Every finding on record at Firesteel Healthcare Center

A. Based on observation, interview, and record review, the provider failed to ensure an environment free from accident hazards for seventeen of seventeen sampled residents (3, 22, 23, 24,29, 43, 48, 70, 74, 78, 83, 84, 86, 92, 102, 106, and 110) who resided within a memory care unit (an area where specialized care is provided in a structured, safe and supportive environment to meet the unique needs of residents with significant memory and cognitive decline, that is secured to minimize unsafe wandering) and had access to the memory care unit exit door key.Findings include:1. Observation on 7/28/26 at 11:57 a.m. in the memory care unit kitchenette revealed resident 86 and her visitor were standing by the refrigerator, which was located by the exit door of the memory care unit. That door exited into one of the main hallways in the facility. Resident 86's visitor stated to resident 86, it's still up here. Resident 86's visitor grabbed a staff member's badge from the top of the refrigerator, touched the badge to the badge reader on the memory car unit's exit door and unlocked the door. Resident 86's visitor placed the badge back on top of the refrigerator, said goodbye to resident 86, and exited the unit. There were no staff members present. 2. Observation on 7/28/26 at 12:10 p.m. revealed that medical memory care unit director W grabbed the badge from the top of the refrigerator and put it on her shirt. 3. Interview on 7/28/26 at 2:31 p.m. with resident 86 revealed that she did not have concerns about being able to leave the unit. She said I just need the key the staff wear. 4. Observation on 7/28/26 at 4:32 p.m. revealed that certified medication aide (CMA) X's badge was sitting on top of the refrigerator and there were no staff members in that area. 5. Interview on 7/29/26 at 2:21 p.m. with memory care unit director W revealed that if there was a visitor who visited a resident in the memory care unit often, the staff would give the visitor a badge to unlock the memory care unit door and instruct them to place it on top of the refrigerator so they could leave the unit and not have to wait for the staff to let them out. She left her badge on top of the refrigerator on 7/28/26 so resident 86's visitor could leave the unit without waiting for her . She was not supposed to do that because a memory care resident could get out of the unit without the staff knowing. 6. Interview on 7/30/26 at 10:42 a.m. with administrator A revealed that all the residents who resided in the memory care unit had a physician's order to be on a locked unit for their safety. The residents who resided in that unit were either at risk for elopement or had behaviors related to their cognitive impairment. She expected that the staff members would not leave their badges on top of the refrigerator because the residents could access them, and leave the unit. The facility did not have a policy related to the memory care or the locked doors. 7. Review of resident 86's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. Her 5/11/26 Brief Interview for Mental Status (BIMS) assessment score was 5, which indicated her cognition was severely impaired. She had diagnoses of psychotic disorder with hallucinations (a mental health condition where a person loses touch with reality and experiences things through their senses that are not actually there), severe major depressive disorder with psychotic symptoms (a mental health condition where a person has extreme, debilitating sadness alongside a total loss of touch with reality), dementia with behavioral disturbance (a brain condition causing memory loss paired with extreme, unexpected shifts in mood and actions like agitation, wandering, and aggression), and anxiety disorder (a mental health condition defined by persistent worry, extreme fear, and physical tension that do not go away and interfere with daily life). Her 3/6/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated she was in the memory care unit, walked around the unit as desired, and would wander, looking for a family member. B. Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure the staff provided accident prevention interventions and device use according to the manufacturer guidelines for one of one sampled resident (96) who needed to be secured into the whirlpool bath chair (a special seat used to lower and support a person during a whirlpool bath safely), by a safety belt, and sustained a laceration (cut or torn skin) above his left eye when he fell from the whirlpool bath chair onto the floor after certified nursing assistant (CNA) (Z) gave him a whirlpool bath without the safety belt on. The resident was subsequently transferred to the emergency room for evaluation and laceration repair with sutures. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include: 1. Review of the provider's 6/26/26 SD DOH FRI revealed that on 6/26/26 at 3:26 p.m., resident 96 was transferred from the whirlpool tub via the whirlpool bath chair. CNA Z moved the whirlpool bath chair backwards, the resident grabbed onto the side of the tub and fell forward onto the floor. CNA Z reported that resident 96 had put his hands out to try to catch himself; however, he hit his face on the floor. CNA Z then called for help from licensed practical nurse (LPN) I and certified medication aide (CMA) V. LPN I completed a head-to-toe assessment (an assessment she completed that looked over his body to see if he had any open areas or redness, checked his range of motion in his extremities, checked neurological vitals, and checked for signs of hip fractures) on resident 96. She identified one bruise on his left knee and left side of his face, with a bleeding laceration above his left eye. There was swelling and bruising to the left side of his face and eye. Resident 96 was able to move all his extremities as per his usual movement. He was alert and oriented to person, place, time, and event. He had no complaints of pain at that time. His neurological evaluation (assessment of nerve function, reflexes, coordination, motor skills, sensation, and mental status) (neuros) was within normal limits. Resident 96 was assisted off the floor by LPN I, CMA V, and CNA Z, who used the total body lift (a mechanical lift and sling used to lift a person's full body) to transfer him into his wheelchair. His emergency contact was notified of his fall and transfer to the emergency department (ED). Resident 96 had a Computed Tomography (CT) scan of his head and facial bones, with no fractures. He received four sutures to the laceration above his left eye. Upon his return to the facility, he denied having pain. The nursing staff completed neurological evaluations per the facility's protocol. CNA Z was suspended from working at the facility pending the investigation of the incident and disciplinary action. Prior to her return to the facility, she was provided education on the use of the safety belt when assisting a resident in the bath. 2. Review of resident 96's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 6/30/26 Brief Interview for Mental Status (BIMS) assessment score was 6, which indicated his cognition was severely impaired. His diagnoses included unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities) and frontotemporal neurocognitive disorder (a brain condition where the front and side parts of the brain slowly break down, causing early changes in behavior, personality, or language rather than memory). His 7/25/26 Morse Fall Scale (a nurse-administered tool used to assess a patient's risk of falling based on history of falling, diagnoses, use of ambulatory aids, presence of intravenous [into or within a vein] equipment, gait quality [the way a person walks], and mental status) assessment score was 40, which indicated he had a moderate risk for falling. His undated care plan indicated he had an activities of daily living (ADL) self-care performance deficit due to his dementia, hemiplegia (a condition in which a person experiences paralysis on one side of the body), and limited mobility. He transferred with the assistance of two staff members and a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position). He was assisted by one staff member when in the bathtub. His 6/26/26 ED notes indicated that there was a facial laceration with mild bleeding, and mild blurry vision during the ED examination. Radiology read the head and facial bone CT, and there were no fractures. Resident 96's vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) remained stable. His mental status did not change, and he was awake and alert. His left upper eyelid was repaired with four sutures. 3. Review of the provider's whirlpool bathing education revealed that the four bath aides received direct education regarding the use of the whirlpool bath chair and the safety belt. 4. Interview on 7/28/26 at 2:44 p.m. with resident 96 revealed he thought he fell out of a tractor scoop and that is how he received the purple and red bruising and swelling to the left side of his cheek. There was no longer a laceration present above his left eye. He was unable to recall the fall at the facility. 5. Interview on 7/28/26 at 4:37 p.m. with resident 96's family member revealed they were informed about his fall from the whirlpool bath chair and had no concerns. 6. Observations from 7/28/26 through 7/30/26 of four of four tub rooms revealed they had the [NAME] Bath System Bed to Bath Transfer Procedures posted for the staff to use during resident baths. This procedure included when staff were to apply the safety belt and remove the safety belt from the resident. 7. Review of the 6/26/26 Quality Assurance and Performance Improvement (QAPI) meeting minutes regarding resident 96's fall revealed the interdisciplinary team evaluated the resident after his fall, interviewed the staff members involved, and an initial audit was completed. The facility's correction actions for the deficient practice (not using the safety belt in the whirlpool bath) included providing education to the bath aides and then demonstrating the placement and use of the safety belt, and providing education to all staff who have the potential to use the bath chair before they assist a resident with a bath. Audits were to be completed by the director of nursing (DON) or designee daily, with three to five observations each day for one week. Then weekly for three weeks. Then monthly for 2 months. The QAPI meeting determined this will be a performance improvement plan (PIP) and would be ongoing with a goal of 100% compliance. 8. Review of the whirlpool tub daily audits completed from 6/29/26 through 7/3/26 revealed that each tub room was audited and in compliance with the safety belt being used when a resident was in the tub chair. There were nineteen individual audits completed of residents with the safety belt on. 9. Review of the whirlpool tub weekly audits completed from 7/6/26 through 7/24/26 revealed that sixteen individual audits were completed and in compliance with the safety belt being used when a resident was in the tub chair. 10. Interview on 7/30/26 at 10:58 a.m. with CNA Z regarding resident 96's fall revealed that resident 96 fell as he grabbed onto the side of the whirlpool tub as she pulled the whirlpool bath chair backward. She immediately opened the tub room doors and hollered for help. CMA V and LPN I came to assist the resident. After LPN I said it was safe to get him off the floor, the three staff members used the total body lift and transferred him into his wheelchair. They then took him to his room to get him dressed before taking him to the ED. CNA Z was suspended pending the facility's investigation until further notice. She was given verbal education on how to use the whirlpool bath chair and the safety belt after resident 96's fall. CNA Z said, This was 100% my fault. I was rushing and trying to get as many baths done as possible, and I missed that step. I have learned to be extra cautious. Now I take my time, and everyone gets the [safety] belt in the whirlpool [bath] chair. 11. Interview on 7/30/26 at 11:09 a.m. with LPN I regarding resident 96's fall revealed that she was alerted to the tub room by CNA Z because resident 96 was on the bathroom floor. He was bleeding from the left side of his face, so she put a cloth over it to help clean it up. After it was cleaned up, we placed ice over the bleeding area. She completed her head-to-toe assessment and then helped transfer him into his wheelchair with a total body lift. She notified contracted travel LPN J, who was the assigned nurse for resident 96 that day. 12. Interview on 7/30/26 at 11:56 a.m. with contracted travel LPN J revealed that she was the nurse for resident 96 on 6/26/26. She assessed the resident, notified the director of nursing (DON) B, called the resident's physician, and received an order to send the resident to the ED for further evaluation. When he returned, she continued his neurological checks. 13. DON B was unavailable during the survey and could not be interviewed. 14. Review of the [NAME] Bathtub System Preparation manufacturer's instructions manual revealed, 9. All residents must always be securely safety belted at the waist when using any of the [NAME] Lift Systems. Ensure that the safety belt is routed through the loose buckle end. 15. Based on the above information, non-compliance at F689 occurred on 6/26/26, and based on the provider's corrective action plans that were initiated on 6/26/26 and implemented for the deficient practice, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review the provider failed to ensure sanitizer solutions were tested and documented for one of one main kitchen. Findings include: 1. Observation, interview, and July sanitizer log review on 7/28/26 at 9:37 a.m. in the main kitchen with dietary aide EE revealed a bucket of sanitizer solution with a wash rag inside of it was on one of the food prep tables. Dietary aide EE used the rag to wipe down the food prep table after she put cookies into Ziplock bags for snacks. She confirmed the sanitizer solution was changed three times a day or if the water was dirty. the July sanitizer log was hanging on a wall in the kitchen next to the dish room, and dietary aide EE confirmed that was where the dietary staff documented the sanitizer tests for the bucket of sanitizer solution. The July sanitizer log was missing 4 of 28 sanitizer test results for breakfast, 4 of 28 sanitizer test results for lunch, and 26 of 28 sanitizer test results for dinner. 2. Interview and April sanitizer log review on 7/29/26 at 4:30 p.m. with registered dietitian L, dietary supervisor M, senior certified dietary manager (CDM) GG, and senior CDM HH revealed they expected the dietary staff to test the sanitizer solution three times a day at each meal time. They agreed that was not being completed. Review of the April sanitizer log revealed 11 of the 30 breakfast sanitizer test results were missing, and 11 of the 30 lunch sanitizer test results were missing. Dietary supervisor M was unable to locate the sanitizer logs for May and June. 3. Interview on 7/30/26 at 1:43 p.m. with administrator A revealed she expected the dietary staff to follow the provider's policy for testing the sanitizer in the kitchen. She agreed that was not being done. 4. Review of the provider's updated November 2020 Sanitizer Solution policy revealed that, Policy Statement: A sanitizing solution is used in the Dietary Department for sanitizing work surfaces. 2. New solution is tested three times daily for proper concentration by using Sink and Sanitizer cleaner test strips or the visual compliance indicator test strips.

Based on interviews, record review, and policy review, the provider failed to ensure the staff responded promptly to four of five sampled residents (31, 46, 105, and 108) who reported concerns about extended call light times.Findings include:1. Interview on 7/28/26 at 9:06 a.m. with resident 46 revealed he had waited a long time, up to two hours, for the staff to answer his call lights. He said that if he had to go to the bathroom, it really hurt waiting, and that he was incontinent (involuntary urine or bowel leakage) if he had to wait too long. 2. Review of resident 46's EMR indicated he admitted to the facility on [DATE]. His 6/10/26 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated his cognition was moderately impaired. His diagnoses included myelodysplastic syndrome (a type of blood and bone marrow disorder where the bone marrow produces too few healthy blood cells and some abnormal cells), type 2 diabetes mellitus (a condition involving disruptions in how the body regulates blood sugar), benign prostatic hyperplasia (an enlargement of the prostate gland) without lower urinary tract symptoms, and dorsopathy (disorders of the spine or back).His 6/10/26 MDS assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs), section GG, indicated he required partial/moderate assistance with oral hygiene, toileting hygiene, dressing his upper body, personal hygiene, and transfers between surfaces. He required substantial/maximum assistance with dressing his lower body and putting on and taking off his footwear. He was dependent on the staff for showering/bathing.3. Review of resident 46's call light log (a structured record used in healthcare settings to track patient call button usage and staff responses) from 7/1/26 to 7/29/26 revealed that there were sixteen call light wait times longer than 15 minutes, eight call light wait times longer than 30 minutes, seven call light wait times longer than 40 minutes, and one call light wait time was 1 hour and 6 minutes.4. Interview on 7/28/26 at 10:31 a.m. with resident 31 revealed that she had to wait up to 45 minutes for the staff to assist her to the commode (a portable chair with a built in toilet seat and removable bucket, used for toileting). She felt like she had lost her independence because she was incontinent of bowel while waiting for the staff.5. Review of resident 31's EMR indicated she admitted to the facility on [DATE]. Her 7/17/26 BIMS assessment score was 15, which indicated her cognition was intact. Her diagnoses included parkinson's disease without dyskinesia (a progressive disorder of the nervous system that gradually damages dopamine-producing cells in the brain, leading to symptoms like tremors (shaking), muscle stiffness, slowed movement, and balance problems), rheumatoid arthritis (an autoimmune, chronic disease where the body's immune system attacks the lining of the joints), neuromuscular dysfunction of the bladder (a condition where nerve or muscle issues disrupt the signals between the bladder and the brain/spinal cord), type 2 diabetes, major depressive disorder, morbid (severe) obesity (excessive weight that significantly impacts health and well-being), and anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). Her undated care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated she was dependent on one to two staff members when repositioning in bed and getting dressed. She transferred using a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) with two staff members. She used the sit-to-stand to get into her wheelchair, bathe, and use the restroom.6. Review of resident 31's call light log from 7/1/26 to 7/28/26 revealed that there were fifteen call light wait times longer than 15 minutes, and one call light wait time of 33 minutes.7. Interview on 7/28/26 at 3:54 p.m. with resident 105 revealed she was incontinent when she had to wait 15-20 minutes for the staff to assist her to the bathroom. That made her feel humiliated. She knew when she had to use the restroom but could not get there on time because she had to wait for the staff.8. Review of resident 105's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 7/9/26 BIMS assessment score was 15, which indicated her cognition was intact. Her diagnoses included anxiety disorder, and depression.Her undated care plan revealed she had an activities of daily living (ADL) self-care performance deficit due to an impaired balance, limited mobility, and limited range of motion. The 7/15/26 added interventions for her bathing/showering indicated she was to have two baths per week and as needed (prn).9. Review of resident 105's call light log from 7/1/26 to 7/29/26 revealed there were seven call light wait times longer than 15 minutes, four call light wait times longer than 30 minutes, one call light wait time longer than 40 minutes, and two call light wait times longer than 50 minutes.10. Interview on 7/28/26 at 9:25 a.m. with resident 108 revealed that she has had her call light on for up to one hour. That made her mad because the staff knew she had put the call light on because she needed their help.11. Review of resident 108's EMR indicated she admitted to the facility on [DATE]. Her 7/10/26 BIMS assessment score was 15, which indicated her cognition was intact. Her diagnoses included chronic kidney disease stage 3b (a moderate to severe decline in kidney function) and major depressive disorder. Her undated care plan indicated resident 108 is at risk for falls related to gait (walking) and balance problems. The interventions added on 4/10/25 indicated anticipating and meeting the resident's needs. Ensure the call light is within reach, and the staff was to encourage the resident to use it for assistance when needed. The resident needed prompt response to all requests for assistance. 12. Review of resident 108's call light log from 7/1/26 to 7/28/26 revealed there were twenty-one call light wait times longer than 15 minutes, and one call light wait time of 33 minutes.13. Interview on 7/30/26 at 7:55 a.m. with contracted travel licensed practical nurse (LPN) K revealed that the residents should not wait more than 5 minutes for their call light to be answered. Any nurse or certified nursing assistant (CNA) can answer a call light to assist the resident. She said they know the call lights are alarming by using a phone that the facility provided. She had a facility phone with her at the time of the interview. 14. Interview on 7/30/26 at 8:00 a.m. with contracted travel CNA AA revealed the resident's call lights should be answered within 15 minutes. She did not have a phone device on her to indicate who had a call light on at the time of the interview.15. Interview on 7/30/26 at 1:15 p.m. with staff development registered nurse (RN) D revealed the facility had a phone system that alerted the staff visually and auditorily when a resident's call light was activated. Each nurse's station had a screen that would show the call lights in each area. She expected each staff member to have a phone with them during their scheduled shift to answer the call lights. She expected the staff to answer the call lights within 15 minutes.16. Review of the provider's 6/1/26 Call Light Education and Expectations revealed although anyone can answer a call light, the care staff assigned to the residents are responsible for ensuring call lights are available, answered, and addressed promptly. The call light system is arranged to notify us as the call light escalates through Excellent, acceptable, needs improvement. Excellent is call answered in less than 10 minutes. Acceptable is call answered in less than 10-15 minutes. Needs improvement is call answered in over 15 minutes.

Based on interview, document review, and policy review, the provider failed to ensure that the resident's grievances were addressed, and documentation reflecting the staff's efforts to resolve those grievances was communicated to the residents and approved as effective resolutions for eight of eight sampled residents (16, 30, 31, 63, 79, 81, 108, and 109) who attended the resident council meeting on 7/29/26 that reported concerns in grievance resolution.Findings include:1. Interview with residents 16, 30, 31, 63, 79, 81, 108, and 109 during the resident council meeting on 7/29/26 revealed that they have not had grievances resolved, and the staff had not come to discuss with the council or any members the resolution of grievances brought from the resident council.2. Review of resident 16's electronic medical record (EMR) indicated she admitted to the facility on [DATE]. Her 6/4/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact.3. Review of resident 30's EMR indicated she admitted to the facility on [DATE]. Her 6/29/26 BIMS assessment score was 11, which indicated her cognition was moderately impaired.4. Review of resident 31's EMR indicated she admitted to the facility on [DATE]. Her 7/17/26 BIMS assessment score was 15, which indicated her cognition was intact.5. Review of resident 63's EMR indicated he admitted to the facility on [DATE]. His 7/7/26 BIMS assessment score was 14, which indicated his cognition was intact.6. Review of resident 79's EMR indicated he admitted to the facility on [DATE]. His 6/5/26 BIMS assessment score was 15, which indicated his cognition was intact.7. Review of resident 81's EMR indicated she admitted to the facility on [DATE]. Her 7/28/26 BIMS assessment score was 13, which indicated her cognition was intact.8. Review of resident 108's EMR indicated she admitted to the facility on [DATE]. Her 7/10/26 BIMS assessment score was 15, which indicated her cognition was intact.9. Review of resident 109's EMR indicated she admitted to the facility on [DATE]. Her 4/3/26 BIMS assessment score was 15, which indicated her cognition was intact.10. Review of grievances from May 2026 through July 2026 revealed 37 of 77 grievances have not had the grievance resolution documented, with the complainant notified and by what method they were communicated with.11. Interview on 7/30/26 at 12:45 p.m. with Administrator A revealed that she was the grievance official in charge of reviewing and ensuring the completion of the grievances. She expected the grievances to be resolved, completed, and followed up with the complainant in 5 days. The grievance resolution, person notified, date and time of notification, and method of communication she would expect to have filled in with the appropriate information.12. Review of the provider's updated March 2025 Grievance Procedure Policy revealed The administrator oversees the grievance procedure and coordinates the center system for collecting, tracking, and responding to grievances. The administrator is designated as the Grievance Official for the center. Their contact information is posted with the policy in prominent areas throughout the center. The Administrator/designees routes the Grievance Form to the appropriate department manager, who reviews the grievance, responds within five business days, and returns the Grievance Form to the Administrator. The person with the grievance has the right to a written decision regarding his/her grievance.

Based on record review, interview, and policy review, the provider failed to minimize the risk of residents acquiring and transmitting pneumococcal disease by ensuring that three of five sampled residents (35, 56, and 60) were offered the pneumococcal vaccination.Findings include:1. Review of resident 35's electronic medical record (EMR) revealed that he admitted to the facility on [DATE]. He had received the PCV 13 (an immunization that protects against thirteen types of streptococcus pneumoniae bacteria) vaccination on 8/21/20. There was no documentation that he was offered and received or declined the additional recommended pneumococcal vaccine.2. Review of resident 56's EMR revealed that he admitted to the facility on [DATE]. He had received the PCV 13 vaccination on 11/21/19. There was no documentation that he was offered and received or declined the additional recommended pneumococcal vaccine.3. Review of resident 60's EMR revealed that he admitted to the facility on [DATE]. He received the PPV 23 (a vaccine that protects against 23 types of streptococcus pneumoniae bacteria) vaccine on 11/12/10. There was no documentation that he was offered and received or declined the additional recommended pneumococcal vaccine.4. Interview on 7/30/26 at 1:06 p.m. with registered nurse (RN) unit manager/infection preventionist (IP) C revealed she started using a new computer system on 6/1/26 for monitoring resident immunizations. When a resident admitted to the facility, they were offered immunizations that were needed according to the new computer system and the state immunization records. She stated, It's a work in progress. She agreed that resident's 35, 56, and 60 were not offered the recommended pneumococcal vaccines, and that they did not decline or refuse the vaccines. She expected new admit immunization records to be reviewed on admission, and that residents were offered the needed immunizations after admission.5. Review of the updated 6/19/25 Pneumococcal Vaccination of Residents policy revealed The facility offers the Pneumococcal vaccination to facility residents among facility residents in accordance with Centers for Disease Control (CDC) recommendations and Federal requirements. Each resident's pneumococcal immunization status is determined upon admission or soon afterwords and is documented in the resident's EHR [electronic health record] medical record.

Based on record review, interview, and policy review, the provider failed to ensure that two of five sampled residents (65 and 73) had a Preadmission Screening and Resident Review (PASRR) level II (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) completed.Findings Include: 1.Review of resident 65's EMR revealed she admitted to the facility on [DATE] and had diagnoses that included depressive disorder, hallucinations, and hoarding disorder. She had a 5/25/23 PASRR Level 1 completed. Her 9/11/23 PASRR Level II screening form determined resident 65 was exempt from a Level II review as the diagnosis of a mental illness was unsubstantiated. On 9/5/24, resident 65 received a new diagnosis of delusional disorders. Social Services director (SSD) N's notes documented on 10/24/24 indicated that the PASRR is appropriate-we do monitor to update. Resident currently has a psychiatric diagnosis. PASRR II screen is not indicated. Resident 65's 11/8/24 quarterly Minimum Data Set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) completed by SSD N did not identify delusions. The 5/8/26 MDS assessment completed by SSD N did not identify delusions. Resident 65's November 2024 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated Resident is exhibiting delusion thoughts. Her 6/2/25 care plan identified she had behaviors including: delusions, hallucinations, hoarding, and neglecting the doctor's orders. SSD N indicated in a 1/24/25 progress note that Resident thought process and decisions are based on her perceived perceptions and beliefs. These are not always realistic and can often be delusional in nature. These do get in the way of her thinking and ability to manage her own needs. Resident does like to take her time with things so that she can sort the details out. These details turn from real to some delusional. Safety awareness is poor at times. Diagnoses were major depressive disorder, single episode, mild and delusional disorders. Continue to see thoughts on delusional side. We have seen resident not making good decisions surrounding her healthcare choices. She has certain beliefs that she follows regardless if they are true or not. 2. Interview and EMR review on 7/29/26 at 4:14 p.m. with SSD N regarding the Level 1 and Level II PASRR provided by the facility for resident 65 revealed that the PASRRs provided by the facility were from 2023. SSD N stated there were no additional PASRRs completed on resident 65. She expected a PASRR to be done if there was a new diagnosis of delusional disorders present. She confirmed in resident 65's EMR that the diagnosis of delusional disorders was added during her stay at the facility and that no PASRR was completed. 3. Review of resident 73's EMR revealed he admitted to the facility on [DATE]. His 6/16/26 Brief Interview for Mental Status (BIMS) assessment score was 0, which indicated his cognition was severely impaired. His diagnoses included unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities) and unspecified psychosis (a diagnostic category used when a person experiences clear psychotic symptoms) not due to a substance or known physiological condition, diagnosed on [DATE]. A PASRR level 1 screen was completed on 10/26/23 with Maximus (a clinical service that evaluates individuals applying for or residing in Medicaid-certified nursing facilities). The level I screen indicated that resident 73 did not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs. His 9/11/2025 pharmacy medication review had a signed order acknowledging he was prescribed the antipsychotic medication Olanzapine 2.5 milligrams (mg) twice a day (BID) for the treatment of unspecified psychosis since July 2024. 4. Interview and EMR review on 7/30/26 at 10:35 a.m. with SSD N revealed that she would submit a PASRR level II for a resident who had a serious mental illness diagnosis. She reviewed resident 73's EMR and confirmed he had a serious mental illness. SSD N was not notified if a resident received a new diagnosis. No additional mental health authorities were notified of resident 73's psychosis diagnosis. 5. Review of the provider's revised 1/1/25 PASRR Process Policy and Procedure revealed 4. If there is a significant change of condition that affects their diagnosed need for a PASRR 2, staff refer for a NEW PASRR Level 2. a. The Level 2 evaluator determines if the resident's current care needs are able to be met at the NF [nursing facility]. b. If the resident remains appropriate for the nursing facility (NF), there may be new recommendations to be placed on the care plan. c. If the resident is no longer deemed appropriate for the NF setting, the evaluator will discuss with the Administrator and/or the social services Director. 8. Follow up as needed per federal PASRR rules.

Based on interview, record review, and policy review, the provider failed to ensure resident bathing choices were being followed for one of one sampled residents (105).Findings include:1. Interview on 7/28/26 at 3:54 p.m. with resident 105 revealed that she requested two baths per week since her admission to the facility. That request was not fulfilled. She then requested her physician to write an order for two baths per week. She said she felt uncomfortable and unclean, not being able to shower two times per week.2. Review of resident 105's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 7/9/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. Her diagnoses included anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and depression.Her undated care plan (personalized plan that addresses a resident's care needs, goals, and interventions) revealed she had an activities of daily living (ADL) self-care performance deficit due to an impaired balance, limited mobility, and limited range of motion. The 7/15/26 added interventions for her bathing/showering indicated she was to have two baths per week and as needed (prn).Her 6/26/26 Minimum Data Set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) section GG functional abilities and goals indicated that resident 105's self-care assessment for bathing was that she needed partial staff assistance. Her physician's order dated 7/14/26 indicated she was to have two baths weekly.3. Review of the 400 hallway daily bath schedule revealed resident 105's bath was scheduled on Monday. There was not a second bath day scheduled for resident 105 that week.4. Interview and 400 hallway daily bath schedule review on 7/30/26 at 1:15 p.m. with staff development registered nursing (RN) D revealed the staff had daily bath sheets that identified who was to get a bath each day. The bath sheets were kept in the tub rooms. These sheets were updated weekly by medical records S. If she was not available, then director of nursing (DON) B updated them. Staff development RN D expected that if there was a doctor's order for a resident to receive two baths weekly, the facility would follow that order. Staff development RN D reviewed resident 105's bath schedule and confirmed the resident was scheduled to receive a bath on Mondays, despite her physician's order for two baths per week.5. Interview on 7/30/26 at 1:35 p.m. with medical records S revealed that she updated the bath schedule two times per week. She received updates on the physician's orders from staff development RN D or DON B and would follow those physician's orders if they regarded the resident's bath schedule. She said that RN D just fixed a bath schedule for resident 105 earlier after she found a physician's order. Medical records S was not aware of the order for resident 105. 6. The survey team requested the bathing policy on 7/29/26 at 9:49 a.m. 7. The facility did not provide a bathing policy. When administrator A returned the requested documents to the team, she said the facility follows the Resident Assessment Instrument (RAI) (an official guide published by the Centers for Medicare & Medicaid Services (CMS) that provides instructions for the Resident Assessment Instrument) for bathing guidelines.8. Review of the provider's updated April 2024 Physician Order Recaps policy revealed the licensed nursing staff is responsible for inputting admission, telephone, and verbal physician's orders into the EHR [a digital electronic health record of a medical chart that stores health information] immediately upon receipt from the provider. The Director of Nursing establishes the licensed clinician responsible for recap and reconciliation of New, Discontinued, or Completed orders in the EHR daily and initiates corrections daily.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one portable oxygen cylinder (a pressurized container that stores and transports compressed or liquid oxygen) was securely transported. Findings include:1. Observation on 7/30/26 at 10:23 a.m. in hallway 400, outside the nurse's station, revealed contracted travel licensed practical nurse (LPN) K removed an oxygen cylinder from the back of a resident's wheelchair and carried it down the hallway towards the 100 hallway.2. Observation on 7/30/26 at 10:28 a.m. revealed contracted travel LPN K carried an oxygen cylinder from the direction of the 100 hallway to the 400 hallway, outside the nurse's station and placed the oxygen cylinder on the back of the same resident's wheelchair as the observation above.3. Observation on 7/30/26 at 11:28 a.m. of the oxygen storage room revealed there were five wheeled carts available to transport oxygen tanks. Three of those wheeled carts had oxygen cylinders in them. There was an orange sign posted on the wall in the oxygen storage room, which stated Do not leave oxygen tanks standing alone! They must be in a holder at all times! 4. Interview on 7/30/26 at 10:25 a.m. with registered nurse (RN) medication nurse H, who witnessed LPN K remove and replace the resident's oxygen cylinder, revealed that the oxygen cylinder should have been in a wheeled cart for both the empty and full oxygen cylinders during transport. 5. Interview on 7/30/26 at 10:32 a.m. with contracted travel LPN K, regarding the oxygen cylinders revealed the oxygen cylinder she removed from the resident's wheelchair was empty and that she retrieved a full oxygen cylinder from the oxygen storage room. She carried the full oxygen cylinder down the hallway and placed it on the resident's wheelchair. She confirmed there were wheeled carts available in the oxygen room for transport, but they are way down the hallway so I just carry them. She would normally carry the oxygen cylinders back and forth from the oxygen storage room when she needed to change out a resident's empty oxygen cylinder. 6. Interview on 7/30/26 at 11:40 a.m. with RN unit manager/infection preventionist C and staff development RN D revealed, staff development RN D would get a wheeled cart from the oxygen storage room or bring the resident to the oxygen storage room to switch out the oxygen cylinders. RN unit manager/infection preventionist C agreed with that process. Staff development RN D stated she had told the staff to put the oxygen cylinders in a cart and wheel them down to the resident; however, she did not provide specific education on switching out the oxygen cylinders. 7. Interview on 7/30/26 at 12:14 p.m. with contracted travel certified nursing assistant (CNA) CC revealed she had seen someone drop an oxygen cylinder before and it made a big hole in the wall. She changed out oxygen cylinders by bringing the residents to their room and using a wheeled cart to transport the oxygen cylinders. She has seen other staff members carrying the oxygen cylinders instead of using the wheeled carts for transportation. 8. Interview on 7/30/26 at 12:21 p.m. with RN medication nurse G revealed, she used the oxygen cart to transport the empty and full oxygen cylinders back and forth from the oxygen storage room. She identified the oxygen carts as the wheeled carts located in the oxygen storage room. 9. Interview and staff education review on 7/30/26 at 2:28 p.m. with staff development RN D revealed she provided the staff members with a five-minute video regarding oxygen use and safety and had them take a test. She confirmed that the printed content of the video identified that the oxygen cylinders should always be kept upright and be in a carrier. She stated that she does not do training with the contracted travel staff as they have their competencies through their agency.10. Review of LPN K's employee file revealed she was provided, fire safety training through Relias (the provider's education training system) on 6/13/25; however, nothing specific related to oxygen safety. 11. Review of the provider's December 2017 Respiratory Care policy revealed Safety precautions and care of oxygen delivery equipment are performed according to State and Federal regulation and manufacturer guidance. The Center observes precautions to prevent explosions, fire, etc. that are associated with oxygen use and storage. All oxygen tanks are secured in appropriate storage containers/stands or secured to a wall with a chain or heavy cable. Center personnel receive training regarding oxygen administration and safety.

Based on observation, document review, and interview, the provider failed to ensure the daily posted nurse staffing information reflected the actual resident census and hours worked by registered nurses (RNs), licensed practical nurses (LPNs), certified medication aides (CMAs), and certified nursing assistants (CNAs) per shift, and was posted in a location visible and accessible to the residents, staff, and visitors. Findings include: 1. Observation on 7/28/26 at 8:30 a.m. revealed the facility resident census and daily nurse staffing information was posted in the window of the facility's main entrance. The information included the date, resident census, and the number of nursing personnel and their total hours scheduled to work for that day. 2. Review of the provider's nursing staff schedule for July 2026 revealed that no registered nurse was scheduled for 7/14/26 and 7/22/26. 3. Review of the provider's daily posted nurse staffing information for 7/14/26 and 7/22/26 revealed that on both days, one registered nurse was scheduled for a 12-hour day shift and one registered nurse was scheduled for a 12-hour night shift. 4. Interview on 7/30/26 at 9:00 a.m. with RN medication nurse H revealed that when the staff called in or missed their scheduled shift, the nurse on duty provided a call-in sheet to director of nursing (DON) B, staff development RN D, or administrator A. RN medication nurse H expected the call-in information to be relayed to receptionist U, who posted the daily nurse staffing information in the window of the main entrance. RN medication nurse H was not involved with completing the daily nurse staffing information and did not know if the posted information was updated throughout the day. 5. Interview on 7/30/26 at 9:15 a.m. with receptionist U revealed that she prepared and posted the daily resident census and nurse staffing information when she arrived at work each morning. She referenced the nursing schedule to obtain the number of CNAs and CMAs scheduled on each shift, but she did not know which nurses were RNs or LPNs. When she was hired in December 2025, receptionist T trained her to always write that one RN and two LPNs were scheduled for the day and night shifts. She did not post updates throughout the day as the census or nursing schedule changed. She agreed the posted information did not reflect the actual resident census or hours worked in each staffing category. 6. Interview on 7/30/26 at 9:48 a.m. with staff development RN D revealed that DON B and staffing coordinator P coordinated shift coverage to ensure that enough nursing staff were working to meet the residents' needs. Staff development RN D said three or four nurses were scheduled per shift, along with five CMAs and five CNAs for the day and evening shifts and four to six CNAs for the night shift. If staff called in for their scheduled shift, five nurse managers were expected to help cover the shift vacancies. The two scheduled bath aides and non-licensed staff activities and restorative therapy staff were also pulled to help where needed. We all just pitch in where we can. 7. Interview on 7/30/26 at 10:32 a.m. with administrator A revealed that she did not update the Facility Assessment since she was hired in November 2025. She expected to see at least three nurses working the day shift and three nurses working the night shift. The nurse managers primarily worked in their offices and were not included in the hours reflected in the Facility Assessment, but she expected them to cover vacant nursing shifts and help the direct care staff as needed. She said that a registered nurse is scheduled to work at least eight hours a day, and if an RN was not on the schedule for 7/14/26 and 7/22/26, then the nurse managers were considered the RN for that day. Administrator A was not aware that the daily posted nurse staffing information should reflect the resident census and the nurse staffing updates throughout the day. She said none of the nurses completed the daily resident census and nurse staffing information, just the receptionists. She expected that receptionists T and U would accurately list the number of LPNs and RNs working each day. 8. The provider did not have a policy on posting the daily resident census and the nurse staffing posting information. 9. Review of the provider's 7/11/25 Facility Assessment, Staffing Plan, revealed that the staffing was evaluated and adjusted based on the resident census and residents' care needs. For a census of 125 residents, the Facility Assessment indicated that each day would include direct care hours performed by RNs (three or more per shift), LPNs (one or more per shift), and CNAs (three or more per shift).

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed standard infection prevention practices regarding enhanced barrier precautions (EBP) (gown and glove use when providing contact care) by one of one contracted travel certified nursing assistant (CNA) (BB) while she changed bed linens for one of one sampled resident (28) who required EBP.Findings include: 1. Observation on 7/28/26 at 11:04 a.m. revealed that contracted travel CNA BB made resident 28's bed. Resident 28 had a sign on his door indicating he required EBP. Contracted travel CNA BB was not wearing gloves or a gown, and the soiled bed sheet was lying on resident 28's floor. Contracted travel CNA BB picked up the soiled bed sheet with her bare hands, put it in a garbage bag, put that garbage bag on the floor, washed her hands in the resident's sink, picked up the garbage and linen bag, and brought them to the soiled utility room. 2. Review of resident 28's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. He had diagnoses of end stage renal disease (permanent kidney failure where the kidneys no longer clean waste or remove extra fluid from the blood). His July 2026 treatment administration record (TAR) indicated he had a dialysis tunneled catheter (a device used for a treatment that removes waste products and excess fluid from the blood when the kidneys are unable to), to right chest. On 7/29/26, his TAR indicated he had a wound to both of his shins and his right foot that the nurse completed treatments for. 3. Interview on 7/28/26 at 11:08 a.m. with contracted travel CNA BB revealed that she removed resident 28's soiled bed sheet and made his bed without wearing a gown. She verified he was on EBP. She did not need to wear a gown when changing or making his bed, but she would have worn a gown if she was providing personal care to resident 28 or if he was in the room when she changed his bedding. 4. Interview on 7/30/26 at 11:07 a.m. with contracted travel licensed practical nurse (LPN) K revealed that resident 28 required EBP because he had a dialysis tunneled catheter and his legs sometimes were severely swollen that they wept (body fluid oozes directly through the skin), and he had open areas on his legs. When a resident required EBP, the staff were to wear a gown and gloves when changing the resident's bed linen because of the possibility of infectious material being on the sheets. 5. Interview and EBP policy review on 7/30/26 at 11:12 a.m. with registered nurse (RN)/unit manager/infection preventionist C revealed that if a resident required EBP, she expected the staff to wear a gown and gloves when handling the residents bedding. She had educated the staff regarding EBP and had educated contracted travel CNA BB regarding EBP before. 6. Review of the providers 3/26/24 EBP policy revealed that if a resident required EBP, the staff were to follow EBP when changing the resident's linens.

Based on South Dakota Department of Health (SD DOH) complaint records, interview, and policy review, the provider failed to report an incident to the SD DOH within the required time frame regarding two of two sampled residents (1 and 6) who had a reportable incident. Findings include: 1. Review of the 2/24/26 SD DOH complaint report revealed resident 1 reported an allegation of verbal abuse and neglect by travel certified nursing assistant (CNA) C and travel CNA D on 2/24/26 at 6:12 p.m. via an email to the director of nursing (DON) B, and administrator A, and the South Dakota Department of Health (SD DOH) complaints department. In her email, resident 1 alleged that travel CNA C and travel CNA D had told her she should have better time management regarding her use of the call light because they were busy delivering meal trays to other residents when she activated her call light. Then, when the travel CNAs were assisting her from the toilet to her wheelchair, her bare buttocks touched the arm of her wheelchair and they refused to clean it. DON B responded by email to resident 1's emailed complaint on 2/24/26 at 8:43 p.m., stating, I am sorry this happened to you today. I will pull the call light report tomorrow and talk to them both. Resident 1 passed away and no interview was possible regarding the provider's follow-up with her concerns. 2. Interview on 5/27/26 at 11:20 a.m. with DON B revealed that although resident 1 had made a formal verbal abuse/neglect complaint, she did not file a facility reported incident (FRI) with the SD DOH as required. DON B verified that the initial and final FRI reports regarding resident 1's incident on 2/24/26 were not reported or submitted to the SD DOH within the required time frame. She indicated that she was aware of the SD DOH required reporting time frames and was responsible for doing so. Immediately after resident 1's complaint was brought to her attention, travel CNA C and travel CNA D were both suspended pending the investigation results. They remained off schedule until the conclusion of the investigation. Because the SD DOH was included in the emailed complaint by resident 1, DON B thought that the email had fulfilled their reporting requirement. The facility's investigation into the incident did not verify verbal abuse had taken place, as it was witnessed by three staff members and they all stated no abuse had occurred. The allegation of neglect for the long response time to resident 1's call light was validated. DON B interviewed resident 1 after the incident and the resident was satisfied with the provider's response to the incident. Travel CNA C and travel CNA D acknowledged they were assisting another resident when resident 1's call light was initiated and that she had to wait a long time for staff assistance. Resident 1 required three staff to assist her with transfers, so they needed a third staff member to come in to assist them, which delayed her care. Travel CNA C and travel CNA D were educated about responding promptly to call lights along with all other nursing staff. Travel CNA C and travel CNA D were both contracted travel staff and their contracts were not renewed. They were unavailable for interview during this survey. No documentation was provided that proved education was completed for all staff regarding this incident. 3. Interview on 5/28/26 at 4:10 p.m. with DON B and administrator A revealed incidents that required reporting to the SD DOH were abuse/neglect, falls with injury, medication errors, falls with unknown origin, allegations, and missing medications. Allegations, falls of unknown origin, and falls with major injury were to be reported to the SD DOH within two hours. All other incidents needed to be reported to the SD DOH within 24 hours. The final investigation report needed to be submitted to the SD DOH within five days. Administrator A and leadership staff were responsible for completing the initial and final FRI reports to the SD DOH. Both administrator A and DON B acknowledged the facility should have submitted a FRI to the SD DOH for resident 1 and failed to do so. They had also failed to document the education that was provided to all staff. But all annual abuse/neglect education was up to date with their staff. 4. Review of the provider's 4/9/26 SD DOH FRI initial report involved resident 6 who was on hospice care. He had a physician's order for Morphine (an opioid medicine prescribed for pain relief). The medication was administered to him on 2/19/26 and 2/20/26. The medication count was correct, but the nurse on 4/2/26 believed the original blue color of the liquid Morphine was a lighter blue color, and again on 4/9/26. The pharmacy was consulted and confirmed if the Morphine was lighter in color to assume it was tampered with, but there was no way to verify the medication in the bottle. The facility's final report revealed the Morphine color discrepancy was reported to the director of nursing (DON) B on 4/2/26 and again on 4/9/26 had notified registered nurse (RN) J who investigated the Morphine and found that it was lighter in color when she drew it into a syringe; it looked more like water than Morphine. The staff who worked on that unit were interviewed on 4/9/26 regarding the color of the Morphine. Licensed practical nurse (LPN) L reported she did recall the color, LPN M thought it always looked lighter, LPN N noted it was blue to her, contracted LPN O noted it was blue and she [he] thought it looked a lot lighter, and LPN P was unsure. 5. Interview on 5/28/26 at 11:25 a.m. with DON B regarding reporting resident 6's morphine revealed she had forgotten to inform her other staff to begin the investigation of the Morphine on 4/2/26 because she was involved in a family emergency. She stated on 4/9/26 the liquid Morphine's lighter color was brought to her attention again, and she had RN J investigate the Morphine color discrepancy as a possible drug diversion. She stated the amount was correct and her staff had signed off on their shift-to-shift report (a report that the staff signed and acknowledged the controlled substance amount was correct). She acknowledged she submitted the report to the state for the possible drug diversion late and knew it was reportable. She called her supervisor, and she was given a verbal warning for submitting the report late. 6. Interview on 5/28/26 at 4:15 p.m. with administrator A revealed she expected incident reports to be completed at the required time and submitted to the SD DOH. 7. Review of the provider's Abuse Reporting and Response policy published in September 2017, revealed, The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law. Staff immediately reports all alleged or suspected violations to the supervisor and Executive Director. The Executive Director or designee reports alleged violations to the state survey agency and other officials in accordance with state law.as follows: Immediately but not later than 2 hours-All allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, if the events that cause the allegation involve abuse or result in serious bodily injury. Note-reporting requirements are based on real clock time, not business hours. The Center reports the results of all investigations to the Executive Director and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident. The Center identifies staff responsible for implementation of corrective actions, expected date of implementation, and those responsible for monitoring. Additional training is conducted with staff, and staff competency is evaluated as necessary. Failure to report suspicion or allegations of abuse timely by staff will result in disciplinary action up to and including termination.

A. Based on interview, record review, document review, and South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, the provider failed to ensure the staff responded promptly to four of five sampled residents (1,2,4,and 5) who reported they had to wait a long time for their call light to be answered. Findings include: 1. Interview on 5/26/26 at 12:30 p.m. with resident 5 revealed he was admitted to the facility recently and was unhappy with the care he received from the staff. When he first came to the facility, he needed more assistance from the staff because his muscles were weaker at that time. His call lights were not answered quickly, and there were times that he was incontinent (involuntary urine or bowel leakage) before the staff arrived which embarrassed and upset him. Now that he was stronger, he avoided using his call light. He was frustrated with waiting for the staff to respond and said, they are here for me and not the other way around. 2. Review of resident 5's electronic medical record (EMR) revealed his Brief Interview for Mental Status(BIMS) assessment score was 15, which indicated he was cognitively intact. He had diagnoses of chronic respiratory failure with hypoxia (not enough oxygen in the blood which makes it difficult to breath), chronic obstructive pulmonary disease (an ongoing progressive lung condition that damages the airways and makes it increasingly harder to breathe), multiple sclerosis (an autoimmune disease that affects the brain, spinal cord and optic nerves), and congestive heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently). Resident 5's 2/18/26 revised care plan indicated he needed the assistance of one staff member with transfers when he was first admitted . He got stronger with physical therapy (PT) sessions and on 3/25/26 was cleared by PT to take himself to and from the bathroom and be independent within his room. 3. Review of resident 5's call light response time report (a report that indicated how long a call light was on before it was turned off) from 2/13/26 through 3/11/26 revealed he had 20 call light response times over 15 minutes long and six call light response times over 30 minutes long. He moved to a new room within the nursing home on 3/11/26. From 3/11/26 through 5/28/26 in the new room location, he had four call light response times over 15 minutes long, two call light response times over 30 minutes long, and one call light response time that was over 53 minutes long. 4. Review of resident 1's 2/24/26 emailed complaint sent to the SD DOH complaint department at 6:12 p.m. revealed resident 1 had also sent her complaint email to director of nursing (DON) B, and administrator A. The email stated she pushed her call light at 4:30 p.m. on 2/24/26 when she was finished on the toilet, and there was no response from the staff for nearly an hour. Contracted travel certified nursing assistants (CNAs) CNA C and CNA D entered her room and told resident 1 she needed to use better time management. They were delivering resident meal trays and were unable to assist her at that time. When they assisted her from the toilet to her wheelchair, her bare buttocks touched the arm of her wheelchair and the CNAs refused to clean the arm of the chair when she requested it. It was then cleaned by another staff member. DON B responded to resident 1's complaint email on 2/24/26 at 8:43 p.m. stating, I am sorry this happened to you today. I will pull the call light report tomorrow and talk to them both. 5. Review of the provider's grievance form for resident 1's 2/24/26 complaint and interview with DON B on 5/27/26 at 11:15 a.m. revealed that resident 1's call light was not answered for 57 minutes. Travel CNA C and travel CNA D were suspended pending their investigation. A skin assessment by nursing was completed on resident 1 with no skin alteration identified following the incident. When interviewed by DON B, both travel CNA C and travel CNA D, who were named as the staff responsible in resident 1's complaint, stated they were in another resident room at the time. They confirmed that resident 1 had waited an extended time for a response. Resident 1 required the use of a Hoyer mechanical lift (a mechanical lift and sling used to lift a person's full body) with the assistance of three staff members, which made it difficult for a timely response. Education was given to travel CNA C and travel CNA D to ensure response times for all resident call lights were completed promptly. DON B interviewed resident 1 after the incident, and she was satisfied with the results of the investigation. Resident 1 was not available for interview during the survey as she passed away in April 2026. 6. Documentation was requested to confirm that all staff were re-educated about abuse, neglect of care, and answering call lights promptly. No documentation was provided before the survey exit. 7. Review of resident 1's closed EMR revealed her Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. She had diagnoses of edema (excess fluid trapped in the body's tissues), morbid obesity (excess weight that creates a serious health hazard that can significantly reduce life expectancy), chronic obstructive pulmonary disease, and osteoarthritis (a chronic degenerative joint disease where the protective cartilage cushioning the ends of the bones gradually wears away causing the bones to rub together usually causing pain and stiffness). 8. Review of resident 1's call light response time report for 2/24/26 revealed she had two call light response times over 15 minutes long, three call light response times over 30 minutes long, and one call light response time that was over 57 minutes long. 9. Review of the provider's 4/23/26 SD DOH FRI regarding resident 2 revealed DON B was in his room asking about his plan of care since he admitted on [DATE]. He informed DON B that there was an incident with the staff that made him mad over the last weekend. He had put his call light on for assistance to use the restroom, and the staff came into his room, turned off the call light, and left. He waited over an hour for the staff to return to assist him, and by that time he was incontinent of urine. DON B identified travel CNA Q was the CNA who had come to resident 2's room, turned off his call light, and did not return. Travel CNA Q was immediately suspended pending the facility's investigation, which validated neglect had occurred. Travel CNA Q resigned on 4/27/26 when informed of the investigation results and did not return to the facility. 10. Review of resident 2's closed EMR revealed his BIMS assessment score was 10, which indicated his cognition was moderately impaired. His 4/22/26 care plan indicated he was independent with transfers at times, but needed moderate staff assistance at other times. Resident 2 was discharged from the facility on 5/4/26. 11. Review of resident 2's call light response report from 4/26/26 through 5/4/26 revealed he had 6 call light response times over 15 minutes long. 12. Interview on 5/27/26 at 11:20 a.m. with DON B confirmed she had met with resident 2 on 4/23/26 to check on how the staff were taking care of resident 2's needs. He informed DON B that he was upset about a situation over the past weekend when a CNA answered his call light, turned off the call light, and did not return to assist him. This resulted in an incontinent episode for him. He waited over an hour for staff assistance and was upset that this had happened. He did not report the incident at the time to any staff member. With the description resident 2 provided DON B, she was able to identify that travel CNA Q was the staff responsible. DON B immediately suspended travel CNA Q until their investigation of the incident could be completed. When the investigation concluded, the provider confirmed the incident had occurred as reported by resident 2. Travel CNA Q resigned when she was informed of the investigation results and did not return to the facility. Abuse and neglect education was provided to all staff on 4/30/26. 13. Interview on 5/27/26 at 3:05 p.m. with resident 4 revealed she had concerns with long call light response times from the staff. The response times had gotten worse in the past few months, and she had waited more than an hour for assistance at times. Some staff would come into her room, shut off the call light and then leave again without assisting her. She was frustrated about that. She had a supra-pubic catheter (a flexible tubing surgically placed through the abdomen into the bladder to drain urine), and the insertion site was to be cleaned daily by the nursing staff. She preferred to receive her catheter care assistance for times when she was already in her bed or wanted to lay in her bed. She required two staff members to assist her with transfers with a sit-to-stand mechanical lift (a mechanical lift used to assist from a seated to a standing position). In the mornings, she preferred to have assistance by 9:00 a.m. The amount of time she had to wait for her call light to be answered depended on who was working. The contracted travel staff generally were not as fast at responding to her call light. At times she needed to request pain medication from the nurse, and the wait could feel long if she was already in pain. She had overheard the CNAs and nurses voice their frustration with there not being enough walkie-talkies to go around for everyone to use during their shift. The walkie-talkies alerted the staff when a call light was activated by the residents, and if one was not available, they would have to watch the monitor at the nurse station for that information. There were no call light indicators outside of the resident room doorways or audible sounds that sounded within the resident rooms. If the staff did not have a walkie-talkie for the day, it made it more difficult for them to be aware of when a resident's call light was activated. 14. Review of resident 4's EMR revealed her BIMS assessment score was 15, which indicated her cognition was intact. She had diagnoses of rheumatoid arthritis (a chronic autoimmune disease where the immune system mistakenly attacks the lining of the joints), morbid obesity, Parkinson's disease (a progressive disorder of the central nervous system that primarily affects movement), and neuromuscular dysfunction of the bladder (nerve damage that disrupts communication between the brain, spinal cord, and bladder muscles). Resident 4's 4/17/26 care plan indicated she required the assistance of two staff members with transfers and the use of a sit-to-stand mechanical lift. 15. Review of resident 4's call light response report from 4/28/26 through 5/28/26 revealed she had 28 call light response times over 15 minutes long, and one call light response time that was 1 hour and 16 minutes long. 16. Interview on 5/26/26 at 12:53 p.m. with certified medication aide (CMA) E revealed there were not enough walkie-talkies to go around for all of the scheduled staff at times. When this happened, the staff had to check the computer screen at the nurse stations for any activated resident call lights. Her expectation was to answer the call lights as soon as possible. To her knowledge, the facility did not have an expected call light response time. 17. Interview on 5/26/26 at 12:58 p.m. with CNA F revealed there were not enough walkie-talkies available for all staff. For the staff who did not have a walkie-talkie, they would not be alerted of an activated resident call light unless they checked at the nurse station computer monitor. 18. Interview on 5/27/26 at 8:54 a.m. with activities aid/CNA G revealed the facility had a problem with not having enough walkie-talkies available for all scheduled staff to use. There were long call light wait times for the residents. The staff sometimes took the walkie-talkies home or forgot to take them out of their pocket before leaving the building. There were frequently staff calling in and not showing up for their scheduled shift, which reduced the number of CNAs available to assist the residents with their needs. She was not aware of the facility's expectation for resident call light response times. 19. Interview on 5/27/26 at 2:10 p.m. with CNA H revealed there were not enough walkie-talkies available for all staff who were scheduled. The staff without a walkie-talkie would have to check the nurse station often to see if there were any call lights activated. She had known resident 1 well and had a good relationship with her. Most of the complaints from resident 1 involved contracted travel staff who had resisted doing things in the order that she instructed them to do. There were no issues if the staff followed resident 1's instructions for her care in the order that she preferred. CNA H was not aware of the facility's expectation for response time to call lights. Her expectation was that call lights be answered as quickly as possible, within just a few minutes of being activated. 20. Interview on 5/27/26 at 2:42 p.m. with LPN I revealed there were times that the walkie-talkies were not available for all staff to use because some staff would forget to turn them in at the end of their shift and take them home. During busy times such as meals, activities, or a resident emergency, call light wait times could be delayed. She was not aware if the facility had an expectation for how quickly staff were to respond to call lights. 21. Interview on 5/28/26 at 3:20 p.m. with staff development/RN J, DON B, and RN unit manager K revealed staff development/RN J was responsible for ensuring the staff were up to date on their training and education. She expected that the staff were trained to answer all call lights promptly. The facility did not have a policy for call light response times. The staff should not enter a resident's room, turn off the call light, and then leave without assisting the residents. There was not a designated time established that the call lights were expected to be answered by the staff. The facility leadership had conducted interviews with the residents, and the feedback that was received indicated that a response time of under 15 minutes was generally acceptable for the residents. They looked at call light response times and assessed the results each month. They analyzed the call light audit reports and tried to find ways to improve the call light response times. When there were staff who called in or the staff did not show up for their shift, the leadership staff assisted with answering resident call lights to ensure a timely response for the residents. 22. Interview on 5/28/26 at 4:10 p.m. with administrator A revealed they did not have a policy or procedure for call light response times. But her expectation for staff response to call lights is less than 15 minutes. During busy times, it may be longer, but she would expect CNAs to answer all call lights within 15 minutes of activation. She confirmed they had problems with the availability of walkie-talkies for all scheduled staff and were working on a solution. B. Based on interview, observation, record review, and document review, the provider failed to ensure the nursing staff were provided clear instructions to care for the physician ordered condom catheter care for one of one sampled resident (5). Findings include: 1. Interview and observation on 5/27/26 at 3:35 p.m. with resident 5 revealed he used a condom catheter during the night. The nursing staff were to ensure that the condom catheter was on each night and removed in the morning. What upset him was that the nursing staff did not come in each night and ensure his catheter needs were met. He felt the nursing staff should be assisting him without him having to make a request. The condom catheter was to be removed in the morning, and the nursing staff did not ensure the tubing and catheter bag were stored properly. The nursing staff expected him to rinse out and store his catheter bag and tubing independently. His catheter bag and tubing were not replaced for six weeks or longer and had a very strong urine odor. He felt it was the nursing staff's responsibility to ensure his catheter needs were met, and he should not be expected to do it himself or to have to request supplies from the nursing staff. His catheter tubing, which was wrapped around a dresser drawer handle, was attached to a catheter bag and was located in his bathroom. There was a strong urine odor surrounding the catheter bag and tubing. It was not stored inside a bag for infection control purposes, and there was no date to indicate when it was last replaced. 2. Review of resident 5's EMR revealed he had a 2/19/26 physician's order for a condom catheter to be applied at night prn (as needed). His care plan indicated an intervention for his condom catheter added on 3/10/26 that stated, condom catheter 26mm [millimeter] on at HS [hour of sleep] off at AM, per patient request. Review of resident 5's February 2026, March 2026 and April 2026 treatment administration record (TAR) revealed an entry for condom cath [catheter] on at night and off in the morning every night shift. Resident 5's TAR since his admission indicated the nursing staff had documented that his condom catheter care was completed. 3. Interview on 5/27/26 at 4:15 p.m. with LPN I revealed she was not sure what the nursing staff was responsible for regarding resident 5's condom catheter care. The overnight staff took care of that, and it was removed before the day shift staff arrived. She was unable to find instructions for his catheter care, but stated it should be on resident 5'sTAR for the overnight shift staff. Instructions for what was expected to be done should have been listed in resident 5's care plan and on his TAR. At times, he came to the nursing station and requested catheter supplies. She thought he was doing his catheter care mostly independently, and the nurses just checked with him to ensure he had what he needed. He could be demanding at times, but she agreed it should not be his responsibility to request new supplies when needed or to clean and store the catheter bag and tubing when not in use. 4. Interview on 5/27/26 at 4:35 p.m. with DON B revealed there were no physician instructions for how often resident 5's catheter tubing and bag were to be replaced. Because it was a condom catheter and it was not inserted into his body, she had researched and found no guidance on how often the tubing and bag were to be replaced. She would not have expected to need a physician's order for that. She acknowledged that new staff may not know the expectations of what needed to be done for resident 5's condom catheter because it was not clear in his care plan or on his TAR, and the instructions should be clarified. The catheter bag and tubing should have been stored inside a dated storage bag indicating when they were last replaced, which was their policy. She expected the nursing staff to store his catheter tubing and catheter bag in a dated catheter bag in his bathroom to avoid any infection control concerns. 5. Interview on 5/28/26 at 3:20 p.m. with staff development/RN J confirmed she had discovered resident 5's condom catheter tubing and bag was stored inappropriately in his bathroom. She replaced them, and put them in a dated storage bag in an appropriate area. She agreed that the information on resident 5's TAR and care plan did not have enough information regarding his catheter care instructions, and a new nurse may not know what to do. The catheter bags and tubing should be stored in a catheter bag, dated and changed weekly. 6. Review of the provider's resident handbook revealed In a spirit of partnership, we design care plans that embrace your individual preferences, desires, and needs to the best of our ability. Here are some standard skilled nursing services you may receive: 24-hour clinical care, comprehensive wound care, post-acute care, intravenous and enteral therapies, restorative nursing care .catheter care. 7. Review of the provider's revised 3/19/25 Infection Control Policy revealed The objectives of facility infection control policies, protocols, and practices are to .support maintenance of a safe, sanitary, and comfortable environment for personnel, residents, and visitors.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), document review, interview, and policy review, the provider failed to secure a controlled medication (medication with risk for abuse and addiction), for one of one sampled resdient (7)'s Dilaudid (an extremely potent schedule II prescription opioid painkiller) that was received at the facility on 3/20/26 was not accounted for the following day on 3/21/26. Findings include: 1. Review of the provider's 3/20/26 SD DOH FRI revealed on 3/21/26 resident 7's Dilaudid was unaccounted for. The Dilaudid was received and signed for by licensed practical nurse (LPN) S from the pharmacy. That Dilaudid was taken by LPN S to the Hall 400 medication room, but was not properly signed or secured in the locked medication cart. The next day, on 3/21/26, the certified medication could not be found by the medication aide (CMA) T, and she notified the nurse. The medication was confirmed to be missing after a facility-wide search was completed. The pharmacy confirmed the medication was sent to the facility and had not been returned. Leadership, authorities, and resident 7 was notified of the incident. 2. Review of the pharmacy shipping manifest revealed resident 7's Dilaudid 2 mg (milligram) was received at the facility in the quantity of 60 tablets on 3/20/26. 3. Interview on 5/27/26 at 3:30 p.m. with director of nursing (DON) B revealed she was notified of the missing medication on 3/21/26, and she, along with other staff, completed a facility-wide search for that medication. She had completed staff interviews, and those who were immediately involved with the signed-in medication and not securing it were terminated for not following the facility process of checking in a controlled medication and securing it. The medication was signed in as received at the front desk from the pharmacy and left in the locked medication room. The medication was not locked in the locked medication cart drawer as it should have been. The CMA had seen the medication in the medication room, but did not put the medication into the locked medication cart drawer or tell anyone before she left. DON B stated LPN R had seen the medication and placed it by LPN S, but did not lock it up. DON B acknowledged that the medication should have been double locked in the medication cart. She did not think to view the camera footage and was not sure how long the footage was available. The CMAs and nurses had keys to the medication rooms. DON B stated she did not completed medication audits until they had another incident of a controlled medication of morphine being diluted. 4. Interview on 10/28/26 at 10:51 a.m. with administrator A revealed that the facility camera footage went back 30 days, and any footage of the incident was no longer available. 5. Review of the provider's undated Controlled Medication Storage policy revealed that scheduled II-V medications must be maintained in separately locked, permanently affixed compartments.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure the staff provided supervision and accident prevention interventions according to the resident's care plans for one of one sampled resident (2) who fell and sustained multiple facial fractures when left unsupervised in the dining room by a nursing staff member and one of one sampled resident (4) who fell from a mechanical lift when being transferred by certified nursing assistant (CNA) L. Findings include:1. Review of the provider's 11/24/25 SD DOH FRI regarding resident 2 revealed:*On 11/24/25 at 1:45 p.m. resident 2 was found face down on the dining room floor.*The fall was not witnessed.*This was resident 2's third fall in the dining room.*Staff had left him in the dining room to finish eating his meal while they assisted other residents.*Upon a nurse assessment resident 2 had blood coming from his nose and a cut on the top of his nose.*Resident 2's family was notified and requested that he be evaluated in the emergency department.*The injuries identified while in the emergency department were, Multiple facial fractures [broken bones in the face] including bilateral [both sides] [NAME] fractures [patterns of midface bone breaks] (probable combination of left-sided [NAME] III [3; severe break that can separate the entire midface from the skull base involving the cheekbones, eye sockets, and nasal bridge] superimposed upon [NAME] I [1; the upper jaw separates from the skull]), left-sided zygomaticomaxillary complex fracture [involves the cheek bone and the connections to the cheek bone], and comminuted nasal bone fracture [nasal bone shattered into multiple pieces].*Resident 2 was receiving hospice services prior to the fall on 11/24/25 and died on [DATE].2. Review of resident 2's electronic medical record (EMR) revealed:*He was admitted on [DATE].*His 11/19/25 Brief Interview of Mental Status (BIMS) assessment score was 0, which indicated his cognition was severely impaired.*His diagnoses included repeated falls, progressive supranuclear ophthalmoplegia (a rare, degenerative brain disorder causing gradual worsening of movement, balance, vision, speech, and swallowing), dementia (a group of symptoms affecting memory, thinking, and social abilities), and anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability).*He was placed on hospice on 11/18/25 and died in the facility on 11/29/25.*He fell in the dining room on 6/17/25 at 9:10 a.m., on 10/25/25 at 10:45 a.m., and again on 11/24/25 at 1:30 p.m.*On 6/17/25 he was found in the dining room lying face down on the floor. A dietary staff member was in the dining room at the time he fell. There were no injuries identified with that fall.-The fall prevention intervention identified on 6/18/25 after the interdisciplinary team (IDT) review was, Do not leave resident in the dining room unattended without [a] CNA [certified nursing assistant].*On 10/25/25 he was found in the dining room lying face down on the floor. He sustained a cut near his left eye and required an emergency room visit for treatment. There was no staff in the dining room to monitor him and his chair was not reclined.-The 10/27/25 fall intervention was, Ensure resident is not taken to dining room early. Should be in room or where staff can visualize him.*On 11/24/25 he was again found lying on the floor in the dining room face down. His nose was bleeding, and he had a cut to the bridge of his nose and was transferred to the emergency room for treatment after he had fallen in the dining room and he returned to the facility on [DATE] at 6:40 p.m.-The interdisciplinary team (IDT) note written by administrator A dated 12/1/25 on the 11/25/25 fall incident report stated fall prevention interventions were, 1.) Staff educated not to leave resident in dining room unattended. 2.) Med [medication] aide will obtain meals and assist resident to start right away upon arriving at dining room so that he might be done around the time staff are assisting residents out of the dining room. 3.) Interventions added to care plan.*Review of resident 2's care plan that was last revised on 12/1/25 revealed an identified problem of, The resident is at risk for falls r/t [related to] Gait/balance problems, Unaware of safety needs, psychotropic [drugs that affect brain activities associated with mental processes and behavior] use, antihypertensive [medications used to treat high blood pressure].-Identified interventions for that problem area included that staff were to: Continue to use two staff members for all transfers due to hx [history] of fainting at times with transfers which was initiated on 6/10/24, Assist resident back to room after eating, not to leave him alone in dining room which were initiated on 6/18/25, Ensure resident is not taken to dining room early. Should be in room or where staff can visualize him and Resident not to be left alone in dining room which was initiated on 10/27/25, Staff was educated on not leaving him alone in dining room which was initiated on 11/25/25, and [Resident 2] cannot be in the dining room alone and for the med [medication] aide to start him eating as soon as he arrives which was initiated on 11/26/25.*Review of resident 2's care plan last revised on 12/1/25 revealed an identified problem of, Potential for Nutrition Hydration issues r/t mechanically altered diet and swallowing difficulties d/t [due to] progressive supranuclear palsy.-Identified interventions for that problem were, Diet: Pureed and moderate thick liquids which was initiated on 10/7/24, Aspiration Precautions(steps taken to prevent food, liquid, or saliva from entering the lungs), and I eat out in [the] dining room due to my risk for choking which was initiated on 7/16/25.3. Interview on 12/17/25 at 11:36 a.m. with certified medication aide (CMA) I revealed:*She had worked on 11/24/25 when resident 2 fell, unwitnessed in the dining room.*She stated resident 2 had gotten up for lunch late, so he did not start eating his lunch at the beginning of the meal service.*CMA I had been told by registered nurse (RN) G that CNA M was to remain in the dining room with resident 2 until he finished eating.*A resident came out of the dining room and told her that resident 2 had fallen.*She then entered the dining room, and there was blood on the floor from resident 2's nose and a cut on his face. She was not sure what he had hit his head on when he fell.*She stated that the daily staffing assignments identified the staff member assigned to the dining room on each hallway for each shift, but the staff member assigned to remain in the dining room often did not.*CMA I stated a resident, such as resident 2, should not have been left unattended in the dining room, especially because he had difficulty with swallowing and was at risk for aspiration.4. Interview on 12/17/25 at 1:40 p.m. with director of nursing (DON) B revealed the provider did not have policies about care planning, resident dining, or resident dining assistance.5. Review of the provider's 11/24/25 Daily Staffing Assignment sheet revealed:*RN G was the nurse assigned to resident 2's hallway, CMA M was the medication aide, the CNAs were CNA M and CNA J. CNA M was identified to be the staff member assigned to the dining room for the day shift.*The Daily Staffing Dining sheet also stated, All resident cleared out prior to laying residents down, Refrain from breaks during resident meal times, and Med-Aids [medication aides] and Nurses are to assist in [the] DR [dining room].6. Interview on 12/18/25 at 9:02 a.m. with RN G revealed:*She was the nurse assigned to resident 2's hallway on 11/24/25, when he fell in the dining room.*When she returned from her lunch break, she was alerted by activity staff N that resident 2 was lying on the floor in the dining room face down.*That was not the first time resident 2 had fallen out of his chair in the dining room while he was unsupervised.*After the staff assisted resident 2 off the floor, RN G applied pressure to the bleeding from his face and nose. When she applied pressure she felt crunching in his face.*Resident 2 was then taken to the emergency department by his family.*RN G stated there were no nursing staff members in the dining room at the time of resident 2's fall.*A nursing staff member was to remain in the dining room while resident 2 was in there.*RN G identified CNA J as the staff member who was supposed to have remained in the dining room that day.*RN G had spoken to CNA J twice that day because she had left the dining room unattended.*She stated that it had been a struggle to keep a staff member in the dining room to supervise the residents because there were so many other tasks they needed to complete on the main floor.*Staff had been educated after resident 2's previous falls in the dining room that someone was to remain in the dining room until he was finished eating and could be removed from the dining room.*RN G verified resident 2 was required to be closely monitored while he ate because of his difficulty swallowing and his risk for aspiration.7. Interview and record review on 12/18/25 at 9:31 a.m. with CNA J revealed:*The CMAs were supposed to assist the residents during meal time because the CNAs had too many tasks to complete on the floor during meal times.*She verified that on 11/24/25 she was instructed by RN G to remain in the dining room to monitor the residents, but she did not because she was assisting CNA M with resident care needs.*She had told RN G that she was not able to remain in the dining room that day.*CNA J agreed that a staff member needed to remain in the dining room while the residents were present to monitor for the residents' safety.*She stated the person responsible for remaining in the dining room was identified on the Daily Staffing Assignment sheet, and the CMA for resident 2's hallway was always assigned to the dining room during the lunch service.*She referred to the resident's care plan to determine what cares a resident required, and verified that resident 2's care plan reflected he was not to be left in the dining room unsupervised.8. Interview on 12/18/25 at 1:55 p.m. with DON B revealed:*She was hired after resident 2's 11/24/25 fall, but she had reviewed the records and documentation related to that fall.*After resident 2 fell in the dining room on 10/25/25, care plan was updated to include that he was not to be left unsupervised in the dining room.*After he fell on [DATE] his care plan was updated to include that the CMA was to get resident 2's meal early to allow him enough time to eat because he was a slow eater and that would minimize the time after the meal a staff member would have to remain in the dining room to supervise him.*She had not considered resident 2 as being unsupervised during his fall on 11/24/25 because there was an activity staff member in the dining room.*She verified a resident who had an altered diet and was at risk for aspiration needed to be monitored by a nursing staff member, which included resident 2.-She agreed that on 11/24/25 resident 2 was not supervised in the dining room by a nursing staff member at the time he fell.*She expected the nurse to be sure the staff member assigned to the dining room remained in the dining room while residents were present.*DON B stated CNA J should not have told RN G no when RN G asked her to remain in the dining room, and DON B expected the CMA to be in the dining room while residents were present.*Resident 2's care planned intervention to be supervised in the dining room by a nursing staff member was not followed when he fell on [DATE].1. Review of the provider's 12/16/25 SD DOH FRI regarding resident 4 revealed:*On 12/16/25 at 8:30 a.m. CNA L was transferring resident 4 with a sit-to-stand mechanical lift (a mechanical lift used to assist from a seated to a standing position off the toilet to return to his chair.*During the transfer resident 4's hands slipped off the lift's handlebars, and resident 4 started to slide out of the lift.*CNA L called for assistance as she unbuckled resident 4's legs from the sit-to-stand lift and assisted him to the floor.*RN F and staff development RN entered resident 4's room, assessed him, and transferred him into his chair.*The provider's investigation of the fall from a sit-to-stand lift revealed that the lift was functioning properly, but CNA L did not follow resident 4's care plan, which indicated he was to be transferred with the sit-to-stand lift and the assistance of two staff members.2. Interview on 12/17/25 at 10:49 a.m. with DON B regarding resident 4's 12/16/25 falling incident revealed:*CNA L used the sit-to-stand lift correctly, but did not follow resident 4's care plan, that indicated two staff members should have assisted resident 4 with the use of that lift while transferring the resident.*CNA L was given disciplinary action and provided education on mechanical lift use and following a resident's care plan.3. Review of resident 4's EMR revealed:*He was admitted on [DATE].*His diagnoses included Parkinson's disease (a progressive neurological disorder that leads to symptoms like tremors, stiffness, slow movements, and balance problems), weakness, and abnormality of gait (walking) and mobility.*His 6/17/25 Morse Fall Scale assessment score was 40, which indicated he had a moderate risk for falling.*Review of resident 4's 12/17/25 care plan revealed an identified problem area that indicated The resident is at risk for falls r/t [related to] Gait/balance problems, [and is] Unaware of safety needs which was initiated on 2/5/24.-On 1/17/25 his bathing, chair to chair, chair to bed, and toilet transfer needs were identified as needing the use of a sit-to-stand lift with the assistance of two staff members due to his not standing well in the sit-to-stand lift.4. Interview on 12/17/25 at 4:20 p.m. with RN F revealed:*She was the nurse on duty on 12/16/25 when resident 4 fell from the sit-to-stand lift.*She and staff development RN O assessed resident 4 after the fall and determined he was not injured as a result of the fall.*CNA L was transferring resident 4 from the toilet to his chair.*CNA L told RN F that resident 4's hands began to slip off the handlebars on the lift, and she lowered him to the foot stand on the sit-to-stand lift.*RN F stated that since resident 4's 12/16/25 falling incident, he was transferred with the use of a full body mechanical lift (a mechanical lift and sling used to lift a person's full body), but prior to that, he was transferred with the use of a sit-to-stand lift and the assistance of one staff member.*She stated if she needed to know how a resident was to be transferred, she would refer to the resident's Kardex (a report of the resident's care needs and interventions) or the cheat sheet (a document that identifies residents' care needs and interventions).*RN F identified a sheet dated 12/14/25, with a list of residents and some of their basic care needs information, such as how each resident was to be transferred.*That cheat Sheet dated 12/14/25 identified that resident 4 was to be transferred with 2 [staff members to] assist [with the use of an] ez stand [sit-to-stand lift].*RN F stated she was not aware that resident 4 needed the assistance of two staff members to be transferred and was unsure when that had changed.5. Interview on 12/18/25 at 11:00 a.m. with CNA L revealed:*CNA L worked at the facility for two years.*She would reference the resident's Kardex if he needed to know how a resident transferred.*She stated he was learning how to use the Kardex to access how a resident's cares were to be provided. *On 12/16/25 while she was transferring resident 4 off the toilet, he let go of the right handlebar on the lift and then his left hand gave out. CNA L unbuckled the leg strap and assisted resident 4 to the floor.*CNA L stated she was not aware resident 4 was to be transferred with the assistance of two staff members while in the sit-to-stand lift because he previously was to be transferred with the assistance of one staff member.6. Interview on 12/18/25 at 1:50 p.m. with DON B revealed:*She expected the staff to follow the residents' care plans.*CNA L had not followed resident 4's care planned intervention to transfer him, which resulted in his falling from the sit-to-stand lift.*She agreed that staff members not following a resident's care plan had the potential to place a resident's safety at risk.7. Review of the provider's January 2025 Fall Management and Neurological Check policy revealed:*The center implements a fall management plan based on medical history review and resident evaluation. The center monitors neurological signs following head injury or suspected head injury.*The residents [resident's] care plan is reviewed quarterly and after a fall to determine effectiveness of current intervention and considers the residents [resident's] goals, choices and preferences .A systematic review of current interventions is completed post fall and root cause is identified.*In the event of a head injury or fall that is unwitnessed and the occurrence leads the nurse to conclude a head injury is likely, neurological checks are initiated.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review the provider failed to ensure one of one sampled resident (1) who committed suicide had received the necessary behavioral health services to treat a diagnosed serious mental illness.Findings include:1. Review of the provider's 12/11/25 SD DOH FRI regarding resident 1 revealed:*On 12/11/25 at 12:50 a.m. a CNA (certified nursing assistant) responded to resident 1's roommate's call light and found resident 1 hanging by a string around his neck off the side of the bed.*That CNA had assisted resident 1 with his urinal at approximately 11:00 p.m. during the routine two-hour rounds (periodic checking on residents' status and assistance needs).*The CNA notified the nurse, the nurse responded to resident 1's room and cut the string that the resident was hanging from.*At the time resident 1 was released from the side of the bed he was cyanotic (bluish discoloration of the skin, lips, or nails due to the lack of oxygen in the blood), his body was cold to the touch, and there was no pulse, or respirations.*The CNA discovered a goodbye note on resident 1's bedside table.*Resident 1 had a do not resuscitate (DNR) directive on record at the facility.*Law enforcement and resident 1's family were notified.*Law enforcement arrived at the facility at 1:15 a.m., and requested that the staff leave the resident's room as the investigation was conducted.*Resident 1's body was released to the funeral home at 2:15 a.m.*The preliminary investigation suggested resident 1 had raised his bed into the highest position, placed a string around his neck, and moved his body off the side of his bed independently. 2. Review of resident 1's electronic medical record (EMR) revealed:*He was admitted to the facility from a hospital on [DATE].*His 10/31/25 Brief Interview of Mental Status (BIMS) assessment score was 12, which indicated his cognition was intact.*His diagnoses included depression.-Suicidal ideations (thoughts of suicide) was not included on his diagnosis list.*There was a 10/27/25 physician's order for Escitalopram Oxalate Oral Tablet 20 MG [Milligrams] (Escitalopram Oxalate) [a medication used to treat depression] Give 1 tablet by mouth one time a day related to depression.*Resident 1's 10/27/25 Level II (2) Preadmission Screening and Resident Review (PASRR) revealed:-Resident 1 was taking Lexapro (Escitalopram) medication for depression.-He had made statements in the past about suicide.-He fell into the category of having a diagnosis that the PASRR program was designed to assess. Your condition is likely to require expert treatment in the future.--The reason for that decision was indicated as, You have a condition of Depression, unspecified that has impacted your day-to-day needs and has led to the need for mental health and medication management services to treat your mental health needs.- You need 24/7 [24 hours per day/ 7 days per week] care and supervision to ensure your health and safety because you may neglect self-care, your daily activities, and your medications due to your physical limitations, and mental health diagnoses.- You will need to be provided the following specialized services:Psychiatric medication management/monitoring:Individual mental health therapy:- You should see a psychiatrist, psychiatric nurse practitioner, or primary care physician to assess your medications to see how well they are working for you at treating your symptoms. The frequency of your visits can be determined by your treatment team.- Counseling (optional) can help you adjust to the changes you've had in your health, and you can learn new coping skills for managing your mental health symptoms.*His 10/31/25 PHQ-9 (a tool used to assess for depression) score was 5, which indicated he had mild depression symptoms.*On 11/3/25 resident 1 had an initial visit to evaluate their psychiatric conditions and determine if [redacted company name] can assist in the management, education and support of these conditions. At that time, he consented for Behavioral Health Integration (BHI) and Collaborative Care Management (CoCM) services.-BHI and psychiatric CoCM services, including the scope of care coordination, availability of 24/7 access to clinical support, and the monthly non-face-to-face nature of services-The note from that visit indicated he denied having suicidal ideations, homicidal ideations, or hallucinations.*An 11/19/25 progress note written by Minimum Data Set (MDS) coordinator D stated, Visited with resident today about his mood. Smiling as he visits with this writer. Stated some days I am more down than others. Stated 'I am [AGE] years old and I do not know why I am still here' as he smiled at this writer. Spent time talking with resident about how none of us know how long we will have, and that it is all in God hands. Asked this writer if he feels his antidepressant medication needs to be increase. [resident] Stated 'No, some days I am just more down than other days.' Counseling was offered to resident [1] at care conferences- [the resident] declined.*An 11/26/25 progress note at 9:02 a.m. written by licensed practical nurse (LPN) resident care manager (RCM) H stated, This writer spoke with [resident 1's family member]. She explained that [the] resident expressed 'I don't want my oxygen and I want to get rid of my meds [medications] I just want to go. If I had a gun or knife I would just do it.' His concerns are about taking care of his family and is reporting he was interested in hospice.*Two additional progress notes written by LPN/RCM H on 11/26/25 stated, Resident denies having a plan of harming himself and Spoke with resident [who] did mention feeling 'down' as his wife is home sick. But denies having any thoughts of suicide.*A 12/4/25 care conference progress note indicated resident 1's wife and son attended the care conference. It was reported [that] resident 1 had a decline in therapy. Discuss hospice vs [versus] continuing skilled therapy to see if resident can get stronger again. Family wished to continue therapy. Wife still hopes to take [the] resident home.*A 12/5/25 interdisciplinary team (IDT) meeting progress notes stated resident 1 copes with stressful situations by verbalizing suicidal comments or negative comments and the latest talk is that [the] resident may not besafe [be safe] to be at ho me.*There were no further progress notes regarding resident 1's suicidal ideations or his mental health status. 3. Review of resident 1's 11/26/25 through 12/11/25 daily skilled assessments revealed no documented notes or assessments to resident 1's mental health status or mood. 4. Review of resident 1's 10/22/25 psychiatry note revealed:*He was referred to psychiatry for evaluation of, worsening mood, functional decline, and suicidal ideations.* He described increased psychological distress, marked by feelings of hopelessness, worthlessness, and being a burden to his family.* He reported being unable to reach the bathroom independently, contributing to embarrassment and loss of dignity. These limitations have led to frustration and a profound sense of helplessness.* He stated that 'everything is falling apart' and that he is 'just wanting to die'. He expressed both passive and active suicidal ideations, stating he has 'finally made up [his] mind' to end his life.* He acknowledged that if a firearm were available, he would use it, though his family previously removed all guns from the home after similar statements. He further indicated he might consider alternative methods if available, expressing these thoughts with seriousness and resolve.*During resident 1's 10/22/25 psychiatry visit resident 1's spouse, expressed concern about his escalating despair and agreed that additional psychiatric intervention and structured support are needed.* The addition of Seroquel was discussed to address mood instability and sleep disturbance. Given his advanced age, male gender, medical frailty, chronic pain, and persistent suicidal ideations, he is considered high risk for self-harm. Plans are underway for transfer [him] to a skilled nursing facility to provide closer supervision, reduce caregiver strain, and ensure safety.* The treatment plan and need for ongoing psychiatric management were discussed in detail with the patient [resident 1] and his wife, both of whom were receptive to the recommendations.*Resident 1's intent is serious. Long-term suicide risk is high due to multiple non-modifiable risk factors and ongoing distress. Short-term suicide risk is moderate to high given active ideation, intent, and lack of current means, but with close monitoring and removal of firearms, risk is somewhat mitigated.* Increase supervision and safety monitoring through [his] transition to [a] skilled nursing facility. 5. Review of resident 1's 10/27/25 discharge summary revealed:*Resident 1 was seen by psychiatry during his hospital admission.*Psychiatry had recommended, having 24- hour supervision at local SNF [skilled nursing facility], continuing Lexapro 20 mg daily, and adding Seroquel 25 mg nightly for mood stability and insomnia.* Patient did reported [report] improved mood on the day of discharge.*Seroquel was not listed on the discharge medication list.*Follow-up with psychiatry services was not documented in the discharge summary. 6. Interview on 12/18/25 at 8:06 a.m. with medical director E revealed:*He was made aware of resident 1's suicide on 12/11/25 and reviewed resident 1's nursing home and hospital records.*While resident 1 was in the hospital just prior to being admitted to the facility he was seen by psychiatry for suicidal ideations with a suicide plan.*Psychiatry started him on Seroquel, an antipsychotic (a drug that alters neurotransmitters activity in the brain to reduce symptoms of mental health conditions) on 10/22/25 that he was able to take at bedtime.*When he was discharged from the hospital to the nursing home the discharging doctor documented there was improvement while he was on the Seroquel but did not order the Seroquel to be continued at the nursing home.*The psychiatry note had included a recommendation of increased supervision during resident 1's transition to the nursing home but identified his suicide risk classification as low.*Medical director E stated he expected the nursing home staff to review resident 1's records from the hospital and to have noticed the psychiatry note and discharge summary which had not continued the order for the Seroquel, even though it was noted to have improved resident 1's symptoms.*Resident 1 had seen his primary care doctor after he admitted to the nursing home on [DATE] and 12/4/25.-Neither of the progress notes on those dates from his primary care provider mentioned resident 1's mental health or suicidal ideations.*Medical director E expected resident 1's primary care provider to have reviewed the resident's notes from the hospital, which included the psychiatry note and the discharge summary.*Medical director E was not aware that resident 1 had suicidal ideations while he resided at the nursing home.*He expected that resident 1's primary care provider would have been notified of resident 1's suicidal ideations, even if it was reported to a family member and not directly to staff.*If resident 1's primary care provider had been notified of the suicidal ideations, medical director E would have expected the primary care provider to have developed a plan with psychiatry and to have made adjustments and recommendations to resident 1's medications or mental health plan of care.*Medical director E expressed that it was concerning to him that resident 1's mental health had only been addressed on the day of his reported suicidal ideations and there was no continued monitoring for his safety.*He stated he felt that there could have been measures put into place for resident 1's safety, such as searching his room for means of suicide and moving him to a room closer to the nurses' station to allow for increased supervision.-Resident 1's room was located at the end of the hall, where he was not easily visible to staff. 7. Interview on 12/18/25 at 11:40 a.m. with social services director (SSD) C revealed:*She completed the PASRR screenings and reviewed them to be sure the recommendations on the PASRR level II were implemented.*She was involved with residents' mental health services in addition to the resident care managers.*She was aware of resident 1's suicidal ideations, but was not aware of how serious it was.*When she talked about the resident's suicidal ideations during his admission assessment, resident 1 laughed about it, and his wife stated that resident 1 would talk about committing suicide anytime he was in a stressful or bad situation.*During the 12/4/25 care conferences, it was discussed that resident 1 may not be safe to go home due to his decline in therapy. Resident 1's son had stated he would be the bad guy and tell resident 1 he was not able to go home.-SSD C did not know if resident 1's son had told resident 1 that information prior to resident 1's suicide.*SSD C confirmed that after the initial mental health visit on 11/3/25, resident 1 had not been seen again by the contracted mental health services.*She verified that the services provided to resident 1 by the provider's current contracted mental health service were inconsistent.-The provider had changed to that contracted mental health service in October 2025 and they did not have a routine schedule for seeing residents.*SSD C was not asked to visit with resident 1 after the report of his suicidal ideations.*She did not know if resident 1 was referred for emergency mental health services with [redacted name] after his reported suicidal ideations.*She did not know resident 1 had suicidal ideations while he was in the hospital.*Resident 1 was not provided with any additional supervision measures when he was admitted to the facility or after his reported suicidal ideations after he resided at the facility.*She verified resident 1's care plan had not been updated to include more than a history of suicidal ideations.-She did not think staff would have understood that resident 1 had current suicidal ideations with his care plan only indicating a history of them, and the care plan should have been updated to include his current suicidal ideations. 8. Interview on 12/18/25 at 12:15 p.m. with MDS coordinator D revealed:*She was made aware of resident 1's suicidal ideations during the leadership meeting on 11/26/25.*Resident 1's care plan should have been updated to include his suicidal ideations while he resided at the facility and updated with interventions.*Resident 1 had not expressed interest in participating in any activities while he resided at the facility and ate most of his meals in his room. 9. Interview on 12/18/25 at 12:25 p.m. with LPN/RCM H revealed:*The information captured in the daily skilled assessment was determined according to what the resident had been admitted to the facility for, such as therapy or wound care.*If, during the resident's stay at the facility, there was a concern identified that was not related to what the resident was admitted for , she would expect a separate progress note to be entered with that information.*On 11/26/25 she was notified by resident 1's family member that resident 1 had expressed suicidal ideations to her.-Resident 1's family member told her that he had made suicidal comments before while he was in the hospital.-She was not aware that resident 1 had suicidal ideations and a suicide plan while he was in the hospital.*LPN/RCM H stated she followed up with resident 1 on 11/26/25, and he denied having a plan and made no further comments related to suicidal ideations.*She expected the corporate staff, who identify potential admissions, would have included the information about suicidal ideations with a plan while he was in the hospital in his admission information.*She did not know if resident 1's primary care provider had been notified of his suicidal ideations at the facility.*She verified his primary care provider should have been notified of his suicidal ideations.*Nursing staff had not been updated on resident 1's active suicidal ideations or to monitor him more closely because his daughter-in-law had made it sound like that was something he always said.*The nurses were not instructed to monitor more closely or to document behaviors or statements in resident 1's EMR. She thought resident 1's family member would give the nurses more information if it was needed.-LPN/RCM H stated she knew that was not best practice, but resident 1 did not say things to staff members that he said to his family.*She did not know if anyone had looked through his room for a means to commit suicide after he expressed his suicidal ideations.*She stated staff should have been notified to increase monitoring of resident 1, and resident 1's care plan should have been updated to include his active suicidal ideations with a suicide plan and interventions related to that.*LPN RCM H verified that resident 1 had not received increased monitoring or supervision as was recommended within the psychiatry notes after he was admitted to the nursing home or after his reported suicidal ideations. 10. Interview on 12/18/25 at 2:05 p.m. with DON B revealed:*All potential resident admissions referred from the hospital were reviewed by a corporate staff member.*If the corporate staff member had a concern related to the admission referral, she would send the potential resident's history and physical, psychiatry notes, and progress notes to the facility's nursing department for review.*DON B was not aware that resident 1 had suicidal ideations with a suicide plan in the hospital and saw psychiatry.*She stated that the nursing staff should have been notified of his suicidal ideations and a suicide plan while he was in the hospital, so he could have been evaluated by the provider to determine if the nursing home could have provided the services, he required to keep him safe.*Resident 1 did not receive increased supervision and monitoring when he was admitted or after he reported suicidal ideations while he resided in the facility.*She stated resident 1's primary care provider was not notified of resident 1's suicidal ideations because he denied having suicidal ideations to the staff.*The provider did not implement any interventions after resident 1 reported his suicidal ideations.*No one had looked in resident 1's room for potential methods of suicide after he expressed his suicidal ideations.*Resident 1's care plan was not updated to include active suicidal ideations with a plan or interventions to be used. 11. Interview on 12/17/25 at 1:40 p.m. with director of nursing (DON) B revealed:*The provider did not have a physician notification policy.*The provider used Lippincott Manual of Nursing Practice 12th edition for a professional standard reference and the federal regulations for physician notification.*Resident 1's physician was not notified of his 11/26/25 suicidal statement because he had made the statement to a family member.-The family member who resident 1 reported his suicidal ideations to was a staff member in the facility.*The provider did not provide an increased in monitoring of resident 1's mental health and safety after he expressed the suicidal ideations.*She stated staff could document within resident 1's daily skilled assessments if there were concerns with resident 1's mood or behavior.*Review of the provider's interventions in response to resident 1's suicide with DON B included:-All staff had been provided education to remain with a resident if they were to report thoughts of suicide and notify the nurse immediately.-All residents had a PHQ-9 assessment completed and their primary care provider was notified if the resident had a score that was concerning for depression.-The provider was completing audits related to the PHQ-9 scores and physician notification. 12. Review of the provider's Lippincott Manual of Nursing Practice 12th edition revealed:Depression* Observe [resident] for sadness, apathy, feelings of worthlessness, self-blame, suicidal thoughts, desire to escape, worsening of mood in the morning, anorexia [abnormal loss of appetite], weight loss, sleeplessness, lessening interest in sex, reduction of activity, or ceaseless activity.* Anticipate that the patient [resident] may be suicidal.* Attempt to find out if the patient [resident] has thoughts about or an attempted suicide and the lethality of the suicide plan.* Do not leave the patient [resident] alone because suicide is usually an act committed in solitude.* Refer for psychiatric consultation or to a psychiatric unit.Suicide Ideations* Assess for risk factors:-Associated psychiatric illness.-Personality traits such as aggression, impulsivity, depression, hopelessness, borderline personality disorder, or an antisocial personality.-Persons who have experienced early loss, decreased social support, chronic illness, or recent divorce.* Determine whether [the] patient [resident] has communicated suicidal intent, such as preoccupation with death or talking about someone else's suicide.* Determine whether [the] patient [resident] has ever attempted suicide- the risk is much greater in these people.* Determine whether there is a specific plan for suicide and a means to carry out the plan.* If there was no active attempt made, use crisis intervention (a form of brief psychotherapy) to determine suicide potential, discover areas of depression and conflict, find out about the patient's [resident's] support system, and determine whether hospitalization, psychiatric referral, and so forth is warranted.* Prevent further self-injury -a patient [resident] who has made a suicide gesture may do so again.* Arrange follow-up care, or admit to hospital or psychiatric unit, depending on assessment of suicide potential.

Based on observation, interview, and record review, the provider failed to ensure one of one sampled resident (3) had a palm protector (a foam device that fits over the hand to prevent severe finger contractures (curling) from digging into the palm) applied as ordered by the physician for contracture management of his right hand. Findings include:1. Observation on12/17/25 at 4:00 p.m. of resident 3 revealed he was seated in his recliner with a blanket covering his lap. His hands were on top of the blanket. His right hand was curled tightly, with his fingers appearing to be digging into the palm of his hand. Observation and interview on 12/18/25 at 9:30 a.m. of resident 3 in his room revealed the fingers on his right hand were curled and closed tightly. There was no device to separate his fingers from the palm of his hand. When asked if he had something to help open his hand, he stated he only wore the device when he was working. 2. Review of resident 3's electronic medical record (EMR) revealed:*His admission date was 2/24/21.*His 8/22/25 Brief Interview of Mental Status assessment score was a 6, which indicated his cognition was severely impaired.*His diagnoses included: ataxia (a nervous system dysfunction that results in poor control of voluntary movements), stiff-man syndrome (a rare autoimmune neurological disorder that commonly causes muscle stiffness and painful spasms), dementia (a group of symptoms affecting memory, thinking, and social abilities), mood disorder, weakness, repeated falls, malignant neoplasm of the brain (cancer), and epilepsy (a brain condition causing repeated seizures).*A 9/18/24 physician's order to wear a Palm protector on [his] right hand during the day and off at meals. every [Every] day shift for contracture management.*His December 2025 treatment record revealed on 12/17/25 and 12/18/25, the palm protector was documented as being applied by the day shift nurse.*A 10/10/25 nurse progress note indicated Residents [3] right hand is contracted but he is able to open it and hold onto the ez [EZ] (a mechanical lift used to assist from a seated to a standing position) stand with assistance and cueing.-A 10/23/25 nurse progress note indicated Resident [3] is transferring better in the EZ stand, standing up straighter and is able to open his right hand more, as it has been contracted. 3. Interview and record review on 12/18/25 at 9:35 a.m. with certified nursing assistant (CNA) M revealed:*She was newly hired and had worked at the facility for three days.*She had never seen resident 3 wear a palm protector.*She was provided a cheat sheet (a typed form that outlined the basic care each resident needed) by the charge nurse.*The cheat sheet was reviewed with CNA M and indicated resident 3 was to have a palm protector on in [the] morning, [and] off at bedtime. 4. Interview on 12/18/25 at 9:45 a.m. with certified medication aide (CMA) I revealed:*She knew how to care for residents by looking at their Kardex (a report of the resident's care needs and interventions). There was also a banner (an area in the resident's electronic medical record (EMR) that indicates any special instructions on how to care for a resident) that a staff member could reference for each resident.*She indicated that resident 3 wore a brace (palm protector) on his hand, and she thought that was to be in place every day.*It was the responsibility of the CNAs to put the palm protector on for resident 3, then the CMA or nurse would document in the EMR that the palm protector was placed on his right hand.-Resident 3 would be brought to the nurse's desk in the mornings for the CMA or nurse to see that his palm protector was on and to document that in his EMR.-The palm protector was to be removed at mealtimes and put back on after the meal. 5. Interview on 12/18/25 at 1:05 p.m. with director of nursing (DON) B revealed:*Resident 3 would come to the nurses' desk, and the nurse would then verify that he had his palm protector in place on his hand.-The palm protector was to be taken off when resident 3 was transferring, and for meals, and then put back on after the transfer was completed or when he was done eating.-There were no further scheduled verification checks to ensure resident 3's palm protector was placed on his hand after the transfer was completed and after his meals. 6. A policy regarding following physician's orders was requested during the survey, but it was not provided by the end of the survey period.

Based on South Dakota Department of Health (SD DOH) complaint intake review, observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were followed regarding: *Hand hygiene practices by staff members BB, GG, and HH during two of two dining observations in two of three dining rooms. *Hand hygiene and personal protective equipment (PPE) use by three of three staff observed (L, M, and BB) during personal cares for one of one sampled resident (41), personal cares for one of one sampled resident (33) on contact precautions (which indicated staff should have worn gowns and gloves), and assisting with resident transportation for two of two sampled residents (33 and 85). Failure to follow infection control practices potentially contributed to a norovirus [a highly contagious virus that causes nausea, vomiting, and diarrhea] outbreak in April 2025 which included three residents (18, 40, and 76) with confirmed norovirus infections and at least forty-two additional residents (1, 2, 3, 4, 12, 13, 14, 16, 22, 23, 24, 25, 29, 30, 31, 33, 34, 35, 36, 41, 42, 43, 45, 53, 58, 60, 64, 65, 67, 68, 69, 77, 78, 79, 80, 85, 93, 99, 100, 107, 258, and 259) with identified gastrointestinal (GI) symptoms. Findings include: 1. Review of the 4/16/25 SD DOH complaint intake form revealed: *An anonymous email reported a concern that the provider had a severe outbreak of norovirus. *The anonymous reporter was concerned the provider was not monitoring hand washing, sanitation, [and] dishwashing. *The writer was fearful for their family member that resided at the facility. 2. Review of a separate SD DOH complaint intake received on 4/16/25 revealed: *The complainant reported that resident 107 was recently hospitalized and had to be admitted to the intensive care unit (ICU). Review of resident 107's electronic medical record (EMR) revealed: *On 4/9/25, she experienced vomiting, diarrhea, weakness, and confusion. She was unable to speak coherently. *On 4/9/25 around 4:45 p.m., she was sent to the local emergency room for evaluation. -She was then admitted to the ICU for a diagnosis of pneumonia. *She continued to experience diarrhea throughout her hospitalization . *She returned to the facility on [DATE]. 3. Observation on 4/22/25 at 3:51 p.m. of certified nurse aide (CNA) M and CNA/certified medication aide (CMA) BB performing personal cares for resident 41 revealed: *Both CNAs performed proper hand hygiene before putting on clean pairs of gloves. *Resident 41 had been incontinent of bowel, and they cleaned her up and removed the soiled brief. *Without removing her gloves or performing hand hygiene, CNA/CMA BB walked over to resident 41's wardrobe and touched the door handles, rummaged around in the wardrobe, and grabbed a clean brief. *She continued to assist resident 41 with putting on the clean brief with those same soiled gloves on. *Both CNAs kept on their same pair of soiled gloves throughout the process of changing resident 41's brief, getting her cleaned up, and redressing resident 41. *Both CNAs then removed their gloves and did not perform hand hygiene. *With their unclean hands, they touched: -The resident's sling used for the full body lift. -The full body lift. -The resident's positioning pillow. -The resident's wheelchair. -The door handle to exit the room. -CNA M also touched the resident's water cup, held the straw between her right index and middle fingers, and helped resident 41 take a drink of water. *CNA/CMA BB wrapped up the trash and walked away with it down the hallway. -After she came back, she brought the full body lift out into the hallway and cleaned it. *Neither of them were observed to have performed hand hygiene after assisting the resident. 4. Interview on 4/22/25 at 4:10 p.m. with both CNA M and BB about the above observation revealed: *Neither of them realized they had missed several opportunities for hand hygiene and changing their gloves. *CNA M questioned how soon she should have performed hand hygiene after removing her gloves as she explained she came out here [the hallway] to do that, is that not soon enough? -The surveyor explained that she touched the resident's water cup and drinking straw after removing her gloves and had not yet performed hand hygiene after assisting the resident with personal care. Her contaminated hands potentially increased the risk of spreading infection. -She agreed she had done that and promptly walked away from the conversation. 5. Observation on 4/22/25 at 4:41 p.m. of CNAs L and M in resident 33's shared room revealed: *There was a sign on the door for Contact Precautions which explained what PPE each person entering the room was required to wear. -PPE was available and hanging on the door. *CNA M came out of resident 33's side of the room with no evidence that she had worn PPE while interacting with the resident. *CNA L came out of resident 33's side of the room with the full body lift and parked it in the hallway. She was not wearing any PPE. -She did not clean the lift. *She did not put on any PPE and then went back into resident 33's side of the room. *She came back out of the resident's room, wearing one glove on her left hand and was holding a small bag of trash. There did not appear to be any PPE in the small trash bag. *She was holding the bag of trash while she was pushing resident 33 in her wheelchair down the hallway. -She was touching the left wheelchair handle with the same hand that she was holding the trash with. *She wheeled the resident all the way down the 400-hallway and turned towards the rehab dining room. *By 4:56 p.m., no staff had come back to clean the lift. 6. Interview on 4/22/25 at 4:58 p.m. with licensed practical nurse (LPN) N revealed: *She confirmed that resident 33 had an order for contact precautions, but she was not sure why the resident was on contact precautions. -She wondered if it was from the gastrointestinal (GI) bug that went through the building for the past several weeks. -When reviewing resident 33's record, she confirmed that the resident had diarrhea and vomiting the previous week. *She explained that contact precautions were implemented for residents known or suspected to be infected with infectious agents transmitted [from] person-to-person. *For contact precautions, she expected staff to wear at least a gown and gloves when providing care to the resident, even for transferring. -If staff were physically touching the resident, she expected staff to wear PPE for infection control purposes. *She indicated that the contact precautions for resident 33 were no longer necessary since her GI symptoms had subsided several days ago. -She discontinued that order for contact precautions in resident 33's electronic medical record (EMR). *She did not know exactly why the contact precautions sign and the PPE were still on resident 33's door and guessed that someone may have forgotten to discontinue the precautions after she was symptom-free. *She expected staff to have followed the contact precautions signage and use the proper PPE or contact a nurse if there were any questions. 7. Interview on 4/22/25 at 5:05 p.m. with CNA L revealed: *She could not remember how long she had been working at that facility. *When asked if she knew which resident in the shared room from the above observation was on contact precautions, she indicated that she did not know how to tell which resident in that room was on contact precautions. *She confirmed that neither she nor CNA M wore gowns while interacting with resident 33, they only wore gloves. *When asked if she knew what contact precautions meant, she said that they were supposed to wear gowns, gloves, and sometimes a face shield when interacting with the resident. *She said she also caught the GI bug that was going around the facility recently. *When asked why she did not follow the contact precautions as posted on the door and in the resident's orders, she said, I don't know, that's what I was trained to do, to just follow the other CNA. *When asked how often she was to clean the lift, she indicated that it was supposed to have been cleaned after each resident's use. -She still did not clean the lift after being informed that she had not cleaned the lift after taking it out of the resident's room. 8. Observation on 4/22/25 at 5:11 p.m. revealed LPN N was removing the contact precautions sign and PPE off resident 33's door. 9. Observation on 4/22/25 from 5:34 p.m. to 5:40 p.m. in the rehab dining room revealed: *CNA/CMA BB was sitting between two residents (41 and 56) to help them eat supper. *With her bare hands, she touched her hair braids to push them back behind her shoulders. *Without performing hand hygiene, she continued to help the two residents eat their meals. -She was taking straws out of their wrappers and placing the straws into the residents' beverages, touching the resident's silverware handles, squeezing condiments out of packets, and wiping the residents' mouths with their napkins. 50915 10. Observation on 4/22/25 at 5:49 p.m. of the evening meal on the memory care unit (MCU) revealed: *Residents were not assisted with cleaning their hands before their meal. *CNA HH did not sanitize her hands before she passed the residents' meal trays. *She was observed coughing into her hand, she did not sanitize her hands after coughing, then she delivered the resident's meal tray. *There was a potentially contaminated rehabilitation cone device on the table. -A resident grabbed the cone and appeared to have been trying to take a drink from the cone as he picked it up and brought it to his mouth. -CNA HH noticed this and gently removed the potentially contaminated cone from his hands. She continued serving meal trays without performing hand hygiene. *She served nine residents their meal trays and did not sanitize her hands. 11. Observation on 4/23/25 at 9:29 a.m. of the morning meal service on MCU revealed: *Some residents were sitting at the table prior to meal service. *CNA GG did not perform hand hygiene before assisting residents with eating. *CNA GG was observed assisting a resident to eat after the resident had coughed. -The resident was not offered hand sanitizer or a hand wipe. *CNA GG then moved to another table without sanitizing her hands and assisted a different resident with eating. 12. Observation on 4/23/25 at 10:09 a.m. near the 400-hallway nurse's station revealed: *CNA M had a glove on her right hand and was holding a bag of trash. *At the same time, she was touching resident 85's wheelchair handle as she pushed him down the hallway. 13. Interview on 4/24/25 at 8:43 a.m. with resident 33 revealed: *She confirmed: -She had the GI bug earlier that month. -Staff did not put on gowns when they helped her with personal cares. *She was no longer experiencing GI symptoms like vomiting or diarrhea. Review of resident 33's electronic medical record revealed: *Her quarterly Minimum Data Set (MDS) assessment completed on 4/4/25 revealed a Brief Interview for Mental Status assessment score of 14, which indicated she was cognitively intact. *A nursing progress note from 4/8/25 that read, Contact precautions and isolation to room implemented per protocol for GI illness. *She experienced diarrhea on 4/8/25, 4/9/25, 4/10/25, and 4/11/25. *A physician's order started on 4/8/25 for Contact precautions as recommended for residents known or suspected to be infected with infectious agents transmitted person to person via the direct/indirect contact route (e.g. VRE [Vancomycin-resistant Enterococcus], Clostridium Difficile, MRSA [Methicillin-resistant Staphylococcus aureus] etc.). 14. Interview on 4/24/25 at 11:32 a.m. with LPN FF regarding resident and staff hand hygiene during meal service revealed: *There was usually hand sanitizer on the tables for residents to use before meals. *Residents were given a hand wipe to clean their hands with their meals. *It was her expectation that staff assisting residents with eating would sanitize their hands before assisting a resident, and before assisting the next resident. 15. Interview on 4/24/25 at 1:50 p.m. with CMA II revealed: *She was aware of a GI outbreak in the facility the past couple weeks. *She reported the outbreak was facility-wide and included many residents and staff members. *She reported if she were assisting residents to eat, she would sanitize her hands before assisting residents, then after assisting them before she assisted another resident. 16. Interview on 4/25/25 at 10:15 a.m. with resident care manager registered nurse (RN) G revealed: *She was a the provider's infection preventionist. *There was an outbreak of norovirus in the facility during April 2025. *They tested three residents, each from different wings of the facility, all were positive for norovirus. *After that initial testing, all residents with GI symptoms (nausea, vomiting, diarrhea) were assumed to have norovirus and were tracked for infection control purposes. *Residents with symptoms were placed on contact precautions to prevent further spread of the virus. *Residents remained on contact precautions for 24 hours after symptoms stopped. 17. Interview on 4/25/25 at 10:51 a.m. with director of nursing services (DNS) B and division director of clinical services (DDCO) C revealed: *DNS B recently started her position at the facility on 4/7/25. *Since the resident GI symptoms started on 4/8/25, she was fully aware of the GI outbreak. -In her time at that facility, she noted concerns in infection control such as hand hygiene. *On 4/8/25, residents who were experiencing diarrhea and vomiting were placed on contact precautions. *The staff collected and sent stool cultures to the laboratory for testing from three residents that had GI symptoms (residents 18, 40, and 76). Those residents resided in different areas of the facility. On 4/12/25, those stool culture results came back positive for norovirus. *Both DNS B and DDCO C appeared disappointed when they were informed about the above observations. -They expected staff to have followed the provider's policies on hand hygiene, glove use, and contact precautions. *A total of 45 residents were affected. -The census at the time of the survey was 104. 18. Review of the provider's Line listings for infections by resident tracking sheet revealed: *Between 4/6/25 and 4/14/25, a total of 45 residents (1, 2, 3, 4, 12, 13, 14, 16, 18, 22, 23, 24, 25, 29, 30, 31, 33, 34, 35, 36, 40, 41, 42, 43, 45, 53, 58, 60, 64, 65, 67, 68, 69, 76, 77, 78, 79, 80, 85, 93, 99, 100, 107, 258, and 259) had been identified to have GI symptoms. 19. Review of the provider's March 2018 handwashing/hand hygiene policy revealed: *Policy statement: This Center considers hand hygiene the primary means to prevent the spread of infections. *Procedure: -1. Personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -2. Personnel follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 20. Review of the provider's May 2015 Initiating Transmission-Based Precautions policy revealed: *Policy Statement: Transmission-Based Precautions are initiated when there is reason to believe that a resident has a communicable infectious disease. -Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. *Procedure: -1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor notified the Infection Preventionist and the resident's Attending Physician for appropriate Transmission-Based Precautions. - .4. Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occur after pertinent criteria for discontinuation are met. -5. When Transmission-Based Precautions are implemented, the Infection Preventionist or designee: --a. Validates protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; --b. Posts the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. This Center's process for notification is signage . -6. In an emergency, the Infection Preventionist, [Executive Director], and/or Medical Director have the administrative authority, accountability, and responsibility to: --a. Institute actions necessary to control or prevent infections within the Center; --b. Notify the health department of reportable diseases, as appropriate; --c. Initiate isolation precautions; --d. Obtain laboratory specimens; --e. Restrict or ban admissions; --f. Restrict or ban visitations; --g. Implement other measures as necessary to prevent and control infections within the Center. 21. Review of the provider's March 2025 Transmission-Based Precautions (Isolation) policy revealed: *Policy Statement: Transmission-Based Precautions (previously referred to as isolation precautions) are implemented for residents known to be, or suspected of being, infected with infectious agents. *Procedure: -1. Use Transmission-Based Precautions in addition to Standard Precautions. -2. The four types of Transmission-Based Precautions may be used alone, or in combination for diseases that have multiple routes of transmission. Determination of use is based on how the infectious agent is transmitted. --Contact precautions. --Droplet precautions. --Airborne precautions. --Enhanced barrier precautions. -3. The need to implement Transmission-Based Precautions is determined by the [facility's] Infection Preventionist (IP), Director of Nursing and/or consultation with the local health department. Precautions are based on CDC [Centers for Disease Control and Prevention] guidelines. Precautions are the least restrictive possible for the resident. -4. The facility documents in the resident's medical record the rationale for the type of transmission-based precautions selected as well as the length of time the precautions is maintained. -5. Communication of Transmission-Based Precautions is accomplished with the pertinent signage and verbal reports to personnel and visitors. -6. Residents on TBP [Transmission-Based Precautions], apart from EBP [Enhanced Barrier Precautions], should remain in their room for the duration of precautions, except for medically necessary care or resident choice. -7. Indirect transmission of infectious agents can occur through contact with resident care equipment. Whenever possible, personal care items such as thermometers, stethoscopes, blood pressure cuffs and gait belts will be dedicated for use by the resident needing contact, droplet, or airborne precautions. All reusable items, including glucometers and other point-of-care devices are cleaned using appropriate disinfectant after using the devices with individual residents. *Contact Isolation Precautions: -Contact, or touch, is the most common and most significant mode of transmission of infectious agents. Contact transmission can occur by directly touching the resident, through contact with the resident's environment, or by using contaminated gloves or equipment. -Personnel having contact with the infected resident should wear gloves and a gown. -Prior to leaving the resident's room, gown and gloves are removed and hand hygiene performed. -Options for residents on contact precautions may include a private room, cohorting with another infected or colonized resident or sharing a room with a resident with limited risk factors (no immunosuppression, IVs, indwelling catheters or open skin lesions). -Residents with wound drainage, fecal incontinence, or diarrhea, that cannot be contained, should be placed on contact precautions until a specific organism for the origin of the medical issue is identified.

Based on interview, observation, record review, and policy review, the provider failed to ensure effective pest control for flying ants for one of twenty-six sampled residents (91) who complained of flying ants in his room and ant bites on his back. Findings include: 1. Interview and observation on 4/23/25 at 10:56 a.m. with resident 91 in his room revealed he stated: *He was having a problem with flying ants in his room. *The problem was daily and he had killed 30 to 40 of the flying ants every day. *The maintenance guy thinks they are coming in from behind [the] heater that was located on the wall below the window in his room. *Every morning his bedside table was covered with them and four to five of the flying ants were in his bed. -He had bites all over his back from the flying ants. -Resident 91 lifted the back of his shirt and showed his back which appeared to have several small red marks on his mid back. *Resident 91 stated he had been having problems with the flying ants for several weeks. -He stated I can feel them [flying ants] when they bite, they grab your attention. *He stated that yesterday (4/22/25), staff had asked him if he would like to move to another room, but he liked his current room. -He was asked to vacate his room for a couple of hours, and said that three staff members had been in his room. -When he woke up this morning (4/23/25), there were around 40 flying ants on his nightstand. *There were three dead flying ants on his nightstand which he stated he had killed with a tissue. *Maintenance assistant X was outside the resident's window with a spray bottle which he used to spray at the area below the window. *A round container of ant bait was on the floor by the window next to the heater on the wall. *A liquid ant bait was on the floor by the wall at the head of resident 91's bed. 2. Observation on 4/23/25 at 11:22 a.m. revealed resident 91 walked into the hallway with his walker and stated he had a bug on his window screen. Upon entering his room, an active flying ant was observed on the window screen in his room. 3. Observation and interview on the morning of 4/24/25 with resident 91 and staff in his room revealed: *At 7:55 a.m. the resident was in his room eating his breakfast and he: -Stated that social services director (SSD) E had brought in his breakfast that morning. -Pointed to seven dead flying ants on his nightstand, and stated he had used a paper napkin to kill them. -Stated five flying ants were in his bed that morning. *At 7:58 a.m. maintenance supervisor (MS) W and SSD E entered his room and asked him about moving to another room. -SSD E offered to move him to another room so they could deal more effectively with the flying ant problem. -SSD E escorted the resident out of the room to show him the other room. -MS W stated they had been working on the flying ant problem for a few weeks: --They had offered to move the resident multiple times. --He had a bug control contractor in to service resident 91's room and he would provide those invoices. *At 8:06 a.m. SSD E stated the resident had agreed to move to the other room that day. 4. Interview on 4/24/25 at 8:15 a.m. with restorative aide Y regarding the problem with flying ants revealed she had seen flying ants in a room on the 500 hallway and a room on the 400 hallway: *In the 400 hallway's room, she had seen flying ants about a week ago, but not since then in that room. *She felt the flying ant problem in the 400 hallway's room had been taken care of. 5. Interview on 4/24/25 at 9:30 a.m. with administrator A regarding the flying ants revealed he had: *A pest control company come into the facility to service the affected room, and after several treatments, the pest control company had told him they could not do anything more regarding the flying ants. *Staff deep cleaned resident 91's room on Tuesday, 4/22/25, as they felt the snacks resident 91 kept in his room had attracted the flying ants. *They had also set out bait traps to help with the flying ants. 6. Interview on 4/24/25 at 4:33 p.m. with resident 91 in his new room revealed: *He stated he was moved into the room by 10:30 a.m. that morning. *The staff had moved his bed and recliner from his other room. *He had not seen any flying ants in his current room yet. 7. Observation on the afternoon of 4/24/25 of resident 91's previous room revealed: *At 4:39 p.m. the room was empty except for one dining room chair and an overbed table. -Two live and active flying ants were noted on the window screen in the room. -There was a sticky strip hanging from the ceiling by the window. -There were three (Product name) liquid ant baits noted on the floor by the base board. -An ant bait was by the heater unit on the floor below the window. *At 4:46 p.m. certified medication assistant/certified nursing assistant (CMA/CNA) BB entered the room and confirmed there were two flying ants on the window screen. 8. Interview on 4/25/25 at 11:00 a.m. with resident 91 in his new room revealed he stated: *He hasn't seen a bug yet and was in a good mood. *Had a good night's sleep and had slept for ten hours. 9. Interview on 4/25/25 at 11:03 a.m. with SSD E revealed she had become aware of the issue with the flying ants yesterday, 4/24/25. When she had delivered resident 91's breakfast tray into his room he had stated he was having a problem with the flying ants in his room. 10. Interview on 4/25/25 at 11:21 a.m. with MS W revealed: *He had reviewed his records. He had become aware of the flying ants in resident 91's room on 4/11/25 when a work order was entered into their electronic maintenance software system called Technology-Enabled Life Safety (TELS). *In response, they had done the following in resident 91's room: -Deep cleaned resident 91's room as they felt the snacks resident 91 kept in his room had attracted the flying ants. -Placed containers of ant bait on the floor in resident 91's room. -Sprayed ant killer on the outside of the facility by resident 91's room. *He had requested the pest control company provide treatment for the flying ants. *He confirmed the flying ants had continued to be a problem as of 4/23/25, when resident 91 had reported the problem to the surveyor. 11. Interview on 4/25/25 at 12:15 p.m. with administrator A revealed he had become aware of the flying ants problem at about the same time as MS W had on 4/11/25. 12. Review of the provider's invoices from the contracted pest control company revealed invoices for monthly contract services detailing: *Target: Spiders, Ants, Roaches. *Location: Interior Baseboards, Kitchen. *On the following dates: -1/8/25. -2/3/25. -3/5/25. -4/1/25. *There was no documentation of the pest-control company having an additional visit or involvement after 4/1/25. Review of an e-mail communication from the provider's contracted pest control company revealed a message on 4/24/25 at 8:34 a.m. stated We were there for monthly scheduled service on March 4th and April 1. We did an extra call on March 21st to spray for ants . Interview on 4/24/25 at 4:55 p.m. with administrator A revealed the provider had no invoice from the contracted pest control company for 3/21/25, but he verified they had provided service at the facility on that date. Review of the requested provider's TELS Work Orders regarding the flying ants revealed: *Work Order #3833 created on 4/11/25 at 3:43 p.m. by licensed practical nurse (LPN) Z regarding resident 91's room indicated: -Comments: Resident states that he has flying ants coming in his room by his window. -Updated Status: 4/14/25 at 10:48 a.m. Set to Completed by maintenance assistant X. --Notes: Housekeeping deep cleaned area, Maintenance checked area and posted Ant traps, resident offered to move and declined. *Work Order #3847 created on 4/17/25 at 7:42 a.m. by CMA AA regarding resident 91's room indicated: -Notes: Resident stated he killed about 15-20 bugs located in his bed and inside of his dresser. Resident states that the strips in the windows do not serve a purpose. -Updated Status: 4/18/25 at 2:54 p.m. Set to Completed by maintenance assistant X. -Notes: [Maintenance assistant X] 04/18 [4/18/25] Traps have been placed, sprayed for bugs, housekeeping has been notified to deep clean [that room] regularly. *Work Order #3858 created 4/22/25 at 6:55 a.m. by LPN N regarding room [ROOM NUMBER]. -Updated Status: 4/22/25 at 7:36 a.m. Set to Completed by MS W. -Notes: House keeping deep cleaned residents [resident's] room, found many food particles all over [the] ground. Maintenance silicone sealed flooring and pest control had recently been out to spray. Also Ant traps placed. Review of the provider's May 2015 Pest Control policy revealed: *Purpose: To provide an environment free of pests. *Procedure: The Center has a pest contract that provides frequent treatment of the environment for pests. It allows for additional visits when a problem is detected. -Monitoring of the environment is done by the Center's staff. Pest control problems are reported promptly.

Based on observation, interview, record review, and policy review, the provider failed to follow standard food safety practices to ensure: *Prepared foods were covered when stored in one of one walk-in cooler. *The food stored in the walk-in cooler was stored appropriately to prevent cross-contamination. *Potentially hazardous food was prepared, stored, and served at safe food temperatures for one of one observed meal service. Findings include: 1. Observation on 4/22/25 at 3:15 p.m. of the walk-in cooler in the kitchen revealed: *A tray of 21 individual servings of chocolate pudding in reusable dessert bowls on a tray rack that were not covered and were open to air. *A shelving unit that contained on its: -Top shelf a cardboard box containing a plastic package of sliced beef that was fully cooked and another cardboard box containing three plastic packages of sliced smoked fully-cooked ham. -Top shelf, a laminated sign zip tied which displayed Safe Refrigerator Storage . with a chart that directed to store: --Ready-to Eat Foods on the top shelf. --Raw Fish and Seafood on the second shelf. --Raw Beef on the third shelf. --Raw Pork on the fourth shelf. --Raw Ground Beef or Pork on the fifth shelf. --Raw Poultry Raw Eggs on the bottom shelf. -Second shelf a cardboard box of Texas Smoked Brand Layflat Bacon that contained strips of raw bacon. --The cardboard box was observed with a small amount of water on top of it. --The box contained a label that stated KEEP FROZEN. -Third shelf, a metal container of turkey slices covered with tin foil dated 4/22. -Bottom shelf, a plastic tub of lettuce mixed with shredded cheese covered with tin foil that was not labeled or dated. --That ready-to-eat salad was stored underneath the cardboard box of raw bacon strips, with water on top of the box, having the potential for cross-contamination. 2. Interview on 4/22/25 at 3:24 p.m. with an unidentified staff member who walked into the cooler regarding the container of salad that was stored on the bottom shelf revealed he replied, I'm not a cook and left the walk-in cooler. Observation and interview on 4/22/25 at 3:26 p.m. with food and nutrition services (FANS) cook S who walked into the cooler regarding the container of salad stored on the bottom shelf revealed she: *Lifted the tin foil covering, looked at the salad, and stated it had been made that day and would be served at the supper meal. *Had not moved the container of ready-to-eat salad stored on the bottom shelf underneath the cardboard box of raw bacon strips. Observation on 4/22/25 at 5:40 p.m. in the main dining room of the evening meal revealed the meals served to the residents included a lettuce salad. Observation on 4/23/25 at 9:03 a.m. of the walk-in cooler in the kitchen revealed the plastic tub of lettuce mixed with shredded cheese was not in cooler. Interview on 4/23/25 at 9:04 a.m. with FANS cook T regarding yesterday's observations of the shelving unit in the walk-in cooler with the ready-to-eat salad stored below the cardboard box of raw bacon strip revealed he agreed that it created the potential for cross-contamination and was a problem. Interview on 4/23/25 at 9:09 a.m. with administrator A in the kitchen regarding the concern with the storage of ready-to-eat salad stored below the cardboard box of raw bacon strips in the walk-in cooler revealed he agreed with the concern for cross-contamination and stated, We've been working on that a lot. Interview on 4/24/25 at 11:32 a.m. with regional dietitian I regarding the ready-to-eat salad stored below the cardboard box of raw bacon strips in the walk-in cooler revealed she agreed that had for potential cross-contamination and it would not have been stored according to the provider's Safe Refrigerator Storage reference. 3. Observation on 4/24/25 at 11:10 a.m. of the walk-in cooler revealed a tray cart was in the cooler with trays of: *Plated egg salad sandwiches covered with clear plastic wrap. *Bowls of egg salad covered with clear plastic wrap. Observation and interview on 4/24/25 during the noon meal service in the kitchen revealed: *FANS cook U was dishing the prepared food onto plates for the residents. *FANS cook V was placing the plates of prepared food onto individual serving trays. *Regional dietitian I and FANS manager H were observing the process. *At 11:49 a.m. FANS cook V pulled a plate with an egg salad sandwich covered with plastic wrap from the tray rack in the walk-in cooler to serve to a resident. -Regional dietitian I used a food thermometer and took the surveyor 43021 requested temperature reading of the prepared egg salad sandwich, which was 53.4 degrees Fahrenheit (F). -That temperature was requested as certain foods are considered more hazardous than others and are called potentially hazardous foods (PHF) or Time/Temperature Controlled for Safety (TCS) food. --PHF/TCS foods include eggs. --PHF/TCS foods must be maintained at or below 41 degrees F for food safety. *FANS cook U stated: -The egg salad mixture had been prepared the day before (4/23/25), using hard-boiled eggs and mayonnaise and then placed into the walk-in cooler overnight. -She had made the sandwiches with that egg salad mixture that morning (4/24/25) at 10:00 a.m. and then had put those egg salad sandwiches into the walk-in cooler. *Regional dietitian I took the food temperature at 51.6 degrees F for the egg salad in the bowls, which she stated was for the International Dysphasia Diet Standardization Initiative (IDDSI)'s level five minced and moist diet. *At 11:52 a.m. FANS cook V pulled another plate with an egg salad sandwich covered with plastic wrap from the tray rack in the walk-in cooler to serve to a resident. *At 11:57 a.m. FANS cook V requested an egg salad sandwich and regional dietitian I pulled a plate with an egg salad sandwich covered with plastic wrap from the tray rack in the walk-in cooler and gave it to FANS cook V who served it to a resident. *At 12:01 p.m. FANS cook V requested another egg salad sandwich and regional dietitian I pulled a plate with an egg salad sandwich covered with plastic wrap from the tray rack in the walk-in cooler and gave it to FANS cook V who served it to a resident. *At 12:02 p.m. regional dietitian I used a food thermometer and took the surveyor 43021 requested temperature reading of the prepared egg salad sandwiches which was: -50.4 degrees F for the egg salad in a bowl for the IDDSI's level five minced and moist diets. -50.7 degrees F for the prepared egg salad sandwiches. -FANS cook U confirmed: --The egg salad mixture had been prepared the day before (4/23/25), using hard-boiled eggs and mayonnaise and then placed into the walk-in cooler overnight. --She had made the sandwiches with that egg salad mixture that morning (4/24/25) at 10:00 a.m. and then had been put those egg salad sandwiches into the walk-in cooler. *There was no record of any food temperatures taken of the egg salad prior to the noon meal service to support the egg salad had been in the appropriate temperature range. *Both regional dietitian I and FANS manager H agreed that the egg salad: -Was a PHF/TCS food item. -Food temperature was not maintained at or below 41 degrees F. -Should not have been served at the noon meal to residents. Observation on 4/24/25 at 3:30 p.m. of the walk-in cooler in the kitchen revealed several uncooked pizzas were on trays in a tray rack that were uncovered. Interview on 4/24/25 at 3:35 p.m. with FANS manager H revealed her expectation was for food that was stored in the walk-in cooler to be covered to prevent cross contamination. She agreed: *The individual servings of chocolate pudding in reusable dessert bowls should have been covered. *The uncooked pizzas should have been covered. Interview on 4/25/25 at 12:10 p.m. with FANS manager H regarding food storage in the walk-in cooler revealed she: *Agreed that the storage of the ready-to-eat salad below the cardboard box of raw bacon strips in the walk-in cooler had the potential for cross-contamination and was not stored safely. *Had posted the laminated sign in the walk-in cooler regarding Safe Refrigerator Storage . with a chart that displayed how to properly store ready-to-eat foods and raw meats. *Had received that Safe Refrigerator Storage . from the regional dietitian and she expected the dietary staff would follow that chart. 4. Review of the provider's October 2017 Food Storage policy revealed Raw eggs and thawing meats are stored in the refrigerator, preferably on the bottom shelf. Do not store them over ready to eat foods. Review of the provider's November 2018 Preparation and Service of Foods - Safety Precautions policy revealed: *Cooling and Cold Holding Methods: -Potentially Hazardous/Time Temperature Control for safety foods (PHF/TCS) are cooled within 4 hours to 41 F or less if prepared from ingredients at room temperature. Review of the provider's October 2017 Food Temperature policy revealed: *For potentially hazardous foods on the trayline, the temperature of the food is periodically monitored throughout the meal service to maintain proper hot or cold holding temperatures. *Corrective action is taken for food temperatures outside of regulatory standards (hot foods should be 140 F or above, cold foods 41 F or less).

Based on observation, interview, record review, and policy review, the provider failed to ensure a homelike environment that was free from foul odors for: *The physical therapy gym, the nurse's desk outside the physical therapy gym, and near the rehab dining room. *The area around the nurse's station on the 200-hallway. Findings include: 1. Interview on 4/22/25 at 3:27 p.m. with therapy director R revealed: *There was a sewer odor coming from the linen closet near the therapy gym. *A contracted company recently performed a smoke test to determine areas of poor ventilation. -Some fixes were made which helped decrease the sewer odor in one of the therapy gym rooms. -There were still periods where a sewer odor was lingering and noticeable. -The odor was worse in the morning, usually around 9:00 a.m. Interview on 4/22/25 at 5:22 p.m. with resident 30 in her room revealed: *She felt the sewer odor throughout the facility had been an issue for a long time. *She said that she was able to smell the same sewer odor on her way to the therapy gym that morning. *She had informed the administrator and other staff about the sewer odor on several different occasions. -The administrator had told her that he solved the problem, but she could still smell the odor. Interview on 4/22/25 at 5:56 p.m. with administrator A revealed: *He confirmed he was aware of the sewer odor issue near the physical therapy gym. *He confirmed a contracted plumbing company performed a smoke test to determine any areas of leaking ventilation. -He showed photos of the smoke coming out from under the wall in the therapy gym. -The drywall in that area was removed to find an uncovered pipe in the cinderblock wall. -That uncovered pipe was potentially the source of the sewer odor. -The pipe was fixed, and the wall was repaired. Observation and interview on 4/23/25 at 9:40 a.m. with resident 30 in the therapy gym revealed: *There was a distinct sewer odor near the entrance to the therapy gym. The odor grew stronger in the therapy gym. *Resident 30 was utilizing a piece of gym equipment. -She indicated that the odor had been there for years. -Her room was near the rehab dining room, and she sometimes could smell the sewer odor near her room. Review of the provider's online maintenance log revealed: *There were seven different work orders provided for review regarding the sewer odor from January through March 2025 including: -Work order #3609 titled sewer smell submitted on 1/30/25 read, Heater units checked and put water in traps to ensure that no traps are empty. [Ran] water in sinks and in bathtub as well to ensure no sewer gases are coming back out of the plumbing. -Work order #3689 titled Sewer Smell submitted on 2/27/25 read, Sink with no water in p-trap allowing sewer [gases] to escape. -Work order #3720 titled sewer smell submitted on 3/10/25 read, checked Room and did not note any odd smells but will contact vendor to smoke test. -Work order #3724 titled sewer smell submitted on 3/11/25 read, Contacted [vendor] to smoke test vents on building but they cannot be out for another week as they are booked up. Drains checked, no problems noted, there is an odor but cannot smell sewer gases. -Work order #3729 titled sewer smell submitted on 3/12/25 at 7:58 a.m. read, Still waiting for vendor to come smoke test, will check drains. The affected locations were documented as the 300 desk area [the nurse's desk outside the physical therapy gym], hallway into therapy, therapy, [staff member's] office, and OP [outpatient] therapy room. -Work order #3731 titled sewer smell submitted on 3/12/25 at 9:34 a.m. read, Still waiting for vendor. Checked room and smell is not as bad as it is being described. Will have Housekeeping spray rooms. Let staff know multiple times that we are waiting for the vendor. -Work order #3776 titled ceiling tile submitted on 3/24/25 read, ceiling tile was removed out of place in the OP room where the recent sewer gas/smoke test was completed. Review of the provider's invoice from the contracted plumbing vendor revealed: *The vendor conducted smoke tests on 3/19/25 and 4/7/25. *They found a 1.5 [inch] pipe in the block wall was not capped off. 45683 2. Observation and interview on 4/23/25 10:30 a.m. with resident 48 regarding his room located on the 200-hallway revealed: *He was lying on his bed. *There was a strong urine smell in his room. *The gray sweatpants he was wearing appeared to be wet. *He had an empty urinal that was hanging from a small garbage can next to the bed. *He did not notice any odors in his room. Interview on 4/23/25 at 9:48 a.m. with certified medication aide (CMA) O regarding the strong urine smell by the 200-hallway nurses' station revealed: *Resident 48's room had a strong urine odor that was noticeable down the hall. *Resident 48 tried to use his urinal and would sometimes spill or miss the urinal causing urine to go on the floor or other areas. *The housekeepers have cleaned resident 48's room when he allows them to. Interview on 4/23/25 at 10:19 am. with housekeeper P regarding the urine odor in the 200-hallway revealed: *She stated they have had several strange smells throughout the building recently. *They had issues with a radiator in a room and needed to call someone to fix it. *Housekeepers have done a deep clean in rooms when residents were not in those rooms. *The deep clean included mopping the floor with Ecolab Rapid Multi-surface Disinfectant Cleaner that addresses urine smells. *If she was notified of an accident or someone urinating on the floor, she would clean it up and use that chemical. Observation on 4/23/25 at 2:53 p.m. in the 200-hallway revealed: *A strong urine odor was noticeable starting near the nurses' station. *The odor became stronger and was very noticeable going down the hall, then lessened and lingered a few rooms down the hallway. Interview on 4/24/25 at 9:55 a.m. with contracted housekeeping supervisor Q regarding the urine odors in the 200-hallway revealed: *She was aware of the odors. *They had daily task sheets that the housekeepers were to fill out for each room they cleaned. *She kept those sheets for a month. *Resident 48 did not like to let people change his sheets or deep clean his room which contributed to the odors. *They tried to coordinate room cleaning with his bath day. *She did not feel housekeeping staff got a lot of help from nursing staff when trying to coordinate problem areas that needed to be cleaned to help reduce the odors. Observation on 4/24/25 at 9:55 a.m. in the 200-hallway continued to show a strong urine smell was noticeable starting at the nurse's station that odor continued past room [ROOM NUMBER]. Observation and interview on 4/24/25 at 10:22 a.m. in the 200-hallway with administrator A revealed: *He confirmed there was a strong urine odor between rooms 201 to 205. *He thought one of those rooms was the source of the odor. *He stated resident 48 had anxiety and exhibited behaviors when staff tried to clean his room. Observation on 4/25/25 at 7:58 a.m. of resident 48's room after it had been deep cleaned revealed: *It still had a strong urine smell. *The urine odor was masked by the scent of an air freshener. Review of the provider's undated 5-step Daily Room Cleaning policy revealed: *Purpose: To teach Environmental Services employees the proper cleaning method to sanitize a patient room or any area in a healthcare facility. *5. Damp mop -Remember-The procedure is to 'damp mop'-not wet mop. -The most important area of a patient's room to disinfect is the floor. This is where most airborne bacteria will settle and so it needs to be sanitized daily. -As with dust mopping, start in the far corner of the room, move all furniture necessary, and run the mop along the edges first. Never push the mop into a corner. That will only lead to build up.

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), record review, interview, and policy review, the provider failed to administer physician-ordered antibiotic treatment and monitoring for one of one resident (1) who had an infection and was readmitted to the hospital. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 1 revealed: *His Brief Interview for Mental Status (BIMS) assessment score was 7 which indicated he had moderate cognitive impairment. *He had been hospitalized and returned to the facility on [DATE] with a diagnosis of clostridium difficile (an infection that causes inflammation of the colon and diarrhea). *He had an order for Vancomycin HCI Oral Suspension 50 milligrams (mg)/milliliter (ml) give 2.5ml by mouth four times a day (antibiotic to treat infection) for clostridium difficile. *Upon his re-admission the admitting team incorrectly entered his antibiotic order into the electronic medical record (EMR) system as unsupervised medication administration (which indicated a resident gave themself the medication unsupervised). *On 11/19/24 the Minimum Data Set (MDS) coordinator registered nurse (RN) F had found the incorrect transcription error. *Resident 1 had not received any of the physician-ordered doses of Vancomycin. *Physician ordered to start vancomycin doses as originally prescribed until all doses were given. *He was readmitted to the hospital on 11/20/24 for hyponatremia (low sodium) and hyperglycemia (high blood sugar) and loose stools. *Audits were completed on all residents to ensure no one else had a medication order in their EMR for unsupervised medication administration. 2. Review of resident 1's EMR revealed: *He was readmitted to the facility on [DATE] at 12:46 p.m. following a hospitalization for a syncope episode (sudden loss of consciousness), pancolitis (a type of inflammatory bowel disease), and clostridium difficile. *He missed 16 scheduled doses of his physician-ordered vancomycin which were marked as U-SA for unsupervised self-administration (indicating he gave himself the vancomycin) on his medication administration record (MAR). *Nurses charted that he did not have any adverse side effects from the vancomycin medication on 11/15/24, 11/17/24 (three times), and on 11/18/24 (two times). *He received scheduled daily glycolax powder (used for constipation) on 11/16/24, 11/17/24, 11/18/24, and on 11/19/24. *He had bowel movements on 11/16/24, 11/17/24, 11/18/24, 11/19/24, and on 11/20/24. *A nursing progress note indicated he complained of frequent loose stools on 11/18/24 at 9:44 p.m. *He received his first dose of vancomycin on 11/19/24 at 3:16 p.m. when RN B was notified of the error and corrected the order on resident 1's MAR. *On 11/20/24 he had a basic metabolic panel (BMP) lab test completed which indicated hyponatremia and hyperglycemia and he was readmitted to the hospital. 3. Interview on 11/25/24 at 3:39 p.m. with RN B revealed: *She received education on 11/22/24 about medication administration and if they have concerns to check with the nurse manager. *She stated she was unaware of any concerns of wrong resident medication orders. 4. Interview on 11/26/24 at 8:23 a.m. with licensed practical nurse (LPN) I revealed: *An unsupervised medication administration is care planned and staff must ensure it is safe for residents to have that medication in their room and be able to administer it themselves appropriately. *If a medication is labeled as unsupervised medication administration on a resident's MAR then it would be shown as a green box. *The green box would indicate a medication had already been given during that medication pass time. *Medications shown as a red box would indicate they need to be administered. *The medication aides (CMAs) would give the residents their medications which included any antibiotics. *She stated the nurses were to chart the resident's signs and symptoms of adverse effects of antibiotics use: -They would go into the resident's room to ask the resident how they were feeling. -The nurse would not know if they had received that medication or not. 5. Interview on 11/26/24 at 08:36 a.m. with staff development RN C and resident care manager (RCM) E revealed: *They were on the admission team and would participate in the process for admitting residents to the facility. *On admission, one person would transcribe the resident's medication orders and another person would double-check they were correct. *On 11/15/24 RCM J entered the vancomycin order into resident 1's EMR as unsupervised instead of clinician by accident. *RCM J had put the vancomycin in the medication refrigerator and said the nurses were aware that it was in there. *Resident 1's discharge order from the hospital included the glycolax powder, give 17 grams by mouth one time a day for constipation (in liquid). *They changed their order entry process of the double-check for medication orders to ensure that this type of incident would not happen again. *Admit orders would be reviewed against a printed MAR to visualize any errors. *They were not aware of anyone having questioned why they were not giving a resident on clostridium difficile precautions antibiotics. 6. Interview on 11/26/24 at 9:32 a.m. with certified medication aide (CMA) H revealed: *If a resident had orders for a scheduled constipation medication, she would administer it even if they had a bowel movement. *She stated if a resident were on precautions for an infection such as clostridium difficile and they still wanted the constipation medication she would administer it. 7. Interview on 11/26/24 at 10:55 a.m. with director of nursing services (DNS) A revealed: *She stated communication among the CMAs and nurses only happened if there was an issue such as when a medication was not given. *She felt the nurse should not need to verify with the CMA that a medication had been given in order for them to complete their medication assessment on a resident because the medication should be labeled on the residents MAR as given or not given. *She agreed that the CMAs should have questioned the green box which indicated resident 1's vancomycin was already given. *She confirmed that resident 1 had not received his doses of vancomycin as ordered. *She agreed resident 1 should not have been given glycolax powder while he was on precautions for clostridium difficile and was having loose bowel movements. *Education was provided to staff to report any time a medication was shown on a resident's EMR as an unsupervised medication administration green box which would indicate the medication was already given. 8. Review of providers Certified Medication Assistant Job Description policy updated April 2019 revealed: *Administers prescribed medications to residents and maintains related medical records under supervision of Nurse. *1. Verifies identify of resident receiving medication and records name of drug, dosage, and time of administration on specified forms or records. *2. Presents medication to resident and observes ingestion or other application, or administers medication, using specified processes. *3. Takes vital signs or observes resident to detect response to specified types of medications and prepares report or notifies designated personnel of unexpected reactions. *4. Documents reasons prescribed drugs are not administered. Review of providers Medication Administration policy updated June 2017 revealed there was no indication of how nurses were to oversee medications administered by CMAs to ensure proper documentation and follow-up nursing assessments were completed appropriately.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, and interview the provider failed to ensure the safety of one of one sampled resident (1) who had a fall from the full mechanical lift and required hospitalization for injuries the following day. The citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include: 1. Review of provider's 10/4/24 DOH FRI resident 1 revealed: *On 10/4/24 at 11:30 a.m. resident fell from the full mechanical lift -Resident 1 was interviewed by staff and stated, it happened so fast I am not sure what happened. -Resident interview also indicated her legs went up in the air and head went down causing her to slide onto the floor on her back. -Her vital signs were taken and were within normal limits. -She complained of upper back pain. -She refused further evaluation. -Neuro checks (the assessment of mental status, coordination, and reflexes) were performed and were within normal limits. -She requested PRN (as needed) acetaminophen (pain medication) and to get up for lunch. -Her family and physician were notified of the fall. *Resident 1 was hospitalized on [DATE] for: -Increased hip pain as well as atrial fibrillation (AFIB), urinary tract infection (UTI), right ventricular response (RVR). -Her x-ray report showed a right hip fracture. -Non-surgical conservative treatment was recommended by an orthopedic doctor. *On 10/8/24 resident 1 was readmitted to facility 2.Review of resident 1's record revealed: *She had diagnosis including cardiomyopathy, gastro-esophageal reflux disease, constipation, hypertension, glaucoma, atrial fibrillation, major depressive disorder, and anxiety disorder. *She had a Brief Interview for Mental Status score of 13 meaning cognitively intact. *Her care plan has been updated to include use of EZ lift with assist of 2. *Care plan has been updated to include the correct sling size of medium. *72 hour neurological checks were completed following the fall. *An updated device evaluation was completed on 10/8/24. 3.Reviw of providers fall policy, dated March 2018 review revealed: *An interdisciplinary progress note, including a summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's current condition will be completed. *Nurse will complete nursing evaluation, notify necessary parties, and review resident's condition following a resident fall. *Resident's Morse scale will be updated for the resident following a fall. *The resident's family and physician will be notified following a fall. *Residents care plan will be updated to include newly identified interventions, as needed. *Nurse will complete neurological checks for 72 hours following the fall and resident's condition will be documented in nurse's notes in resident's chart. 4. Interview on 10/16/24 at 2:15 pm with CNA D and CNA E revealed: * CNA E states that she has been a CNA for [AGE] years * She reports that she has working this facility 2-3 months -She works on 400 and 500 wings -She reports that there are 2 sit to stand lifts and 2 full mechanical lifts available to use for 400 and 500 wings *CNA D states that he thinks the sling used for resident 1 at the time of the fall was too large for her. -He states that when resident 1 was lifted from her bed, she became unbalanced and slid out of the sling and onto the floor. -He states that audits are being completed regarding lifts and transfers -He reports that prior to resident 1's fall, the sling that was with the lift was the one used for the resident, regardless of size. *CNA D and CNA E both state that they were immediately educated regarding lifts and transfers 5. Interview on 10/17/24 at 7:56 am with registered nurse (RN) C revealed: *She was the nurse on duty at the time of resident 1's fall -She states that she entered resident 1's room following the fall and observed her on the floor still strapped in the sling -She states that she observed that the sling had been placed on resident 1 incorrectly. -She states that the shoulder straps were longer than needed for the resident *She states that she completed an assessment and neuro checks on resident 1 *She states that staff education regarding lift procedure and correct sling size has been completed since resident 1's fall. 6. Interview on 10/17/24 at 11:35 am with director of nursing (DON) B revealed: *Mechanical lift and sling size education was completed for all care staff including CNA D and CNA E dated 10/7/24 *Mechanical lift competency was complete with CNA E on 10/4/24 *Facility assessments are completed annually and as needed *All resident care plans requiring lifts have been updated verifying the correct sling size for resident use *Audits have been completed for staff since the date of the incident -Audits were to be reviewed at the next scheduled quality assurance and performance improvement meeting on 11/8/24 The provider implemented action on 10/4/24 to ensure the deficient practice does not recur and was confirmed on 10/17/24 after record review revealed the facility had followed their quality assurance process, education was provided to all direct care staff regarding mechanical lift safety and following residents' care plans, observations and interviews revealed staff understood how to correctly operate mechanical lifts according to each resident's individualized care plan, review of the appropriate sling sizes for each resident's mechanical lift needs, care plans were updated to include the resident's correct sling size, and verification certified nurse aide (CNA) competencies and audits were being performed.

Based on observation, interview, record review, and resident rights review, the provider failed to ensure staff were available to promptly respond to call lights for seven of seven sampled residents (1, 2, 3, 4, 5, 8, and 9) who used call lights to alert staff of their assistance needs. Findings include: 1. Observation on 9/16/24 at 3:45 p.m. throughout the facility revealed there was: *A sit-to-stand lift (mechanical lift used to assist to a standing position for transfers) and total lift (a mechanical lift with a body sling used for transfers) located in the hallway between rooms [ROOM NUMBERS]. *A sit-to-stand lift located in the 400 hallway outside of room [ROOM NUMBER]. -The lift had two safety slings stacked on top of it. *Two sit-to-stand lifts and two total lifts located in the 200 hallway. *A sit-to-stand lift located in the 100 hallway. Interview on 9/16/24 at 3:50 p.m. with certified nursing assistant (CNA) C revealed: *She worked as a bath aide in the 400 and 500 hallways. *She would have completed eight to ten baths during an 8-hour shift. *She estimated ten residents who resided in those hallways required a sit-to-stand lift for all transfers. -Some residents required one staff to assist them with that lift, some required two staff to assist with that lift. *She estimated five residents who resided in those hallways required a total lift for all transfers. -Residents always required two staff to assist them with a total lift. *She reported that they had two sit-to-stand lifts and two total lifts. *She stated, Residents sometimes have to wait for a lift to be available. *Residents who required two staff to assist with the transfer sometimes have to wait longer for two staff to be available. Interview on 9/16/24 at 3:54 p.m. with resident 1's daughter revealed: *She visited every day. *Her mother required a total lift for transfers. *It sometimes took 30 to 45 minutes or longer for one person to come to answer the call light and It's even longer if you have to wait for a second person. -She stated, They will come and shut off the call light while they wait for a second person to come to assist with transfers. *She did not feel the long wait times were not limited to a certain time of day or a certain day of the week. It varies. Review of resident 1's call light audit report from 8/29/24 to 9/3/24 revealed: *There were two call light response wait times over 25 minutes. *On 9/3/24 at 6:47 p.m. the wait time was 30 minutes. Interview on 9/16/24 at 4:12 p.m. with resident 2 revealed: *She required the sit-to-stand lift for transfers. -Sometimes one staff assisted her and sometimes they needed two staff to assist. *Sometimes they don't come for a very long time. I pull the string and they just don't come. -She clarified she felt a long time to wait was over 15 minutes. -She became visibly upset when she discussed how long she had waited for someone to answer her call light. *She preferred her bathroom door to be open just a little. If they close it [the door], I get scared because I have to wait so long. Interview on 9/16/24 at 4:19 p.m. with resident 3 revealed: *She shared a room and bathroom with resident 2. *She could walk to the bathroom, But I am supposed to wait for help. -I just can't wait that long. *She stated she fell next to her bed last week. -After putting my light on I waited 25 minutes [for staff assistance] then, I got up and went by myself. -She reported that was when she fell . Review of resident 3's electronic medical record (EMR) revealed: *She had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she was cognitively intact. *A 9/14/24 progress note indicated Resident was self-transferring from bed to recliner and lost her balance. Resident call light was on prior to the fall. Review of residents 2 and 3's room call light audit report from 8/23/24 to 9/17/24 revealed: *There were 88 call light response wait times over 15 minutes. -21 of those were over 30 minutes. -6 of those were over 45 minutes. -On 9/5/24 at 4:44 a.m. the wait time was 64 minutes. *On 9/14/24 the call light was activated at: -4:53 p.m. -6:55 p.m. -9:00 p.m. -9:15 p.m. -9:37 p.m. -10:17 p.m. Interview on 9/16/24 at 4:26 p.m. with resident 4 revealed she said: *They get mad at me for pushing my call light. They think I am playing with it. *She knew when she needed to use the bathroom, But when they don't come I just go in my pants. *I can't hold it as long as it takes them to get here. *She could not state how long it took staff to answer her call light in minutes. *They don't have enough people working here. Review of resident 4's EMR revealed: *She had a Brief Interview for Mental Status (BIMS) score of 8 which indicated she was moderately cognitively impaired. *From 8/27/24 through 9/17/24 she was incontinent of urine 34 times. -She had been continent 24 times in that same period. * From 8/27/24 through 9/17/24 she was incontinent of bowel two times. -She had been continent 11 times in that same period. Review of residents 4's room call light audit report from 8/26/24 to 9/17/24 revealed: *There were 45 call light response wait times over 15 minutes. -Six of those were over 30 minutes. -Two of those were over 45 minutes. -On 9/13/24 at 7:08 p.m. the wait time was 88 minutes. Interview on 9/16/24 at 5:08 p.m. with resident 8 and resident 9 revealed: *Resident 8 and resident 9 shared a room and a bathroom. *They said staff could take a long time to respond to their call lights. -Resident 9 felt a long time was over 20 minutes. *They both acknowledged the staff was trying hard but there isn't enough of them. Review of residents 8 and resident 9's shared room call light audit report from 8/26/24 to 9/17/24 revealed: *There were 38 call light wait times over 15 minutes. -12 of those were over 30 minutes. -6 of those were over 45 minutes. *On 9/11/24 at 7:11 p.m. the wait time was 57 minutes Interview on 9/16/24 at 5:40 p.m. with CNA D revealed: *There were 40 residents who resided between the 400 and 500 hallways. *There were two CNAs assigned to care for the residents on the 400 and 500 hallways. -There was a third CNA there that day, but that was not always the case. *Ten residents required the use of a sit-to-stand lift, and five residents required the use of a total lift. -They had two sit-to-stand lifts and two total lifts available for use that day. *There were not enough lifts or staff to assist the residents. *Residents got frustrated because they had to wait to be assisted with a lift or for two staff to help them. Interview on 9/16/24 at 5:54 p.m. with resident 5 revealed: *She required the sit-to-stand lift for assistance with all of her transfers. *There were only two CNAs assigned to the 400 and 500 hallways over the weekend *She had to wait over 30 minutes for staff to respond to her call light. -They know I only call when I need to use the bathroom. -There are not enough lifts or staff. *Two weeks ago, I had to wait so long that I was incontinent of BM [bowel] while sitting in my wheelchair and it leaked on the floor. -It's so embarrassing. *She had not filed a grievance about the long wait times but was aware of the process. *She did not attend the resident council. She stated, All we do is complain and nothing gets done. Review of resident 5's EMR revealed she had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Review of resident 5's room call light audit report from 8/23/24 to 9/17/24 revealed: *There were 35 call light response wait times over 15 minutes. -Five of those were over 30 minutes. *On 9/14/24 at 4:54 p.m. the wait time was 38 minutes. Interview on 9/16/24 at 4:34 p.m. director of nursing (DON) B revealed: *They do not have a lift policy or a call light policy. *She confirmed that the call lights are not visible outside the resident rooms when the call lights are activated. -Staff carried a walkie-talkie that announced when a call light was on. *There was a monitor that CNAs could look at that indicated which call light was active and for how many minutes it had been waiting for staff response. Interviews on 9/17/24 between 8:00 a.m. and 4:00 p.m. with staff members E, F, G, H, and I who requested anonymity for fear of retaliation revealed: *Issues with insufficient staff have impacted residents' having to wait to be toileted, dressed, repositioned, and changed. *At times one CNA may be responsible for the care of up to 20-33 residents. *At night when a CNA needs to leave their assigned area to help another staff member there was no staff available to assist residents in that area for over 15 minutes. -We are doing the best we can with what we have. *A bath aide was assigned 12 baths in an 8-hour shift. *We are always rushed. *Some of the residents require two [staff to] assist [them] and there is only two of us on the hallway so they have to wait while we help the others. *Sometimes we have to tell the resident we will come back as soon as we can, but then two more people need help. Interview on 9/17/24 at 3:15 p.m. with activities director K revealed: *Resident council meetings are held monthly. *Residents raised concerns about food and call lights at almost all resident council meetings. *She assisted residents individually to complete a grievance when needed. -The resident group did not complete a grievance form when they had concerns during the resident council meetings. Interview on 9/17/24 at 3:36 p.m. with resident 6 and resident 7 about the resident council meetings revealed: *Resident 6 became the president of the resident council last month but had attended those meetings regularly before that. *Resident 7 attended all of the resident council meetings. -She confirmed the resident council met monthly. *Residents are unhappy about the food and long call wait times. *Executive director (ED) A had attended resident council meetings. -Resident 6 stated, We tell him about the food and call lights -Resident 7 stated, .but [it] doesn't do any good. Interview on 9/17/24 at 5:00 p.m. with ED A and DON B revealed: *Two additional sit-to-stand lifts had been ordered and were expected to be received the following week. *Nurse staffing is based on the facility assessment. -They considered the facility adequately staffed. *They conducted call light audits for Quality Assurance (QA) and had not identified a problem with extended call light times. *ED A stated he was not aware of resident concerns about long call light wait times. *ED A stated there had been a problem with the call light system activating lights when residents were not in the room and staff were not able to turn those lights off. *There was no time range provided to staff on how quickly call lights were expected to be answered. -Don stated, As quickly as we can. -DON B would not confirm that 15 minutes was a reasonable time for a call light to be answered, but confirmed that 30 minutes was a long time. *They did not have a call light policy or a lift policy. Review of the provider's updated November 2016 Notice of Resident Rights under Federal Law handout revealed: *The Resident has the right to a dignified existence and self-determination. *The Resident has the right to be treated with respect and dignity. *The Resident has the right to reside and receive services in the Center, with reasonable accommodation of Resident needs, except when doing so endangers the health and safety of other Residents. Review of the provider's The 4 R's of Resident Satisfaction Employee Acknowledgement form revealed: * .the 4R's of resident satisfaction that ALL employees adhere to and implement. *Relieve- We want to relieve any and all pain! *Reposition - We want our residents comfortable! *Restroom- We want our residents dry! Assist the resident to the restroom, if needed or as scheduled. *Reach- We want our residents to have what they need!

Based on South Dakota Department of Health (SD DOH) complaint report review, record review, and interview, the provider failed to correctly administer medications as ordered for one of one sampled resident (1) who required hospitalization . Failure to administer medications as ordered may have contributed to resident 1's health condition and need for hospitalization . This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of SD DOH complaint revealed resident 1 had not received his medications as ordered after his 1/10/24 admission to the facility and he required another hospitalization on [DATE] . Review of resident 1's electronic medical record (EMR) revealed: *He was hospitalized on [DATE] for the evaluation and treatment of hypokalemia (low potassium), falls, rib fractures, acute kidney injury, and dehydration. *On 1/10/24 he was admitted to the facility following the hospital stay. His diagnosis included hypopotassemia (low potassium), anemia, acute kidney injury, chronic kidney disease stage III, hypertension, and malignant neoplasm (cancer) of the bladder. *His potassium level at the time of his discharge from the hospital on 1/10/24 was 2.8. (normal range is 3.5-5.1). *His 1/10/24 hospital discharge orders included new orders for four medications including: -One Folic acid 1 milligram (mg) tablet daily for anemia due to folic acid deficiency. -Two Potassium chloride 20 milliequivalents (mEq) extended-release tablets twice daily for Hypopotassemia. -Two Sodium bicarbonate 650 mg tablets three times daily for acute kidney injury. -Urea-lactic acid 10-4% cream topically twice daily for sebaceous cyst. Review of resident 1's January 2024 medication administration record (MAR) revealed he had not received his ordered: *Folic Acid 1 mg to be given once daily on 1/11/24 and 1/12/24. *Potassium Chloride ER Give 40 mEq to be given twice daily on: -1/10/24 at 8 p.m. -1/11/24 at 8 a.m. -1/11/24 at 8 p.m. -1/12/24 at 8 a.m. -1/12/24 at 8 p.m. Review of resident 1's progress notes revealed: *On 1/11/24 at 10:41 a.m. a pharmacy note regarding the review of resident 1's admitting orders indicated remote review per facility request, no recommendations . *Registered nurse (RN) E documented on 1/13/24 at 1:40 p.m. Family made aware of not receiving Potassium and 40 MEQ taken from E-kit [emergency medication supply] (4- 10 meq tabs) earlier this AM and given to resident. *Licensed practical nurse (LPN) G documented on 1/14/24 at 8:21 a.m. Received lab report; abnormal results as follows: -Potassium: 2.6 L -Chloride: 114 H -CO2: 15 L -Calcium: 8.4 L -BUN: 42 H -Creatine: 4.9 H -BUN/Create Ratio: 8.6 L -GFR (MDRD) 12 L -GFR (CKD-EPI) 12 L *LPN G documented on 1/14/24 at 8:30 a.m. Called PCP [primary care provider] with lab results, send to ED [Emergency Department] for IV therapy per PCP verbal order. Called [family] notified about resident getting transferred to ED. *LPN G documented on 1/14/24 at 1:21 p.m. Hospital called stated they admitted resident to ICU [Intensive Care Unit] for low potassium and were going to administer potassium via IV [intravenously] . Interview on 5/29/24 at 2:06 p.m. with executive director (ED) A revealed: *They did not have policies regarding physician orders or medication administration. *They would follow the medication administration quick reference guide updated in June 2017. Further interview on 5/29/24 at 2:31 p.m. with ED A regarding the admission process for medication orders revealed: *Medication orders upon admission should be entered into the EMR by the admission nurse manager. *The orders should be double-checked by another nurse for accuracy. *Medication orders should be faxed to the pharmacy for review and dispensing to the facility. *Medications should be delivered on the same day they were ordered. -There are two scheduled medication deliveries daily, one mid-afternoon and one late evening. *In addition, the pharmacy would deliver stat (rush) medications if needed. *There were medications available in the E-kit also. Interview on 5/30/24 at 10:03 a.m. with LPN F revealed: *The admissions team nurse enters all orders into the EMR system. *If medications are not delivered, an RN should be notified. *Medications should be taken from the E-kit for administration if available. Interview on 5/30/24 at 10:12 a.m. with the resident case manager (RCM)/RN D revealed: *The admissions team nurse inputs the orders into the EMR system. *Orders should then be faxed to the pharmacy. *Another nurse should double-check the orders for accuracy. *Pharmacy reviews the orders. *Orders will indicate pending confirmation in the EMR and are not activated to prompt for administration until they have been double-checked and marked as confirmed. *Medications must be confirmed before the pharmacy would send the medications to the facility. *The pharmacy would call or fax the provider if they had questions about medication orders the facility had input into the system. *She was unsure if the pharmacy called or faxed anything regarding resident 1's medication orders. *She agreed resident 1's potassium level of 2.8 at the time of his 1/10/24 hospital discharge was low. *She confirmed resident 1 did not receive two doses of folic acid and five doses of potassium chloride as ordered while he was at the facility from 1/10/24 through 1/14/24. *Potassium chloride ER 10 mEq tablets were available in the E-kit. Interview on 5/30/24 at 11:30 a.m. with director of nursing (DON) B and minimum data set (MDS) coordinator C revealed: *DON B confirmed blanks on the MAR indicate the medication was not administered. -They confirmed resident 1 had not received medications as ordered following his 1/10/24 admission to the facility as indicated above. *An EMR integration was completed in January 2024. *The pending confirmation notice for new orders was new following the integration. *On 1/13/24 at 8:09 a.m. a medication error form was completed for resident 1's missed doses of potassium. -The reason for the error was listed as pending confirmation. *On 1/13/24 the resident's PCP had been updated on the medication error. *They had recognized the concern with the pending confirmation notice and implemented corrective action. *The facility had an E-kit available for certain medications. That E-kit could be used if medications were not available from the pharmacy. *Education was provided to staff on 1/25/24 that orders pending confirmation, need to be addressed by a nurse to activate the orders for the resident. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 5/30/24 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding medication orders processing, pharmacy notification, E-kit medication availability and administration of medications as ordered, interviews revealed staff understood the education provided regarding those topics, observation of the E-kit contained medications, as listed on its content sheet were available for resident use, and a review of recently admitted residents revealed no omissions on medication administration records. Based on the above information, non-compliance at F760 occurred on 1/10/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 5/30/24, the non-compliance is considered past non-compliance.

Based on observation, interview, policy review, record review, and reference source review, the provider failed to implement proper infection control practices for the coronavirus (COVID-19) pandemic with the potential for exposing residents and staff to serious harm including death. On 1/20/21 at 3:45 p.m. an immediate jeopardy was identified when the provider failed to ensure: A. Ensure N95 masks worn into quarantine rooms were discarded or changed upon leaving (widespread). B. Disinfect face shields after contact with quarantined residents (widespread). C. Ensure one of twenty-three residents (1) remained quarantined while in quarantine status. D. Ensure staff caring for quarantined residents were aware of how to properly remove personal protective equipment (PPE) (widespread). E. Ensure doors for five out of twenty quarantined rooms remained closed. F. Ensure one of one registered nurses (RN) (I) followed proper infection control practices and hand hygiene after leaving one of twenty quarantine rooms. G. Ensure there were separate stations to put on and remove PPE in order to prevent cross contamination. Surveyor: These failures have a potential to expose all residents, staff, and visiting essential personnel to COVID-19, a [MEDICAL CONDITION] infection that could lead to serious harm or death. NOTICE: Verbal notice of immediate jeopardy and the template was given on 1/20/21 at 3:45 p.m. an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Notice of Immediate Jeopardy was given verbally to the administrator, nurse consultant/RN A, infection preventionist/RN D and minimum data set (MDS) coordinator/RN C. For specific immediate jeopardy noncompliance, see above findings A, B, C, D, E, F, and G. At the above time the administrator was asked for an immediate plan of removal to ensure all staff working in the quarantine COVID-19 unknown status residents as well as the COVID-19 negative residents received education and competencies for nationally recognized infection control procedures. PLAN: On 1/21/21 at 1:05 p.m. the administrator provided an email that included the final written removal plan. That removal plan was approved by the surveyors on 1/21/21 at 1:10 p.m. A removal plan was accepted and the Immediate Jeopardy was removed on 1/21/21 at 4:30 p.m. after the implementation of the plan was verified by the surveyors. After removal of the Immediate Jeopardy, the scope/severity of this citation is level F. The facility provided the following acceptable removal plan on 1/21/21: This removal plan is prepared and submitted as required by law. By submitting this IJ removal plan, (the provider) does not admit that the deficiency listed on this form exist , nor does the center admit to any statements, findings, facts, or conclusions that form the basis for the alleged deficiency. The center reserves the right to challenge in legal and/or regulatory or administrative proceedings the deficiency, statements, facts, and conclusions that form the basis for the deficiency. 1. Staff and residents directly observed will be reeducated on the quarantine status precautions and remaining in their room during that time. Staff will be re-educated on donning and doffing of PPE based on specified isolation status required. This education will be completed by the end of the day on 1/21/21. 2. All staff including housekeeping, laundry, and activities educated on proper infection control practices regarding all elements of the (provider) policy regarding active monitor quarantine for residents. Including keeping quarantine residents out of the general population of other residents and keeping them physically separated, discarding masks between quarantined residents, discarding face shields after caring for a quarantined resident and proper hand hygiene. The staff members observed with the N95 mask inappropriate donning and doffing, face shield improper disinfection, hand hygiene discrepancy cy was given formal education and will undergo competency for understanding of the process by 1/21/21. Resident #1 was immediately corrected and moved to a room closer to the desk for closer monitoring by staff due to restlessness and cognition. 3. All masks will be disposed of after caring for each quarantined resident by 1/21/2021. This will be disposed of in the same garbage receptacle as the other PPE inside the door of the room. New face shields and masks will be kept in the PPE carts. 4. No doffing station will be necessary as face shield and mask will be disposed of after each use in a quarantined room by 1/21/2021. The shield will be disposed of in the same receptacle as the other PPE insider the door. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term.html 'Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (healthcare professionals) should wear an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection (ie: goggles or a face shield that covers the front and sides of the face), gloves , and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected.' Unfortunately, this pandemic has shown us to expect the unexpected. Residents who are quarantined and placed in transmission-based precautions need to be physically separated from residents who are have not tested positive for COVID-19. Residents are in quarantine because their COVID-19 status may change during that 14-day time period. When you have a hallway of residents who are negative for COVID-19 and residents who are under quarantine there needs to be a physical barrier in place. 5. All staff re-educated and competency done for proper PPE don/doffing prior to their next working shift. This includes ALL staff employed by (provider) by the next working shift, including contracted staff prior to their next working shift and PRN (as-needed) staff prior to their next working shift and PRN staff via email communication by 1/21/21. Competencies will be completed on all staff prior to their next working shift. 6. Regarding above, all staff will be educated prior to their next working shift beginning immediately. PRN staff will be emailed education by 1/21/2021. ED (executive director) or designee will ensure education is completed on all staff prior to their next working shift including direct care, indirect care and contracted staff, including therapy and housekeeping laundry. 7. The center will audit each shift for the above competency completed as specified and observational audits for compliance with quarantine area PPE, and infection control every shift beginning 1/21/2021 until substantial compliance is met. ED or designee will complete the audits. 8. Eight residents #3, 4, 5, 6, 7, 9, and 10 that were not needing to be quarantined were removed form quarantine on 1/21/2021. On 1/21/2021 residents on 100 hall previously negative and not on quarantine will be moved. On 1/23/2021 three more residents, #14, 15, and 20 will be removed from quarantine as long as they remain symptomatic. The other residents will remain on quarantine status for the duration of 14 days and then move at that time. Residents #1, 8, 11, 12, 13, 16, 17, 19, 21, 23, 24, 25, 26, 27, 28, and 29 remain on quarantine at this time. 100 hall will become the quarantine hall at this time. The ED or designee will monitor the recovery period to move residents off the quarantine hall. 9. All doors will be closed on quarantine rooms. Reference guidelines 1. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html. Surveyor: Findings include: 1. Observation on 1/20/21 at 10:15 a.m. of licensed practical nurse (LPN) E revealed: *She opened resident 17's door to inquire about a call light alarming. *The door had signs on the outside with instructions on how to put on and remove PPE. *There was a sign on the door to keep the door closed. *She left the door open and put on a gown and gloves. *She took off her gown inside the doorway after caring for resident 17. Further observations and interview on 1/20/21 at 10:20 a.m. with LPN E revealed: *She had not cleaned off her face shield or changed it after leaving resident 17's room. *This surveyor had asked her what staff were supposed to do with their shield and N95 masks upon leaving a quarantined resident's room. *She stated, staff put their N95 masks in a brown paper bag and keep it in the clean PPE container. *She stated that some staff throw their N95 masks away. *She stated staff clean off their face shield with a wipe. *LPN E then threw away her N95 mask. *She then walked to a sink by the nurses station and washed her face shield. 2. Observation and interview on 1/20/21 at 10:30 a.m. of the 100 wing revealed: *A resident sitting in a chair across from the nurses' station. *The resident was identified by LPN E as resident 1. *Resident 1 was on the surveyors list of quarantined residents. *Resident 1 was sitting in the chair with her mask underneath her chin. *There were two open resident doors adjacent to where she was sitting. *LPN E stated they put her by the nurses' station so they could watch her since she had a fall this morning. 3. Observation on 1/20/21 at 10:45 a.m. of activity assistant K revealed: *She walked to resident 1's room to retrieve resident 1's glasses. *She was wearing an N95 mask and face shield. *She had put on a gown and gloves and went into resident 1's room. *She placed resident 1's glasses outside the door on the clean PPE supply cart. *She had taken off her gown and gloves inside the room. *She walked out of the room and cleaned off the glasses. *She did not clean her face shield or change her N95 mask. 4. Observation on 1/20/21 at 11:05 a.m. of registered nurse (RN) I revealed: *She was walking down the hallway carrying a glucometer with a test strip inside of it and a cotton ball. *She had on a face shield and an N95 mask. *She put down the glucometer with the test strip, cotton ball, and insulin pen on top of a three-drawered container housing PPE items. *She put on a gown and gloves. *She went into resident 2 and 3's shared room, their door was open. *After a short time, she came back out of the room. *She was still wearing her N95 mask, face shield, and gloves. *She was carrying the glucometer and insulin pen. *She brought them down to the medication cart by the nurses' station *RN D handed her a disinfection wipe. *Still wearing her soiled gloves, she cleaned off the glucometer and insulin pen. *She removed her gloves and put clean gloves on. *She did not clean off her face shield. *She did not change her N95 mask. *She did not perform hand hygiene. 5. Observation and interview on 1/20/21 at 11:30 a.m. with RN D and occupational therapy assistant (OTA) H revealed: *OTA H was going into resident 23's room, who was on quarantine. *She had on a face shield and an N95 mask. *She put on a gown and gloves and went into resident 23's room. *When she came out of the room, she did not change her N95 mask or clean of her face shield. Interview on 1/20/21 at 11:45 a.m. with RN D revealed she: *Was in charge of infection prevention for the facility. *Expected staff to hang up their face shield in a resident's room prior to exiting. *Said that staff can choose to discard the shield and get a new one. *Stated staff do not change their N95 mask after caring for quarantined residents. *Stated when staff care for COVID-19 positive resident's they change their N95 mask but not for quarantined residents. Surveyor: 6. Observations on 1/20/21 from 10:15 a.m. through 12:00 noon revealed: *The 100 hall contained both quarantined resident room and COVID-19 negative resident rooms. The eight quarantine rooms were spread throughout the hall, without a break between the quarantined rooms and COVID-19 negative rooms. *The 200 hall contained four quarantine rooms scattered between COVID-19 negative rooms. *The 300/400 hall contained eleven quarantine rooms scattered between COVID-19 negative rooms. *The 500 hall was currently empty. *The two COVID-19 positive residents were separated by a door in their own hall. Interview on 1/20/21 at 10:15 a.m. with the administrator regarding revealed: *The 300/400 hall contained mostly recovered COVID-19 residents and two COVID-19 negative residents. *Other halls contained hospital returns or admissions from a hospital. Two residents had refused to be tested . *There was no separation between quarantined residents and COVID-19 negative residents. 7. Observation on 1/20/21 at 10:20 a.m. of resident 20's room (129) revealed: *The door was open with a quarantine sign giving PPE instructions. Another sign instructed staff to keep the door closed. *An unidentified staff member brought resident 20 into the room . *That staff member: -Told the resident he needed to stay in his room with the door closed. -Closed the door and walked away from the room. *The resident opened his door after the staff member left. Interview on 1/20/21 at 10:25 a.m. with certified nurse assistant (CNA) F regarding the process for PPE revealed: *The staff wore gowns, gloves, N95 mask, and a face shield into all quarantine rooms. *After caring for quarantined residents the staff removed their gown and gloves and placed them in a garbage can inside the resident's room. *Staff members continued to wear the same N95 mask and a face shield between quarantine rooms and non-quarantine rooms. *The only time staff members had removed their N95 mask and put on a new N95 mask and face shield was after they had cared for a COVID-19 positive resident on the COVID unit. 8. Observation on 1/20/21 at 10:30 a.m. through 11:10 a.m. of resident 18 in room [ROOM NUMBER] revealed: *The door: -Was open and remained open during the observed forty minutes. -Had a quarantine sign giving PPE instructions. -Had another sign instructing staff to KEEP DOOR CLOSED. *The resident remained in her bed with oxygen on during the observation. *Staff members had not entered the room during the observation. 9. Observation and interview on 1/20/21 at 11:15 a.m. with housekeeper L regarding PPE use during cleaning and disinfection of resident rooms revealed: *She had worked as a housekeeper for approximately one year. *She applied a new gown and gloves for each room she cleaned. *She wore the same N95 mask and face shield throughout her entire shift. *At the end of her shift she threw the N95 mask and face shield away. *Her face shield was visibly soiled with finger print marks on the outer edges of the shield. *She did not know she was supposed to disinfect the face shield after exiting each resident room. *She was not aware she was supposed to change N95 masks between quarantined residents and COVID-19 negative residents. 10. Interview on 1/20/21 at 11:25 a.m. with LPN M regarding the process for PPE use revealed she: *Wore a gown and gloves to enter the quarantine rooms. *Removed the gown and gloves before she left the room. *Left her mask on. *Cleaned the inside of the face shield after leaving each resident room. *Only changed the N95 mask every couple hours and not between residents. 11. Interview on 1/20/21 at 11:30 a.m. with maintenance assistant N regarding the use of N95 masks revealed he wore the same N95 mask throughout the building and changed to a new mask daily. Review of 20 PPE carts in the 100, 200, and 300/400 hallways revealed only one PPE cart (room [ROOM NUMBER]) had only three N95 masks. The other 19 carts did not have any available. Surveyor: Review of the signs placed on quarantine residents' doors revealed: *There were three signs on the quarantined resident doors. -One sign stated to keep doors closed. -One sign was information on how to put on PPE. -One sign was information on how to remove PPE. *The signs instructed staff to remove all PPE, except for a respirator prior to exiting a resident's room. *Respirator or mask was to be removed once outside the closed residents room. Review of provider's current staff competencies for putting on and removing PPE revealed: *4. Removes mask or respirator last. DO NOT TOUCH! Grasps bottom ties or elastic, then the ones at the top, and remove without touching the front. If respirator is used it is not removed until after leaving the resident room and closing the door. If hands become contaminated during glove removal, immediately washes hands or uses ABHR (alcohol based hand rub). *LPN E, activities assistant K, RN I, and OTA H had all had competencies completed. Surveyor: 12. Interview on 12/20/21 at 1:15 p.m. with administrator B regarding the above observations for: *Inconsistent and incorrect responses regarding how to use PPE. *Use of the same N95 masks that had not been changed between quarantined residents and residents that were negative for COVID-19. *Face shields that had not been disinfected when caring for both quarantined residents and COVID-negative residents. *Allowing quarantined resident room doors to remain open without a barrier. *One observation of failure to perform hand hygiene after exiting a resident room that was in quarantine. *Allowing a resident that was to be quarantined to sit in the hallway. *Lack of doffing stations at outside quarantine rooms for disinfecting face shields. *The administrator stated: -She thought since the quarantined residents were not symptomatic or tested positive the staff were able to share the PPE between quarantined residents and COVID-negative residents. -There were supplies for disinfecting the face shields available in the carts outside the residents rooms. -Staff PPE competencies had been completed for nursing staff, but they had not been disposing of the masks between residents. 13. Interview on 1/21/21 at 9:30 a.m. with nurse consultant regarding the immediate jeopardy for the above observations revealed: *The DON was not available due to illness. *The infection control preventionist D and Minimum Data Set (MDS) coordinator C had been filling in for the DON to fulfill her duties. *The nurse consultant had not visited the provider recently and did not know the provider was not using PPE and infection control guidelines appropriately. *The provider was using the PPE in crisis capacity, but no longer needed to use the crisis capacity strategies now that PPE was readily available. Surveyor: Review of provider's 11/30/20 COVID-19 policy and procedure revealed: *All new admissions and readmissions will be treated as potential COVID positive per CDC (Centers for Disease Control and Prevention) recommendations and place in active monitoring quarantine based precautions for a minimum of 14 days and actively monitored for symptoms. *Patients with known or suspected COVID-19 should be placed in a single-person room with the door closed in a dedicated area per center's plan and in accordance with recommendations from the state health department and CDC guidance. The patient should have a dedicated bathroom if possible. *As a measure to limit HCP(health care personal) exposure and conserve PPE, Centers could consider designating entire units or sections within the Center, with dedicated HCP, to care for known or suspected COVID-19 patients. Dedicated means that HCP are assigned to care only for these patients during their shift. *Eye protection and the facemask should be removed, and hand hygiene performed if they become damaged or soiled and when leaving the unit. *HCP should strictly follow basic infection control practices between patients (e.g., (for example) hand hygiene, cleaning and disinfecting share(d) equipment). *Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized-housekeeping to be performed by care staff if possible. Review of CDC's https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, Preparing for COVID-19 in Nursing Homes, reviewed on 1/25/21 revealed: *Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (healthcare professionals) should wear an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection (ie: goggles or a face shield that covers the front and sides of the face), gloves , and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected.'

Based on observation, interview, record review, policy review, South Dakota Department of Health (SD DOH) on-line incident report, and job description review, the provider failed to follow their Skin Integrity policy for: *Accuracy of weekly skin assessments and/or wound documentation for eighteen of twenty-three sampled residents (1, 2, 3, 4, 9, 10, 11, 13, 14, 15, 16, 17, 18, 19, 21, 22, 24, and 25). *physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Notification to physician, resident and/or family representative of skin and wound issues in a timely manner for seven of twenty-three sampled residents (2, 3, 4, 13, 14, 15, and 23). *A turning and repositioning program for ten of twenty-three sampled residents (2, 3, 4, 10, 11, 15, 22, 23, 24, and 25) to off load pressure areas. These failures have the potential to cause serious harm up to and including death. Specifically, a resident with a pressure injury that resulted in a hospitalization . All residents have the potential to be affected by this deficient care practices. Due to the lack of ongoing monitoring, assessments, documentation prevents identification of care needs and provision of care. NOTICE: Verbal notice of immediate jeopardy and the template was given on 2/19/21 at 6:00 p.m. an Immediate Jeopardy was identified when the facility failed to ensure: *Ongoing monitoring, assessments, and documentation of pressure injuries for twenty-two of seventy-four residents. *The facility identified residents with pressure injuries. They put a plan in place to monitor and assess the identified injuries. They failed to follow their plan of weekly wound assessments, weekly wound audits, and notify providers. At the above time the Divisional Director of Clinical Operations A was asked for an immediate plan of removal. PLAN: On 2/24/21 at 10:30 a.m. the following immediate jeopardy removal plan was accepted by the South Dakota Department of Health: 1. Educate nursing management on weekly wound assessments, on appropriate treatment and interventions, provider, dietician, and family notification. Educate all licensed nurses on performing weekly skin assessments and documenting any issues identified during the skin assessment and notifying provider and family. Educate all staff on stop and watch to alert licensed nursing staff of any abnormal skin findings. The nurse in charge of the weekly wound assessments will be in charge of changing the treatments. Educate certified nursing assistants CNA's [certified nursing assistants] and NA's [nursing assistants] on inspecting skin during ADL's [activities of daily living] and reporting abnormal findings. Education provided by Divisional Director of Clinical Operations to nursing management team. They, in turn will educate all nursing staff prior to their next working shift by 2/22/2021. 2. An audit will be conducted on ensuring preventative measures are in place to prevent skin breakdown on residents with and without wounds, Braden assessments completed per policy annually, quarterly, change in skin condition completed by licensed nursing staff, bathing preformed a minimum of weekly, peri-care completed timely and resident is clean and dry residents with incontinence are checked every one to two hours, weekly wound assessments completed every seven days, treatments done as ordered and changed if no improvement in wound noted per provider direction or every 14 days as stated in policy, family notification, physician notification, and dietician notification with assessment and knowledge of staff who has wounds on their unite. The DNS or designee will be responsible for the audits. 3. Compliance date 2/22/2021. An onsite revisit was completed on 2/24/21 at 12:35 p.m. to verify the immediate jeopardy removal plan. Immediate Jeopardy was removed on 2/22/21 at 2:56 p.m. After removal of the Immediate Jeopardy, the scope/severity of this citation is level H. Findings include: 1. Review of the following report submitted to the South Dakota Department of Health (SD DOH) regarding resident 1 revealed: *The initial self-report had been completed on 2/1/21 by the director of nursing services (DNS) for allegations of physical harm/injury regarding the status of a stage four (being the most severe stage) pressure ulcer to the sacral region and [CONDITION(S)] (a serious infection in the bloodstream). *Resident 1 had been admitted to the provider on 11/3/20 after being hospitalized for a left [CONDITION(S)] and [CONDITION(S)] of the left lower leg. *On her 11/3/20 admission to the provider she had: -A reddened coccyx and perineal area. -Two open areas to her coccyx. -One open area on her left buttock. *She required staff assistance with repositioning in bed. *She had virtual visits from:-Certified nurse practitioner (CNP) I on 12/3/20. -Her primary physician on 12/24/20 to visit about her left lower leg wound. --Review of the physician's clinic documentation for this visit located in the hospital records indicated the resident was not accompanied to this appointment and had not indicated why she had been sent to the clinic. The physician had not assessed the resident's coccyx. Further physician communications had included: *On 12/29/20 her primary physician was updated on the condition of her worsening sacral wound and had requested orders for her to see the wound clinic. *On 1/21/21 her physician made another virtual visit. -Orders were received for her to consult the wound clinic for recommendations for treatment. -She went to the wound clinic on 1/26/21. On 1/28/21 at 8:30 p.m. resident 1 was noted to be lethargic. Her blood pressure was low at 72/44 and she had a low-grade fever of 99.8 degrees Fahrenheit. She was transferred to the hospital by ambulance. She was admitted for infection to her pressure ulcer wound. Review of resident 1's 1/29/21 hospital admission records requested from the SD DOH complaint department revealed: *On 1/26/21 the wound clinic had identified: -One Stage 4 pressure injury pressure ulcer measured 8.2 centimeters (cm) long by (x) 6.5 cm wide x 2.5 cm depth. --Necrotic adipose tissue was exposed. --A large amount of drainage with a strong odor. --That wound was debrided on 1/26/21. -One Stage 3 pressure injury to her left calf measured 3 cm long x 2 cm wide x 0.2 cm depth. *Review of resident 1's 1/29/21 hospital physician's History and Physical Assessment and Plan had indicated: *[CONDITION(S)]. *Stage 4 pressure ulcer of sacral region. *Ulcer of left calf. *Infected decubitus ulcer. *Concern for underlying [CONDITION(S)]. *Consulted general surgery since it appears this may benefit from a debridement. Review of resident 1's electronic medical record (EMR) from the provider revealed her 11/3/20 admission nursing evaluation from the provider revealed the following skin concerns: *An intact dressing to her left hip surgical wound with no drainage. -The area had not been measured. *A Stage 2 pressure injury to her coccyx measured 1 cm long x 1 cm wide. No depth was identified. *Another Stage 2 pressure injury to her coccyx measured 1 cm long x 1 cm wide. No depth was identified. *A Stage 2 pressure injury to her left buttock measured 1 cm long x 2 cm wide. No depth was identified. *Her coccyx/peri area was identified as red, without documented measurements. *A left lower leg was identified as [CONDITION(S)] without documented measurements. *Wound treatment at that time was for a foam dressing to open buttocks. *Her Braden Scale for Predicting Pressure Ulcers form revealed a score of 14, indicating a moderate risk for skin breakdown. *There was no documentation on admission of a skin concern to her left calf. *No skin/wound evaluations had been completed for the above pressure injuries. Other skin interventions located in resident 1's medical record had included on: *11/30/20 a Braden Scale indicated a score of 15, indicating At risk (a slight improvement from 11/3/20). *11/9/20 orders were received to apply [MEDICATION(S)] and foam dressing to open area on buttocks. *11/15/20: Nutritional intervention for Calorie Dense Medication Pass 2 ounces after meals for wound healing. *A 12/8/20 Braden Scale indicated 15, without change. *A 12/14/20 Braden Scale indicated 15, without change. *A 1/20/21 Nutrition Hydration Skin Committee Review indicated: -The reason for the review was Weight. -Her 11/3/20 admission weight was 125 pounds (lb). -On 12/13/20 the weight was 107.5 lb. -On 1/12/21 the weight was 102.5 lb. -Pressure ulcer stage comments: Unstageable. -Resident has a large open area to her bottom which has been slow to heal. -The dietitian increased her protein powder to one scoop three times daily. -The dietitian signed the committee review form (to have been used to summarize the current skin and wound status, with no other staff identified as participating. Review of resident 1's Skin and wound evaluations from 11/3/20 through 1/28/21 revealed only two skin/wound evaluations had been completed after her admission on 11/3/20: *On 12/9/20 by registered nurse (RN) B: -Stage 3 full-thickness skin loss to her sacrum. --Present on admission. --The area had been first identified 1 month ago. --Area: 2.7 cm2 (square centimeter) (The total measurement of the entire wound area). --2.6 cm long x 1.5 cm wide x 0.1 cm depth. --100 percent (%) wound filled slough (necrotic tissue). --Light, serous exudate. --No odor. --Nothing had been addressed regarding: ---Periwound edges and surrounding tissue. ---Wound pain. ---Orders. ---Infection. --Her dressing was missing. --Her treatment included a generic wound cleanser, [MEDICATION(S)] and foam dressings. --Progress had stalled. --Additional care included: ---Foam mattress. ---Incontinence management. ---Nutrition/dietary supplementation. ---Positioning wedge. ---Repositioning devices. --Protein powder was added to promote wound health, encouraged to lay down and offload will implement a schedule, cushion placed in recliner. --Turning/repositioning program had not been checked. --There was no identified notification to the physician, resident or responsible party or dietitian.--There was no documentation on this 12/9/20 skin evaluation or in other areas of the EMR regarding the resident having gone from three areas of concern on admission to one large open area at this assessment. *On 1/25/21 by RN B: -Stage 3 full-thickness skin loss to her sacrum. --Present on admission. --The area had been first identified 1 month ago. --Area: 10.3 cm2. --7.1 cm long x 2.5 cm wide x 0.3 cm depth. --Wound bed: ---11% wound covered epithelial tissue. ---11% granulation. ---9.20 % slough. --Light, serous exudate. --No odor. --Periwound edges were non-attached. --Surrounding tissue was excoriated and fragile at 2.0 cm. --Wound pain: 1. --No orders were identified. --Infection had not been addressed. --Her dressing was intact. --Her treatment included sterile water for cleanser, autolytic debridement, automicrobial, [MEDICATION(S)], and 'other' dressings. --Progress Deteriorating. --Additional care included: ---Foam mattress. ---Incontinence management. ---Moisture barrier and moisture control. ---Nutrition/dietary supplementation. ---Positioning wedge. --The turning/repositioning program had not been checked. --The physician was contacted and orders received to contact the wound clinic to change the treatment. There were no Skin and Wound evaluations completed for resident 1's left calf Stage 3 pressure ulcer that had been identified at the 1/26/21 wound clinic evaluation. Review of the 11/3/20 through 1/28/21 nursing progress notes revealed the left calf had only been documented on twice: *1/7/21: Dressing removed from L [left] posterior calf. Medial side of the black scab treatment area is loosened with a dark red clot that is pulling away from the wound bed. *1/26/21: Resident went to [hospital name] wound clinic today for an appointment. Wounds changed and dressed, orders for treatments on coccyx and L calf wound sent. Review of the provider's resident 1's revised 2/2/21 (after she had been transferred to the hospital) care plan revealed:*An 11/3/20 problem: The resident was receiving antibiotic therapy for [CONDITION(S)] of left lower leg. -Interventions were added 11/15/20 for antibiotic medications and to apply lotion to the left lower leg and watch for signs of [CONDITION(S)]. *A 12/23/20 problem regarding an injury to the left lower leg. Interventions had included: -Ice to the ankle four times daily. -[MEDICATION(S)] to keep area clean and X-rays. -An antibiotic due to signs and symptoms of infection. *An 11/15/20 problem indicating a pressure ulcer to the coccyx and buttock. Interventions included: -A cushion to her recliner and to lay down for one hour twice daily. -Keep skin dry and lotioned. -Ointment and dressings to area as ordered. -A 12/9/20 intervention for protein supplement and 2 Cal two ounces twice daily. *An 11/3/21 baseline plan of care revised on 2/2/21 (after she went to the hospital) indicated the goal was that she would maintain safety. Interventions had included: -Providing extensive assistance of two people for bed mobility. -Keep heels up off bed with pillow or heel up pillow. -Skin at risk: Elevate heels. -A pressure reducing mattress. -Turn/reposition routinely. --The care plan had not indicated how often routinely was to have occurred. *There were no further interventions or updates of the pressure injuries. Resident 1's 11/3/21 through 1/28/21 progress notes indicated she had an increase in confusion and delusional hallucinations with agitation beginning around 12/1/20, but had not indicated the resident was refusing her care. Review of resident 1's medication and treatment records requested and received during the survey had been for the month of February, 2021. The resident had been transferred to the hospital on 1/28/21. Interview on 2/18/21 at 8:30 a.m. with the divisional director of clinical operations (DDCO) A regarding a 2/1/21 self-report of resident 1's identified Stage 4 ulcer provided to the SD DOH revealed she confirmed: *Resident 1 was hospitalized on [DATE] for a stage 4 pressure ulcer that had become infected, causing [CONDITION(S)]. *The provider had two nurses (RN B and C) that had been working with pressure ulcer wounds. *On 2/2/21: -RN B and C were interviewed by the former executive director (ED), DDCO A, and medical director G regarding why weekly wound assessments and measurements had not been completed. -RN B and C were given a final written warning for not completing the wound assessments. -A skin sweep was conducted to review the skin status on every resident in the facility. -She stated a skin sweep had identified eleven residents with a total of eighteen pressure ulcers. *When asked for the list of residents identified on 2/2/21 with newly identified pressure ulcers, DDCO A provided a list of thirteen residents. -That list had not identified the dates they had been found or where or how many pressure injuries had been identified for each resident. *RN B no longer worked at the facility. *RN C: -Had only worked for a few months in the facility. -Did not have previous experience with wounds. *The provider had two nurses from a sister facility come to the facility on [DATE] and 2/17/21 to provide wound care education to RN C. *DDCO A had been working to correct the pressure injury problems, but the pressure ulcer plan was not completely up and running. *On 2/4/21 an all-staff meeting was held with DDCO A and medical director G. Wound care and skin integrity hand-outs were provided to the staff. *ED U and/or DNS E were to have been monitoring and auditing the weekly skin assessments to see that they had been completed, and the physicians had been notified and updated timely on changes in skin integrity wounds. Review of the above 2/2/21 skin and wound investigations provided by DDCO A revealed RN B confirmed: *She had taken over the wound measuring and treatments after the previous wound nurse RN V had quit her job. *She was to have trained RN C with wound assessments. *RN B and C were completing a weekly wound report to give to ED U, DNS E, or DDCO A. *RN B had not looked at the residents' wounds when she filled out the wound reports. *She had copied the information the administration had put on the quality conference sheet. Continued above interview with RN B revealed the administration educated her about the need for a seven-day wound assessment, physician, family and dietitian notification of changes, and communicating with the physician for wound care changes. Continued review of the above 2/2/21 skin and wound investigation revealed: *RN C confirmed: -It had been her job to have assisted RN B with the wound measurements and treatments. -She had not completed those wound measurements or treatments. *The administration educated RN B about the need for a seven-day wound assessment, physician, family, and dietitian notification of changes, and communicating with the physician for wound care changes. Interview on 2/18/21 at 9:04 a.m. with medical director G regarding the self-report of resident 1 revealed he: *Had been the medical director for approximately three years. *Also worked for the hospital. *Assisted with interviewing RN B and C for the investigation. *Participated in the 2/4/21 education to all staff regarding pressure ulcer skin and wound care. *Planned to continue as the medical director because he wanted to correct the problems for the residents. Interview on 2/19/21 at 5:10 p.m. with DDCO A revealed: *She had asked this surveyor where she received her first list because it was not accurate. -This surveyor reminded her that she had provided that list. -DDCO A then gave this surveyor a second list identifying 8 residents. -The second list also contained only names, with no identification as to the date the pressure ulcers occurred or were identified, and had not identified wound measurements or the area the pressure ulcer was located. *When asked for information on the skin sweep findings, DDCO A stated all the information from the skin sweep was located in each resident's chart. Review of the 2/1/21 plan submitted to SD DOH complaint department revealed: *The ED [executive director] and/or DON will monitor/audit that weekly skin assessments are being completed, documented, and the physician has been updated timely on changes to skin integrity/wounds. Surveyors requested audits from DDCO A that were being conducted to ensure weekly skin assessments were being completed, documented, and the physician had been updated timely on changes to skin integrity/wounds on the following days and times: *2/18/21 at 8:30 a.m. *2/18/21 at 12:30 p.m. *2/18/21 at 5:30 p.m. *2/19/21 at 4:00 p.m. Interview on 2/18/21 at 5:10 p.m. regarding pressure ulcers with DNS E revealed: *The nursing staff completed a skin sweep on 2/2/21. *Audits would be done weekly, but had not started them yet. *Quality Assurance Performance Improvement (QAPI) notes were requested from DNS E. On 2/22/21 at 5:15 p.m. this surveyor informed DDCO A the surveyors needed to review all the investigation information they had obtained from the 2/2/21 sweep. DDCO A was informed the surveyors had requested PIP [performance improvement plan] information from QAPI and had not received it. DDCO A stated QAPI and PIPs were not needed because they only had 1 pressure ulcer in the facility prior to the skin sweep. On 2/22/21 at 5:30 p.m. surveyors asked for audits again. At that time DDCO A and RN D were printing off progress notes for each affected resident to show that residents had a skin assessment completed on 2/2/21. On 2/22/21 at 5:45 p.m. DDCO A stated her statement about a 100% skin sweep was not correct because one resident was at [CONDITION(S)]. Interview on 2/18/21 at 3:14 p.m. with RN/Minimum Data Set (MDS) coordinator D regarding pressure ulcer concerns identified after resident 1 was hospitalized revealed: *She helped complete the 2/2/21 skin sweep. *The sweep was completed as a leadership team. *All residents were reviewed to identify skin concerns.*The team had discussed a root cause analysis for not having identified pressure ulcers. *She didn't know if it had been completed. *All staff were educated on 2/4/21. *After they completed the skin sweep and education, the leadership team began looking at notifying families of pressure ulcers, obtaining physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *DNS E wanted to receive a report every Thursday from every unit. *RN C would not have been able to review all the pressure ulcers weekly, so a member of the leadership team was given one unit to assist RN C with wound assessments. *The units were divided as: -RN D - 400 unit. -RN F - 300 unit. -RN C- 200 unit. -RN B - 100 unit. *RN B no longer worked in the facility, since just before the survey. *RN D was not sure who would be replacing RN B. *Physicians had not been allowed in the facility since the beginning of the pandemic. *Physicians had been allowed into the building for special reasons and it was very rare. *They are always looking at the COVID community. Further review at the above time with RN D regarding identification of skin concerns revealed:*Before the skin sweep on 2/2/21 the nurses were expected to complete weekly skin checks on all residents. -She was not sure why the weekly nursing skin checks had not identified the new skin ulcers/wounds. *There was a daily huddle the staff could communicate concerns that had been identified over the previous day. *RN C took over the skin and wound assessments approximately three weeks ago after RN unit managers V and W had quit their jobs. *Nutrition/Hydration Skin Committee reviews had been done virtually since the dietitian had not entered the building during the pandemic. *Going forward after the identification of the lack of skin assessments the leadership team members involved in skin and wound care were expected to: -Document new skin concerns and progress weekly. -Step in and complete the weekly skin assessments if it had not been done. *Prior to the pressure wound assessments concern Braden assessments were to have been completed on admission, annually, or with a significant change in status. *Going forward if there was an identified skin concern the Braden scale was to have been completed once the skin issue was identified. -She was not sure why the provider would wait until the skin had breakdown to begin a Braden skin scale. Interview on 2/19/21 at 4:00 p.m. with RN/wound nurse C revealed: *She started working in September. *RN V had planned to train RN C in wound care but she abruptly quit in November. *She had not received any skin or wound training until 2/16/21 and 2/17/21. *At that time the sister facility sent two nurses to help her learn about skin and wound issues. *To say stuff didn't fall through the cracks I would be lying. *She was not aware the skin and wound assessments were required to be completed every seven days. *The skin sweep done on 2/2/21 had identified somewhere between ten and fifteen unidentified pressure areas. *After the skin sweep, the nurses had been educated about notifying the physician of pressure injuries, notifying the family of skin changes, and getting documentation in place. *It had been chaos since [DNS E] was gone. *When asked if the wound care was her only job, she stated she got pulled to the floor to work if there had been a sick call or if a temporary staff person was not working out. *When asked if the team had completed a root cause analysis for pressure ulcers she stated yes and no but had not provided any reasoning for that response. *She stated four new pressure ulcers had been identified on 2/18/21 for residents 11, 13, 16, and 17. *Audits were to have been completed to monitor if weekly wound assessments were being done correctly. -She was not sure who was to have completed those audits. *DNS E was to have received a pressure ulcer skin report every Wednesday. 2. Review of resident 15's medical record revealed:*She was admitted on [DATE]. *A 2/2/21 progress note by RN D indicated -Resident noted to have area on right heel. -Resident last fall was 10/22/20. *A 2/2/21 at 5:58 p.m. indicated a skin assessment was completed with a picture taken of the right heel area. *The physician had been notified of a purple discoloration to the right heel on 2/3/21. *There was no documentation the family had been notified of the skin concern. Review of resident 15's medical record revealed two skin and wound evaluations:*On 2/9/21: -Indicated an in-house acquired deep tissue injury (DTI) to her right heel. -The injury measured 0.36 centimeters long by (x) 0.24 cm wide. The total skin area was less than (<) 0.1 cm2. -The Wound evaluation only contained wound measurements. --It had not been completed for the periwound, treatments, orders, monitoring, or notifications to the family. *On 2/16/21: -The DTI measured 1.37 cm wide x 2.08 cm long. The total skin wound area was 2.4 cm 2. -The wound was 100% epithelial wound covered. -It had indicated the resident was on a repositioning program. A 2/16/21 at 3:26 p.m. progress note by RN C indicated the resident's heel wound had healed, and the heel area would be lotioned twice daily. Review of resident 15's revised 2/3/21 Care plan indicated she: *Had a new suspected DTI. *Was to have been turned and repositioned every two hours and as needed. Review of resident 15's Turning and Repositioning program was to have been completed every two hours from 2/2/21 through 2/20/21 (nineteen days) revealed of 240 opportunities in twenty days the resident had been repositioned 114 times, with 126 missed repositioning opportunities. 3. Review of resident 2's medical record revealed:*She was admitted on [DATE]. *She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . *On 2/2/21 RN F had identified excoriation to bilateral inner buttocks. Review of resident 2's 2/2/21 skin and wound evaluation revealed: *Moisture Associated Skin Damage (MASD) had been identified related to incontinence. *The evaluation had not identified the location of the area or any measurements of the area identified. *There was 100% of wound filled granulation (new tissue). *There was no exact date of the excoriation (wearing off of skin). *No treatments had been identified. *She was to have a foam mattress, seat cushion, moisture barrier nutrition supplementation. *No turning/repositioning program had been identified. *There was no documentation on notification to the physician, family, or dietitian. *Progress had been marked for Monitoring. *Her care plan had not been updated with the 2/2/21 skin changes. Review of resident 2's February Treatment record revealed: *A weekly skin check had been completed on 2/5/21 and 2/12/21. *There was no documentation in her progress notes to indicate there were skin concerns. On 2/9/21 resident 2's physician completed virtual rounds and documented the resident voiced no concerns. There was no discussion of skin concerns. On 2/15/21 LPN AA documented resident 2 had an open area to her right buttock. She applied hydrogel and [MEDICATION(S)] to the area. -No measurements or notifications to the physician or family had been documented. On 2/16/21 for resident 2 RN C documented a skin and wound evaluation indicating:*An in-house acquired Stage 3 pressure injury was identified on her right buttock. *No exact date was identified. *Wound measurements: -Area of wound was 3.6 cm2. -2.4 cm long. -2.0 cm wide. -0.2 cm depth. *There was 10.0 cm area of fragile periwound. *Some bleeding was identified in the wound. *The skin and wound evaluation suggested the dressing was intact, but failed to document the identified treatment. *Additional care had been added for turning and repositioning program and incontinence management. *The nurse documented the physician and family were notified in the 2/16/21 evaluation. *On 2/16/21 RN C documented a progress note asking the physician for treatment orders. Phone interview on 2/19/21 at 8:50 a.m. with resident 2's primary physician J regarding the identified Stage 3 pressure injury revealed he had been notified of a pressure injury, but had not been notified that it was at a Stage 3. On 2/23/21 a skin and wound evaluation was done for resident 2's Stage 3 pressure injury: *Wound measurements had not been documented. *The wound bed was 100% wound filled. *There was light sanguineous/bloody exudate. *Pain had not been addressed. *A foam dressing was intact. *Additional care provided included incontinence management. *The turning/repositioning program had not been addressed. Review of resident 2's updated 2/17/21 care plan revealed. *She had a Stage 3 pressure injury. *A turning and repositioning program had not been added to the care plan. Review of resident 2's Turning and Repositioning program for every two hours from 2/2/21 through 2/22/21 (twenty days) revealed of 240 opportunities in twenty days the resident was repositioned 118 times, with 122 missed repositioning opportunities. 4. Review of resident 4's medical record revealed: *She was admitted on [DATE]. *An 11/26/20 progress note indicated that her 'bottom' was red and she had an open area on her inner buttock. The area was cleaned and a barrier applied. The nurse covered the area with a foam dressing. -A skin and wound evaluation had not been located in her medical record. -There was no documentation of notification to the physician or family. *On 11/27/20 RN F added a progress note indicating: -Her left buttock had a 4 cm x 4 cm white area with a black center. -Her right buttock had a 1 cm x 0.5 cm open Stage 2 area. -A skin barrier cream was applied to the open area on the right buttock. -A foam dressing was applied to the left buttock. -Staff reposition resident every two hours. -No skin and wound evaluations had been located in the record for these wounds on or before 11/27/20. -There was no documentation of notification to the physician or family of the wounds. *On 12/4/20 a nursing progress note by LPN R indicated the resident had open areas to bilateral buttocks. The nurse applied a foam dressing. -There was no documentation the physician or family had been notified. -No skin and wound evaluation was located in the medical record. *Review of a 12/7/20 Nutrition Hydration Skin Committee form regarding resident 4 revealed: -She had Unstageable pressure ulcers on bilateral buttocks. -She received protein powder for her skin. -Continue to monitor. *There were no November 2020 skin and wound evaluations located in her medical record. *Review of RN F's 1/9/21 progress not for resident 4 revealed her physician had completed virtual rounds with her and any/all concerns addressed at this time and new orders. The nurse had not documented if the skin concerns had been reviewed with the physician. *Review of a 1/15/21 Quarterly Nursing Review form for resident 4 by RN D revealed: -Her last Braden Skin assessment dated [DATE] had a score of 10 indicating high risk for pressure injuries.<

Based on observation, interview, record review, closed record review, policy review, and South Dakota Department of Health (SD DOH) online report, the provider failed to ensure residents received treatment and care in accordance with professional standards of practice for: A. Ensuring monitoring and dosing for one of one newly admitted sampled (6) resident receiving monitoring of anti-coagulant therapy for signs and symptoms of bleeding. B. Resident call lights were answered in a timely manner for two of two sampled residents (7 and 8). C. Resident's received a bath every seven days for seven of seven sampled residents (11, 12, 13, 14, 15, 16, and 22). D. Facility having enough walkie talkies for staff to be able to meet each resident needs (non-IJ finding). E. Ensuring one of one sampled resident (20) with multiple recurring self-inflicted wounds received nail care to prevent skin breakdown (non-IJ finding). Surveyor Failure to monitor lab values and follow physician dosing orders have a potential to affect all residents who receive anti-coagulant medications. NOTICE: Verbal notice of immediate jeopardy and the IJ template was given on 2/19/21 at 6:00 p.m. An Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare & Medicaid Services (CMS) monitoring of lab values and physician dosing for a newly admitted resident that had received anti-coagulant therapy. Notice of Immediate Jeopardy was given verbally to the Divisional Director of Clinical Operations A, director of nursing services E, and registered nurse/staff development coordinator F. At the above time the Divisional Director of Clinical Operations A was asked for an immediate plan of removal to ensure a plan to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . PLAN: The administrator submitted an email that included the final written removal plan. That removal plan was approved by the South Dakota Department of Health on 2/24/21 at 10:30 a.m. the following plan was approved: 1. Educate all licensed nursing staff on the anticoagulation therapy policy. Education provided to the nursing management team by the Divisional Director of Clinical Operations. Education in turn will be delivered to the licensed nursing staff by nursing management prior to their next working shift. Education provided to therapy, CNA's and NA's staff to report signs or symptoms of bleeding to LN's. Education to begin immediately. Education provided by nursing management team. Education started on 2/20/2021. Education will be completed by 2/22/2021. Nurse management team will ensure that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Communication with physician will occur on day of admission in regards to [MEDICATION(S)] and PT/INR orders in regards to what current orders should be in place and who will be doing the doing of [MEDICATION(S)] and PT/INR. Physicians with patients on [MEDICATION(S)] will be educated on the new process immediately by 2/24/2021 via fax/phone communication. 2. An audit will be conducted by ED, DNS or designee on all residents receiving [MEDICATION(S)] to ensure accurate dosing and scheduling of PT/INRs by 2/21/2021. 3. Compliance date 2/24/21. An onsite revisit was conducted on 2/24/21 at 12:35 p.m. Immediate Jeopardy was removed on 2/24/21 at 10:45 a.m. after the removal plan implementation was verified during an onsite visit by the surveyor. After removal of the Immediate Jeopardy, the scope/severity of this citation is level G. Surveyor Findings include: 1. Observation and interview on 2/17/21 at 3:00 p.m. with RN F revealed: *This surveyor asked why there was not any precautions signs on the door of a quarantined residents door. *RN F said that was resident 6's room. -She had passed away that morning. *RN F said it was a very: -Unexpected death. -Traumatic death for the new nurse on duty. --The new nurse had to go home because she was so upset. Review of the SD DOH online report submitted by the provider on 2/17/21 at 5:29 p.m. revealed: *The director of nursing services (DNS) E submitted the online report, which stated: *0430 [4:30 a.m.] The nurse was walking down the hall when she was summoned to the resident's room by two CNA's. The nurse entered the residents room to find the resident in bed with many bloody tissues on the bed. Resident was laying on her right side with blood coming out of her nose and mouth. Resident had dried blood on her right hand. Resident was pale in color, respirations absent and no palpable pulse present . * .Oral suctioning done during this time with bright red blood returning . * .No change in condition and Code Blue was stopped 0500 [5:00 a.m.] per EMS [emergency medical staff]. Review of resident 6's admission documentation revealed she: *Had been admitted on [DATE]. *Received outpatient hemodialysis therapy. *Had been on anti-coagulation therapy. Review of resident 6's electronic medical record (EMR) revealed: *On 2/11/21 the facility had certified nurse practioner (CNP) I sign an order to Please have eLTC adjust/monitor and order PT/INR [prothrombin time and international normalized ratio] for [MEDICATION(S)]. *The order was noted by a licensed nurse (LN) on 2/11/21. *On 2/13/21 at 2:38 p.m. a progress note stated: -During assessment residents BP [blood pressure] was low. 79/45 with automatic BP machine; I took it manually and got a reading of 62/34; resident does not appear to be in any distress; I reached out to family and asked if resident would like to be evaluated by ER [emergency room ] or continue to be monitored here and both family [family member's name] and resident stated to continue monitoring here; I also reached out to eLTC for anything further we can do and the CNP on shift stated to give her the 0800 [8:00 a.m.] dose of 10 mg [MEDICATION(S)] now and continue to evaluate BP; if it drops call back. *On 2/13/21 at 11:32 p.m. a progress note stated: -Resident laying in bed on her right side, CNA enters to assist with a bloody nose. Resident became limp, eyes rolled back in her head, then developed a full body shaking. Resident is not responding verbally at this time. Episode lasted <2 minutes. Resident recovers and is verbally responsive, following commands. She denies any aura prior to event. She has a gash to the right side of her tongue and is bleeding. BP 133/88, P [pulse] 47, R [respirations] 18, blood glucose is 118. Denies any pain. [Family member's name] informed of the event. States she has had these in the past, and quickly recovers. She and resident decline going to the hospital. [Doctor's name] phoned and updated. Orders to monitor her status and if a repeated event send to [hospital's name] ED [emergency department]. Review of resident 6's pharmacy documentation revealed: *LPN T sent a fax to the eLTC pharmacy on 2/15/21. *On 2/15/21 the pharmacy returned communication stating to draw the resident's PT/INR on 2/17/21. *Resident 6 passed away the morning of 2/17/21 and they were not able to draw the PT/INR. Interview on 2/18/21 at 2:00 p.m. with CNP I regarding resident 6 revealed: *She was not familiar with resident 6. *The order to have eLTC pharmacy monitor [MEDICATION(S)] was the standard for residents being admitted . *Her expectation would have been for staff to contact eLTC the day the order was written on 2/11/21. *She was not sure why staff had not called eLTC pharmacy until 2/15/21. Interview on 2/19/21 at 8:50 a.m. with MD J revealed he: *Believed having eLTC pharmacy to dose [MEDICATION(S)] and monitoring PT/INRs was a standing order for the facility. *Was called about resident 6's [CONDITION(S)] activity on 2/13/21. *Did not feel like it was a [CONDITION(S)] due to what staff described. *Stated resident 6 was coherent during the entire event so it did not seem like a typical event. *Was not aware of any issues of bloody noses or other bleeding. Interview on 2/25/21 at 2:15 p.m. with RN F regarding resident 6 revealed: *She stated that she would never forget the smell in her room the day she passed. *The surveyor asked what was the smell and she had replied the blood. *All of the bleeding from her had caused a strong odor in the room that staff would never forget. Review of provider's July 2014 Anticoagulation Therapy policy revealed: *Residents who are on anticoagulation therapy are monitored to deliver proper care and treatments. This includes monitoring lab levels to validate they are within therapeutic range, as well as monitoring resident for any signs or symptoms of complications from the medication(s) utilized. 2. Interview and observation on 2/18/21 at the following times with resident 7 regarding her admission on 2/3/21 revealed at: *4:00 p.m.: -She had been admitted to the facility due to having hip surgery. -She was going to be at the facility for a short time to get physical therapy so she could return to her own home. -The facility had explained to her about being on quarantine status. -She did not like it but was dealing with it. -Her call light was not always answered and had not worked. -She had told staff multiple times her call light had not worked. -The last time her call light had not worked was over the past weekend being Valentine's weekend. -She had reported to the staff her call light had not worked on the Friday before Valentine's weekend. --Staff had told her she would have to wait until the following Monday to let maintenance know. -A certified nursing assistant (CNA) had given her a different call light cord on Saturday night. -They had plugged her call light cord into her roommates call light unit located on the wall. --During the interview her call light was plugged into her roommates wall call light system. *4:05 p.m.: -She put on her call light. -The light on the call light unit was blinking from her roommates wall unit. *4:08 p.m.: -Nurse aide Q brought in a container of water for her. -Interview at that time with nurse aide Q revealed: --She had not noticed the call light was on. --She had not asked resident 7 if she had needed anything. --She was going to come into the room anyway with the water. --It was her fourth day working solo. *4:15 p.m. continued interview with resident 7 revealed: -She had chronic pain which usually was scored at a four out of ten. --A score of four was tolerable and a ten was untolerable. -She had to wait long periods of time for the staff to get her pain medication. -She had not gotten pain medication on February 4, 5, and 8. -On February 8th she put her call light on at 6:30 a.m. -She had not gotten her pain medication by 9:00 a.m. so she put her call light on again. -No one had stopped by to confirm they had seen her call light on or were getting her pain medication. -Her pain level was between a six or a seven out of ten. -She had a [MEDICATION(S)] patch and could have PRN (when necessary) [MEDICATION(S)]. *4:20 p.m.: She had put on her call light. *4:37 p.m.: -No staff had stopped in her room to answer the call light. --The surveyor went out to the nurses station. --Behind the nurses station was a computer monitor. ---On the monitor screen were different rooms listed and the amount of time the call lights had been on. ----room [ROOM NUMBER] had been on for 23:20 minutes and room [ROOM NUMBER] had been on for 23:30 minutes. *4:40 p.m.: -Licensed practical nurse (LPN) T came behind the nurse station. Interview at that time with LPN T regarding call lights revealed: --The call lights came across the walkies. --CNAs had the walkies with them at all times. --Nurses and medication aides did not always have a walkie with them because they were dead and not had not been recharged. ---They did not have enough walkies for all the staff. -She confirmed the time listed on the computer monitor was the amount of time the call lights had been on. Review of resident 7's medical record revealed: *An admitted [DATE]. *diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *She had orders for [MEDICATION(S)], [MEDICATION(S)] patch, [MEDICATION(S)], [MEDICATION(S)]-acetaminophen PRN and [MEDICATION(S)] PRN for pain. *Order to shower only. *The 2/9/21 admission Minimum Data Set (MDS) assessment review period was coded: -Brief Interview for Mental Status (BIMS) examination score of fifteen indicating she was cognitive. -She received scheduled and PRN pain medication. -She had pain or was hurting in the last five days. -The severity of the pain was coded mild in the last five days. -She had received scheduled narcotics in the last seven days. -The care area assessment (CAA) summary triggered the care plan for ADL (activities of daily living) and falls. It had not triggered for pain. Review of resident 7's 2/3/21 admission pain evaluation revealed she was immobile, was interviewable, pain type was achy, worse with movement, site was the left leg/hip, pain scale was coded seven indicating severe pain, sudden onset, pain effects was coded for changes in activities, ADL function, independence, and mobility. Rest and medication improved the pain. Review of resident 7's February 3 through February 18, 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *She had received pain medication on February 4 and 5. *On February 8th she received [MEDICATION(S)]-acetaminophen at 11:11 a.m. for pain level score of seven out of ten. Review of resident 7's 2/3/21 admission care plan revealed there was no information on it for pain. Interview on 2/22/21 at 2:50 p.m. with DDCO A regarding resident 7's pain management and the length of time to answer her call light revealed she would need to check into it before she would be able to answer the question. -By 2/23/21 at 2:00 p.m at exit she had not replied regarding the above. 3. Review of resident 8's (resident 7's roommate) bathing task flow sheet from February 5 through 24, 2021 revealed: *She had received a: -Bed bath on 2/5/21, 2/8/21 and 2/24/21. -Whirlpool bath on 2/17/21. *She had gone nine days without a bed bath or whirlpool. Review of the call alarm report from 2/1/21 through 2/17/21 for resident's 7 and 8 regarding call light response time revealed: *On 2/8/21 resident 7 had put her call light on at 6:38 a.m., 9:14 a.m., 9:40 a.m., and 10:58 a.m. *From 2/1/21 through 2/17/21 resident 7 had: -Fifty-two occasions it took over eight minutes to have her call light answered. -Three occasions it took over sixty minutes to have her call light answered. -Two occasions it took forty to fifty-nine minutes to have her call light answered. -Twenty occasions it took twenty to thirty-nine minutes to have her call light answered. *The last documented call light for her was on 2/13/21 at 4:55 a.m. *From 2/1/21 through 2/17/21 for resident 8 had: -27 occasions it took over eight minutes to have her call light answered. -One occasion took fifty-six minutes. 4. Interview on 2/22/21 at 12:50 p.m. with resident 9 revealed she: *Sometimes did not get a bath. *Would like to get a bath weekly. Review of resident 9's medical record revealed: *A 12/7/20 admitted . *The 12/10/20 admission five day MDS assessment revealed: -A BIMS examination score of fourteen indicating she was cognitive. -It was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath. Review of resident 9's January 27 through 31, 2021 and February 1 through 17, 2021 bathing task flow sheet revealed she: *Had received a bath on 1/27/21, 1/28/21, 2/3/21, 2/9/21, and 2/17/21. *She had gone eight days without a bath from 2/9/21 through 2/17/21. Surveyor Review of bath records from 2/1/21 to 2/21/21 for 8 randomly sampled resident's (11, 12, 13, 14, 15, 16, and 22) with documented skin concerns revealed: *Resident 11 had documentation that revealed: -From 2/1/21 to 2/21/21 resident 11 had 1 documented bath. -On 2/18/21 she refused a bath. -On 2/19/21 she had a whirlpool bath. *Resident 12 had documentation that revealed: -On 2/4/21, 2/5/21, and 2/8/21 she refused baths. -On 2/10/21 and 2/18/21 she received baths. -There was 8 days in between documented baths. *Resident 13 had documentation that revealed: -On 2/10/21 and 2/16/21 he had a bed bath. -There was not any documentation of refusals. -There was 10 days without a documented bed bath. *Resident 14 had documentation that revealed: -On 2/2/21 and 2/9/21 he had a whirlpool bath. -On 2/19/21 he had a shower. -There was 10 days without a documented bath. -There was not any documented refusals. *Resident 15 had documentation that revealed: -On 2/5/21, 2/9/21, and 2/18/21 she received a bath. -There was a 9 days gap between baths for resident 15. *Resident 16 had documentation that revealed: -On 2/2/21, 2/9/21 she received a whirlpool bath. -On 2/18/21 she received a bed bath. -There was a 9 day gap between baths for resident 16. *Resident 22 had documentation that revealed: -On 2/1/21 he received assistance with a bath. -On 2/9/21 and 2/17/21 he had total dependence. -There were eight days between baths for him. Surveyor 5. Interview on 2/18/21 at 5:09 p.m. with DNS E regarding call lights revealed: *The staff were alerted to call lights over the walkies. *The call lights showed up on the computer monitors behind each nurses station. *Each staff member was to have a walkie with them. *There were times when the staff did not have a walkie. Those times had included: -If the prior shift had not plugged them in to be recharged. -If the walkies had been misplaced. -The staff had taken the walkies home with them. *It was not acceptable for a call light response time of twenty-three to twenty-four minutes. *The response time should be eight minutes or less. *She was out on the floor every day and if she observed a staff member without a walkie she would ask where it was and remind them to have one with. *There was no walkie or call light policy or procedure. Further interview on 2/18/21 at 6:10 p.m. with DNS E regarding call lights and the walkies revealed: *They had thirteen walkies available for staff who were working the floor. *There were not enough walkies for each staff member who was working the floor. *She had collected all the managers walkies for the staff to use on the floor for the evening/night shift on 2/18/21. *Her expectations would have been for call lights to be answered within eight minutes. *She confirmed twenty-one to twenty-four minutes was too long for residents to wait for a response to a call light. *They did not have a bathing policy or a resident personal care/nail care policy. -They were considered standards of practice. 6. Review of an undated and unsigned post-it note attached to the Facility Risk Assessment received on 2/19/21 revealed Standard of practice to meet residents needs and per regulation for each resident to have a call light. Telephone interview on 2/19/21 at 5:18 p.m. with LPN R regarding resident 6's INR's revealed: *She had worked at the facility since August 2020. *She had taken care of resident 6. *Labs were done routinely. --They did whatever the physician had ordered. *She worked the night shift. *Confirmed resident 6 was on [MEDICATION(S)]. *The order usually came from the eLTC. -She could not remember who gave the order for the PT INR the day she had passed away. -She had not talked to CNP I. -She had not had any interaction with eLTC for her. --They would fax orders over. --She had noted it was to be done on the 17th. --The standard was to draw a PT INR every two weeks. --She did not deal with new admissions. --If things needed to be followed up on she would do it but it was usually done on the day shift. --She did not know how to deal with getting information back from eLTC pharmacy. --She had been working when resident 6 coded. --Resident 6 had:---A bloody nose a day or two prior to the incident. ---[CONDITION(S)] activity over the weekend, had bit her tongue, had bleeding. ---No one had reported a bloody nose on Tuesday. --Two CNAs came into resident 6's room. ---CNA EE had been in resident 6's room but had not reported any bloody nose. -She did not know why lab had not been drawn earlier than the 17th. Surveyor: 7. Review of resident 20's medical record revealed: *He was admitted on [DATE]. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Persistent vegetative state, [CONDITION(S)], unspecified. -[CONDITION(S)] affecting right dominant side. *His nursing progress notes revealed: -On 11/22/20 LPN Z documented he had open areas to his coccyx that were starting to weep and bleed. He had drainage on his hands from itching the site. She applied a dressing and planned to notify the physician of his status. -On 11/28/20 the dietitian documented he had been receiving protein powder for his skin integrity. -On 12/6/20 LPN AA had applied a foam dressing to his bottom due to sores and drainage. -On 1/14/21 his physician made virtual visit. There was no documentation of skin concerns in the progress notes. *Section M (skin) of the 1/21/21 Minimum Data Set assessment indicated skin tears and moisture associated skin damage (MASD) were present. -A 2/2/21 progress note by RN C indicated a Stage 2 open area to on buttocks, scar tissue surrounding area, history of skin breakdown in this area. Moisture barrier cream twice daily and PRN [as needed] until healed. *An initial skin and wound evaluation was completed on 2/2/21 for an abrasion to the coccyx. -The wound area was described as 0.41 centimeters (cm) long by (x) 0.35 cm wide. *On 2/4/21 resident 20's physician ordered a referral to the wound clinic. *On 2/4/21 the resident returned from the wound clinic with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *On 2/8/21 RN contacted the wound clinic for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *A 2/8/21 progress note progress note by RN indicated the resident had a red bottom. He also had scratches to his right lower abdominal area and had the draining area to left abdomen, area cleaned and new bandage applied. Large amount of yellow drainage noted. * 2/9/21 skin and wound evaluation was completed for the coccyx abrasion. -The wound was identified as Deteriorating - Age unknown. -Measurements described as 1.7 cm long x 2.99 cm wide, with an area of 4.51 cm2 (total measurement of the entire wound). *The resident was seen again on 2/12/21 at the wound clinic, with no new orders. *A 2/16/21 skin and wound evaluation for the coccyx abrasion revealed: -The area was 7.91 cm long x 10.44 cm wide, making the total area 44.96 cm2. -A photo of the resident's buttocks revealed heavy scarring across both sides of the buttocks from self-scratching and other areas of skin gouges with some bits of skin hanging off. *A 2/18/21 nursing progress note by LPN CC indicated Picking at buttock and abdomen. Tearing up brief. -The nurse had not indicated what interventions might have been used to prevent the resident from picking at his skin. *A 2/20/21 progress note by LPN CC indicated Buttocks skin is broken down. Right buttock is open. [MEDICATION(S)] and [MEDICATION(S)] applied. Review of resident 20's revised 2/2/21 care plan revealed: *He had open areas on his coccyx. *Interventions had included: -Keep fingernails clean and trimmed. -[MEDICATION(S)] to coccyx. Observation on 2/22/21 at 2:25 p.m. of resident 20 revealed: *He was laying in bed. *He had no clothing or incontinent brief on from the waist down. *His blankets had been pulled off. *Observation of his hands revealed his fingernails and thumbnails had grown beyond the tips of his fingers and thumbs. Interview at that time with unlicensed assistive personnel DD regarding resident 20's fingernails revealed: *The residents get their nails trimmed on their bath day. *She was not sure when resident 20 had his bath last. *She was not sure where a bath list was kept. Interview with health unit coordinator N at 2:35 p.m. regarding resident 20's bath revealed: *All residents were to have their nails trimmed with every bath. *His last bath was on 2/16/21. *The resident was a diabetic so he required a nurse to trim his nails. *Regarding the resident scratching his skin off the health unit coordinator stated: -He was admitted in May of 2019. -He has been doing that since the day he came in. -He takes his brief off and scratches and scratches. Interview at the same time with LPN CC regarding resident 20's long fingernails revealed: *She confirmed that resident 20 required a nurse to trim his nails. *She usually had RN B trim resident 20's nails. *When questioned she confirmed that RN B no longer worked in the facility. Review of resident 20's February 2021 medication, treatment, and aide task records revealed none of those documents had included documentation indicating the resident was to have his nails trimmed to reduce skin problems. Review of resident 20's nursing progress notes on 2/23/21 revealed that his nails were finally trimmed on 2/22/21 at 7:30 p.m. Surveyor 8. Interview on 2/22/21 at 11:55 a.m. with maintenance director S regarding the call light system revealed: *There should be one call light per resident. -Each room had a wall unit for the call light to be plugged into. -One side of the wall unit indicated falls and the other side indicated need for assistance. -There should not have been two separate call cords plugged into one wall unit. -He has had to switch the call cords back when staff plugged two call cords into one wall unit. -He was informed of call lights needing maintenance through their internal system called TELS, a maintenance work order, or the staff informed him of the issues. -The TELS system could be entered as a work order on the computer. --He printd out the work orders. --He tried to check the best he could for call light orders. --No one had let him know they were having call light issues in resident 7's room over the past few days. --He had done call light audits. --He checked the call light system weekly. *If a call light was not working over a weekend there was a maintenance person on call or they should have let the director of nursing services know. 9. Review of the provider's Resident Admission Packet revealed residents have the following rights under Federal law including: *Rights related to care and treatment: -7. The Resident has the right to be informed of , and participate in, his/her treatment, including:--f. The right to receive services and/or items included in the plan of care. *Rights as a resident of the Center: -21. The Resident has the right to reside and receive services in the Center, with reasonable accommodation of Resident needs, except when doing so endangers the health and safety of other Residents. -22. The Resident has the right to reasonable accommodation of individual needs or preferences, except where the health or safety of the Resident or other Residents is endangered. -24. The Resident has the right to make choices about aspects of his/her life in the Center that are significant to the Resident. Review of the provider's updated March 2012 Certified Nursing Assistant (CNA) job description revealed: *Essential Functions:-1. Answers signal lights, bells, or intercom system to determine resident needs. -2. Provides assistance with bathing, dressing, toiletry, and oral hygiene activities of daily living (ADLs). -5. Turns and repositions bedfast residents, alone or with assistance, and utilizing proper body mechanics, to prevent pressure ulcers. -7. Completes documentation (e.g. meal monitor, I&O) records, ADL, and Aide flow sheets). Review of the provider's updated March 2012 Charge Nurse job description revealed: *Job Summary: -Directly accountable to the Director of Nursing Services (DNS) to manage the nursing care of assigned residents to maximize independence and self-direction for residents. -Responsible for safety of residents under their supervision. -Manages day-to-day compliance with Federal and State regulations, Center policies and procedures, and standard of practice with regard to resident care. *Essential Functions: -3. Supervises and evaluates direct resident care provided within assigned unit and initiates corrective action as necessary. --d. Identifies special nursing problems and emergency situations quickly, and initiates appropriate interventions for individual residents. --e. Supervises and evaluates the implementation of Resident Bill of Rights. --g. Documents resident care provided and resident's response or lack of response to treatment provided, --h. Assesses and reports changes in resident's condition, including development of pressure ulcers, to physician, the DNS and responsible party, and takes recommendations for nursing action to be implemented. --i. Assesses resident responses to medication and treatment, and makes appropriate recommendations for nursing action to be implemented. -4. Assesses on a weekly basis via resident rounds the condition of existing pressure ulcer by stage, size (measurements), sites depth, color, drainage, and odor. reports problems to the DNS; takes necessary follow-up action. -7. Supervises the timely response of call-lights within assigned unit. -9. Follows up on physician orders, lab, and x-rays. -10. Observes resident, records significant conditions and reactions, and notifies family (responsible party) and physician of resident's condition, and reactions to drugs, treatment, and significant incidents. --Documents it according to Center policy and Standards of Practices. *Administrative: -3. Provides clinical supervision to nursing assistants. Review of the provider's updated March 2012 Director of Nursing Services job description revealed: *Job Summary: -Is directly accountable to the Executive Director (ED) for the day-to-day operations, activities, and success of the resident care staff, as governed by the Center policies, and state and federal regulations. -Validates that the Nursing Department continues to develop and maintain high standards of excellence. *Essential Functions: -2. Manages, supervises, and develops plans of action for assigned units, providing consistent monitoring and follow-through. Review of the provider's updated November 2019 Executive Director job description revealed: *Job Summary: -Is directly accountable to the Divisional Vice President of Operations (DVP) to provide strong overall leadership and management of a long-term care center. -Manages delivery of the highest level of health services and quality of care that is responsive to customers' needs. -Directs efforts to facilitate the overall well-being of Center. *Essential Functions: -2. Quality Management:--a. Lead the process to develop and implement programs to maintain quality of care to meet established goals. --c. Hold Department Managers accountable for departmental quality performance. --d. Verify the Center meets state and federal requirements for long-term care Centers for licensure. Review of the provider's updated January 2019 Divisional Director of Clinical Operations (DDCO) job description revealed:<BR/

Based on interviews, closed record review, policy review, and the unexpected death report submitted to the South Dakota Department of Health (SD DOH), revealed the provider failed to ensure one of one closed sampled resident record (5) who was a full code, with no pulse or respirations received emergency services for cardiopulmonary resuscitation (CPR). Surveyor: : All residents who are full code status have the potential to be affected by this deficient practice. NOTICE: Verbal notice of immediate jeopardy and the template was given on [DATE] at 6:00 p.m. An immediate jeopardy was identified when the facility failed to start CPR immediately for one of one resident who was a full code status. Notice of Immediate Jeopardy was given verbally to the director of nursing services (DNS) E, divisional director of clinical operations (DDCO) A, and registered nurse (RN) F. For specific immediate jeopardy noncompliance, see above finding in the base statement. At the above time DDCO A and DNS E were asked for an immediate plan of removal to ensure all staff working in the facility received education and competencies for CPR. PLAN: 1. Educate all licensed nursing on recognizing change of condition using einteract Change of Condition handouts. Education to all CNA's [certified nursing assistant] and NA's [nursing assistant] on recognizing and reporting change in condition. Education to also include that if the situation is emergent to call 911 and send to ER, not to delay waiting for a provider response. Education to all licensed and unlicensed nursing staff to include how to deflate an air mattress in the need for CPR, where the on call calendar is located and to call the primary on call for urgent needs and if no response, call eLTC. Education includes the process for CPR, how to record a CPR event when it is occurring. All licensed nurses and CNA's and unlicensed NA's will be educated to be able to record a full code. Education to all CNA's and nurses that they are to have a walkie with them to call for help. All nurses deemed competent though BLS [Basic Life Support] training and certification. A full audit of current certification was conducted. There has since been an order placed to have adequate walkies for all managers and a reserve should some be missing or malfunctioning. ED, DNS or designee will be responsible for updating the on-call calendar and ensuring each station has one daily. Divisional Director of Clinical Operations will educate nursing management who will in turn educate all licensed and unlicensed staff prior to their next working shifts starting immediately. All education emailed to all staff not educated on [DATE]. Education started on [DATE] and completed [DATE]. 2. An audit will be done by ED, DNS or designee of licensed nursing staff on knowledge of recognizing a change of condition and actions to take if there is an acute change in condition. Audit licensed and nursing staff on the process of CPR, licensed and unlicensed nursing staff on the recording of CPR events, if staff have a walkie with them to call for assistance, where the on call calendar is located at each nursing unit, and how to deflate an air mattress in emergent situations. 3. Compliance date [DATE] An onsite revisit was completed on [DATE] at 12:35 p.m. to verify the immediate jeopardy removal plan. Immediate Jeopardy was determined removed on [DATE] at 2:56 p.m. After removal of the Immediate Jeopardy, the scope/severity of this citation is level G. Surveyor: : Findings include: 1. Review of the provider's unexpected death report submitted to the SD DOH involving resident 5 revealed: *At 4:10 a.m. on [DATE] RN L went into resident 5's room and he was verbally non-responsive. *He was on oxygen (O2) at 4 liters (L) and his oxygen saturation (sat) level was 90%. -RN L stated that was normal for him. *He had a low-grade temperature of 99.8 F (Farenheit). *Abdominal and chest retractions. *Registered nurse (RN) L called the [hospital name] telehealth line to try to get an order to transfer him to the hospital. *Certified nurse practitioner (CNP) O from the telehealth line stated it was risky to send him to the ED (emergency department). *CNP O ordered lab work and wanted RN L to contact an outside company to get a chest x-ray for him. *Lab work was ordered and drawn from resident 5, then taken to the hospital. *At 5:00 a.m. RN L returned to resident 5's room and he was grey, had no pulse, and his chest was not rising which would indicate breathing. *CPR was started at 5:11 a.m. *Emergency services were called at 5:14 a.m. *Emergency services arrived at the facility at 5:18 a.m. *At 5:41 a.m. medical technicians pronounced resident 5 deceased . Review of resident 5's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *He had multiple co-morbidities which included: -Chronic venous hypertension with ulcer. -Chronic kidney disease, stage 3. -Type 2 diabetes. -Morbid (severe) obesity. *He was a full total lift of four people. Review of RN L's [DATE] documentation on his EMR revealed, 0500[5:00 a.m.] returned to residents room to assess resident and color is grey, no pulse no chest rise. Sputum all around lips. Code blue initiated. CPR started at 0514 [5:14 a.m.]. AED [automated external defibrillator] applied and analyzed x3. No shock advised x3. CPR continued, 911 called at 0511 [5:11 a.m.]. CPR continued. [Name of city] ambulance services arrived at 0518 [5:18 a.m.]. They applied their AED and analyzed the rhythm and continued CPR. Pronounced [NAME] [time of death] by EMT's [emergency medical technician] at 0541 [5:41 a.m.]. Review of resident 5's daily task record on [DATE] revealed: *Resident 5 was monitored for the following at 2:38 a.m.: -Bowel and bladder. -Dressing, bed mobility, locomotion on and off the unit. -Personal hygiene and toliet use. -Transferring, [NAME] in corridor, walk in room. -He was turned and repositioned at 2:36 a.m., and 3:17 a.m. *Resident 5 also had the following tasks marked at 9:49 a.m, after he was deceased : -Bed mobility and dressing. -Locomotion on and off the unit. -Personal hygiene and toliet use. -Turning and repositioning. *As far as nutrition, swallowing, and meal monitoring: -That was also marked at 9:49 a.m. for the 8:00 a.m. and 12:00 p.m. time. Review of resident 5's prescribed physician medical orders revealed he was to receive 2 L of oxygen at sleep and PRN (as needed) during the day as needed. Interview on [DATE] at 1:35 p.m. with RN F regarding contacting physicians on call revealed: *Each wing had an on call calendar located at each desk. *The on call calendar was a month view and had: -About nine names listed each day. -There were no times listed. -There were no specialities listed. *The surveyor asked RN F how new staff knew who to call. *RN F said she believed they went over it in orientation. *It was up to each nurse to decide whether to call the physician on call or electronic long term care (eLTC) telehealth. *She said the on call calendar was for the hospital doctors. *In order to reach the clinic on call doctors the nurse would need to call the clinic. *The surveyor pointed out that the clinic doctors were also listed on the on call calendar. *She stated well, that makes it easier, she did not realize that the clinic doctors were also listed on the calendar. Interview on [DATE] at 11:00 a.m. with medical director G revealed he thought that it was up to the physician whether they wanted to be called or if the facility should call eLTC telehealth. Interview on [DATE] at 5:10 p.m. with DNS E regarding the on call schedule for physicians. *When surveyors asked how new nurses would know how to read the on call calendar, she replied that is a good question. *DNS E said she would not know who to call either. *She said she would look in the computer and see who the physician was if she needed to find out. Interview on [DATE] at 8:50 a.m. with medical doctor (MD) J revealed he: *Was resident 5's physician. *Never saw resident 5 in person since it was his belief that physicians were not allowed in the building. *Believed it was facility policy that eLTC telehealth was called instead of physicians on call. *Did not recall being asked what his preference was regarding being called after hours. *He was on call on [DATE] but wasn't sure what time his call started that day. *Had not been told that CPR for resident 5 started 11 to 14 minutes after a code blue was called. Record review revealed the facility called MD J at 9:00 a.m. on [DATE] to inform his office of resident 5's death. Interview on [DATE] at 3:14 p.m. with RN/MDS coordinator D regarding CPR revealed: *When a code blue was called all the nurses that were working were expected to respond. -There were more nurses working on the day shifts so there were more nurses that could respond. -There were three nurses on the evening/overnight shift. *The process for CPR was: -The nurse made a call overhead. -The nurse would get a crash cart and go to the location of the code. *There were four AEDs in the building. *There were three code carts in the clean linen or clean utility rooms. *They did not need to have an order to send a resident to the emergency department at the hospital. * For emergencies they went through eLTC because they were always available. Interview on [DATE] at 4:01 p.m. with RN/wound nurse C regarding on call physicians revealed: *She knew there was a list of who was on call at each nurses station. *The nurses could call the acute care hospital for emergencies. *They used eLTC which she considered a nice resource. *She confirmed the night shift started at 6:00 p.m. for the nurses. Interview on [DATE] at 4:45 p.m. with RN L regarding the CPR incident with resident 5 revealed: *She worked the 6:00 p.m. to 6:30 a.m. shift. *Resident 5 had needed to go to the ED. *She: -Had called eLTC. -Felt that would have been the easiest way to transfer him. -Did not know she did not need an order to send him to the ED. *The hospital ED was across the road. *She had drawn his blood. -She had another nurse take the blood sample to the hospital. *When she found resident 5 in his room: -He was gray. -She had gone in at 4:00 a.m. to reposition him. -He was not responding verbally. -She decided to call eLTC knowing he required further medical care. -She could not remember what time it was. *He was fine when she went in to draw his blood. -He had looked the same as earlier. *She was concerned because he was not himself. *He was gray and had a difficult time breathing. *She could not find the aide. *She called code blue. *She had pushed his call light. -There was one aide on her unit. -That aide working on her unit was pretty quick to get to his room. *She went to the 200 unit wing nurses station to call the code blue overhead. *The aide had a walkie talkie but she did not have one. *The nurses came from the other two units. *She got the crash cart. *The nurses were there. -They started CPR and hooked him up to the AED. --The AED had monitored to continue with CPR. *The aide let the ambulance people in to the facility. -The ambulance crew hooked him up to their AED. *The nursing home staff had left the air mattress on the current setting and had not deflated it during CPR. *She was not sure what time CPR was started. *The two nurses were very fast at getting to his room and starting CPR. *She didn't believe that it took them fourteen minutes to start CPR. *She thought CNA P was recording times during the code blue. *CNA P had: -Never been involved in a code before so she didn't know how to record times. -A clip board in her hand, but didn't know what she had recorded. *They didn't know what happened to the sheet of paper CNA P was documenting on. *She stated she did re-read her documentation and it was accurate as far as she could tell. -The documentation could have been off a few hours. *For the notification of the on call physician she would go by eLTC. *There was a folder with names of physicians on call kept at the nurses station. *There was not a folder with names of physicians on call at the 200 wing nurses station. *The on call calendars were done ahead of time. *RN B and LPN K were the nurses who had started CPR on him. Surveyor : Interview on [DATE] at 4:00 p.m. with RN C regarding the physician on call schedule revealed it is not clear cut when to call eLTC versus calling the physician on call. Further interview on [DATE] at 4:45 p.m. with RN L regarding the CPR event for resident 5 revealed she: *Found out after the fact that she did not need an order to transport a resident to the ED. *Had remembered why she called eLTC instead of the physician on call it was because the calendar had not been updated. *Had remembered being so mad because she tried to find the on call calendar but was unable to so she contacted eLTC. *Did not fill out any documentation after the code other than what was documented in the electronic medical record. *Did not know how effective compressions were due to the resident's size and since he was on an air mattress. Interview on [DATE] at 6:00 p.m. with DNS E, RN F, and DDCO A revealed: *DDCO A did not believe that the medical record stated that CPR was started fourteen minutes after code blue was called: *DNS E felt like there was nothing that they could have done differently. Interview with LPN K regarding the CPR event for resident 5 revealed she: *Worked the night of [DATE]-[DATE]. *Had worked on the 300 & 400 wing, which was the memory care unit. *RN L was going to get an order to transfer resident 5 to the ED. *Stated each unit had 1 nurse and 1 aide during the night shift. *Stated resident 5 needed 4 to 6 people to reposition every 1 to 2 hours. *Had walked down to the 100 unit to check on RN L, because she did not feel they had enough staff. *Thought maybe an hour later she heard RN L calling a code blue over the intercom. *Stated when she arrived to resident 5's room RN B was doing CPR on the resident. Interview on [DATE] at 3:30 p.m. with CNA P revealed she: *Was working on the 100 hallway the night of ,d+[DATE]-[DATE]. *Was doing her rounds around 3 a.m. and noticed that resident 5 was very lethargic, not responding. *Stated resident 5's vital signs were declining rapidly. *Informed RN L of resident 5's condition. *Stated she had heard the code blue when she was coming back from taking resident 5's labs to the hospital. *Stated she had a walkie talkie that night. *Stated the facility does not have enough walkie talkies for everyone. *Stated she was not writing anything down during the code. Interview on [DATE] at 12:30 p.m. with DDCO A revealed she: *Stated that she completed a 100% audit as part of their facility investigation. *Audited the three code carts to ensure nothing was missing. *Interviewed staff. *Educated staff about sending to the ED. *Did not have documentation of this audit. Surveyor : Review of provided undated nursing education revealed: *There were 6 topics on the education. *One of those topics was regarding CPR/ change of condition, it stated: Change in condition-notify MD, family, send to ER-do not need a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -It proceeds with handwriting stating, needs evaluation/change in condition. *Four licensed nurses signed the education. *The facility currently has 19 licensed nurses working in the facility. Review of the provider's [DATE] Code Blue policy revealed: *The 1st responder calls for help by announcing a Code Blue. *The Code Blue is announced with the exact location on the overhead page system. [DATE] is called immediately. *The resident's code status is established immediately by the nearest Licensed Nurse (LN) using the POLST/POST/Advance Directives. *A code team leader is clearly established and necessary duties assigned. *The Emergency cart is promptly brought to the scene. *Oxygen management is promptly brought to the scene. Physician and family are notified, CPR is continued if indicated until EMT arrival and take over. *Completion of the post event evaluation and code event minutes is done by the LN and support team during the Code Blue event. Surveyor Review of the provider's [Name] eCare Senior Care Services Agreement signed on [DATE] revealed: *Article III [name] Senior Care Telemedicine Services: -Urgent Care Services [DATE]. [Name] agrees to be available to provide the following urgent care Telemedicine Services:--a. twenty-four hour access to a team comprised of APPs, RNs, and physicians led by a board-certified geriatrician to allow for rapid access to care to help prevent re-hospitalization of Residents and promote reduction in length of stay at hospitals. --b. phone-call based assessments of the Residents with the Facility to determine the need for a video encounter. -Facility and Customer each agree to take all actions which may be necessary to ensure [Name] is able to effectively provide urgent care Telemedicine Services, such actions will include without limitation: --u. contacting [Name] at the earliest sign of change in condition in order to expedite clinical intervention in an effort to see the greatest impact on a reduction of unplanned transfers, emergency department visits, re-hospitalization , and length of stay. --y. ensure orders from [Name] are implemented once received. Review of the provider's undated document entitled When to Call [Name] eCare Senior Care? revealed:*Any clinical questions. *Support during medical emergencies. *Assessment of resident over video. *Address urgent lab results. *Change in condition concerns. *Pharmacy consults. *Any concerns about a resident. *Pain management. *Skin Concerns.

Based on interview, record review, policy review, and the South Dakota Department of Health (SD DOH) online report review, revealed the provider failed to ensure one of three closed record sampled residents (19) and one of one sampled resident (7) received pain management for ensuring a: *Hospice resident's pain was managed, and the provider and/or hospice agency was notified. *Resident who was receiving pain medication received her medication timely. Surveyor These failures have a potential to expose all residents not receiving effective pain management to have their quality of life to be affected. NOTICE: Verbal notice of immediate jeopardy and the template was given on 2/19/21 at 6:00 p.m. An Immediate Jeoopardy situation was identified when the facility failed to implement Centers for Medicare & Medicaid Services. Notice of Immediate Jeopardy was given verbally to the Divisional Director of Clinical Operations A, director of nursing services E, and registered nurse/staff development coordinator F. At the above time the Divisional Director of Clinical Operations A was asked for an immediate plan of removal to ensure all staff working wth residents ensured they maintaned an ongoing communication regarding pain management between the facility, Hospice Provider, and the physician. PLAN: The administrator submitted an email that included the final written removal plan. That removal plan was approved by the South Dakota Department of Health on 2/24/21 at 10:30 a.m. the following plan was approved: 1. Educate all licensed nurses on pain policy and notification to hospice and physician per policy, on proper documentation of pain level and communication with hospice and/or provider on residents with uncontrollable pain, recording pain scale in the medication/treatment record. Educate all licensed and unlicensed nursing staff on non-therapeutic pain interventions, and signs and symptoms of pain immediately prior to their next working shift. Education provided by Divisional Director of Clinical Operations to nursing management team who in turn will educate all nursing staff. Education will be completed by 2/22/2021. Sweep of all residents will be completed on 2/22/21 to check for pain and had pain medication administered as ordered by the physician. 2. Audits will be verified by the ED after the DNS completed/DNS or designee on proper notification and intervention on residents with uncontrollable pain to provider and hospice (if involved), recording pain scale in the medication/treatment record, and knowledge of non-therapeutic pain interventions. 3. Compliance date 2/22/2021. An onsite revisit was conducted by surveyors on 2/24/21 at 12:35 p.m. Immediate Jeopardy was removed on 2/22/21 at 2:56 p.m. after the removal plan implementation was verified during an onsite visit. After removal of the Immediate Jeopardy, the scope/severity of this citation is level G. Surveyor Findings include: 1. Review of the SD DOH online report submitted on 2/16/21 revealed: *Registered nurse (RN) Y was the primary hospice nurse for resident 19. *She had been coming in the facility everyday for the last 10 days. *RN Y arrived at the facility at 11:00 a.m. on 2/16/21. *She stopped at the nurse's station to receive an update from the nursing staff for resident 19. -While at the desk she stated she could hear him screaming and crying from behind his closed door. *RN Y entered his room and found him screaming and crying in pain. *RN Y asked LPN X when resident 19 was last treated for [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] [MEDICATION(S)] 2 miligram (mg) /1 mililiter (mL) earlier this morning. *At 11:20 a.m. RN Y administered his scheduled dose of Oxycodone 5 mg which was scheduled every 4 hours. -She also administered 20 mg of [MEDICATION(S)] (20 mg/1 mL) and 1mL of [MEDICATION(S)] [MEDICATION(S)]. *At 11:50 a.m. he was still crying in pain so RN Y notified her supervisor and the hospice medical doctor (MD) H. *He had been transferred by ambulance to the hospital to receive pain management. Review of resident 19's EMR revealed: *He was admitted to the facility on [DATE]. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Personal history of [CONDITION(S)]. -Cerebral infarction without residual deficit. -Major depressive disorder, recurrent sever without psychotic features. -Epiepsy. -[CONDITION(S)] (COPD). -[CONDITION(S)]. -Anxiety disorder. *Stage II pressure ulcer to his right hip. *Healed pressure ulcer to his left hip. Review of resident 19's current care plan with the following dates revealed: *On 05/05/2020 there was a problem listed as: -The resident has the potential for discomfort -A goal of: The resident will not have an interruption in normal activities due to pain through the review date. --Target date 4/18/21. *The interventions and tasks that were listed were: -Administer scheduled pain medication as ordered. -Monitor/record/report to Nurse any s/sx [signs/symptoms] of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). *Monitor/record/report to Nurse loss of appetite, refusal to eat and weight loss. *Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. *Transferred to [NAME] Queen of Peace for uncontrolled pain. Review of resident 19's current February 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Tylenol Tablet 325 MG (Acetaminophen) Give 650 mg by mouth three times a day for general pain. *Acetaminophen Tablet Give 325 mg by mouth every 3 hours as need for pain Give 2 tabs every 3-4 hours prn [as needed] for pain. *IBU Tablet ([MEDICATION(S)]) Give 600 mg by mouth two times a day for Pain related to OTHER INTERVERTEBRAL DISC DEGENERATION, LUMBOSACRAL REGION. *An order with a start date of 2/15/21, oxyCODONE HCL [hydrochloride] Tablet 5 MG Give 5 mg by mouth every 4 hours for pain. *LORazepam Concentrate 2MG/ML Give 0.25 ml by mouth every 2 hours as needed for Anxiety AND give 0.5ml by mouth every 2 hours as needed for Anxiety AND Give 0.75 ml by mouth 2 hours as needed for Anxiety AND Give 1ml by mouth every 2 hours as needed for Anxiety. *[MEDICATION(S)] (concentrate) Solution 20mg/ml *Controlled Drug* Give 0.25 ml by mouth every 1 hours as needed for Mild pain AND Give 0.5 ml by mouth every 1 hour as needed for Moderate pain AND given 0.75 ml by mouth every 1 hour as needed for Moderate/Severe pain AND given 1 ml by mouth every 1 hours as needed for Severe pain. *An order that was discontinued on 2/6/21, oxyCONDONE HCL Tablet 5MG Give 2.5mg by mouth every 4 hours as needed for Pain-Moderate 1 tab [tablet] po [by mouth] every 4 hour[s] prn pain while awake. *An order that was discontinued on 2/12/21, MS Contine Tablet Extended Release 15 MG ([MEDICATION(S)] ER) Give 15 mg by mouth at bedtime for pain. *An order, Discontinue the [MEDICATION(S)] 15mg scheduled but still ok to give prn [MEDICATION(S)] as needed. *An order, Pain Monitoring: Monitor for pain every shift either verbal or non-verbal signs. Document yes if monitored and no pain was observed or verbalized, Select chart Other/see nurses notes' and enter findings in appropriate progress notes including the pain scale of 1-10. every shift. Review of resident 19's February 2021 treatment administration record revealed: *For pain monitoring, Pain Monitoring: Monitor for pain every shift either verbal or non-verbal signs. Document yes if monitored and no pain was observed or verbalized, Select chart Other/see nurses notes' and enter findings in appropriate progress notes including the pain scale of 1-10. every shift. *There was a check mark every day shift and night shift from 2/1/21 to 2/15/21. -There was a check mark on the day shift 2/16/21. Review of resident 19's February 2021 medication administration record revealed: *He was to receive 600 mg of [MEDICATION(S)] by mouth two times a day for pain. -It was on hold from 2/1/21 through 2/15/21 at 8:46 a.m. --He had not received it on 2/15/21 or the morning of 2/16/21 because it was on order from the pharmacy. *He had an order to receive acetaminophen 325 mg by mouth every 3 hours as needed for pain. Give 2 tabs [tablets] every 3-4 hours for prn pain. -He received PRN Tylenol once on 2/11/21 and twice on 2/12/21. --He had not received PRN Tylenol any other days in February 2021. Review of resident 19's recorded pain levels revealed: *2/13/21 through 2/16/21 he had pain levels ranging from 8 to 10. -The pain scale was from 1 to 10 with 10 indicating severe pain. *Documented pain levels on: -2/13/21 at 11: 01 a m.: 10. -2/15/21 at 3:56 a.m.: 8. -2/15 at 9:47 a.m.: 9. -2/15/21 at 12:54 p.m.: 9. -2/15/21 at 2:56 p.m.: 8. -2/15/21 at 2:57 p.m.: 8. -2/16/21 at 11:42 a.m.: 10. -2/16/21 at 2:38 p.m.: 9. *There was not follow up pain scales on 2/13/21 or 2/16/21. -There was not documented pain ratings on 2/14/21. Review of resident 19's progress notes with the following dates revealed: *On 2/13/21 at 10:06 p.m. RN BB documented: -Hospice called and spoke with [nurse's name] was updated on continues with pain and calling out to clarify orders. *On 2/14/21 at 1:35 a.m. RN BB documented that he had not received his Oxycodone for pain because he was asleep. *On 2/15/21 at 4:19 a.m. there was documentation by RN BB stated: -Resident fell out of bed to floor but fell on to mat on floor and bed was in low position . -- Resident is on Hospice and contines having pain. Will update Hospice to see if can improve pain control . *On 2/15/21 at 4:40 a.m. RN BB documented that she spoked to Hospice about fall, new abrasions, lack of pain control . *He continued to receive PRN [MEDICATION(S)] that was ineffective for managing his pain levels. *On 2/16/21 at 11:42 he was given [MEDICATION(S)]. *On 2/16/21 documentation by LPN X stated: -Resident was transferred to the Hospital per Hospice. For general admission, d/t [due to] decline in condition. Resident was moaning and s/s [signs and symptoms] for discomfort, medication was not comforting resident. Left the building at 1220 on this day [DATE]. *On 2/16/21 at 2:39 p.m. LPN X documented the given medication was not effective. Further review of resident 19's medical record revealed: *On 2/11/21 documentation stated: -At 3:00 a.m. RN II documented: Resident has been more anxious and restless off and on from evening until present. Resident given Acetaminophen 650 mg for discomfort and [MEDICATION(S)] for itching, and will hold oxy at 4:00 a.m. -RN II had given him Tylenol at 3:10 a.m. -One hour later RN II held his scheduled oxycodone because he was sleeping. -LPN AA documented on 2/11/21 at 4:35 p.m., Resident is weak and restless . -He was given prn Lorazepam at 5:35 p.m. -His scheduled Oxycodone was not given at 8:00 p.m. due to drug refused. -The MS [MEDICATION(S)] was also held at bedtime. -No other prn Lorazepam, Tylenol, or [MEDICATION(S)] was given to resident 19. *On 2/12/21 documentation stated: -2/12/21 at 8:04 a.m. Hospice note regarding 2/11/21 stated: RN from facility called hospice with an update. Patient had a fall last night. Patient was switching from one end of the bed to the other. Patient slipped out of bed and fell on the mat. Held the MS [MEDICATION(S)] last night and patient did sleep much better. [RN II's name] has also been giving [MEDICATION(S)] prn for itching. -On 2/12/21 at 1:00 p.m. RN C documented, Spoke with [hospice nurse's name] with hospice, she is working on adjusting pain medications . -Hospice note on 2/12/21 at 1:13 p.m. stated: .staff noted he is more aggitated [sp] after taking MS [MEDICATION(S)] 15 mg at bedtime. SN [skilled nurse] spoke with [pharmacists name] and [Doctor's name] and will change orders- d/c [discontinue] MS [MEDICATION(S)], start Oxycodone 5 mg at bedtime and 0200 [2:00 a.m.] and cont [continue] previous order for Oxycodone 2.5 mg every 4 hours while awake. --The note continued, .Staff heled [sic] Oxycodone during day yesterday due to agitation and gave ACM [Acetaminophen] prn and Lorazepam x 1 dose. -He was documented to have received his Oxycodone during the day on 2/11/21, he had received it at 8:00 a.m., 12:00 p.m., and 4:00 p.m. -On 2/12/21 he had not receive four of his scheduled six doses of Oxycodone. *On 2/13/21 documentation stated: -3:50 a.m. he received Tylenol. -4:00 a.m. his scheduled dose of Oxycodone was held due to resident sleeping. -4:38 a.m. he was restless, agitated yelling out in pain earlier in the evening. -2:43 p.m. he was yelling out -10:06 p.m. the facility documented that they called hospice and let them know he was calling out, continued with pain, and to clarify orders. -No prn [MEDICATION(S)] was given on 2/13/21 which he could receive every hour. -One dose of prn Lorazepam was given at 2:06 p.m. which he could receive every 2 hours. -No PRN Tylenol was given on 2/13/21. *On 2/14/21 documentation stated: -12:36 a.m.: .Continues having quite a lot of pain. Meds given as ordered. -10:31 a.m.: Resident occasionally restless and yells out . -8:10 p.m.: Resident remains very high anxiety and continues to try to get out of bed. -On 2/14/21 prn Lorazepam was given at 12:13 a.m., 3:59 a.m., 8:21 p.m., 11:36 p.m., -On 2/14/21 no PRN Tylenol or PRN [MEDICATION(S)] was given. *On 2/15/21 documentation stated: -4:00 a.m. he had not received his scheduled Oxycodone because of drug refused. -4:19 a.m., Documentation of Fall. Hospice updated on pain. -On 2/15/21: PRN [MEDICATION(S)] was given at 9:47 a.m., 1:13 p.m., 2:57 p.m. -On 2/15/21: PRN Lorazepam was given at 1:13 p.m. and 3:40 p.m. *Prior to Hospice arriving at the facility resident 19 had not received PRN pain medication. Inteview on 2/19/21 at 6:00 p.m. with divisional director of clinical operations (DDCO) A, RN E, and RN F regarding resident 19 revealed: *DDCO A felt hospice was responisble for resident 19's pain control and had been in facilty every day. *DDCO A stated that staff could not give [MEDICATION(S)] to the resident because he was allergic to it. *DDCO A agreed the facility nurses are responsible for monitoring and treating resident 19's pain control when hospice providers were not in the building. Review of resident 19's hospice notes revealed: *[MEDICATION(S)] was discontinued because of some falls and he had and because staff felt he had been more aggitated after taking it. -He had been taking [MEDICATION(S)] for years prior. *RN Y documented: [nurse's name] called with an update. Patient had a fall last night. Patient was switching from one end of the bed to the other. Patient slipped out of bed and fell on the mat. Held the MS [MEDICATION(S)] last night and patient did sleep much better. [nurses name] has also been giving [MEDICATION(S)] prn for itching. 2. Interview and observation on 2/18/21 at the following times with resident 7 regarding her admission on 2/3/21 revealed: *At 4:00 p.m.: -She had been admitted to the facility following hip surgery. -The call lights had not always worked. -She had told staff multiple times it had not worked. -The last time being the past weekend which had been Valentine's weekend. -She had reported it on a Friday and staff told her she would have to wait until Monday to let maintenance know. -A CNA had given her a different call light cord on Saturday night. -They had plugged the call light cord into the room mates call light unit located on the wall. --There was no call light cord plugged into the call light unit designated for her side of the room. *At 4:05 p.m.: -She put her call light on. -The light on the call light unit was blinking from her roommates wall unit. *At 4:08 p.m.: -Nurse aide Q brought a container of water. -She had not seen the call light on. -She was going to come into the room anyway with the water. -It was her fourth day working solo. *At 4:15 p.m. continued interview with resident 7 revealed: -She had to wait long periods of time for the staff to get her pain medication. -She had not gotten pain medication on February 4, 5, and 8. -On February 8th she had put her call light on at 6:30 a.m. -She had not gotten her pain medication by 9:00 a.m. so she put her call light on again. -No one had stopped by to confirm they had seen her call light on and were getting her the pain medication. -She stated her pain level was between a six and a seven out of ten. -She had chronic pain usually scored at a four out of ten. -She had a [MEDICATION(S)] patch and could have PRN [MEDICATION(S)]. *At 4:40 p.m. licensed practical nurse (LPN) T came behind the nurse station. Interview at that time regarding call lights revealed: -When a call light was activated a notice came across the walkies. -CNAs had the walkies with them at all times. -Nurses and medication aides did not always have a walkie with them because they did not have enough for all staff or they had not plugged them in so the batteries were dead. -The time listed on the computer screen monitor was the time the call lights had been on. Interview on 2/18/21 at 5:09 p.m. with director of nursing services (DNS) E regarding call lights revealed: *The staff were alerted to call lights over the walkies. *The call lights showed up on the computer monitors behind each nurses station. *Each staff member was to have a walkie with them. *There were times when the staff did not have a walkie. Those times had included: -If the prior shift had not plugged them in to be recharged. -If the walkies had been misplaced. -The staff had taken the walkies home with them. *It was not acceptable for a call light response time of twenty-three to twenty-four minutes. *The response time should be eight minutes or less. *She was out on the floor every day and if she observed a staff member without a walkie she would ask where it was and remind them to have one with. *There was no walkie or call light policy or procedure. Further interview on 2/18/21 at 6:10 p.m. with DNS E regarding call lights and the walkies revealed: *They had thirteen walkies available for staff who were working the floor. *There were not enough walkies for each staff member who were working the floor. *She had collected all the managers walkies for the staff to use on the floor for the evening/night shift on 2/18/21. *Her expectations would have been for call lights to be answered within eight minutes. *She confirmed twenty-one to twenty-four minutes was too long for residents to wait for a staff response to a call light. Interview on 2/22/21 at 2:50 p.m. with DDCO A regarding resident 7's call light and pain medication not documented until 11:11 a.m. for a pain score of seven with after results document E for effective revealed she would need to check into it before answering the question. She never returned a reply to the surveyor. Review of the provider's updated June 2016 Pain Management policy revealed: *The Center evaluates for, and attempts to manage/minimize, pain in residents. *Procedure: -2. Residents' pain level is evaluated every shift by the LN (licensed nurse). Noted pain is evaluated and treated accordingly by the LN. Pain is also evaluated quarterly and PRN (when needed) using the RAI (resident assessment instrument)/nursing process. --a. Pain level is monitored and documented on the MAR (medication administration record). -3. When pain is not adequately controlled by current regimen, I, or if there is newly identified pain, the LN contacts the physician for consideration of new or modified treatment orders. -6. If the resident is a hospice client or receiving palliative/comfort care, the LN and hospice personnel collaborate to develop and evaluate the pain management Plan of Care (POC).

Based on record review, interview, and policy review, the provider failed to ensure: *The policy and procedure was followed for the use of an AED (automated external defibrillator) (delivers electric shock when the heart rhythm has stopped) for one of one sampled resident (1) who required cardiopulmonary resuscitation (CPR). *A process was in place to identify each staff members responsibility/task during a CPR occurrence. NOTICE: Notice of immediate jeopardy was given to the executive director, director of nursing (DON), and clinical nurse specialist on [DATE] at 5:20 p.m. They were asked for a plan of correction to be given to the surveyors on [DATE] at 8:00 a.m. They were asked that the plan of correction include: *The requirement to use the AED or not during CPR and follow the facility policy. *Review and update the policies and procedures for CPR and using the AED. *The education of all the licensed nursing staff regarding the provider's policy and procedure for CPR and the use of the AED. *The plan to identify each staff members responsibility and/or task during a code green (emergency situation). The plan should include and identify: -The lead nurse. -Who is to retrieve the crash cart and AED. -Who is responsible for the documentation of the events during a code green. PLAN: A plan of correction was accepted on [DATE] at 11:43 a.m. regarding: *The education and verbalized understanding of all the licensed nursing staff regarding the policy and procedures for CPR and the AED. *The terminology code green had been changed to code blue for a cardiac or respiratory arrest. *Education began on the evening of [DATE]. No start time was documented on the inservice training form. That education would continue through [DATE]. *All nurses would be educated prior to working their next shift by the DON or designee. *The provider's protocols during a code blue situation. Those protocols reflected: -"The first licensed nurse on the scene will assess and start the code process and be the lead nurse until the first registered nurse (RN) arrives." -"The central wing nurse or designee will be in charge of obtaining the crash cart and AED to bring to the code." -"In the event the code is on the central unit, the west wing nurse will bring the crash cart and AED to the code." -"The east/south wing nurse or designee will be the designated recorder for the code." -"In the event that the code is on the east/south wing, then the west nurse will be the recorder." *Eleven of eighteen licensed nurses had been provided the above training and education at the time of the acceptance and removal of the immediate jeopardy on [DATE] at 11:43 a.m. Findings include: 1a. Review of resident 1's medical record revealed an [DATE] admitted from an acute care hospital. Review of resident 1's [DATE] hospital discharge summary revealed: *Bilateral pneumonia had improved. *"At the time of discharge temperature 98.1 degrees (normal 98.6) and oxygen (O2) saturation (amount of O2 in the blood normal greater than 90 percent (%) was98 % on 2 liters of O2." *Lung sounds had no wheezing or rhonchi (loud abnormal lung sounds). *"We will put her back on her oral [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic)." *"On the day of discharge, she had another infectious disease telemedicine conference that felt three more days of oral antibiotics is all that is necessary and then they can simply follow. He recommended discharge also." *"She will need ongoing physical and occupational therapy." *"We will see back in the office on [DATE]. Repeat her laboratory tests and chest x-ray then." *"Activity will be with assistance wheelchair or lift." Review of resident 1's physician's admission orders [REDACTED] *Admit for skilled care. *Full code-do cardiopulmonary resuscitation (CPR). *Additional Diagnoses: [REDACTED]. Review of resident 1's [DATE] care plan revealed: *"I plan to stay here short-term with future plans to return to my own home." *"My short and long term memory are intact. I am able to communicate my needs to others." *"Assist me in creating a comfortable environment in my room." *"Observe me for changes in my cognitive (memory) functioning, an increase in my depression signs, and for any changes in behavior." *"I want to sleep in my recliner." *"I was in hospital with pneumonia and am on oxygen (O2) as ordered." (There were no goals or interventions for her respiratory (breathing) status.) *"I have had falls in the past. I am at risk for falls due to my [DIAGNOSES REDACTED]. I am nonambulatory and EZ stand lift (mechanical lift that allowed the resident to bear weight on the legs) is used for transfers." *"I want to be able to smoke. A nicotine patch was offered and I declined. The doctor was updated and an order received to smoke. I would like to be able to go outside and smoke. I have been educated on the risk of smoking and the affect if can have on my health. I am aware I can not smoke with my O2 on or in the facility. A smoking assessment was completed." Review of resident 1's [DATE] smoking assessment revealed: *Scheduled smoking times 9:30 a.m., 1:30 p.m., 4:00 p.m., and 7:00 p.m. (if not dark). *"Will have four scheduled times to smoke a day. Staff will take her outside to smoke within one-half hour before or after scheduled time depending on other issues happening on the floor." Review of resident 1's [DATE] and [DATE] assessment report notes revealed: *[DATE] at 8:23 a.m. by registered nurse (RN) D- "On room air O2 saturations were in the upper 70% to low 80%. After applying O2 resident recovers to the 90%. She is noncompliant with the O2 because she wants outdoors to smoke. Breath sounds left lung rhonchi. Breath sounds right lung rhonchi. Productive cough. Staff reported little sleep during the night. She did slide out of her chair a couple times during the night shift." *[DATE] at 8:00 p.m. by licensed practical nurse (LPN) A- "Breath sounds left lung diminished. Breath sounds right lung diminished. Respirations a little shallow. Slides in chairs. Has a grippy pad placed in chairs to help with less movement. Shortness of breath (SOB). Is requesting a cigarette but has had her quota of 4 for today per CNA." *[DATE] at 6:53 a.m. by RN B- "O2 saturation 76% on room air. Breath sounds left lung wheezes, rhonchi, and diminished. Breath sounds right lung wheezes and rhonchi. SOB while sitting. Increasing respiratory distress. O2, 2 liters. Resident having increased difficulty breathing, reports feeling SOB, noted O2 saturations 76% on room air. Resident placed in bed with head of bed (HOB) elevated 60 degrees. Noted respirations evened and less labored and O2 saturations improved to 91%. Disoriented (confused). Resident noted to have change of level of consciousness (LOC) in comparison to yesterday per staff. Minimally alert and responding vaguely to yes or no questions until respiratory status stabilized. Then noted intermittent confusion. Resident unable to transfer from wheelchair to bed do to current change in LOC and respiratory status. Transferred with assist of three and total lift to bed. Resident having tremors in wheelchair, noted arms and legs to flail (move randomly), transferred to low bed with bedside mat for safety until resident condition stabilizes." *[DATE] at 8:00 a.m. by RN B- "Noted improvement in respiratory status at this time. Respirations even and shallow. O2 saturations 97% on 3 liters O2. Resident is alert and responding. States continues to feel SOB. Will administer a.m. medications and nebulizer (device used to deliver medication using a mask) and continue to monitor at this time." *[DATE] at 6:22 p.m. (for incident that occurred at 8:30 a.m.) by RN B- "Housekeeping personnel informed certified nursing assistant (CNA) that resident is not breathing. CNA called RN to room immediately. Code green (in-house emergency call system for all emergencies). Resident complains of SOB this a.m. and experiencing low O2 saturations on room air. Resident laying in bed with nebulizer. Color dusky (grey). No pulse or respirations noted. Assessment performed, resident transferred to floor with assist of three and turn sheet." *[DATE] at 8:35 a.m. by RN B- "Compressions (external stimulation of heart) started and assistance and crash cart were called for. Three rounds of compressions were completed, crash cart arrived and rescue breaths were given." *[DATE] at 8:38 a.m. by RN B- "Continues without pulse or respirations. Staff continue to perform CPR and 911 was called." *[DATE] at 8:40 a.m. by RN B- "Call placed to mother and update given. emergency room (ER) called and updated of situation and resident's transfer." *[DATE] at 8:45 a.m. to 8:50 a.m. by RN B- "Emergency services arrived on scene. Staff continue CPR and report given to emergency service staff. Emergency service staff applied monitor and asystole (no heart beat) read on monitor." *[DATE] at 11:26 a.m. by RN B- "Telephone call from ER. Code was stopped and time of death called at 9:22 a.m. in ER." *There was no documentation the AED had been utilized during the code. Review of the twenty-three RNs and the three LPNs (all licensed nurses in the facility) personnel files revealed all had current CPR certification and the use of the AED training. Interview on [DATE] at 12:00 noon with LPN A regarding resident 1 revealed she: *Had worked on [DATE] at 6:00 p.m. through [DATE] at 6:30 a.m. with her. *Was orienting with RN C that night and had never worked with the resident. *Completed the nursing assessment (vital signs, lung sounds, pain control, and activities of daily living assistance) on the resident that night. *Had not noticed anything unusual about the resident that night. *Stated the resident was restless and kept trying to get out of her recliner and was sitting on the footrest. *Was sure she had informed RN C about her assessment but had not documented she had. It was not normal to document she had reported her assessment to the RN. *Had assisted the resident with her 12:00 midnight and 4:00 a.m. nebulizer treatments. She had to stay with the resident during the treatments as she was very restless and kept pulling off the mask. The resident had complained of being SOB, but she thought that was usual for her. *Was unsure what time she had checked the resident's blood sugar, but she thought it was sometime between 12:00 midnight and 5:00 a.m. on [DATE]. *Thought she had rechecked the resident's blood sugar after she had given her the orange juice. *Had not documented a follow-up blood sugar. *Was not sure if the staff had assisted her with a cigarette on her shift when the resident had requested one at 8:00 p.m. She was anxious then. The CNAs did not document anywhere when they assisted a resident with a cigarette. She had not checked with the CNA but had assumed they had assisted her to smoke. Interview on [DATE] at 1:10 p.m. with RN D regarding resident 1 revealed: *She was the house supervisor on [DATE] from 6:00 a.m. to 6:00 p.m. *RN B was the charge nurse that day and would have done the nursing assessment and notified the physician and family if it had been necessary. *She did not recall the RN telling her anything unusual about the resident nor had she heard anything in report from the night nurses. *She thought she had heard the resident slid out of her chair a couple of times during the night but nothing else alarming. *She was surprised when the resident coded (without pulse or respirations). *She was called to the resident's room about 8:30 a.m. When she entered the room the crash cart was not in the room. *RN B and medication aide (MA) F were putting the resident on the floor. *"We didn't think to use the AED. We do not typically bring the AED that is located on central by the nurse's station." *She was unsure how long the facility had the AED but did not think they had ever used it. Interview on [DATE] at 2:00 p.m. with medication aide F regarding resident 1 revealed: *On [DATE] was the first time she had worked with her. *She was unsure if she had gone into report from the night staff that morning, but no one had told her the resident was not feeling well. *The resident was restless when she went by her room between 6:30 a.m. and 6:45 a.m. *The CNAs had asked her to assist them with transferring the resident. They were using an EZ stand lift. The resident was able to stand okay but kept sliding in the chair. *They assisted her into a wheelchair, and they had taken her across the hallway to put her in bed in another room. She did not have a bed in her room per her request as she usually slept in the recliner. *She was unsure who made the decision to put the resident into bed. "She was a full lift into bed." When we put her O2 on she settled down. *Between 8:00 a.m. and 8:30 a.m. RN B told her to give the resident her nebulizer treatment and her a.m. medications. The resident was not anxious when she put the mask on her for the nebulizer treatment, so she left her and went to get another resident her medications. "The resident was talking and breathing when she left the room." *In about two to three minutes after she had left the resident's room the CNAs called her back and told her the resident was not breathing. She called RN B immediately. Interview on [DATE] at 4:00 p.m. with RN B regarding resident 1 revealed she: *Was the charge nurse on [DATE] at 6:00 a.m. *Knew the CNAs had called her down to the resident's room that morning between 6:00 a.m. and 6:30 a.m. *Said the night nurse had gone to the resident's room with her, and had said things were normal for the resident. *Said the CNAs had just gotten her up in her wheelchair for the day, and they thought the resident was acting differently. *Put the resident's O2 back on, and her O2 saturations had improved. *Made several follow-up visits to the resident's room, and she was improving and doing better. *Said between 8:00 a.m. and 8:30 a.m. the resident said she needed her nebulizer. *Told medication aide F to go ahead and give her the nebulizer and her morning medications. *Got called back into the resident's room by the CNAs she was not breathing. *Helped the CNAs transfer her to the floor using a lift sheet from the low bed she was in. *Started chest compressions right away, and the crash cart arrived in the room shortly after. *Felt like it was five minutes before the crash cart arrived but was doubtful it was that long. *Said the staff member that grabbed the crash cart should have grabbed the Automatic External Defibrillator (AED) (delivers electric shock when the heart rhythm has stopped), and they had not. *Had not felt it necessary to contact the physician at 6:53 a.m. when she had done her assessment, as the resident's O2 saturations had improved when they put her O2 back on. *Contacted the family prior to her being transported to the ER. No one had felt it was necessary to contact the family prior to that. Interview on [DATE] at 4:40 p.m. with RN I regarding resident 1 revealed: *She had worked on [DATE] when the resident had two falls close together. She kept sliding out of the recliner chair. *The resident had a lot of respiratory issues. *She knew the facility had an AED and thought they usually used it. She had not had to use it since she started on [DATE]. *All the nurses had been educated on the AED in the CPR certification done in [DATE]. *During a code green no one was designated to bring the AED to the emergency. A code green did not necessarily mean a resident was without respirations or a pulse, it could mean any type of medical emergency (such as a fall with injury). Interview on [DATE] at 8:12 a.m. with the medical director regarding resident 1 revealed: *That was the first time he had heard about all the problems with the resident. *If it was the provider's policy to use the AED and they had one, the AED should have been used for her. *"A code team is important to know who is doing what." *The goal is to have all residents be "no codes (no CPR to be initiated)." *If AEDs are available, they should have been used. *He was not sure what her cause of death was or if the AED use would have made any difference, but they should have used it. Interview on [DATE] at 9:30 a.m. with RN C regarding resident 1 revealed she: *Confirmed she was working with orientee LPN A on [DATE] at 6:00 p.m. through [DATE] at 6:30 a.m. *Knew that LPN A had done the resident's assessment (vital signs, lung sounds, and pain monitoring) that night. *Knew LPN A had voiced no concerns to her regarding the resident's assessment. *Had stopped in a couple times during the night to see the resident, and she found nothing alarming with her condition. *Felt there was no need to contact a physician during the night or when she had gone into the room on [DATE] at 6:53 a.m. with RN B. *Was amazed the resident died on the morning of [DATE]. Phone interview on [DATE] at 9:57 a.m. with resident 1's physician revealed: *To his knowledge he had not been informed on [DATE] or on the morning of [DATE] of her change in condition. *He had a note on his desk when he went to work on [DATE] that the resident had expired (died ) on [DATE]. *It was his expectation the facility should have used the AED. *He left it up to the nursing staff to inform him of changes in a resident's condition. *He would have expected to have been notified of the resident's change in lung sounds and increased SOB. Interview on [DATE] at 10:40 a.m. with the DON and the clinical services specialist regarding resident 1 revealed: *"Hindsight the expectations should have been the physician had been notified of her change in condition on [DATE] at 6:53 a.m." *They were unable to state if the resident's needs were being met on the night of [DATE] and the morning of [DATE]. "They would have to review the notes again." *"She should have been more comfortable and the physician should have been notified of her change in condition prior to coding (without respirations or pulse) at 8:30 a.m. on [DATE]. *Their CPR policy was followed. *Their AED policy was not followed and their expectation was that it should have been. *They did not know why there was a discrepancy in the time the emergency services was contacted. RN B had documented they had been called at 8:38 a.m. and the emergency services had documented they had been called at 8:52 a.m. *They agreed they had 34 out of 132 residents who were also a full code status. Review of resident 1's [DATE] ER notes revealed: *"Per report, resident was given a neb (nebulizer) treatment earlier this morning." *"She was then found down and unresponsive and CPR was started." *"It is unclear when the last time she was seen awake and normal." *"Emergency services was called at 8:52 a.m. and upon responding to the call found the resident in asystole (no heartbeat)." *"Patient is cyanotic (purple) with unresponsive pupils and has been coded for 30 minutes with no spontaneous return of pulses or blood pressure. The code was called (stopped) at 9:20 a.m. Family was notified and are present in the ER." Review of the [DATE] emergency services report revealed: *"Time 911 called was 8:52 a.m., time dispatched 8:52 a.m., time arrived scene 8:56 a.m." *"On scene we were directed to the patient's (resident's) room where we found numerous staff members performing CPR." *"The staff member near me advised the patient (resident) had not been acting normal since they checked on her this morning and appeared to be having some breathing difficulty." *"They administered a neb (nebulizer) treatment to the patient (resident) and when they returned to the patient (resident) they found her unresponsive with no breathing or pulse." *"They started CPR immediately and called us." *"Due to the panic and confusion in the room, no one was exactly sure the time frame from when she was last seen breathing and I did not waste time waiting for them to find out the information." *"I applied the de-fib (defibrillator) patches and monitor showed her to be in asystole." *Departed scene at 9:10 a.m. to the hospital. Review of the provider's [DATE] CPR policy revealed: *"CPR will be provided to residents/patients experiencing a respiratory or [MEDICAL CONDITION], unless they have indicated their choice to DNR (do not resuscitate) with valid medical doctor (MD) order." *"Staff members will respond with the modified crash cart. If facility has an AED it may also be used." *"The charge nurse will designate a staff member to get the crash cart and AED as well as assign a recorder." Review of the provider's [DATE] Defibrillator-AED policy revealed: *"The AED is indicated for use on victims of sudden [MEDICAL CONDITION] on whom an apparent lack of circulation is indicated by all of the following: -Unconsciousness. -Absence of breathing. -Absence of detectable pulse. -CPR has been initiated." *"Defibrillator certification will be offered at least twice yearly at the facility." *"The facility will ensure it will be staffed 24 hours per day with someone certified to use the AED." *"When a code blue is called, a designated staff person will the bring the AED to the site of the code."

Based on record review, interview, policy review, and job description review, the provider failed to ensure one of one sampled resident (4) with a new [MEDICAL CONDITION] (breathing tube inserted into the neck) was monitored, assessed, treated, and documented the physician notification and involvement with a change in condition. Findings include: 1. Review of resident 4's medical record revealed a 9/3/14 admitted from a rehabilitation care hospital. Review of resident 4's 9/3/14 hospital discharge summary revealed: *[DIAGNOSES REDACTED]. *At the time of discharge her temperature was 98.1 degrees Fahrenheit (F) (normal 98.6). *Respiratory assessment "Has copious (large) amounts of tracheal and oral secretions, requiring frequent suctioning. Lungs are coarse at times, but usually clear with suctioning.[MEDICAL CONDITION] site without signs and symptoms of infection." Review of resident 4's 9/3/14 provider admission assessment revealed she: *Was unresponsive. *Had abnormal sounds in both lungs. *Had white and frothy secretions from her [MEDICAL CONDITION] with suctioning. *Had a temperature of 99.8 degrees F at 2:45 p.m. *Was incontinent of both urine and bowel. *Had no documentation to support the condition of her skin. Review of resident 4's medical record revealed: *A physician's orders [REDACTED]. -[MEDICATION NAME] (pain medication) 325 milligrams (mg) one or two tablets every fours as needed for elevated temperature. -[MEDICATION NAME] (pain medication and blood thinner) 600 mg every six hours as needed for elevated temperature. -Zarelto (blood thinner) 15 mg once a day to prevent blood clots. -Menthol-zinc oxide ointment was to have been applied to her bottom every shift for redness and irritation. That medication had been documented as unavailable from pharmacy for nine shifts form 9/3/14 through 9/11/14. *She had: -Required frequent use of the [MEDICATION NAME] and [MEDICATION NAME] for uncontrollable and elevated temperatures. -Increased oral and [MEDICAL CONDITION] secretions that had required frequent suctioning. *Her lung sounds had always been abnormal. *On 9/17/14 she had been admitted to an acute care hospital for worsening of pneumonia. *On 9/25/14: -She was readmitted to the facility. -The [MEDICATION NAME] was changed to 600 mg three times a day for pain. -The Zarelto order remained unchanged. *On 9/29/14 she was emergency admitted to an acute care hospital for: -Uncontrollable and elevated temperatures. -Bloody secretions from the [MEDICAL CONDITION] site. -Increased secretions from the [MEDICAL CONDITION]. *On 10/2/14 she was discharged from the acute care hospital and admitted to another facility. On 12/11/14 this surveyor had requested all of the provider's nurses' documentation for resident 4's entire stay in their facility. This surveyor had been provided the following documentation for review: *Nurse's progress notes from 9/3/14 through 10/2/14. *Assessment reports documented by the nurses from 9/3/14 through 9/17/14. No documentation had been provided for assessments from 9/25/14 through 9/29/14. Review of resident 4's nurse's progress notes from 9/4/14 through 10/2/14 revealed: *On 9/4/14: -At 8:38 a.m. [MEDICATION NAME] had been given for an elevated temperature. The [MEDICATION NAME] had been effective. There was no documentation on how elevated her temperature had been or the level of effectiveness. -At 2:10 p.m. the menthol-zinc oxide ointment had not been available. A "remedy" had been applied. No documentation on what that remedy was. -At 9:11 p.m. the menthol-zinc oxide continued to not be available and a "remedy" was used. *On 9/5/14: -At 9:42 a.m. [MEDICATION NAME] had been given for an elevated temperature of " .3" The nurse had documented the medication had been effective with a temperature of 99.1 degrees F. -At 4:03 p.m. the resident had been administered [MEDICATION NAME] for an elevated temperature. There was no documentation to support how elevated her temperature had been. *On 9/6/14 her temperature had been 99.9 F. "Administration had been ineffective." No documentation to support what was ineffective. The menthol-zinc oxide had remained unavailable, and a "remedy" was being used. *On 9/7/14 at 1:47 p.m. the menthol-zinc oxide continued to be unavailable. "Ordered from (pharmacy name) yesterday, will use remedy." That medication continued to be unavailable on 9/8/14 at 4:23 p.m. *No charge nurse documentation for 9/9/14 and 9/10/14. *On 9/11/14 at 4:25 p.m. the physician had been in the facility to assess the resident. No documentation to support: -The resident's elevated temperatures had been discussed and reviewed. -The unavailability of the menthol-oxide ointment from the pharmacy for the resident's red and irritated bottom. -Clarification and review for the two blood thinning medications. *On 9/12/14 the following charge nurse documentation had been provided: -At 11:11 a.m. "Resident noted to have increased yellow/green (yesterday was white frothy) sputum from [MEDICAL CONDITION] the past 24 hours. She has had elevated temps in the 99's lung sounds are coarse throughout all lobes. The resident has had to be suctioned five times since 6:00 this a.m. With moderate amounts of sputum suctioned. Oxygen sat (%) is 90 % with the humidified oxygen via the trach, oxygen is at 4 liters." -At 3:25 p.m. orders had been received to give [MEDICATION NAME] (antibiotic) 2 grams intravenously (IV) everyday for one week. -No documentation to support the resident had been given any type of treatment for [REDACTED]. *From 9/13/14 through 9/17/14: -Her temperatures had remained elevated. Those temperatures ranged from 99.5 F to 102.0 degrees F. -She had been given [MEDICATION NAME] and [MEDICATION NAME] as directed for the elevated temperatures. -The medications had been ineffective for treatment of [REDACTED]. -On 9/15/14 the physician had been contacted with orders for a chest Xray, lab (laboratory tests) work, physical therapy to do chest compressions, and [MEDICATION NAME] (antibiotic) 500 mg everyday for ten days. *On 9/17/14 her [MEDICATION NAME] had been discontinued and [MEDICATION NAME] (antibiotic) was ordered. Her temperatures had remained elevated, and she was admitted to an acute care hospital. Review of resident 4's nurse assessment reports from 9/3/14 through 9/17/14 revealed: *Those reports reflected a head-to-toe assessment of the resident documented by the charge nurse. *Those assessments had only been done once a shift. *There had been no assessment report provided for 9/5/14. *The times of day for documentation had been random. *The resident had increased [MEDICAL CONDITION] secretions that required frequent suctioning. *From 9/12/14 through 9/17/14 her secretions had been described as green, yellow, thick, and dry. *On 9/16/14 her [MEDICAL CONDITION] secretions had been documented as "red." *No documentation to support: -Her lungs had been assessed for clearing after suctioning had been performed. -The staff had been monitoring for any bleeding episodes with the use of two blood thinning medications. -Clarification had been done with the physician to ensure the use of two blood thinning medications was appropriate. -When the Menthol-zinc oxide ointment had been available, what the remedy was, and if the physician had been aware of the unavailability of that medication and the "remedy" being used. *No further documentation by the staff had been provided after 9/1714. Review of resident 4's 9/17/14 hospital report revealed "She is brought over from the nursing home because of difficulties with temperature control as well as bloody secretions from her [MEDICAL CONDITION] site and increased sputum production today." On 9/25/14 she had been readmitted to the facility. From 9/27/14 through 9/29/14 her temperatures ranged from 99.4 to 101.5 F degrees. [MEDICATION NAME] had been given and ineffective. On 9/29/14 at an unknown time the charge nurse had documented the following: *"In residents room at 7:30 p.m. to change feeding, as bottle was empty. Noted resident to be having difficulty with breathing, respirations were 38. Felt residents skin and was hot and sweaty. Checked residents temperature. Temperature equaled 105.2 degrees F." *At 7:50 p.m. the resident was emergency admitted to an acute care hospital for: -"Significant" pneumonia. -Bloody secretions. -Elevated and uncontrollable temperatures. -Increased secretions from her [MEDICAL CONDITION]. Review of resident 4's 9/3/14 and 9/25/14 pharmacy side effect record (SER) revealed: *On 9/3/14: -Drug dispensed "[MEDICATION NAME] 600 mg tablet." That medication interacts with "Zarelto 15 mg tablet." -Patient management "Monitor patients receiving concurrent (duplicate) therapy for signs of blood loss." *On 9/25/14: -"[MEDICATION NAME] can interact with her Zarelto." -Concurrent use might result in unwanted blood loss. *The provider had the 9/25/14 notification from the pharmacy but not the 9/3/14. *No documentation on those two forms by the physician or nurse to support acknowledgement and clarification for continued use. Interview on 12/15/14 at 11:50 a.m. with the pharmacist revealed: *She had confirmed the pharmacy had informed the provider of the potential risks of giving two blood thinning medications together on both of the resident's admissions to the facility. *She had emailed the 9/3/14 notification they had given the provider to this surveyor. *The medication notifications would have been sent to both the provider and physician. *Menthol-zinc oxide ointment had been an over-the-counter medication. They would not have supplied this medication to the provider. It was the provider's policy to supply their own over-the-counter medications. *[MEDICATION NAME] had been the "remedy" medication the provider should have been using. *She would not have been aware if the provider was using the correct supplemental medication for the menthol-zinc ointment. *It was the provider's responsibility to ensure the correct over-the-counter medications were used and available. Interview on 12/15/14 at 1:03 p.m. with registered nurse (RN) D revealed: *She had worked with resident 4 on 9/12/14. *She had remembered the resident having trouble with elevated temperatures, and the physician recommending alternating [MEDICATION NAME] and [MEDICATION NAME]. There should have been documentation to support that recommendation or clarification from the physician. *She had helped with suctioning the resident in the past. One of the days there had been "some bloody sputum" with suctioning. *It was the expectation that all the charge nurses were responsible to notify the physician with any acute change in condition of a resident. *All nurses were responsible for monitoring the side effects of medications. *The pharmacist would have notified the provider of any potential medication interactions. It would have been the nurses responsibility to further clarify with the physician. There should have been documentation to support the physician involvement and clarification of orders. *The provider supplied the over-the-counter medications. *She had not been aware [MEDICATION NAME] had been a supplemental medication for menthol-zinc oxide ointment and an over-the-counter medication. *When a medication was not available the nurse should have contacted the pharmacy first to clarify why the medication had not been delivered. If there were continuing issues with the unavailability of the medication then the physician should have been notified. On 12/15/14 at the time of the above interview this surveyor requested from RN D any documentation to support the physician had been aware: *Of the uncontrollable temperatures and recommendations to alternate the [MEDICATION NAME] and [MEDICATION NAME]. *The resident had been taking two blood thinning medications. *The prescribed medication to treat her reddened and irritated bottom had not been available and clarification the "remedy" being used was acceptable. On 12/15/14 at 1:30 p.m. RN D had provided this surveyor with: *A patient instructions signature page upon resident 4's discharge from the acute care hospital on [DATE]. *The hospital discharging RN had signed and dated the form on 9/25/14. *Attached to the patient instructions signature page had been a list of discharging medications for resident 4. *The physician had electronically signed the discharging medications list on 10/3/14. Interview on 12/15/14 at 8:30 a.m. with the medical director revealed: *He had not liked the medication Zarelto. The side effects of that medication were not good, and he had three patients die from the use of that medication. *The pharmacy notified the physician regarding any potential for medication interactions, side effects, and concerns. *He would have expected the primary physician would have been aware of the above concerns regarding resident 4. *He stated "If the provider would have contacted me I would have said getting over your head." Interview on 12/16/14 at 9:45 a.m. with RN C revealed: *She primarily worked the night shift. *She had worked with the above resident on several occasions. *Resident 4 had been a complicated resident who had required a lot of "attention." *When the resident had first been admitted her lungs cleared with suctioning. As time progressed her lungs became more course with increase in suctioning needed, and clearing of the lungs had not occurred. There should have been documentation to support those assessments. *She had been provided information to alternate the [MEDICATION NAME] and [MEDICATION NAME] for elevated temperatures. She had assumed the reporting nurse had reported the uncontrollable temperatures to the physician and was following his recommendations. There should have been documentation to support that recommendation in the resident's chart. *All nurses were responsible for monitoring the side effects of medications. The nurse who had received the notifications from the pharmacy was responsible to follow-up and clarify any concerns with the primary physician. There should have been documentation in the resident's chart to support this clarification with the physician. *To her knowledge the resident assessment reports were done once per shift. All other concerns and assessments throughout the shift were to have been charted in the resident's progress notes. Interview on 12/16/14 at 10:40 a.m. with the DON and clinical care nurse regarding resident 4 revealed: *There had been no comment offered on what the expectation would have been from the provider for nurses monitoring side effects of medications. *The DON would not have expected the nurses to clarify with the physician regarding any potential medication interactions. She had assumed the physician would have been aware of any medication interactions upon prescribing them for the residents. *Confirmed the pharmacy would have sent or faxed any medication notifications to the provider and the physician. *They confirmed the provider supplied their own over-the-counter medications for the residents. *They would have expected the pharmacy to notify them with any concerns regarding over-the-counter medications. *The provider had no over-the-counter medication policy. *They offered no comment regarding the expectations from the licensed nursing staff regarding the accuracy and timeliness for: -Assessments. -Documentation. -Providing prescribed treatments. -Notification to the physician regarding any acute change in conditions. Review of the provider's June 2013 Resident, Physician, and Family Notification policy revealed: *"To assure all necessary parties are notified promptly when a resident has had a change in condition which may necessitate orders from the physician and maintain accuracy with the resident's overall plan of care." *Procedure: "The facility will inform the resident, physician, and family or legal representative when there is a change in condition such as but not limited to:" -"A significant change in the resident's physical, mental, or psychosocial status." -"A need to alter treatment significantly, such as discontinuing an existing treatment or commence a new treatment." Review of the provider's April 2013 Change of Condition policy revealed: *Policy: "To notify the physician in the event of a status change." *"The resident's condition is assessed and reported to the medical doctor (MD) immediately if the resident experiences:" -"Vital signs that vary significantly from the resident's normal limits, and have been monitored for an 8-24 hour period and have not improved with basic nursing intervention such as treatment for [REDACTED]. -"Any other significant change in condition as determined by a licensed nurse." Review of the provider's 5/1/10 Pharmacy Services and Procedures Manual regarding Side Effect Record (SER) policy revealed: *"Pharmacy may, at its option or as required in a pharmacy services agreement, provide a SER that lists all current medications, their most common side effects, medication class, and special messages/instructions." *"If pharmacy provides a SER, the side effects listed may not be all-inclusive. Facility should consult the manufacturer package insert, and/or the Omnicare Geriatric Pharmaceutical Care Guidelines, and/or other current literature for additional details." *"Facility should file and maintain the resident's most recent SER with the most recent Medication Administration Record [REDACTED]." *Nothing to ensure physician involvement with medication side-effect monitoring. Review of the provider's undated Nurse Staff (RN) Job description revealed: *General purpose: "Assess resident needs, develop individual care plans, administer nursing care, and evaluate nursing care." *"Adhere to state rules and regulations concerning delivery of care and assure that effective quality nursing care is delivered which is outcome focused through utilization of the nursing process." *"Identify rationale and anticipated outcomes for each nursing intervention." *"Keep physician and/or other health care professionals informed of resident's condition; and notify physician and/or other health care professionals immediately of significant changes of condition." *"Critique and take responsibility for evaluating nursing care delivered." *"Ensure accurate documentation of all medical records and reporting forms." *"Demonstrate knowledge of drug reactions and sensitivities and nursing interventions." Review of the provider's undated Director of Nursing Job description revealed: *"Manage the overall operation of the department in accordance with company policies, and standards of nursing practices and government regulations, so as to maintain quality care." *"Carry out, coordinate and manage administrative functions and areas of programs related to nursing services which may include departmental documentation or medical records." *"Monitor quality of care and resident activity, assessment of resident's status, administration of medication and treatments, admissions and discharges; and consult with family members, physicians, and other health care professionals."

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Emergency first aid and first responder protocols/standards were followed for one of one sampled resident (1) who sustained head, neck, and facial trauma as a result of a fall. *Proper supervision and delegation of nursing tasks were followed for one of one sampled resident (1) who sustained head, neck, and facial trauma as a result of a fall. Findings include: 1. Review of the provider's event reports submitted to the South Dakota Department of Health on [DATE] and on [DATE] related to the fall of resident 1 on [DATE] revealed: *The resident had fell and struck his head/face from an elevated bath chair lift. His legs were suspended under that chair lift by the chair safety strap. *The bath tub lift chair safety strap had been noted as fastened in a loose position on the resident prior to the fall. *After the fall the resident was noted by nursing personnel as agitated, confused, and restless. *The following injuries were noted by nursing personnel at the time of the fall: quarter sized skin tear to the right forehead, right eye swollen shut, and bloody nose. *Nursing personnel did not perform a full neurological assessment as a result of the resident's agitated, confused, and restless state at the time immediately following the fall. *Nursing personnel rolled the resident to his back, and then used a mechanical lift to get him off the floor into a wheelchair where the resident sat until the ambulance personnel came to transport him approximately 30 minutes later. Once in the wheel chair the resident was noted lunging back and forth. The resident was then noted to start complaining of right sided neck and shoulder pain. *The resident was transferred by CNA A, CNA B, CNA H to the ambulance crews gurney by standing the resident and then pivoting him with assistance of one of the paramedics. *No attempts were noted in those reports to immobilize the resident's neck or back. *911 was not contacted until after physician G had been contacted. *The resident had sustained head, neck, and facial trauma as a result of that fall from that bath tub lift chair on [DATE] at approximately 1:10 a.m. Interview and a reenactment of the incident on [DATE] at 9:32 a.m. with certified nursing assistant (CNA) A regarding resident 1 revealed: *She was the aide who was responsible for giving the resident his bath *He was confused most of the time. He was more anxious that day when she had approached him to have a bath. *He had walked with her to the tub room using a walker. She had to steer him multiple times as he wanted to go to the dining room. *She thought it was about 9:30 a.m. or 10:00 a.m. when the resident received his bath. *At the time of the fall there were two CNAs in the tub room. *CNA B had her back to the resident as she was looking at the list of residents who needed a bath. *He was seated in the tub chair, and the chair was up in the air because she had just taken him out of the tub. *He was wiping his face while she was beside him putting his socks on him. *The tub chair was at about her waist height which meant the resident's buttocks would be about three feet off the ground. *The tub chair was not in its lowest position, because she was trying to get his socks on. His feet were not touching the floor. *Whenever she gave a resident a bath she put the safety belt around the resident's waist, and it was looped through the belt buckle. *The safety belt had been fastened loosely around him. *She had questioned herself if she should have put a gait belt around his chest, but had not done so. *He lunged forward out of the chair. She could not stop him, and he fell forward out of the chair. *She heard the thud as he hit his head on the floor. *He had not put his arms out to stop the fall. *His legs were caught in the safety belt, so they were off the ground. *He laid there and said repeatedly "I have to get up." *He was bleeding at the head, and he said "I got hurt. I have to get up." *She could not explain how he was able to fall out of the chair if the safety belt was in place. *She restated how she heard a crack as the resident's head hit the floor. *She kept him in place until the nurses got there. *She was having a hard time recalling the incident because there was so much going on at the time. *She told the nurses he had fell out of the chair and he had hit his head. *She did not think he was any more confused than he normally was. He was continually moving his arms and legs as he lay on the floor. *She knew she should not move him. *CNA A and B had a towel on his head to stop the bleeding. *There were three staff people in the tub room CNA A, CNA B, and LPN E: -They had rolled him on his back. -They had put a sling under him and put him in the medi-man lift, and then put him in a wheelchair. -The medi-man lift sling cradled him, and no neck support/immobilization was performed at that time. -They had used the medi-lift, because they thought it was the best choice to get him off the ground. He weighed between 186 and 190 pounds. *CNA A, CNA B, CNA H, and LPN E had not put a cervical collar on him or attempted to immobilize his neck, because they did not think there was anything wrong with his neck. *She did not have a current cardiopulmonary respiratory (CPR) training or First Aide training. *She would get ahold of a nurse right away whenever there was a resident who had any type of head injury. Interviews and record review on [DATE] beginning at 10:35 a.m. with registered nurse (RN) C, RN/nurse manager (NM) D, and licensed practical nurse (LPN) E regarding the fall of resident 1 on [DATE] revealed: *LPN E was resident 1's primary nurse for that day but at the time of the incident she was at break. She had not been able to be reached per radio communication. *RN/NM D was the nurse manager for the area where the incident had occurred and had supervisory responsibility over LPN E. *RN C and RN/NM D were the first two nurses on the scene of the fall in the tub room. They had been summoned to the tub room by CNA B. The resident was found by RN C and RN/NM D face down with his legs trapped under the bath tub lift chair by the tub lift chair safety belt. The resident was noted by both RNs to have been bleeding from his nose and right side of his head. It was further noted the resident's right eye had a large hematoma above it, and that eye was swollen shut. *RN C and RN/NM D were both made aware the resident had fallen face first from the lift by CNA A. They estimated the height of the seat of the tub lift chair to be 3 to ,[DATE] feet off of the floor at that time. *Both RN C and RN/NM D noted the resident was restless, agitated, and confused. *RN/NM D left the scene of the fall as she needed to continue physician rounds. Before she left she told CNA A and CNA B the resident's legs needed to be taken down. *RN C with the assistance of CNA A and CNA B lowered the resident's legs to the floor. *RN C left the scene of the fall shortly after RN/NM D as she needed to take a phone call. RN C left CNA A and CNA B alone with the resident and instructed them not to move the resident. After a unknown period of time LPN E entered the room and made the decision to roll the resident to his back and then use a mechanical lift to lift the resident from the floor to a wheelchair. LPN E stated she had not been given any report regarding the nature of the resident's fall from RN C and RN/NM D or CNA A and CNA B prior to making the decision to move the resident. However LPN E did note the facial and head trauma noted by RN C and RN/NM D. *Neurological signs were attempted by LPN E upon first finding the resident. However she was unable to ascertain them due to the resident's agitation. No subsequent attempts at ascertaining neurological signs was documented or attempted after that initial attempt. Also no documentation by either of the RNs indicated neurological signs had been assessed by them. *RN C arrived back on the scene as LPN E, CNA A, CNA B, and CNA H were placing the resident into the wheelchair. She assisted them by placing the wheelchair under the resident. RN C stated she never questioned or mentioned to LPN E that the resident might have had neck and head trauma and they should have tried to limit his movement. *Once the resident was in the wheelchair RN C once again left the scene as LPN E stated she had the situation under control. At that time the resident was noted as complaining of neck and shoulder pain and continued to be agitated, confused, and restless. The resident was documented as lunging back and forth in the wheel chair. *LPN E then left the scene leaving CNA A, CNA B, and CNA H to monitor the patient in the tub room as she went out to contact physician G. After physician G was called and replied back with the order to call the ambulance and transport the resident to the emergency room , LPN E then made the call to activate emergency medical services. After that call the LPN E made a call to the resident's family member informing them of the resident's current status. During LPN E's absences no other licensed nursing personnel were monitoring the resident's status. LPN E was unsure of the amount of time the resident was left with no direct licensed nursing observation. *Once the ambulance crew arrived on the scene the resident was allowed to stand and transfer to the ambulance gurney with the assistance of CNA A, CNA B, CNA H, and a paramedic. While that occurred LPN E gave a brief history and the paperwork to the other paramedic. *Neither RN accepted responsibility/accountability for the serious injury scene, instead they delegated that to LPN E as she was the resident's nurse that day. Interview on [DATE] at 10:50 a.m. with CNA B regarding resident 1's fall revealed: *At 1:00 p.m. on [DATE] she had just finished distributing supplies to residents and had some extra time, so she went into the tub room to see who was on the schedule to receive a bath that she could do. *Resident 1 and CNA A were in there. *As she stood with her back to resident 1 she heard a cough and then a large crash. *When the resident hit the floor it was so loud it sounded like a bowling ball hitting the floor. *She turned and saw resident 1 on the floor, she ran out of the tub room to get a nurse, and told them they needed to come in right away. *RN D came in and said they needed to get his feet down, as they were tangled in the safety belt. *RN C came in and RN D left the tub room. *She stated she tried to get his feet down, but the belt was so tight she could not get them down. *The tub chair was not in its lowest position. *RN C told her they needed to get his vitals, but she was unable to get the blood pressure cuff around his arm, because he was thrashing so much. *CNA A went to get the medi-man lift. *She was not sure if that piece of equipment was designed to get a resident off the floor. *While he was on the floor he was turning himself. *He was more agitated than she had ever seen him. *Four staff were there when they got him up, because he was so agitated. *LPN E had told them to get him up in the chair. *He had not complained of pain in his neck until he was up in the chair. *LPN E left the tub room to call an ambulance and was in and out while she was getting paperwork ready to transfer him to the hospital. *She was not certified in CPR. *She was trained that when a resident fell they were not to touch the resident. *While she was in the room she did not see a nurse hold or stabilize his neck or back. *When the paramedics arrived he stood up at the gurney. When they got him on the gurney they put a belt on him to secure him on the gurney. Interview on [DATE] at 11:10 a.m. with CNA H regarding resident 1 at the time of the [DATE] fall revealed: *She was not present when the fall had occurred. *He was on the floor when she had come into the tub room. *She recalled: "They had towels compacting his head. He was bleeding pretty good. He was agitated and fighting. He started out on his right side. We turned him over on his back. There were four to five of us in there. He was trying to get up, so they put the sling under him and they lifted him up in the chair. He had a big lump, almost like a rug burn. His eye was swollen shut-it was huge, huge. There was a big chunk of pussy stuff he blew out of his nose, and there was some blood. That blood and pussy stuff also came out of the corner of his eye. Once he got up he complained his neck hurt, and he could not breathe. There were two nurses in there. There was a nurse in there most of the time except when the nurse went to call the ambulance and the other nurse went to get a supply." *No nurses were present at the time the resident blew pussy stuff and blood out of the corner of his eye. She did not report that to nursing. *No staff attempted to stabilize his neck when rolling him or moving him. *Resident 1 normally did his own thing but lately he had not been himself. He had been a little more confused. Telephone interview on [DATE] at 12:30 p.m. with physician G regarding resident 1's fall revealed: *He was the resident's primary physician. *He had evaluated the resident once he was admitted to the hospital. *The resident had sustained severe head, facial, and neck trauma from his fall and should not have been moved from the floor. *He had not been made aware of all of the circumstances and events related to the resident's fall. *The resident died as a result of his injuries. Interview on [DATE] at 2:00 p.m. with the administrator, director of nurses (DON), and nurse consultant regarding resident 1's [DATE] fall revealed: *The DON agreed he probably should not have been put in the bath based on his anxiety that day. *The DON confirmed: -The tub chair was not in the lowest position at the time of the fall. -The first nurse to response to the emergency should have stayed with the resident and that had not occurred. -They followed "general nursing practice/standards regarding moving a resident with a potential neck injury and should have stabilized the resident's neck and head." -They could not answer if resident 1's level of agitation made it hard for the staff to keep him on the floor, as that had not been determined in their internal investigation. -She did not think the nurses had recognized the gravity of the situation. *These surveyors re-enacted how CNA A demonstrated how the belt was on the resident, they concurred it would be impossible to fall in the manner resident 1 did without the belt being looser than demonstrated by CNA A. They further concurred only one of two things could have happened to have allowed resident 1 to fall in the manner in which he did: 1. The tub chair safety belt was not properly applied by CNA A. 2. The resident had loosened the belt when CNA A was not watching the resident. Further interview on [DATE] at 8:50 a.m. and at 9:15 a.m. with the administrator, DON, and nurse consultant revealed: *The provider's reenactment of the fall had not looked at any of the nursing processes after the fall. *They had talked to RN/NM D and LPN E but had not taken any disciplinary action as a result of the investigation. *They were unable to determine how tight the belt had been on resident 1 at the time of the fall. They agreed the belt was not as tight as it should have been, because the resident would not have fallen out of the tub chair at it's recommended tightness. *They had made no determination as to whether that fall had been preventable or not. *They concurred: -The tub chair was not in the lowest position. -The tub chair belt was loose. -The resident's head/neck should have been stabilized. If staff could not stabilize the resident's neck and back then nursing rationales for moving the resident should have been explained in the medical record. -The resident should not have been placed in a lift or wheelchair. -The first responder nurse should have stayed with the resident until the emergency resolved. -The RNs should not have left the LPN alone in the emergency. -The licensed nurses should not have left the CNAs alone with the resident. *They had not found negligence in their investigation. *The nurse consultant revealed LPN E said she knew she should not have moved resident 1. *They agreed since a physician was in house with RN D that physician should have been asked to evaluate the resident. *A "Code green'" had not been called for the resident's fall. Review of the provider's undated emergency care response code green policy revealed: *A "Code green" was to be called for falls with significant injury. *Upon hearing a "Code green" paged overhead all available nursing personnel will respond to the paged location. *Detailed nursing documentation will reflect that the standard of care was met." Review of Medline Plus Encyclopedia, "Head Injury and Neck Injury", Service of the National Institute of Health, http://www.nlm.nih.gov/medlineplus/ency/article/ 8.htm, ([DATE]) revealed: *In the case of a serious head or neck injury 911 should be contacted immediately. *Signs of head and neck trauma can include: agitation, confusion, restlessness, fluid draining from the nose mouth and ears, changes in the size of the pupils, behavioral changes, and lack of coordination. *Persons with suspected significant head and neck injuries should not be moved. All attempts should be made to immobilize the injured persons neck and back to prevent further injury. Review of the South Dakota Board of Nursing's Administrative Rules, Chapter 20:48, revealed: *"A licensee is personally responsible for the actions that the licensee performs relating to the nursing care furnished to clients and cannot avoid this responsibility by accepting the orders or directions of another person." *"The registered nurse is responsible for the nature and quality of nursing care that a client receives under the nurse's direction." *"The registered nurse shall recognize and understand the legal implications of delegation and supervision. The nurse may delegate to another only those nursing interventions which that person is prepared or qualified to perform and shall provide minimal or direct supervision to others to whom nursing interventions are delegated. The registered nurse may only delegate nursing tasks to unlicensed assistive personnel in accordance with the standards in chapter 20:48:04.01." *The licensed practical nurse may practice in two general settings: with at least minimal supervision when providing nursing care in a stable nursing situation; and with direct supervision when providing nursing care in a complex nursing situation; *"The licensed practical nurse shall consult with a registered nurse or other health team members and seek guidance as necessary and shall obtain instruction and supervision as necessary." Review of the provider's job descriptions revealed: *The nurse manager: -"Oversees entire operation of their assigned station to ensure quality care." -"Provides direct supervision to all nursing employees and monitors nursing care given and assumes for same." -"Must possess leadership skills, have the ability to make sound decisions, and Work under pressure." *The nurse staff RN: -"Responsible for the independent supervision of the delivery of care to a group of residents in a nursing unit." -"Assess resident needs, develop individual care plans, administer nursing care, and evaluate nursing care." *LPN: -"To assist an RN with supervising routine functions of an assigned area to include functioning as a Charge Nurse in providing nursing care to resident under the direction of an RN and as prescribed by the physician and in accordance with standards of nursing practices and regulations; and as may be directed by the RN Director of Nursing."

Based on observation, interview, record review, and policy review, the provider failed to ensure adequate supervision and safety for one of one sampled resident (1) who fell from a bath tub chair lift. Findings include: 1. Review of the provider's event reports submitted to the South Dakota Department of Health on [DATE] and [DATE] related to the fall of resident 1 on [DATE] revealed: *The resident had fell and had struck his head/face from an elevated bath chair lift. His legs were suspended under that chair by the tub chair safety strap. *The bath tub lift chair safety strap had been noted as fastened in a loose position on the resident prior to the fall. *After the fall the resident was noted by nursing personnel as agitated, confused, and restless. *The following injuries were noted by nursing personnel at the time of the fall: quarter sized skin tear to the right forehead, right eye swollen shut, and bloody nose. *The resident had sustained a head, neck, and facial trauma as a result of that fall from that bath tub lift chair on [DATE] at approximately 1:10 a.m. Review of resident 1's [DATE] interdisciplinary care plan revealed: *He had a history of [REDACTED]. *He was seen by his physician on [DATE] as a result of his falls. *Nurses and CNAs were to monitor for any changes in moods and behaviors and mental status. *His goal was to be free of falls. *No interventions outlined the details of his safety/fall risk during bathing. Review of resident 1's [DATE] Minimum Data Set revealed: *He had severely impaired cognition and recall. *He had a history of [REDACTED]. *He was assessed for needing physical help in part of the bathing activity. Interview and a reenactment of the incident on [DATE] at 9:32 a.m. with certified nursing assistant (CNA) A regarding resident 1 revealed: *She was the aide who was responsible for giving the resident his bath. *He was confused most of the time. He had been more anxious that day when she had approached him to give him a bath. She had to steer him multiple times, as he thought he should go to the dining room. *He walked with her to the tub room using a walker. *She thought it was about 9:30 a.m. or 10:00 a.m. when the resident received his bath. *He loved his bath and the hot water. *At the time of the fall there were two CNAs in the tub room. *CNA B had her back to the resident as she was looking at the list of residents who needed a bath. *He was seated in the tub chair, and the chair was up in the air because she had just taken him out of the tub. *He was wiping his face while she was beside him putting his socks on him. *The tub chair was at about her waist height that meant the residents buttocks would have been about three feet off the ground. *The tub chair was not in its lowest position. She was trying to get his socks on so his feet were not touching the floor. *Whenever she gave a resident a bath she put the safety belt around the resident's waist, and it was looped through the belt buckle. *The safety belt had been loosely around him. *She demonstrated that 'loosely' meant a couple of fingers away from the abdomen. *She had questioned herself if she should have put a gait belt around his chest but had not done so. *He had lunged forward out of the chair. She could not stop him, because she was at his side by his feet putting on his socks and shoes. He then fell forward out of the chair. *She heard the thud as he hit his head on the floor. *He did not stop the fall with his arms. *His legs were caught in the safety belt, so they were off the ground. *He laid there and said repeatedly "I have to get up." *He was bleeding from his head, and he said "I got hurt. I have to get up." *She could not explain how he fell out of the chair if the safety belt was in place in the manner she had demonstrated. When she demonstrated how the belt was supposed to be fastened she agreed she could not have fallen out of the chair in the manner resident had fell out. *She restated how she had heard a crack, as the resident's head hit the floor. *She had kept him in place until the nurses got there. *She was having a hard time recalling the incident because there was so much going on at the time. *She told registered nurse (RN) C and D he had fell out of the chair, and he had hit his head. *She did not think he was any more confused than he normally was. He was continually moving his arms and legs as he lay on the floor. *She put his legs down, so his face was down on the floor. *She knew they really did not want to move him. *She had been a CNA for [AGE] years, 25 of which had been with this current employer. *She did not have a current cardiopulmonary respiratory (CPR) training or First Aide training. *She participated in the provider's annual training videos on different subjects. *She would get ahold of a nurse right away whenever there was a resident who had any type of head injury. Interview on [DATE] at 10:35 a.m. of registered nurse (RN) C regarding resident 1's fall revealed: *The incident took place about 1:10 p.m. She knew that was about the time, because she had been on break and a medication aide had come to talk to her about one of her residents who needed to see the doctor. She was assigned to a different work station, and resident 1 was not one of her patients. *She had returned from break a couple of minutes early to communicate to RN/nurse manager (NM) D who was going to be doing rounds with a physician, and she wanted that physician to see a particular resident. *CNA B came out of the tub room and said they needed a nurse in the tub room. *RN/NM D had went in the tub room and found it serious. *She was not familiar with resident 1's usual cognitive status as she had not worked with him. *His assigned nurse was on break, and they had tried to call her on the walkie-talkie, but she had not responded to the call. *When she had entered the tub room she had found resident 1 on the floor, and his feet were still 12 to 15 inches off the floor in the safety belt. *His right cheek was on the floor, and he had a cut or abrasion on his forehead. *He was trying to get up, pushing with his arm. *He did not mention any pain. *RN/NM D said they needed to get his legs down, before she left the room to go on doctor rounds. *She was getting towels to put pressure oh his head. *He was thrashing. *She was shouting at him to lay still, but he was very hard of hearing, and he did not seem to be able to hear or understand. *He remained on his stomach the entire time she was in the tub room, but he kept trying to get up. *She had been employed as a, RN with this provider for two years and had training in first aide and CPR. Interview on [DATE] at 10:50 a.m. with CNA B regarding resident 1's fall revealed: *At 1:00 p.m. on [DATE] she had just finished distributing supplies to residents and had some extra time. She went into the tub room so see who was on the schedule to receive a bath that she could do. *Resident 1 and CNA A were in there. *As she stood with her back to resident 1 she heard a cough and then a large crash. *When the resident hit the floor it was so loud it sounded like a bowling ball hitting the floor. *She had turned and saw resident 1 on the floor, and she had run out of the tub room to get a nurse and told them they needed to come in right away. *RN/NM D came in and said they needed to get his feet down, as they were tangled in the safety belt of the tub chair. *RN C came in and RN/NM D left the tub room. *She stated she tried to get his feet down, but the belt was so tight she could not get them down. *The tub chair was not in its lowest position. *RN C told her they needed to get his vitals, but she was unable to get the blood pressure cuff around his arm, because he was thrashing so much. *CNA E went to get the medi-man lift. *She was not sure if that piece of equipment was designed to get a resident off the floor. *While he was on the floor he was turning himself. *He was more agitated than she had ever seen him before. *Four staff were there when they got him up, because he was so agitated. *LPN E had told them to get him up in the chair. *He had not complained of pain in his neck until he was up in the chair. *She was not certified in CPR nor was she first aid trained. *They were trained that when a resident fell , they were not to touch the resident. Interview on [DATE] at 11:11 a.m. with RN/NM D regarding resident 1 revealed: *The incident had occurred in the central tub room, and she was standing outside the tub room at the central nursing desk. *CNA B came out of the tub room and said they needed a nurse in there now, so she had gone in. *She saw the resident on the floor with his face down, and his head was cocked to the side a bit. *She had knelt down and looked at him and assessed the source of blood and noted the following: -His eyes were open. -His lips were moving, but no words were coming out. *His feet were still in the tub belt suspended in air about one foot off the ground. *The tub chair was not in its lowest position. *RN C also came in, so RN/NM D left to do doctor rounds as a physician was seeing residents. *She told CNA B they needed to get his legs down, and then left the tub room. Interview on [DATE] at 11:40 a.m. with LPN E revealed: *When she had entered the central tub room she saw resident 1 laying face down with his head facing south. *She could not really assess him, but she could see the hematoma on his eye and forehead. *He had good hand strength, and he was agitated. She saw that his right eye was swollen shut. *He was confused more than normal. *They could not keep him on the floor. She said they needed to get him up. *He denied any pain, except a headache. He held his face and continued to complain of a headache. *He complained of shoulder pain and being short of breath more than his head once he was put in the wheelchair. *She had not been told by the other nurses that his legs had been caught in the tub chair belt. *She did not know until after the fact that they had lowered the tub chair after he had fell . *She had basic CPR and First Aide training. *The resident recently had had an upper respiratory infection and had been more wobbly on his feet in the past few days. *She confirmed that a chest belt probably should have been used in the tub chair since the resident showed increased signs of confusion. *She had not been told by the CNAs or anyone that he had complained of neck pain. *She confirmed the tub belt should have been tight enough that you could only get your hand between the belt and the resident. Interview on [DATE] at 12:00 noon with human resources manager F regarding the fall with resident 1 revealed: *She and RN/NM D had completed a re-enactment of the fall of resident 1 with CNAs A and B. *The re-enactment revealed: -How high the tub chair had been when he fell out if it. -The safety belt on the chair had not been tight against resident 1's skin, because CNA A did not want to cause a skin tear. -CNA A said the belt when the resident's feet were tangled in it was looser than it had been while the resident was in the bath tub. -When the resident fell forward the belt came across the front of the chair, and the resident's legs were trapped under the chair and in the belt. *The re-enactment confirmed: -The belt was not tight enough to secure the resident. -The belt had never been on tight enough or the resident had loosened the belt. -CNA A had not been able to definitely recall if she had loosened the belt. -The belt could not have accidentally gotten so loose. -The belt went below the chair when the resident fell . -The tub chair only had a waist belt at the time of the fall. It did not have a second chest belt. Interview and manufacturer's recommendations review on [DATE] at 1:35 p.m. with the assistant director of nursing revealed: *She had no involvement in the actual fall and treatment of [REDACTED]. *After resident 1's fall she had met with the bath aides and the administrator and they had discussed: -Tub safety. -Ways to make bathing safer including making sure the tub chair belt was tight, lowering the chair as low as it would go, and watching the resident at all times. -The humidity in the tub room. *There was no discussion or review of the tub manual, but the manual was in the meeting. *When asked in reviewing their tub manufacturer's guidelines in light of resident 1's behaviors and demeanor prior to the fall if the resident should have received a bath, she said "He probably should not have been put in the bath based on his agitation." *In review of basic tub guidelines she confirmed: -The belt should have been tight enough allowing the resident to breathe, but to only get a finger between the belt and the person. *She confirmed: -Resident 1's feet were trapped under the chair. The tub chair safety belt had not been tight enough. Interview and manufacturer's recommendations review on [DATE] at 2:00 p.m. with the administrator, director of nurses, and nurse consultant revealed: *The DON had been out of the building on the day of resident 1's fall and had been gone for the next three days. *The administrator had asked the HR manager F and RN/nurse manager D to be involved in the follow up investigation and re-enactment of resident 1's fall on [DATE]. That re-enactment found nothing wrong. *They had not seen the re-enactment of how resident 1's feet were tangled up in the belt of the tub chair. *These surveyors re-enacted how CNA A demonstrated how the belt was on the resident, they concurred it would be impossible to fall in the manner resident 1 did without the belt being looser than demonstrated by CNA A. They further concurred only two things could have happened to had allowed resident 1 to fall in the manner in which he did: 1. The tub chair safety belt was not properly applied by CNA A. 2. The resident had loosened the belt when CNA A was not watching the resident. *The DON agreed the resident probably should not have been put in the bath that day based on his documented anxiety prior to bathing. *They agreed the tub chair should have been in its lowest position as per the manufacturer's recommendation. They further agreed if the chair had been in the lowest positron, it would have been impossible for the resident's legs to become entrapped in the safety belt in the manner in which he was found. Review of the provider's revised February 2011 fall prevention policy revealed it did not contain any specifics in relationship to bathroom or tub safety. Review of the provider's care specialist for certified nurse aides job description revealed the CNA was to: -"Observe and practice safety according to facility policy and procedure." -"Properly use and maintain facility equipment." -"Follow facility policy and procedure." -"Report significant changes in a resident's condition."

Based on observation, interview, record review, and policy review, the provider failed to prevent pressure ulcers from developing for 1 of 4 sampled residents (11). Findings include: 1. Observation on 5/9/11 at 2:35 p.m. of resident 11 in room revealed: *He was lying in bed. *Oxygen was on per nasal cannula. *There was no pressure relieving device on the bed. *There was a gel cushion in the wheelchair beside the resident's bed. Interview on 5/9/11 at 3:00 p.m. with RN E revealed: *He had lost significant weight since the beginning of the year. *His weight had been 189 pounds on 3/7/11. *His weight had been 176 pounds on 4/26/11. Interview on 5/9/11 at 4:00 p.m. with RN E about resident 11 revealed: *He had weakness and had several falls. *The last fall had been 4/29/11. *He had a gel cushion on his wheelchair. *The pressure ulcer on the left buttock had first been discovered on 5/2/11. *The treatment to the pressure ulcer was done twice daily. *The nurses measured the pressure ulcer daily. *She did not believe he had a pressure relieving device on his bed. Interview on 5/9/11 at 4:30 p.m. with the registered dietitian regarding resident 11 revealed: *He had been started on 2 cal supplement 2 ounces twice daily. *He had received a supplement with each meal. *She would be starting the resident on a multivitamin because of the pressure ulcer. *She had not updated the assessment of the resident. Observation of resident 11's pressure ulcer treatment on 5/10/11 at 9:15 a.m. revealed: *[MEDICATION NAME] hydroactive gel (Duogel) had been used twice daily on the left buttock pressure ulcer. *The pressure ulcer was cleansed and then measured by RN F. *The measurement of the pressure ulcer was 0.8 cm (centimeters) by 0.3 cm. *There was no specialized mattress on the resident's bed. *RN F stated the pressure ulcer had looked improved to her. Review of resident 11's pressure ulcer/open area record on 5/10/11 at 10:30 a.m. dated from 5/2/11 through 5/10/11 revealed: *The measurements and treatment for [REDACTED]. *The treatment for [REDACTED]. *The measurements of the left buttock pressure ulcer were: -On 5/2/11: 0.2 cm by 0.2 cm, superficial and unable to determine the depth. -On 5/3/11: 0.2 cm by 0.2 cm, described as a scab. -On 5/4/11: 0.2 cm by 0.2 cm, described as a scab. -On 5/5/11: 0.4 cm by 0.4 cm, described as purple red tissue nonblanching and closed. -On 5/6/11: 0.3 cm by 0.2 cm, described as [MEDICATION NAME] tissue. -On 5/7/11:1.5 cm by 1.5. cm, described as reddened and not opened.. -On 5/8/11: 0.3 cm by 0.2 cm, described as superficial and not open red area. -On 5/9/11: 0.4 cm by 0.2 cm, described as superficial and red. -On 5/10/11: 0.8 cm by 0.3 cm, described as unable to determine the depth and [MEDICATION NAME] tissue/granulation tissue. Interview on 5/10/11 at 12:05 p.m. with the director of nursing regarding resident 11 revealed: *The wound team consulted monthly regarding pressure ulcers. *They needed to do better skin assessments to be preventative in skin breakdown. Interview on 5/11/11 at 9:45 a.m. with the director of nursing regarding resident 11 revealed she agreed the care plan did not address the resident's current needs. Record review of resident 11's current care plan initiated on 4/12/11 revealed: *Last care plan review had been completed 4/28/11. *"2000-2400 cc needed daily for adequate hydration." *"Staff to monitor and encourage fluids at meals and between meals." *"Staff to report signs of dehydration upon discovery." *"Staff to provide additional fluids for intake during warm weather and acute illness per preference." *"Nursing would give 2 cal supplement 2 ounces twice daily." *"Supplement at meals." *"Staff to encourage oral intake at meals." *"Monitor weight." *"Dietary to provide constant carb (carbohydrate) no added salt diet." *"Staff to provide mechanical texture." *"Foot board on bed due to diabetes." *"Gel cushion to wheelchair." *"Resident would like staff to monitor skin folds on bony prominences during care and baths for signs of irritation or breakdown and report changes for further evaluation." *There had been no focus, goal, or intervention for the pressure ulcer. *The had been no intervention for a pressure relieving device for the bed. *There had been no focus, goal, or intervention for the residents current 13 pound unplanned weight loss. Review of the provider's undated Skin Policy and Procedure revealed: *"Nursing personnel will develop a POC (plan of care) with interventions consistent with resident's and family preferences, goals and abilities, to create an enviroment to the resident's adherence to the pressure ulcer prevention/treatment plan. POC to include; Impaired mobility, Pressure relief, Nutritional status and interventions, Incontinence, Skin condition checks, Treatment, Pain, Infection, Education of resident and family, possible causes of pressure ulcers and what interventions have been put into place to prevent. Skin checks to be completed at least weekly by a Licensed Nurse."