *Focus: [Resident] has a potential for impaired skin integrity r/t [related to] Impaired Mobility, Impaired Cognition, Incontinence. *Goal: [Resident] will have intact skin through review date. *Interventions included: -[Resident] has a pressure redistributing mattress on her bed. -[Resident] has a pressure relief cushion in her chair. -Monitor/document/report PRN any changes in skin status. -Weekly skin inspection by licensed staff. Daily sin inspections with cares. *The care plan was reviewed for any changes or cancelled items. *Resident 3's stage two pressure ulcer to her right outer ankle had not been included. *Her use of the Prevalon boots on at HS had not been included. Interview on 9/28/21 at 3:30 p.m. with the interim director of nursing (DON) M revealed she: *Had not reviewed any of the residents skin documentation to ensure all preventative, ongoing wound assessments, care plan updates, and documentation had been completed. Review of the provider's undated Wound Care policy revealed: *Guidelines for the care of wounds to promote healing. *How to perform a wound care dressing change. *Documentation including: -The type of wound care performed. -Any change in the resident's condition. -All assessment data obtained when inspecting the wound. Wound bed color, size, and drainage. *The provider did not have any preventative skin policy.

Based on observation, record review, interview, and policy review, the provider failed to ensure: *Interventions were followed to prevent recurrent urinary tract infections for two of two sampled residents (6 and 9) who had an indwelling Foley catheter (tube inserted into the bladder to drain urine). *One of two sampled residents (6) had a medical [DIAGNOSES REDACTED]. Findings include: 1. Review of resident 9's 6/24/15 physician's orders [REDACTED].>*Change Foley catheter once a month. *Push fluid every shift for urinary tract infection. Review of resident 9's 4/14/15 through 7/7/15 nursing progress notes revealed he: *Had a Foley catheter inserted on 4/14/15 related to urine retention (unable to urinate or empty bladder). The catheter was removed on 4/21/15, 5/6/15, and on 5/11/15 and was re-inserted immediately each time as he was unable to void. *Was on an antibiotic for a urinary tract infection on 4/14/15 for ten days, 6/18/15 for ten days, and on 7/1/15 for seven days. *Had been encouraged to drink fluids (there was no documentation regarding what amount had been encouraged and how much he had accepted). Review of resident 9's 4/20/15 updated and revised care plan had no documentation related to the use of the Foley catheter. There was no documentation related to the recurrent urinary tract infections or to push fluids. Observation on 7/8/15 at 12:00 noon of certified nursing assistant (CNA) J assisting resident 9 with Foley catheter care revealed: *She washed her hands in the resident's bathroom and put on gloves. *She transferred him from his wheelchair into the bed with the use of a stand-aide (mechanical lift that required the resident to be able to bear weight on his legs). *She washed her hands in the resident's sink and put on a new pair of gloves. *She obtained a washbasin from the resident's bathroom and filled it with water and a few drops of soap. *She pulled his foreskin (covering over penis) back. There was a large amount of white film under the penis with the skin being red under the foreskin. Both inner groins were reddened. *The resident verbalized discomfort several times while she was washing around and under the foreskin with a washcloth and drying the areas with a hand towel. *She washed her hands in the resident's bathroom while wearing the gloves she had used to wash his foreskin and penis. *She took the plastic container to empty his Foley catheter drainage bag. She did not use anything to wipe the tip of the drain tube when she unclamped it to empty the urine from tube into the container, or when she reconnected the end back to the catheter tubing. *She adjusted the height of the bed with the control on the head board and put his call light that was on the easy chair over to him. She continued to wear the same gloves she had used to provide the Foley catheter care and to empty the urine from his drainage bag. *She went into the resident's bathroom and removed one glove. She emptied the urine container into the toilet with her ungloved hand and flushed the toilet with the gloved hand. *She removed both gloves in the resident's bathroom and washed her hands. Interview on 7/8/15 at 12:15 p.m. with CNA J regarding the above observation revealed: *I guess I should have changed my gloves. *Foley catheter care was usually done when a resident was gotten up for the day and at bedtime. *CNA K had gotten him ready for the day. She had not said anything to her about the resident being red and having discomfort under his foreskin and in the groins. *She would inform the nurse of the resident's redness as she knew there was a special powder that could be used. Interview on 7/8/15 at 12:30 p.m. with CNA K regarding resident 9's morning Foley catheter care revealed she: *Had done Foley catheter care on him that morning when she got him dressed for the day. *Had noticed some redness under the foreskin and in the groin areas more pinkish. *Had put baby powder around the foreskin and in the groins. *Did not feel he was uncomfortable when she was washing and drying the areas. *Should have let the nurse on duty know about the redness in the areas. Interview on 7/8/15 at 12:50 p.m. with registered nurse L regarding resident 9 revealed: *She was not aware of the redness and irritation around his foreskin and groin areas. *CNA K should have informed her when she had gotten him up in the morning. *CNA J had informed her, and she had put some [MEDICATION NAME] (antifungal powder) powder on the areas. Interview on 7/8/15 at 3:00 p.m. with the dietary manager regarding resident 9's fluid intake revealed: *They tried to offer him at least 360 mililiters (ml) daily with meals. *She was unsure how much nursing offered him inbetween meals and if that fluid intake was documented anywhere. *According to his March 2015 through July 2015 dietary fluid intake records he usually accepted 80 ml to 180 ml each meal. Interview on 7/14/15 at 4:30 p.m. with the director of nursing regarding resident 9's Foley catheter care observation revealed: *CNA J should have removed her gloves and washed her hands after providing catheter care. She should not have washed her hands with her gloves on. *CNA K should have informed the nurse of his foreskin redness and groin irritation when she had assisted him with catheter care in the morning. *The physician's orders [REDACTED]. *They did not record any fluid intake that nursing offered him inbetween meals. *They were unable to state on any given day how much fluid intake he was offered, and how much fluid intake he accepted. Review of the providr's undated Serving of Drinking Water policy revealed: *Purpose is to encourage an adequate fluid intake. *Record amount taken on intake record if required. *Encourage fluid intake. 2. Interview on 7/9/15 at 10:40 a.m. with resident 6 regarding catheter care revealed: *Catheter care was not completed every shift. *The CNAs (certified nursing assistants) do catheter care after I have a bowel movement. I have a bowel movement every two or three days. I will have them call you if they do it while you are here. *Certified nursing assistants (CNA) B and C entered the room and were asked to notify the surveyor when they were going to do any cares for resident 6. -There had been no call to the resident's room to observe cares provided during the remainder of the survey. Interview and review of resident 6' medical record on 7/13/15 at 3:20 p.m. with the director of nursing (DON) revealed: *The resident had an indwelling Foley catheter. *She had two urinary track infections [MEDICAL CONDITION] within the last six months. -Those were on 1/8/15 and 4/22/15. *There was a 1/9/15 physician's orders [REDACTED]. *The catheter was found pulled out on 6/4/15 with no documentation how it had happened. *The order to replace the catheter monthly was discontinued on 6/6/15. *The catheter was replaced on 6/14/15. -There was no documentation clarifying if the catheter should be replaced monthly or not following its re-insertion. *The 4/21/15 care plan documented the Foley catheter was in place to promote skin healing and integrity. - Catheter care was not documented on the care plan. *DON stated catheter care was to have been done each shift by the CNAs. *The DON had no comment concerning the resident's interview that stated catheter care was not done each shift but only after a bowel movement. *Catheter care was checked as completed in the electronic medical record on each of the three shifts since 6/30/15. *No medical [DIAGNOSES REDACTED]. *The DON agreed there was no medical [DIAGNOSES REDACTED]. Surveyor Review of the provider's 6/3/15 Catheter Care, Indwelling Catheter policy revealed: *Purpose is to prevent infection and reduce irritation.*Assessment guidelines may include, but are not limited to: -Color, consistency, and amount of urine. -Condition of skin at site of insertion. -Pain, burning, discomfort. -Level of activity. -Nutritional intake. -Hydration and fluid balance status. *Hand washing remains the single most important step in preventing the spread of infection. *Enter the catheter care as an approach under the appropriate underlying problem on the resident's care plan. *Identifying the underlying problem will assist the nursing staff to develop an individualized care plan. B. Based on interview, record review, and policy review, the provider failed to have an individualized toileting program for three of three sampled residents (3, 5, and 12). Findings include: 1. Review of resident 3's 4/28/15 Minimum Data Set (MDS) assessment revealed he was on a toileting program. Review of resident 3's 9/19/14 care plan with a hand written reviewed and updated date of 6/2/15 revealed: *Staff will assist him to the bathroom upon rising, before and after meals, before bed, every 2-3 hours through the night, and PRN (as needed). Review of resident 3's medical records revealed: *An assessment had not been done to determine when he needed to use the bathroom. *There was not an individualized toileting program. 2. Review of resident 5's 2/11/15 annual and 5/7/15 quarterly MDS assessment revealed he was on a toileting program without improvement. Review of resident 5's 8/30/14 care plan revealed the same toileting program as for resident 3. Review of resident 5's medical records revealed: *An assessment had not been done to determine when he needed to use the bathroom. *There was not an individualized toileting program. 3. Review of resident 12's 4/20/15 initial MDS assessment revealed she was on a toileting program. Review of resident 12's 4/30/15 care plan revealed the same toileting program as the above other two residents. Review of resident 12's medical records revealed: *An assessment had not been done to determine when she needed to use the bathroom. *There was not an individualized toileting program. Surveyor: Interview on 7/8/15 at 9:20 a.m. with the Minimum Data Set (MDS) assessment coordinator revealed: *She oversaw the restorative program which included the bowel and bladder toileting program. *They had not completed individualized resident bowel and bladder assessments to determine resident needs. *The resident toileting programs had not been individualized. Surveyor: Review of the provider's undated Bladder Management Program revealed: *Assessment guidelines to include: -A three day bowel and bladder study upon admission to determine continence (ability to hold urine or stool). -Levels of mobility and comprehension. -Type and cause of incontinence. *Intervention strategies to include: -Scheduled toileting and habit training. -Develop a toileting schedule as close to the resident's routine as possible. -Encourage the resident to continue the program until continence is achieved. -If incontinence persists identify possible causes and type of incontinence. *A scheduled toileting program should be individualized and based on a voiding diary.

Based on observation, record review, interview, and policy review, the provider failed to: *Assess, investigate, and follow interventions to prevent falls with injuries for three of six sampled residents (1, 2, and 9). *Ensure the appropriate use and placement of the lift sling straps during transfer for one of one observed resident (6). *Identify and address staff training needs for the safe and appropriate use of all facility mechanical lifts. Findings include: 1 Review of resident 9's 3/20/15 through 5/17/15 nursing progress notes revealed: *3/20/15 at 6:07 p.m., Resident was found lying on the left side on floor beside bed. Resident reports attempted to transfer self to bed from wheelchair. Resident denies any pain or discomfort and denies hitting head. There are multiple bruises to left arm and one on left side of abdomen but they all look to be old. Will continue to monitor. *5/5/15 at 4:57 p.m., Resident found on the floor at 4:40 p.m. Per certified nursing assistant (CNA) resident had a visitor and had been left alone in his room with the door closed after she left. CNA was trying to watch and see when the family left to take resident out to the dining room. Resident hit the back of his head on the right side and has a bruise/raised area. Called son and relayed above. Asked him to pass on to family not to leave the resident alone in his room. *5/17/15 at 9:50 a.m., Resident was found sitting on floor beside his bed. Resident reports attempting to transfer self from wheelchair to bed. No injury noted and resident denies hitting head or any pain. Will continue to monitor. Review of resident 9's 3/20/15 through 5/17/15 Fall Investigation Worksheets revealed: *3/20/15, After supper resident wheeled self back to room and attempted to self transfer to bed from wheelchair. -Resident did not call for assist. -Cause of fall was weakness. -Fall unwitnessed. -Care plan updated was left blank. *5/5/15, Trying to put himself to bed. -Cause of fall was weakness. -Did resident call for help or call light within reach was left blank. -Fall unwitnessed. -Care plan updated was checked yes. *5/17/15, Transfer from wheelchair to bed. -Resident did not call for assist. -Cause of fall was weakness. -Fall unwitnessed. -Care plan updated was checked yes. Review of resident 9's 4/20/15 reviewed and updated care plan revealed: *At risk for falls. *Interventions will be utilized to reduce the risk of falls. *Has severe cognitive (memory) impairment. *Decreased safety awareness, impaired gait (walking), and weakness putting him at risk for falls. *He wears a personal alarm to alert staff when he tries to transfer self as he does not always remember to ask for assistance. *There was no documentation regarding his recent falls or any interventions to not leave him unattended in his room in his wheelchair. Interview on 7/14/15 at 9:45 a.m. with the director of nursing regarding resident 9 revealed: *She confirmed there was no documentation on his care plan regarding the above three falls when he was attempting to transfer himself from his wheelchair to bed. *He no longer had a personal alarm on. They had discontinued all the TABs (alarm attached to resident that would sound when a resident attempted to transfer self) in June 2015. *He was not able to use the call light or consistently verbalize his needs to the staff due to his severe memory impairment. 2. Review of resident 2's 6/9/15 fall investigation worksheet and nursing progress note revealed: *He was agitated and yelling out after his wife left at approximately 1:15 p.m. *Staff transferred the resident to bed at 1:25 p.m. and left the room. *He was found on floor beside his bed at 1:35 p.m. -Had hit his forehead on the bedside stand. -Physician was contacted with results of the vitals (blood pressure, heart rate, breaths per minute, respirations, and temperature) and neurological (hand grasps, memory, pain, and the size of pupils in the eyes)assessment. No new orders were obtained. *A fall scene (looks at the fall in detail) investigation report was initiated by staff. -The cause was determined to be agitation following a family member leaving. -Proposed intervention was to call the physician to schedule Haldol (a mood and behavior altering medication) around the lunch hour when the family was present. -No non-pharmacological interventions were documented or appear to have been implemented. Review of resident 2's 6/30/15 reviewed and updated care plan revealed: *Increased risk for falls, personal alarm to alert staff when he gets up. *No changes had been made to the care plan following the 6/9/15 fall. Interview on 7/8/15 at 8:15 a.m. with the director of nursing (DON) and social worker regarding resident 2 revealed: *They had discontinued the use of personal alarms (alarm attached to residents' body that would go off when the resident attempted to self transfer) in June 2015 for all residents. *They had not documented any non-homological interventions other than administering the Haldol to relieve his mental distress. *They were unable to provide the rationale for the resident being left alone and unattended during a period of increased agitation. *There was no documentation regarding additional investigation and interventions that had been put into place to prevent future falls. Review of resident 2's 6/9/15 medication administration record revealed Haldol was administered at 4:57 p.m. for yelling out and agitation. There was documentation at 7:38 p.m. the Haldol had been effective. 3. Review of resident 1's medical record revealed: *On 9/20/14 he had an unwitnessed fall with no injury. *He had been walking to the bathroom and lost his balance. *Interventions marked on the fall short term care plan were: -Monitor and report changes in anxiety, sleep patterns, behaviors, or mood. -Assess blood sugar fluctuations. -Promote adequate hydration. -Increase staff assistance. -Monitor and remind resident appropriate use of assistive devices, keep within easy reach. -Call light within reach and secured. *On 10/14/14 he had an unwitnessed fall with no injury. -He had been sitting in his recliner and went to stand up. -He had not been wearing gripper socks. *Interventions marked on the fall short term care plan were: -Appropriate footwear. -Non slip mat to wheelchair. *On 10/31/14 he had an unwitnessed fall with minor injury. -He had slid out of his recliner. -He had not been wearing gripper socks. *Interventions marked on the fall short term care plan were: -Pain Management. -Assess blood sugar fluctuations. -Promote adequate hydration. -Keep bed in lowest position while in bed. -Clear path to the bathroom. -Call light within reach and secured. -Appropriate footwear. *On 12/18/14 he had an witnessed fall with no injury. -He had attempted to get up from his wheelchair and lost his balance. *Interventions marked on the fall short term care plan were: -Assess blood sugar fluctuations. -Promote adequate hydration. -Low vision precautions. -Corrective lenses. -Increase staff assistance. -Increased bathroom safety. -Promote wheelchair safety. -Check brakes and instruct patient on use. -Monitor and remind resident appropriate use of assistive devices, keep within easy reach. -Remind, monitor residents ability to maneuver change in flooring. -Clear path to the bathroom. -Call light within reach and secured. -Appropriate footwear. -Increase assistance or surveillance. -Frequent rest periods. -Increase activity involvement. *On 1/25/15 he had an unwitnessed fall with major injury. -He had been found on floor. *Interventions marked on the fall short term care plan were: -Low vision precautions. -Clear path to the bathroom. -Call light within reach and secured. -Increase assistance or surveillance. *On 2/15/15 he had an witnessed fall with no injury. -He went to stand up out of his wheelchair and lost his balance. *Interventions marked on the fall short term care plan were: -Pain Management. -Promote adequate hydration. -Low vision precautions. -Corrective lenses. -Increase staff assistance. -Increased bathroom safety. -Check brakes and instruct patient on use. -Monitor and remind resident appropriate use of assistive devices, keep within easy reach. -Remind, monitor residents ability to maneuver change in flooring. -Clear path to the bathroom. -Call light within reach and secured. -Toileting schedule. -Appropriate footwear. -Increase assistance or surveillance. -Frequent rest periods. -Increase activity involvement. *On 3/24/15 he had an witnessed fall with major injury. -He stood up from table in dining room and lost his balance. *Interventions marked on the fall short term care plan were: -Assess blood sugar fluctuations. -Promote adequate hydration. -Increase staff assistance. -Monitor and remind resident appropriate use of assistive devices, keep within easy reach. -Increase activity involvement. *On 5/16/15 he had an witnessed fall with no injury. -He had been sitting in his wheelchair and got up to sit in recliner, and he lost his balance. *Interventions marked on the fall short term care plan were: -Assess blood sugar fluctuations. -Increase staff assistance. -Promote wheelchair safety. -Check brakes and instruct patient on use. -Monitor and remind resident appropriate use of assistive devices, keep within easy reach. -Call light within reach and secured. -Restorative program. -Assess for PT/OT (physical therapy/occupational therapy) possibility. -Increase assistance or surveillance. -Personal or pressure change alarm. -Increase activity involvement. *None of the above interventions had been transferred to the care plan. *There was no documentation the above falls had been investigated thoroughly. *There was no documentation the interventions had been monitored to determine if they had been effective. Review of resident 1's 4/8/15 care plan revealed he was at an Increased risk for falls d/t (due to) antidepressant medication use, and decreased safety awareness. Staff to assist with transfers and toileting. Review of resident 1's 6/20/14 admission Minimum Data Set (MDS) assessment revealed he required limited assistance of one staff person to transfer from one place to another and to walk. Interview on 7/7/15 at 3:15 p.m. with the DON revealed the fall interventions should have been included on the care plan. The investigations had not been completed thoroughly. There was no documentation to support the interventions had been monitored for their effectiveness. 4. Review of the provider's 6/4/15 fall policy revealed: *The resident care plan should have been revised and updated. *The fall scene investigation report should have been completed. *All incidents were reviewed by the DON and administrator. *The falls committee should have reviewed all falls. 5. Observation on 7/9/15 at 10:45 a.m. of certified nursing assistants (CNA) B and C using a mechanical lift (type of equipment used to move a resident from one place to another) to transfer resident 6 from a chair to her bed revealed the incorrect placement of straps on the lift sling. 6. Review of resident 6's medical record revealed resident had slid out of a mechanical lift sling due to improper placement of the sling under the resident. Refer to F 224, findings 2 and 3.

Based on record review, interview, job description review, and policy review, the governing body failed to ensure the facility was managed in a manner that: *A change in condition for 1 of 1 sampled resident (14) was appropriately assessed, treated, and documented. *Pain was addressed and managed for 1 of 1 sampled resident (7). *Interventions were followed to prevent recurrent urinary tract infections for 1 of 2 sampled residents (9) who had an indwelling Foley catheter (tube inserted into the bladder to drain urine). *There was a medical [DIAGNOSES REDACTED]. *Behavioral disturbances were identified and treated for [REDACTED]. *Ensured neglect had not occurred for 1 of 1 sampled resident (13) who needed assistance with transferring from one place to another resulting in a major injury. *Ensured neglect had not occurred for 1 of 4 sampled residents (6) who used a Hoyer lift (equipment used to transfer a resident from one place to another place) for transfers resulting in her falling out of the sling. *Ensured neglect had not occurred for 1 of 1 sampled resident (14) who used her call light to request staff assistance resulting in mental anguish when they refused to get her out of bed. *Pressure ulcers for 3 of 3 sampled residents (1, 6, and 7) were assessed and treated. *Falls with injuries for 6 of 6 sampled residents (1, 2, 5, 6, 9, and 13) were assessed, investigated, and interventions followed. *An antypsychotic medication (alters mood and behavior) for staff convenience of agitation and anxiety had not been used for 1 of 1 sampled resident (2). *An appropriate [DIAGNOSES REDACTED]. Findings include: 1. Interview on 7/14/15 at 2:00 p.m. with the governing body (consisted of one person) regarding the above issues revealed: *He felt the administration had kept him informed of any concerns with the residents. *The administrator had communicated to him verbally, and he had not documented anything down. *The administrator and the director of nursing (DON) had talked about the multiple falls they had in the facility. He had not given them any specific instructions on the falls, as they were very resident specific. *He knew they had removed all the TABs (alarm attached to the resident that would sound when the resident tried to self-transfer). He was not aware the facility had not put any interventions in place for each specific resident when they had removed the TAB alarm. *He would try and come to their quarterly Quality Assurance Performance Improvement (QAPI) meeting. He had last attended on March 18, 2015. *The administrator would usually inform him of the monthly QAPI meetings, but he did not document any of the meetings. *He usually would come to the facility more frequently whenever he had a change in administration, then would wean himself away. *He confirmed the present administrator had been at the facility for two months, and the director of nursing (DON) had been in her position since November 2014. *He had not been at the facility since the March 2015 QAPI meeting. Refer to F156, F157, F159, F166, F222, F224, F226, F241, F248, F250, F253, F280, F281, F283, F309, F311, F314, F315, F323, F329, F371, F425, F441, F456, F501, and F520.

Based on observation, record review, interview, and policy review, the provider failed to ensure one of one sampled resident (2) had not received an antypsychotic medication (alters mood and behavior) for staff convenience of agitation and anxiety. Findings include: 1. Observation on 7/7/15 of resident 2 revealed: *At 11:05 a.m. he was sitting in his wheelchair at a small table in the activity area of the dining room. -He was not doing an activity. -He was faced away from the activity group of residents for greater than ten minutes. -There was no interaction with staff or peers during that time. -He was awake, quiet, and no yelling was observed. *At 11:45 a.m. his wife was assisting him with the noon meal. -Verbal coaching was used by his wife to encourage him to eat. *At 2:45 p.m. he was in his bed and sleeping. Review of resident 2's complete medical record revealed: *A 12/6/12 admitted . *[DIAGNOSES REDACTED]. Review of resident 2's 9/17/13 through 10/4/13 behavioral health hospitalization notes revealed: *[MEDICATION NAME] (a mood and behavior altering medication) 5 milligrams (mg) as needed twice daily was initiated for agitation/anxiety/behavioral changes. * A [DIAGNOSES REDACTED]. *The provider made a recommendation to consider treating pain, as agitation might have been the resident's method for expressing pain. *Follow-up medication management was to be completed by the resident's primary care physician. Review of resident 2's 6/19/14 pharmacy consultation note revealed: *The resident had been prescribed [MEDICATION NAME] 5 mg twice daily as needed. *He had only been using the medication a handful of times each month. *A recommendation was made to treat anxiety with as needed (PRN) [MEDICATION NAME] (a medication to reduce anxiety). Review of resident 2's 6/26/14 through 7/25/14 nursing progress notes revealed: *A physician's orders [REDACTED]. *The [MEDICATION NAME] was administered fourteen times for the resident yelling or showing unspecified signs of anxiety. -The follow-up results of twelve of the [MEDICATION NAME] doses were documented as effective. -Two doses of the [MEDICATION NAME] were documented ineffective. One of the ineffective doses had music was helpful. *On 7/20/14 at 10:21 p.m. Placed call to on-call physician related to PRN [MEDICATION NAME] ([MEDICATION NAME]) not being effective. Informed that a fax had been sent to his office asking to change the PRN [MEDICATION NAME] ([MEDICATION NAME]) back to PRN [MEDICATION NAME]. Review of resident 2's 7/24/14 physician's orders [REDACTED].>*[MEDICATION NAME] PRN was to be discontinued. *[MEDICATION NAME] 5 mg twice daily as needed for agitation/anxiety. *[MEDICATION NAME] ([MEDICATION NAME]) was tried and found to be less effective. Review of resident 2's 3/10/15 consultant pharmacist communication revealed: *A recommendation for a gradual dose reduction of [MEDICATION NAME] to 2.5 mg twice daily PRN. *The physician agreed, and an order was obtained for [MEDICATION NAME] 2.5 mg twice daily PRN. Review of resident 2's 4/1/15 through 7/7/15 Medication Administration Record [REDACTED] *Twelve times from 4/1/15 through 4/30/15. *Eleven times from 5/1/15 through 5/30/15. *Seventeen times from 6/1/15 through 6/30/15. *One time from 7/1/15 through 7/7/15. Review of resident 2's 4/1/15 through 7/7/15 nursing progress notes revealed: *There was no documentation of any non-pharmological interventions that had been attempted prior to the administration of the [MEDICATION NAME]. *The resident had been treated with antibiotics for a urinary tract infection twice in April and once in June. *Resident had difficulty with bowel movements and required the use of PRN laxatives (medications to promote a bowel movement.) *On 4/19/15 at 2:22 p.m. [MEDICATION NAME] was given for the Resident was yelling for approximately one hour and no quieting down even after redirection x (times) three. -No documentation was made regarding the redirection interventions that were attempted. *On 5/23/15 at 4:41 a.m. [MEDICATION NAME] was given without non-pharmological documentation for Yelling and crawling out of bed. *On 7/7/15 at 9:37 a.m. [MEDICATION NAME] was given for Yelling out. Interview on 7/8/15 at 8:15 a.m. with the director of nursing and the social worker revealed: *[MEDICATION NAME] was used twice a day as needed (PRN) for agitation/anxiety. *Use of the [MEDICATION NAME] had increased over the last three to four months. *There was no documentation the physician had been notified of the increased use of the [MEDICATION NAME]. *They had not assessed for pain which was a chronic issue or treated his frequent constipation. *The resident's agitation consisted of yelling out for family members after they had visited him and for farming. *There was no documentation of non-pharmacological interventions that had been attempted when he hollered out. *The nursing staff had discussed administering [MEDICATION NAME] around noon. His wife usually came and assisted him daily with his noon meal. *They did not have a policy related to chemical restraint usage. Interview on 7/13/15 at 12:00 noon with the activities director regarding resident 2 revealed there were no interventions put in place for episodes of increased agitation. Review of the provider's 6/3/15 Dignity Policy revealed, Staff shall treat cognitively impaired (having difficulty with memory, thinking, and reasoning) residents with dignity and sensitivity; for example, addressing the underlying motives for root causes for behavior; and not challenging or contraindicating the resident's beliefs or statements. Refer to F248, finding 1.

Based on observation, record review, interview, and policy review, the provider failed to ensure neglect had not occurred for: *One of one sampled resident (13) who needed assistance with transferring from one place to another resulting in a major injury. *One of four sampled residents (6) who used a Hoyer lift (equipment to move a resident from one place to another) for transfers resulting in her falling out of the sling. *One of one sampled resident (14) who used her call light to request staff assistance resulting in mental anguish when they refused to get her out of bed. Findings include: 1. Review of the undated final report sent to the South Dakota Department of Health (SD DOH) regarding resident 13 revealed: *The resident had fallen while being assisted by certified nursing assistant (CNA) J. *The resident hit her head on the corner of the table and received a cut to her forehead. *She was sent to the clinic where they determined she had a broken nose. *She received staples to the top of her right eye and forehead. *CNA J had not used the gait belt (belt device used to help move an individual from one surface to another, or while walking an individual who may have balance problems) while transferring the resident from her recliner to her wheelchair. *The provider had determined there was no neglect and had given CNA J a verbal reprimand regarding the use of the gait belt. Review of resident 13's 4/30/15 Minimum Data Set (MDS) assessment revealed she needed extensive assistance of one staff person when transferring. Interview on 7/14/15 at 8:50 a.m. with the director of nursing regarding resident 13's above incident revealed: *Using a gait belt was standard practice when assisting residents with transfers or walking. *CNA J had not used the gait belt and had not followed the appropriate protocol resulting in injury to the resident. *She agreed neglect had occurred. Review of the provider's 5/12/15 Resident Freedom from Abuse, Neglect, and Exploitation policy revealed neglect was harm to an elder's or a disabled adult's health or welfare, without reasonable medical justification, caused by the conduct of a person responsible for the elder's or disabled adult's health or welfare, within the means available for the elder or disabled adult, including failure to provide adequate food, clothing, shelter, or medical care. Review of the provider's undated nurse's assistant job description revealed they were responsible for: *Handling and treating residents in a manner conductive to their safety and comfort. *Adhering to instructions issued by nurse and to established routine. *Performing duties in accordance with established methods and techniques and in conformance with recognized standards. 2. Review of resident 14's 5/31/15 nursing progress notes revealed: *10:14 a.m. (behavior note)- Resident told certified nursing assistant (CNA) that she wanted to get up at noon and sit up in her room for 15 minutes and then go back to bed. CNA replied that at noon we are all in the dining room passing trays and helping residents eat and could we get you up earlier. The resident replied no that she wanted to be gotten up at noon. *12:17 p.m. (behavior note)- Resident put call light on at noon and wanted to get up and sit in her wheelchair. Writer replied that we are all in dining room for lunch, and we will get you up as soon as we are done. The resident replied that she was going to put her light on and just wait then. *1:51 p.m. (behavior note)- Resident requested to speak to the nurse. Resident upset that call light was on for 40 minutes before it was answered. Explained to resident that everyone was in the dining room for lunch so there is nobody to even see that your light was on. Resident replied she knew but told them that I wanted up at noon. My daughter is going to be up here later and was going to raise cain. Nurse replied you know that lunch is at noon and everyone is in the dining room and it's just not feasible to do that. Nurse asked her how about tomorrow we get up at 11:00 a.m. and that way we can get you layed back down before lunch. Resident replied that might work. *2:20 p.m. (behavior note)- Resident was just helped to bed by CNAs. Nurse went back to see how the soup went down and resident was in bed and coughing up clear phlegm (saliva). Resident reported she was so sick and she was up too long. The hospital had told her she should be up only 15 minutes at a time at the most and she was up way too long. CNAs got resident up at 1:45 p.m. and she was layed back down at 2:15 p.m. Resident just kept saying she was so sick and was up too long. Interview on 7/14/15 at 10:30 a.m. with the director of nursing regarding resident 14 revealed: *The resident could often be very demanding. She would often tell her daughter one thing and tell the staff something else. *The provider was aware that answering residents' call lights during meal times was a problem. *They had talked frequently about rearranging staff during meal times, so someone would be available to answer call lights. But they had not actually done anything about it yet. *She confirmed that daily from 12:00 noon to 12:30 p.m. and from 5:00 p.m. to 5:30 p.m. if a resident turned on their call light it might be at least thirty minutes or more before a staff member would answer the light. *They did not have any CNAs on the nursing wings at mealtimes to answer lights. All the CNAs were to be in the dining room passing trays and assisting residents to eat. *During the week the administrative staff might answer a resident's call light to see what they needed and let the nursing staff know. The nursing staff though would not honor the residents' request until they were done in the dining room. *On weekends and during the supper meal there was not usually the administrative staff to help with call lights. *During the noon meal both nurses were usually done passing their medications in the dining room and would possibly help with call lights if they were able. *One nurse would usually go to lunch, and the other nurse was usually charting. *She confirmed there often would not be a nurse in the dining room while the residents were eating. She had not thought about that until it was brought to her attention by the surveyor. *She agreed not answering residents' call lights for at least thirty minutes during meals could be a problem if a resident had a medical emergency. *They just had not come to the right solution on how to solve residents' call lights to be answered during meals. 3. Observation on 7/9/15 at 10:45 a.m. of resident 6 being transferred from her recliner to her bed using a mechanical lift revealed: *One of the multiple mechanical lifts was being utilized. *CNAs B and C were assisting the resident to move from her chair to her bed. *When hooking up the four lift straps to the four hooks, one hook was not utilized. -CNA B had placed both the sling lift straps onto the back hook instead of one being on the back and one on the front. *They were ready to start the lift with the straps as described above. This surveyor stopped them from attempting to raise the resident and asked the CNAs if the straps were positioned appropriately. This surveyor pointed out the empty hook. -CNA C stated we would have noticed that eventually. Record review and interview with the director of nursing (DON) on 7/14/15 at 10:20 a.m. regarding the resident sliding out of sling on 4/4/15 revealed: *Incident note in electronic medical record stated a certified nursing assistant (CNA) was attempting to transfer the resident to her bed from her wheelchair. The resident slid out of the mechanical lift sling, because it was not positioned properly under the resident. *The 4/4/15 Fall Investigation Worksheet revealed: -The resident had fallen on 4/4/15. -The resident had been seated in her wheelchair in her room. -A CNA had attempted to use a mechanical lift to transfer the resident to her bed. The mechanical lift sling had moved, and the resident slid out. The resident was lowered to the floor by a CNA. -The resident was not injured. -Two CNAs were listed on the document, but the DON was not sure who placed sling, who operated the lift, or who lowered the resident to the floor based on the documentation. -The DON could not identify from the documentation which mechanical lift or sling was involved in the incident. Further interview with the DON on 7/14/15 at 10:20 a.m. regarding the above observation on 7/9/15 revealed they: *Had not done skills testing with employees on using a mechanical lift during the last year. *Would do training if there was a concern. Review of provider's 5/12/15 Resident Accident Prevention policy and procedures revealed: *An accident was described as an unexpected, unintended event that could cause resident bodily injury. *All reports would be reviewed quarterly at Safety Meetings and Quality Assurance Meetings for number or pattern of accidents and corrective actions.

Based on record review, interview, and policy review, the provider failed to ensure: *A change in condition for one of one sampled resident (14) was appropriately assessed, treated, and documented. *Pain was addressed and managed for one of one sampled resident (7). Findings include: 1. Review of resident 14's medical record revealed: *A 7/3/13 admitted . *Diagnoses: [REDACTED].) *She had been hospitalized from [DATE] to 5/30/15 for pneumonia (lung infection), gastritis (stomach inflammation), and [MEDICAL CONDITION] (bacteria in the intestines that causes diarrhea (loose stools)). *She was alert and oriented (memory okay). Review of resident 14's June 2015 Medication Administration Record [REDACTED]. Review of resident 14's 6/14/15 through 6/25/15 nursing progress notes revealed: *6/14/15 at 9:51 p.m.- Resident denied any pain times three this shift. Resident called writer down to room related to her left leg. She stated she thought she had a blood clot. Leg was examined. Leg is free from any swelling and able to wiggle toes. Bruising noted to lower shins (front of lower legs). Informed resident there was no evidence of a [MEDICAL CONDITION], but will pass on to monitor. *6/15/15 at 1:02 a.m., Resident complains of left leg pain. *6/15/15 at 4:50 a.m., Resident complains of left knee and leg pain. *6/15/15 at 5:04 a.m., Resident repositioned every two hours and asked about pain level. She did express having pain within her left knee and and leg and nurse gave her as needed (PRN) [MEDICATION NAME] (pain medication) which was effective. Resident is pale (white) and hard to awaken when checked on. *6/15/15 at 11:49 a.m., [MEDICATION NAME] given for pain. Asked where her pain was and stated my left foot and left knee. Rated pain 7 out of 10 (on a 1 to 10 scale with 1 being minimal pain and 10 being severe pain). *6/16/15 at 10:36 p.m., Weekly skin assessment completed. Resident has 2+ [MEDICAL CONDITION] (swelling on a 1+ to 4+ scale 1+ is minimal swelling and 4+ is severe swelling). No complaints of pain. *6/17/15 at 8:04 a.m., Resident rated pain at 7 out of 10 each time when asked throughout the night. Refused pain medication. Resident appeared to have no pain and looked comfortable. *6/17/15 at 7:49 p.m., Asked resident if she had pain and she said not very much. Recommended she take something for pain so it would not get any worse. She wanted [MEDICATION NAME]. Got the [MEDICATION NAME], gave it to resident and asked her where her pain was and how bad it was. She stated it was in her left leg and it was about a 9 out of 10. Asked her how her pain went from not much to a 9 and she stated she did not know. *6/18/15 at 1:00 a.m., Asked resident what her pain level was. She said 7 out of 10. She showed no signs and symptoms of pain and looked like she was comfortable. This nurse advised her if she needed something that I would bring something to her. Will continue to monitor through the night. *6/18/15 at 2:42 p.m., Talked to daughter about transportation to hospital to get peripherally inserted central catheter (PICC) (catheter inserted into the vein in an arm that goes directly into the heart). I explained to her that if she goes to the local hospital that she would be fine going by wheelchair van. I told her to go by ambulance that the doctor will have to fill out paperwork for insurance to pay. *6/18/15 at 3:45 p.m., Resident transferred to hospital by ambulance. Possible admission for respiratory issues. *6/19/15 at 9:17 a.m., Writer called hospital to check on resident's status. She was admitted to the hospital with [REDACTED]. *6/22/15 at 4:14 p.m., Daughter states her mother was not doing well and is in intensive care unit. The [MEDICAL CONDITION] is taking over and she has blood clots in her legs that are moving. There is nothing they can do for her. *6/23/15 at 9:30 a.m., Received phone call from daughter and resident is being moved to a hospice (end-of-life) house. She stated she will be up to get her belongings after she passes (dies). *6/25/15 at 8:24 a.m., Resident passed away. Interview on 7/14/15 at 10:00 a.m. with the DON regarding resident 14 revealed: *The physician should have been called on 6/14/15 when the resident told the nurse she had a blood clot in her leg. *The resident was alert, but she would often tell the nursing staff one thing and tell her daughter something else. *An increase in [MEDICAL CONDITION] in the left leg on 6/16/15 also should have been reported to the physician, and her continued complaints of pain in the leg. The [MEDICATION NAME] had been effective to control her pain when she would accept it from the nursing staff. *The nurse should not have told her on 6/14/15 she had no evidence of a [MEDICAL CONDITION] until she had spoken to the physician. Review of Patricia A. Potter and Anne Griffen Perry, Fundamentals of Nursing, 8th Edition, St. Louis Mo., 2013, pages 1133-1134 and 1149 revealed: *Some signs and symptoms of [MEDICAL CONDITION] would include swelling usually in one leg and/or leg pain or tenderness. *Some patients (residents) experience no symptoms. *Usually the clots form in the legs and can be fatal (deadly) if the clots travels to the lungs. *Report suspected [MEDICAL CONDITION] to the healthcare provider immediately. 2. Review of resident 7's 5/29/13 physician's orders [REDACTED]. Review of resident 7's 4/14/15 physician's orders [REDACTED]. Review of resident 7's 4/20/15 physician's orders [REDACTED]. Review of resident 7's 4/16/15 physician's progress note revealed she was under his care for pain management. Review of the 10/9/14 Minimum Data Set (MDS) assessment regarding resident 7 revealed pain: *Intensity at 10 on a 0-10 numeric scale (0 was no pain to 10 was severe pain). *Frequency was almost constant. *Interfered with sleep and activities. Review of the 6/19/15 MDS assessment for resident 7 revealed pain: *Intensity was severe. *No documentation on a 0-10 numeric scale was given. *Frequency was almost constant. *Interfered with sleep and activities. Review of resident 7's 6/30/15 care plan revealed: *Administer scheduled and as needed (PRN) medication for pain management in a timely manner. *Assess for pain every shift and administer PRN [MEDICATION NAME] for breakthrough pain, and monitor effectiveness of PRN medications. Interview on 7/8/15 at 4:25 p.m. with resident 7 regarding her pain revealed: *She felt her medication helped for only a short time but wore off too quickly and the pain returned. *She told registered nurse (RN) A about her increased pain a few weeks ago to the region of the current and healed pressure ulcer in the buttock region. -RN A told the resident he would send a facsimile to the physician in the morning. -No response or feedback was given to her regarding a response from physician. -She did not inquire about a physician response from RN A or any other nurse. -No reason was given for her not following up with staff. Interview on 7/8/15 at 5:00 p.m. with RN A regarding resident 7's pain revealed he: *Was unable to recall the period of time referenced with the resident stating she had increased pain *Had not made any contact with the physician recently regarding her pain. *Thought it could be related to a change in treatment to her pressure ulcer at that time. *Had not completed a pain assessment with resident 7 when she had increased complaints with her pressure ulcer treatment changes. Interview on 7/9/15 at 9:40 a.m. with the DON regarding resident 7 revealed: *Pain assessments were always completed with a quarterly MDS assessment. *It was her expectation that a pain assessment would have been completed for a change in level of pain. *All pain management was handled through the resident's primary care physician. *The resident had not been assessed or treated at a pain clinic. No reason was given for that lack of referral. *Stated resident 7 will always say she has pain. Review of the provider's 6/3/15 Pain-Clinical Protocol policy revealed nursing staff were to assess for pain: *On admission to the facility. *At quarterly review. *When there was a significant change in condition. *With onset of new pain or worsening of existing pain.