Every finding on record at Five Counties Nursing Home

Based on observation, interview, and policy review, the provider failed to follow standard food safety practices regarding: *Hand hygiene (handwashing or the use of an alcohol-based hand sanitizer) and glove use by two of two cooks (J and K) who did not wash their hands as required and wore soiled gloves to handle ready-to-eat foods, one of one restorative therapy (RT) (D) who did not wash her hands between feeding a resident and eating her own meal, and one of one certified nursing assistant (CNA)/certified medication aide (CMA) (E) who did not remove her soiled gloves before handling food items during two of two meal services. *The disposal of garbage away from a portable food serving station during one of two observed meal services. Findings include:1. Observation and interview on 5/5/26 with cook J from 12:15 p.m. through 12:45 p.m. during the mid-day meal service in the dining room revealed cook J washed his hands, used his clean, wet hands to turn the unclean faucet handles off, and dried his hands with a clean paper towel. He then put his unclean hands into a pair of clean gloves. During the meal service, cook J used those same gloved hands to open the cabinet door handles, touch individual resident menus, and then handle ready-to-eat food items (baked potatoes and bread slices) he was serving. [NAME] J acknowledged that his improper hand hygiene and handling of the ready-to-eat food with his unclean gloves had increased the risk for cross-contamination to occur. 2. Observation on 5/6/26 from 8:05 a.m. through 8:15 a.m. of cook K during the breakfast meal service revealed she wore the same pair of gloves while touching and handling ready-to-eat food items (grapes, bananas, waffles, bread, and boiled eggs). After her left glove became greasy from handling buttered toast and waffle slices, cook K used her gloved right hand to remove the left glove. [NAME] K discarded the left glove into a small garbage container that hung over the side of the portable food serving station she was using. The unlidded garbage container was three to five inches from opened peanut butter and brown sugar containers, and a bag of opened grapes. [NAME] K wiped her ungloved left hand on her unclean apron and, with her gloved right hand, put a new glove on her unclean left hand. That contaminated both gloves. [NAME] K resumed food service and distribution with those gloved hands. 3. Interview on 5/6/26 at 8:25 a.m. with dietary manager (DM) I and cook K revealed the above ready-to-eat food items should have been handled using tongs, spoons, or some other clean serving utensil. [NAME] K did not follow infection prevention and control practices for proper glove use, hand hygiene, and garbage disposal, which increased the risk of a food-borne illness occurring. 4. Interview on 5/6/26 at 2:00 p.m. with administrator A regarding the above food service observations revealed DM I had discussed the above observations with her, and DM I began immediately re-educating her staff members regarding safe food-handling practices. 5. Observation on 5/5/26 from 12:02 p.m. through 12:55 p.m. in the dining room revealed RT D helping residents 15 and 23 eat their lunches. She did not perform hand hygiene between assisting the two residents to eat their meals. At 12:40 p.m., RT D got up from the table and went to the serving counter. She picked up a plate with a baked potato and butter. She took that plate back to the table and sat between residents 15 and 23. She put the butter on the potato and took a bite of the potato. Without performing hand hygiene, she assisted resident 15 to take a bite of Jello with a spoon. She set that spoon down, picked up her own fork, and took another bite of her potato without performing hand hygiene. This practice continued for the rest of the lunch meal service. 6. Observation on 5/6/26 at 9:34 a.m. in the dining room revealed CNA/CMA E picking up the plates of the residents who were done eating breakfast. She took one dirty plate from the table with gloved hands and brought it to the dirty dish container. She then walked over to another table and asked the resident if he wanted his unopened juice cup. The resident did not want the juice, so with that same gloved hand, CNA/CMA E picked up the juice cup and brought it over to the refrigerator. She opened the handle to that refrigerator with her gloved hand and placed the unused juice cup inside. 7. Interview on 5/6/26 at 1:52 p.m. with director of nursing (DON) B revealed that she expected the staff to follow hand hygiene practices in the dining room environment. She agreed that RT D did not follow the expected practices when she ate from her own plate and then assisted a resident to eat from their plate without performing hand hygiene between those two actions. DON B expected CNA/CMA E to dispose of her gloves after touching a plate that a resident had eaten from. She acknowledged that touching the clean cup with those dirty gloved hands would have made that cup dirty and it should not have been put back in the refrigerator with clean food items. 8. Interview on 5/7/26 at 10:18 a.m. with administrator A revealed that the staff was allowed to eat with the residents, but hand hygiene practices were expected to be followed if they were assisting the resident with eating. She expected RT D to perform hand hygiene between eating her own food and assisting residents 15 and 23 to eat their food. She also expected the staff to throw away their soiled gloves and perform hand hygiene after touching a plate that a resident had eaten from. She agreed that touching a clean cup with dirty gloves and placing it back in the refrigerator while wearing those gloves would have contaminated that cup and the door handle of the refrigerator. 9. Review of the provider's reviewed March 2026 Hand Hygiene policy revealed that after washing and rinsing the hands, the staff was expected to thoroughly dry their hands with a single-use paper towel and use a clean towel to turn off the faucet. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 10. Review of the provider's revised January 2026 Use of Disposable Gloves policy revealed disposable gloves were expected to be changed after touching any object or surface that could possibly be contaminated. 11. Review of the provider's 3/26 Hand Hygiene policy revealed that using gloves still requires hand hygiene before and after wearing those gloves. Hand hygiene procedures were intended to prevent the spread of infection to other personnel, residents, and visitors. 12. Review of the provider's undated Food Safety Requirements policy revealed, strategies to prevent foodborne illness included a. Preventing cross-contamination of foods.

Based on interview, record review, and policy review, the provider failed to ensure a self-administration of medication assessment was completed for one of one sampled resident (10) who was allowed to keep her bedtime medications in a cup on her nightstand without supervision. Findings include: 1. Review of resident 10's electronic medical record (EMR) revealed that she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15, which indicated her cognition was intact. Resident 10 had a 11/14/25 medication self-administration safety screen to self-administer saline nasal mist (non-medicated mix of salt and water designed to moisturize and flush out irritants in the nasal passages) and Refresh eyedrops (artificial tears used to treat dry, burning, or irritated eyes). The staff's instructions on the safety screen were to complete this assessment prior to the resident initiating self-administration of medication and with any medication order changes, change in function/condition that might affect the residents ability to safely self-administer medications. Her 5/3/24 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) had a focus section that indicated she was able to self-administer saline nasal mist and Refresh eyedrops. The interventions under this focus section included to assess resident's ability to safely self-administer medications and that she often wants to wait until she's ready for bed before taking her pills. If the night nurse comes before that time, it has been ok'd by [her] physician to leave the pill cup bedside for her to take prior to going to bed. Resident 10 had a 2/4/26 physician's order that stated, ok to self-administer meds [medications] when nurse leaves [them] on her nightstand. She took four scheduled medications at bedtime, and they included a thyroid (an endocrine gland at the front of the neck that produces hormones) medication, a blood thinner medication, a blood pressure medication, and an opioid (a class of drugs used to treat moderate-to-severe pain) medication. She did not have a medication self-administration safety screen documented for these four medications. 2. Interview and EMR review on 5/6/26 at 1:40 p.m. with registered nurse (RN) C revealed that residents were not allowed to self-administer opioid medications at the facility. If a resident wanted to self-administer medications, then the staff were to obtain a physician's order and perform a self-administration screening assessment. The nursing staff were expected to educate and monitor the resident on appropriate administration techniques for that medication to ensure that the resident was able to perform that administration safely. RN C reviewed resident 10's EMR and agreed that a self-administration assessment was not performed on the resident's oral medications at bedtime, and that those bedtime medications included Tramadol, an opioid medication. 3. Interview on 5/6/26 at 1:52 p.m. with director of nursing (DON) B revealed that residents were not allowed to self-administer opioid medication at the facility. She looked at resident NORA's EMR and agreed that a self-administration assessment was not performed on the resident's bedtime oral medications. She acknowledged that having a self-administration assessment on her bedtime medications should not have included an opioid medication. 4. Interview on 5/7/26 at 10:18 a.m. with administrator A revealed that the residents were not allowed to self-administer opioids at the facility. She acknowledged that even though resident 10's cognition was intact, the practice of leaving an opioid at the bedside of a resident put the resident, the resident's roommate, the facility, and staff members at risk for negative outcomes such as diversion of medications. She expected a self-administration assessment to be performed for every one of resident 10's bedtime medications to determine if she was safely able to perform that self-administration. 5. Review of the provider's January 2026 Self-Administration of Medications policy revealed that an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. After this assessment was performed by the interdisciplinary team, the results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record. 6. Review of the provider's undated Medication Management policy revealed that residents were allowed to self-administer medications with a physician's order and in accordance with procedures for self-administration of medication.

Based on observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (31) who was left outside of his room unsupervised by one of one certified nurse aide (CNA) (M) after his room was cleaned and the floor was wet, which placed the resident at risk for falling and sustaining an injury.Findings include:1.Observation on 5/5/26 at 12:55 p.m. revealed CNA M walked beside resident 31 and used physical and verbal cues to guide the resident towards his room. The resident wore a pair of Crocs (lightweight, slip-on foam clogs) on his feet. There was a Caution Wet Floor sign placed on the floor at the entrance of the resident's room. The room floor was visibly wet. CNA M instructed resident 31 to wait before he entered his room because the floor was still wet from having been mopped. CNA M then walked away from the resident. 2. Interview on 5/5/26 at 1:00 p.m. with environmental services L revealed she had recently cleaned resident 31's room, which included mopping the room floor. She placed the caution sign in front of his door after she cleaned his room because the floor was still wet. She stated the room floor had to be absolutely dry before the resident re-entered his room. We don't want them [the residents] to fall and hurt themselves. A mopped floor usually took about ten minutes to dry. When the floor was dry, it was her responsibility to remove the caution sign. That notified the residents and the staff that it was safe to re-enter the room. 3. Interview on 5/5/26 at 1:05 p.m. with CNA M revealed she knew the floor was still wet in resident 31's room when she asked the resident to wait outside of his room before going in. The resident usually complied with the staff's instructions. She did not know resident 31 had entered his room after she had told him to wait outside the room for the floor to dry. CNA M stated she should have stayed with resident 31 until she knew the floor was dry to mitigate his risk of falling on a wet floor and possibly injuring himself. 4. Interview on 5/5/26 at 1:07 p.m. with administrator A revealed she removed the caution sign by resident 31's door because she assumed his room was cleaned and the floor was dry, even though she knew it was environmental services staff's responsibility to have removed that sign. 5. Review of resident 31's electronic medical record (EMR) revealed his 4/20/26 Brief Interview for Mental Status assessment score was 12. That indicated he had moderate cognitive impairment. His diagnoses included autism (a chronic neurological and developmental condition that affects how people interact with others, communicate, learn, and behave) and visual impairment. 6. Interview on 5/6/26 at 10:30 a.m. with resident 31 in his room revealed his verbal interaction was limited to short word responses to questions. He stated that his vision was limited to some light and shadows, and he liked his personal belongings to be consistently kept in the same place so that he knew where to find them. 7. Review of the provider's revised May 2025 Potential Hazard Prevention policy revealed the provider was responsible to ensure that the resident's environment remains as free as possible of accident hazards and that each resident receives adequate supervision and assistive devices to prevent accidents.

Based on observation, interview, and policy review, the provider failed to ensure a homelike environment and staff assistance was provided in one of one dining room during two of two observed mealtimes.Findings include:1. Observation on 5/5/26 from 12:02 p.m. through 12:55 p.m. of restorative therapy (RT) D in the dining room revealed that she sat between residents 15 and 23 for the meal service, and they both required assistance to eat their meals. Resident 23's eyes were closed for most of the meal service, but she would open them when spoken to by RT D. Resident 23 was given one sip of juice from RT D, and they did not converse with one another at the table. 2. Observation on 5/6/26 from 9:15 a.m. through 9:43 a.m. of certified nursing assistant (CNA) G in the dining room revealed that she sat between residents 23 and 30 at a dining room table. Two other unidentified residents sat at that same table. The four residents did not converse with one another, but resident 30 responded to the staff who passed by the table and spoke to her. Resident 23's eyes were closed. Breakfast was not served yet. CNA G's head was lowered, and she remained silent while she used the iPad on the table in front of her. At 9:25 a.m., she got up from her chair and walked out of the dining room. At that same time, CNA/certified medication assistant (CMA) H sat down between resident 23 and one of the unidentified residents. In response to CNA/CMA H speaking to her, resident 23 opened her eyes and drank juice that was offered to her by CNA/CMA H. At 9:28 a.m., CNA G returned to the dining room table and resumed working on her iPad without speaking to the residents at the table. At 9:32 a.m., she got up from the table and left the dining room, returned to the table at 9:34 a.m., and she resumed using the iPad. CNA G did not establish eye contact or verbally engage with any of the residents at that table during this observation. At 9:36 a.m., resident 30 was served breakfast. Her eyes were closed. CNA G said resident 30's name and asked the resident, Are you thirsty?, but the resident did not respond. CNA G returned her attention to the iPad from 9:36 a.m. until 9:43 a.m., then attempted to feed resident 30 her breakfast. 3. Interview on 5/7/26 at 8:45 a.m. with CNA G regarding resident meal services revealed that she encouraged residents to make choices and allowed them to do as much for themselves during a meal as possible. She stated, good conversation and laughter [with the residents] was expected. CNA G acknowledged that during the above mealtime observation, she used the iPad for work-related documentation. It's something I try to do when I'm waiting [for the meal to be served]. During the above meal service, CNA G stated that she had rubbed resident 30's back and encouraged the resident a few times, but she stated I could have done more, such as making eye contact with all the residents seated at the table and engaging in conversation with them. 4. Interview on 5/7/26 at 9:00 a.m. with administrator A and director of nursing (DON) B revealed that the staff were expected to respect and maintain residents' dignity before, during, and after meal services. That did not occur when CNA G prioritized the use of an iPad over interacting and assisting the residents during the above breakfast meal service. 5. Review of the provider's revised August 2025 Resident Rights and Responsibilities policy revealed, Residents shall be treated with dignity, respect, and consideration at all times, including during the provision of care and services.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to ensure the safety of one of one cognitively impaired sampled resident (3), identified as being at risk for elopement, who eloped (left the facility without staff knowledge) and was outside of the building for an unknown amount of time after she entered the doorlock's key pad code and exited the building. Failure to adequately supervise and monitor the resident's location and to provide environmental controls (doorlock keypad code unknown to the resident) may have contributed to her elopement and placed the resident at risk for an accident and/or injury while she was out of the building and unsupervised. Findings include: 1. Review of the provider's 4/12/25 SD DOH FRI revealed: *On 4/12/25 at 11:00 a.m. resident 3 exited the building through the [NAME] wing doors. -She stated she had entered the door code to unlock it and left as she was looking for her son. -The door locked behind her. *She went to the front door of the building and rang the front doorbell. *At 11:00 a.m., certified medication aide D opened the door for resident 3, and she came back into the building. *The report indicated resident 3's care plan would be reviewed on Monday [4/14/25] to revise for high-risk elopement. *The facility ordered AirTags [a tracking device] to assist in monitoring residents' location to ensure safety. *Resident 3 had refused to utilize the WearTech devices as she insinuates her watch is broken and does not like the emblem on it. 2. Review of resident 3's electronic medical record revealed: *Her admission date was: 6/7/22 *Her 3/3/25 Brief Interview of Mental Status assessment score was an 8, which indicated she was moderately cognitively impaired. *Her diagnoses included: dementia with agitation, Alzheimer's Disease, schizophrenia, , altered mental status, and heart failure. *Her 5/15/25 care plan indicated: -A 6/14/22 focus area of appropriate placement (a facility with a dementia unit) with a 4/29/25 initiated intervention of Resident high elopement risk, considering other options for a facility better suited for her needs. -A 6/14/22 focus area of is at moderate risk for wandering and high risk for elopement. --A 1/31/25 revised goal for this focus area was Resident will remain in facility unless staff present and have no attempts at elopement through the review date. --The current interventions for that focus area included: --A 9/9/24 initiated and 9/24/24 revised intervention is a moderate risk for elopement, --A 4/3/25 intervention Window alarm placed on 4/3/25 in resident room. --A 4/14/25 intervention is at high risk for elopement, efforts in place to look for a facility more suited to her needs. --A 4/29/25 intervention Air tag placed in soles of shoes. *Her 12/3/24 elopement risk assessment indicated she was at moderate risk for elopement. -Elopement precautions for her included: routine monitoring of her whereabouts, involve in psychosocial programs and activities programs, re-direction, care plan was updated, DON notified, and up-to-date photo in system. *Her 3/2/25 elopement risk assessment indicated she was at a low risk for elopement. -Elopement precautions for her included the same as indicated above. 3. Review of the provider's undated Elopement, Risk Reduction Strategies, and Management of Missing Residents policy revealed: *The facility strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk of elopement, implement risk reduction strategies for those identified as an elopement risk, institute measures for resident identification at the time of admission, and conduct a coordinated resident search in the event of a missing resident. *Elopement is the ability of a cognitively impaired resident, who is not capable of protecting himself or herself from harm, to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. *An elopement risk evaluation is completed on all residents on admission, and with a change in condition or mental status. *A facility approved risk evaluation tool (or scoring system) is utilized -a. The evaluation is based on various risk factors that may precipitate an elopement event -b. The risk score includes a defined parameter which, when reached, indicates an increased risk and prompts strategies, as described below. *The risk evaluation . addresses the resident's mobility and psychological, behavioral, physical, and cognitive functions. Specific risk factors include: -Any cognitive impairment which results in an inability of the resident to appreciate safety risks and an inability to protect himself or herself. -Interference with risk reduction strategies, including an expressed displeasure with a wander bracelet or an attempt to remove it. -Behavior problems, including those where the resident is not easily redirected or managed when he or she is agitated or aggressive. *Interventions that may be used for residents identified as high risk for elopement include: -Frequent monitoring of the resident's whereabouts to assure he or she remains in the facility. -Implementation of wander bracelet or other electronic alert systems. -Environmental controls such as: --The physical plant is secured to minimize the risk of elopement through: (a.) Functional alarm system . c. Safety locks or keypad entry that restrict access to dangerous areas. *Verification of control systems. -Door alarm codes are changed routinely. -Resident electronic monitoring sensors (e.g. bracelets/pendants) will be utilized as needed. They will be checked quarterly for placement and proper functioning and documented in the Care Plan. *When a resident has been found: -The resident's service plan [care plan] is updated, including: --Additional measures such as a wander bracelet if not in current use --15-minute safety checks or continuous observation if transfer to a more secure facility is determined --A Missing Resident form is completed, and all staff involved sign the form. The form is forwarded to the Administrator or Resident Services Coordinator. --The incident is reported to the state authorities as required. *All elopement attempts and events are documented in the resident record, including objective and factual statements regarding: -a. Circumstances and precipitating factors -b. Interventions utilized to return the resident to the unit -c. The resident's response to the interventions -d. Results of reevaluation upon the resident's return and the condition of the resident e. Care rendered f. Notification of police, physician, and family g. Physician orders following notification h. Additional risk reduction strategies implemented *Resident-specific safety concerns are noted on the resident care plan and interventions that address his or her needs. Interventions to reduce risk are reviewed by the interdisciplinary team on a quarterly basis, at least, or with a change in condition for effectiveness of risk reduction strategies. These measures include realistic measurable goals and avoiding statements such as 'will have no events or no injuries related to elopement'. *Elopement drills will be conducted annually. Each elopement will be considered a drill and evaluated to improve outcomes. 4. Interview on 5/15/25 at 12:50 p.m. with licensed practical nurse C regarding resident 3 revealed: *Resident 3 was often exit seeking, and she was aware that resident 3 had recently eloped from the building. *She thought resident 3 also had an elopement in October 2024, but she was not certain. *She was not working when resident 3 eloped on 4/12/25, but she was aware of the elopement and the intervention at that time for redirecting resident 3 when she was exit seeking. *She stated they had not had any elopement drills since she had started her employment. *She was not aware of a photo book or any other book at the reception desk for residents at risk for elopement. 5. Observation and interview on 5/15/25 at 1:05 p.m. with resident 3 while she was in the activity room revealed: *She walked independently, without the use of an assistive device such as a walker. *She stated she did not like living at the facility as she was unable to see her family. *She did not respond to any additional questions. 6. Interview and policy review on 5/15/25 at 2:43 p.m. with administrator A regarding resident 3's elopement revealed: *Resident 3 had eloped from the building on 4/12/25. *Administrator A could speculate that she [resident 3] walked with a visitor out [of the building]. -There were no cameras that would have captured resident 3's elopement. *She confirmed there was no way to determine how long resident 3 was outside of the building. *When administrator A interviewed resident 3 after the elopement, resident 3 indicated she had overheard the code to unlock the doors and used it to unlock the door that day. *There was no signage posted that directed non-staff members to ensure residents did not follow them out of the building when they left. *Administrator A thought the door alarm codes were changed maybe quarterly. -The door alarm codes were change after resident 3's elopement on 4/12/25. -She stated she knew the [door] codes were changed when we have noticed increased wandering and when we heard family screaming out the code. -There was no documentation of when the door alarm codes were changed. *She stated staff members were given the code and somehow family and volunteers get a hold of it and then we change it. *Resident 3 had eloped from the facility more than once, but she was not certain of the dates of those elopements. *They did not routinely execute elopement drills, but every elopement is reviewed as a drill. *Regarding the provider's undated Elopement, Risk Reduction Strategies, and Management of Missing Residents policy -They did not annually photograph residents at risk for elopement. --She was not certain how often a resident's photograph was taken. -There was no photo book or any other book of at-risk for elopement at the receptionist desk. --The MDS Coordinator would be responsible to create and update this book. *Resident 3 currently wore AirTags in the soles of her shoes, and it was monitored through an iPad at the nurse desk. -She confirmed the device would only give resident 3's location and not if she had left the building without staff's knowledge. -She stated We would be able to track her [location] if she left and I can't speak to its accuracy, it is in the settings if she leaves. *Resident 3 previously wore a wear tech device, but that was agitating her. *Regarding resident 3's care plan, administrator A indicated: -Her care plan was updated to include she was at high risk for elopement, and previously indicated she was at medium risk for elopement. -The alarm on resident 3's window intervention was due to her threatening to throw her clothes out her window. *Administrator A confirmed their Elopement, Risk Reduction Strategies, and Management of Missing Residents policy had not been followed. *Administrator A confirmed: -Resident 3 had left the facility without staff knowledge through an alarmed door when the resident entered the keypad code that deactivated the alarm. -The facility was responsible for the safety and supervision of residents. -Resident 3 was at high risk for elopement and had eloped on several occasions.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure one of one sampled resident (1) was free from a significant medication error that involved a controlled medication (medications with risk for abuse and addiction) that she did not have orders to receive. She required an emergency room (ER) evaluation and treatment related to a change in her condition. Findings include: 1. Review of the provider's 3/25/25 SD DOH FRI regarding resident 1 revealed: *Staff found resident 1 unresponsive, shaking, with a weak pulse and a blood pressure of 81/47. -She was transported to the ER by ambulance. *A drug screen was performed at the ER. -The drug screen indicated resident 1 had a benzodiazepine (sedative) medication in her system. -Resident 1 was not on a prescribed benzodiazepine medication. *Resident 1 was returned to the facility via ambulance on 3/25/25 at 4:00 p.m. *The provider did not identify when or how resident 1 received a benzodiazepine that was not prescribed to her. Administrator A, licensed practical nurse (LPN) H, and registered nurse (RN) I had completed the investigation for the SD DOH FRI, but were not available for interview. 2. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 1/21/25 Brief Interview of Mental Status assessment score was 10, which indicated she had moderate cognitive impairment. *Her diagnoses included: Chronic Obstructive pulmonary disease, hypertension, hypo-osmolality and Hyponatremia, constipation, insomnia, emphysema, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, respiratory failure, osteoporosis, atelectasis. *Her physician orders indicated the medications she was prescribed were: -Calcium-Vitamin D Tablet 600-400 MG-UNIT [milligrams-unit] (Calcium Carb-Cholecalciferol) Give 1 tablet by mouth two times a day. -Fluticasone-Umeclidin-Vilant Aerosol Powder Breath Activated [inhaler used to treat breathing issues] 100-62.5-25 MCG/INH [micrograms/inhalation] 1 puff inhale orally one time a day -Psyllium Husk Powder Give 1 Tbsp [tablespoon] by mouth one time daily for constipation. -Citalopram Hydrobromide [anti-depressant medication] Oral Tablet 10 MG Give 10 mg by mouth one time a day related to ANXIETY DISORDER. *Resident 1's EMR indicated she was to receive her medications whole. *According to resident 1's medication administration record (MAR) on 3/25/25 at 8:08 a.m. resident 1 received her Calcium-Vitamin D tablet, citalopram, psyllium husk powder, and her inhaler from certified nurse assistant/ certified medication aide (CNA/CMA) N. Review of resident 1's progress notes revealed: *On 3/25/25 at 10:35 a.m. licensed practical nurse (LPN) F was called to the activity room where she witnessed resident 1 shaking, having almost seizure like activity. Non responsive. Vitals taken, O2 sats [oxygen saturation] dropping. BP [blood pressure] 81/47. Arms limp. Pupils fixed non reactive. Shallow breathing. Sudden onset. *On 3/25/25 at 10:37 a.m. LPN F documented in a progress note, Ambulance called and hospital called. *Resident 1 left in the ambulance at 11:02 a.m. with emergency medical services (EMS) staff. *On 3/25/25 at 3:38 p.m. Received report from ER, She [resident 1] was found to have benzodiazepines in her system. She continues to be very lethargic and unable to sit up in [a] wheelchair, she was sent back to the facility via ambulance. She is on oxygen via NC [nasal cannula] and [an] order has been placed to monitor resident status and vitals hourly until she returns to baseline, it is possible that she will return to baseline by morning per the ER staff. They gave her a 500ml [milliliter] bolus and has been on a normal saline drip [intravenous fluids]. She continues on Bactrim [antibiotic] for 2 more administrations. Her sodium is low at 121- they are not going to do anything to treat it, daughter [name] was in the ER with her and was in agreement with that. She is back in the facility since 1500 [3:00 p.m.]. She arrived back via ambulance in [a] hospital gown, they cut her clothes off of her upon arrival to the ER. Her vitals are stable, O2 [oxygen] 91% on 4L [liters] via NC, BP 153/66, HR [heart rate] 91, T [temperature] 97.6 [degrees Fahrenheit]. She is in bed sleeping at this time. Review of the 3/25/25 ambulance report regarding resident 1 revealed: *Resident 1 was foaming [at the] mouth on sight. *Her oxygen was increased from 2L to 4L. *Her pupils were nonreactive to light. *Her skin was cold to the touch. *At 11:19 a.m. resident 1 opened her eyes. *At 11:23 a.m. resident 1 moans/groans. *They arrived at the hospital with resident 1 at 11:25 a.m. Review of the 3/25/25 emergency room Note regarding resident 1 revealed: *EMS had reported oxygen saturations (O2 level in blood) between 50% and 70%. *During the assessment in the emergency room resident 1 withdrew from painful stimuli and as the examination progressed, she became more alert. *She began to smile and attempt to answer questions. *Physical examination noted Patient appears obtunded [slowed responses and not alert]. *Resident 1's urine drug screen was positive for benzodiazepines. *Her problem list indicated Drug ingestion, accidental. *The emergency department plan indicated It does appear she has ingested a benzodiazepine. Not on her medical record. Administration at [the] nursing facility was advised and are investigating/reporting [the] medication error resulting in [the] hospital visit. Review of resident 1's 3/26/25 repeat urine drug screen revealed she had tested positive for benzodiazepines. 3. Review of records regarding residents who resided at the facility with a physician's order for a benzodiazepine medication revealed: *There were six residents prescribed benzodiazepines. -Two of those residents were prescribed clonazepam (a controlled medication used to treat anxiety). -Four of those residents were prescribed lorazepam (a controlled medication used to treat anxiety). *Two residents were documented as having received their ordered benzodiazepine medication in the morning of 3/25/25 as follows: -Resident 2 received lorazepam at 7:36 a.m. on 3/25/25. -Resident 3 received clonazepam at 8:03 a.m. on 3/25/25. 4. Interview on 4/7/25 at 4:33 p.m. with certified nursing assistant (CNA)/certified medication side (CMA) N revealed: *On 3/25/25 at 8:08 a.m. she had crushed resident 1's medications, put them in pudding, and administered them to her in the dining room. *She indicated resident 1 was fine at that time. *At approximately 10:00 a.m. activities director O came out of the activity room to alert staff of a change in resident 1's condition. *CNA/CMA N responded with LPN F to the activity room where resident 1 was noted to be unresponsive, her face was gray, and her lips were blue. *CNA/CMA N was unable to feel a pulse in resident 1's wrist. LPN F was able to feel a pulse in resident 1's neck. *Resident 1's oxygen was on. *LPN F performed a sternal rub (firmly rubbing the breastbone with knuckles to assess response) with no response from resident 1. *CNA/CMA N stated she knew she had not given resident 1 a benzodiazepine because resident 1 was not near anyone who received a benzodiazepine at the time her morning medications were administered to her. *She indicated she did not know how resident 1 could have taken a benzodiazepine unless the night nurse had given her someone else's medication. 5. Interview on 4/7/25 at 4:47 p.m. with activities director O revealed: *On 3/25/25 resident 1 was in the activity room while other residents played Yahtzee (a dice game) after breakfast. *Activities director O stated that resident 1 usually played Yahtzee but had not that day or a couple of days prior. *There was no food or drink in the activity room during that time. *Activities director O stated she was alerted by another resident that resident 1 had tightened up. *Once she saw resident 1, she went out to the nurse's station to get help from the nurse. 6. Interview on 4/8/25 at 8:17 a.m. with LPN F revealed: *She was the charge nurse on 3/25/25 when resident 1 was sent to the ER. *She stated when she saw resident 1 in the activity room the resident was shaking, her lips were blue, her blood pressure was low, her pulse varied, her oxygen saturations were low, her fingers were blue, and her pupils were pinpoint in size and did not react to light. *Staff assisted resident 1 to her room to lie her down and the ambulance was called and transported her to the ER. *The hospital later called with a report and informed the facility staff that resident 1 had tested positive for benzodiazepines in her urine. *During the investigation of that incident RN I asked LPN F about medications having been brought in by a visitor and given to resident 1. *LPN F indicated the only visitor resident 1 had was her daughter and she had not been in the facility since the Thursday prior [3/20/25]. *LPN F stated resident 1's room was searched for medications, and none were found. *LPN F indicated RN I and LPN H had not reviewed the controlled medications in the medication carts after the facility staff were notified that resident 1 had tested positive for benzodiazepines. *LPN F indicated she was not sure how resident 1 had received a benzodiazepine but it could have possibly been a medication error. *When asked about resident 1's mealtime tablemates she stated resident 1 sat with one other resident, resident 4, and resident 4 was not prescribed a benzodiazepine medication. 7. Interview on 4/8/25 at 9:50 a.m. with environmental services staff K revealed: *She had, at times, found medications in residents' rooms when she cleans the rooms. *When she found a medication, she took it to the charge nurse. 8. Interview on 4/8/25 at 9:55 a.m. with doctor C revealed he: *Was resident 1's primary physician. *Was aware of resident 1's unresponsive episode on 3/25/25 that resulted in an ER visit where she tested positive for benzodiazepines. *Verified Citalopram or any of the resident's other prescribed medications would not have caused a false positive benzodiazepine level in the urine. *Verified resident 1 did not have an impaired liver or kidneys that may alter the absorption or elimination of a benzodiazepine. *Reviewed the ambulance report and indicated none of the staff on the ambulance during resident 1's transfer to the ER were able to administer medications. *Indicated that the ambulance does not have a benzodiazepine available in its medication box. *Indicated resident 1's sodium level alone would not have caused the symptoms that she had that day. *Felt resident 1 had a reaction to a medication she was not supposed to have received. 9. Interview on 4/8/25 at 1:45 p.m. with resident 1's daughter revealed: *The nurse practitioner (NP) at the hospital ER had told her, Someone gave her a sedative. *She stated the NP told her she was going to report the incident because mistakes could happen, but this mistake should not have happened. *She did not know how her mother could have gotten a medication she was not prescribed. *She did not feel her mother would ever willingly take another resident's medications because she did not like taking medications. *She felt her mother had declined since she was sent to the ER on [DATE]. 10. Interview on 4/8/25 at 1:59 p.m. with consultant pharmacist E revealed: *He confirmed resident 1 was not prescribed a benzodiazepine. *Resident 1 was not prescribed a medication that would have resulted in a positive for a benzodiazepine in her urine *He indicated lorazepam would start taking effect in about 15 to 40 minutes after administration and the effects would last about six hours. *Clonazepam would start taking effect in about 30 to 40 minutes after administration and the effects would last up to a day later. *He did not think the medication had been administered the night before because of the time of the onset of resident 1's symptoms. Continued interview on 4/8/25 at 4:07 p.m. with consultant pharmacist E revealed: *He felt lorazepam was more likely to have been the benzodiazepine ingested by resident 1 rather than clonazepam due to the length of time the symptoms lasted. *He stated he had reached out to a laboratory, and they had indicated clonazepam, and lorazepam could remain detectable in the resident's urine for one to five days after ingestion. *After he reviewed resident 1's urine drug tests, he felt there had been one or very few administrations of the benzodiazepine because of the amount of time resident 1 remained positive. 11. Interview on 4/9/25 at 11:13 a.m. with director of nursing (DON) B revealed: *She was not in the facility on 3/25/25 but did provide phone consultation to administrator A and RN I related to resident 1's event. *When she was notified of the incident, she advised RN I to be sure resident 1 had not received another resident's medication. *DON B sent administrator A a list of medications that may cause a false positive for benzodiazepines in a urine drug screen. *She advised administrator A and RN I to consult a pharmacist regarding resident 1's event. *She indicated, although resident 4 did not have a prescribed benzodiazepine, resident 1 was moved from her table in the dining room because resident 4 liked to share her food and they wanted to be sure there was no chance that resident 1 could have received something from her. *Resident 4 was the only resident at the breakfast table with resident 1's on 3/25/25 and there were no other residents at nearby tables that were prescribed a benzodiazepine medication. *DON B reported resident 1's room was searched while resident 1 was in the ER and there were no medications found. *She indicated they were not able to identify how resident 1 could have taken or been given a benzodiazepine. -The possibilities that were identified included a family member, the hospital staff, the ambulance staff, or a medication error by the facility staff, but those were all speculation. *She agreed that a resident receiving a benzodiazepine that was not prescribed for that resident is a medication error. *She indicated administration had not investigated the time between resident 1 receiving her morning medications and the onset of her symptoms to determine the potential time the resident would have received the medication. *She stated that they had concluded the onset of symptoms was variable after their discussion with the pharmacist during their investigation. 12. Review of the provider's undated Medication Administration- Required and Critical Performance Criteria policy revealed: *The CMA will administer oral .medications utilizing the following criteria. -1. Check the Medication Administration Record (MAR) against the physician orders as recommended by the facility. -4. Perform 3 checks on each medication. -8. Safely administer medications to resident utilizing the 7 rights of administration --a. Right drug --b. Right dose --c. Right patient/resident --d. Right route --e. Right time --f. Right technique --g, Right documentation -9. Ensure that all oral medication as offered is swallowed by the resident. Review of the provider's undated Medication Error Reporting policy revealed: *Includes: -Wrong Medication -Wrong Person -Wrong Dose -Wrong Route -Missed Medication Review of the provider's undated Medication Management Policy revealed: *Medications will be administered to residents as prescribed. *Medications are administered in accordance with written orders of the attending physician or physician extender. *Residents are identified before medication is administered. Methods of identification include: -a. Checking photograph attached to medical record. -b. Asking a resident to say and/or spell his/her name. -c. If necessary, verify resident identification with other facility personnel. *Medications supplied for one resident are never administered to another resident. *The resident is always observed after administration to ensure that the dose was completely ingested.

Based on observation, interview, record review, and policy review, the provider failed to implement pressure ulcer prevention interventions for one of one sampled resident (1) identified at risk for pressure ulcers who developed a pressure ulcer to her spinal area. Findings include: 1. Observation on 4/7/25 at 2:48 p.m. of resident 1 in her room revealed: *She was lying on her back in her bed. *She was very thin in appearance. *There were Prevalon boots (cushioned boots used to decrease heel pressure) on the floor next to her closet. *There was a cushion in the seat of her wheelchair. 2. Review of resident 1's electronic medical record revealed: *She was admitted on [DATE]. *Her 1/21/25 Brief Interview of Mental Status assessment score was 10, which indicated she had moderate cognitive impairment. *Her 1/18/25 Braden Scale for Predicting Pressure Sore Risk assessment indicated she was At Risk for the development of a pressure ulcer. *Her physician orders indicated: -On 5/22/24 to use pressure relieving mattress on her bed. -On 11/22/24 to use a pressure relieving cushion in her wheelchair. -On 11/19/24 a reminder to change the resident's position frequently. -On 11/7/24 a skin assessment was to be completed weekly. -On 3/5/25 to off load the resident's heels when she was in bed as needed to prevent skin breakdown. -On 4/8/25 On open areas of [the] spine area, use wound cleanser, pat dry. APPLY XEROFORM ONLY TO THE OPEN AREAS. Cover [the] area with ABD [abdominal gauze] pad and use soft silicone Tape to apply to the skin. Change daily and PRN. Document wound condition. -On 4/8/25 STRICT OFFSETTING Q [every] 2 HRS TO KEEP RESIDENT OFF HER BACK. Every 2 hours for Wound injury to spine area. *Her care plan included: -Her care plan indicated she had dementia related cognitive impairments, was dependent on staff to assist her with her activities of daily living including bathing, repositioning, dressing, personal hygiene, oral care, bathroom use, and eating set up and received dietary supplement. -A 1/8/25 revised focus area that she had the potential for pressure ulcer development related to her limited mobility. --Interventions for that focus area included: encouragement and assistance with the use of assist bars on her bed to assist with turning and repositioning. Education given about importance of offloading pressure, refuses to offload pressure and lay down throughout day, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor nutritional status, monitor intake and record, pressure relieving cushion to wheelchair and mattress to bed, protect heels from pressure, use padding to help prevent pressure areas, 11/22/24 intervention of Sacral dish cushion placed on [the] backrest [her] of WC [wheelchair] at an elevated position to assist in pressure relief per OT [occupational therapy]. *Her kardex included Sacral dish cushion on backrest of WC at an elevated position to assist in pressure relief per OT. *A 3/23/25 progress note completed by the dietician revealed resident 1 is a 83 y.o. [year old] female with a BMI of 17 (underweight) that presents with COPD [chronic obstructive pulmonary disease] on a regular diet. Inadequate intake related to decreased appetite as evidence by 50% avg [average] meal completion with wt [weight] change of -5.0% change over 30 days (Comparison Weight 2/19/2025, 104 Lbs [pounds], -12.5%, -13 Lbs). Encourage meal completion of >= [greater than or equal to] 65% and a nutritional supplement BID [twice daily]. -The dietician's progress note did not address past or current skin conditions or the risk for the redevelopment of pressure ulcers. *Review of Resident 1's skin assessments revealed: -Her 11/20/24 skin assessment indicated mid spine between the shoulder blades on the boney [bony] prominence she now has an open area that is 2.0 cm [centimeters] x [by] 1.0 cm and she had an alternating pressure relieving mattress on her bed. -Her 3/5/25 skin assessment indicated she had a slight pink area on the mid upper spine. -Her 4/8/25 skin assessment indicated, Wound location: Spine, skin trauma/skin tear. Full thickness .total length is 8.0 cm width 2.2 cm and depth 0.1 cm .She has two open areas that are adjoining together. Suspected deep tissue injury on [the] surrounding area. *Review of the resident's pain assessments in the EMR revealed she was last documented as being assessed for pain on 4/4/25 at 3:12 p.m. when she indicated her pain was 0 on a scale from zero to ten (0-10). 3. Phone interview on 4/8/25 at 1:45 p.m. with resident 1's daughter revealed: *She felt her mother had taken a turn for the worse. *Resident 1 did not want to eat by herself and wanted to lie in bed all the time. 4. Interview on 4/8/25 at 3:30 p.m. with licensed practical nurse (LPN) F regarding resident 1 and pressure ulcer prevention revealed: *LPN F was wound certified and was able to document and initiate treatment for wounds under the guidance of a wound specialist and the resident's physician. *Resident 1 had a newly identified pressure ulcer on her back along her spine. *She indicated there were two open skin wounds over the resident's spine with the edges of the skin rolled back and the skin edges were black in color. *The area surrounding the open wound was dark red to purple which she identified as a suspected deep tissue injury (underlying tissue injury due to prolonged pressure). *LPN F stated resident 1 preferred to lie on her back and had been noncompliant with the use of wedges for positioning to relieve pressure. *She had a cushion in the seat of her wheelchair. *There was no cushion for the back of resident 1's wheelchair that LPN F was aware of. *Resident 1 did not have a specialized mattress on her bed, but LPN F had requested an alternating pressure relieving mattress be applied to resident 1's bed due to her newly developed pressure ulcer on 4/8/25. *She had implemented a strict repositioning schedule for resident 1 after that pressure was identified. *She indicated that when a pressure ulcer was identified she notified the resident's physician, the resident's family and the director of nursing (DON). *The dietary manager would only be notified if the physician had ordered a dietary supplement. 5. Observation on 4/8/25 at 3:40 p.m. of resident 1 in her room revealed: *She was lying on her side with the wedge cushion behind her back. *The bones of her spine could be visualized through her shirt. *She did not have a specialized mattress on her bed. *She had Prevalon boots on both feet. *Her wheelchair had a cushion on the seat of the chair. *There was no cushion or added protection on the back of her wheelchair. 6. Interview on 4/9/25 at 7:35 a.m. with certified nurse aide (CNA)/certified medication aide (CMA) N regarding resident 1 revealed: *She was not aware that resident 1 had a pressure ulcer previously. *She was not aware that resident 1 was to have a sacral dish cushion in her wheelchair to decrease pressure to her back. *She indicated the only cushion resident 1 used in her wheelchair was the cushion on the seat. *Staff would reposition her in bed but resident 1 was noncompliant and would often remove the wedge cushion and lie on her back. 7. Interview on 4/9/25 at 8:35 a.m. with CNA/CMA L regarding resident 1 revealed: *Staff would lay resident 1 down after meals, apply Prevalon boots to her heels and turn her from side to side while she was in bed. *She indicated the Prevalon boots were a new intervention started about three days ago. *She indicated resident 1 did not like to be repositioned. *She was not aware of previous open skin areas to resident 1's back, but stated she had an open area to her buttocks previously. *She indicated resident 1 previously had a cushion for her back in her wheelchair but it was no longer available. 8. Interview on 4/9/25 at 8:48 a.m. with CNA Q revealed: *Resident 1 used to have a cushion for her back in her wheelchair. *Therapy had removed the cushion because she was sliding down in her wheelchair. *There were no alternate pressure relieving interventions put in place when that cushion was removed. 9. The occupational therapist was not available during the survey for interview related to the sacral dish cushion for the resident's wheelchair. 10. Interview and review of the provider's undated Nursing Skin Care Protocol on 4/9/25 at 12:05 p.m. with DON B revealed she: *Was aware of resident 1's previous skin issues on her back but was unsure if they were pressure ulcers. *Indicated she would have to review resident 1's care plan to determine what pressure prevention interventions were in place prior to resident 1's development of her current pressure ulcer on 4/8/25. *Recalled resident 1 had wedge cushions to be used for repositioning in bed but resident 1 had been noncompliant with the use of them. *Expected if the sacral dish cushion was in her care plan to decrease pressure to her back, the staff should have followed the resident's care plan. *Was not aware that staff were no longer using the sacral dish cushion when the resident was in her wheelchair. *Expected the charge nurse to request an occupational therapy evaluation if it was determined the current interventions were needed to be changed related to the sacral dish cushion. *Indicated the Nursing Skin Care Protocol was the policy the facility used related to skin issues and pressure ulcers. *Stated, after reviewing the Nursing Skin Care Protocol, the protocol was not up to date and did not reflect the provider's current process. -She believed the process on the Nursing Skin Care Protocol was prior to the implementation of the EMR. 11. Review of the provider's undated Nursing Skin Care Protocol revealed: *All skin care issues require the assessment of the resident's overall clinical status using the following guide. -1. Complete the skin assessment tool (Braden) and communicate the results in a Progress note (under skin/wound note) with notification to the CNA with guidance for turn reposition if indicated. -2. Assess the skin care issue and document findings in the progress notes (under skin/wound note). -3. Review causative factors and implement preventative/pressure relief devices if indicated. (document in skin/wound note) -4. PCP [primary care provider] notification of skin care issues and obtain treatment order. DO NOT classify an ulcer as pressure without PCP consultation. (document notification in skin/wound note) -5. Notify DON, Dietary Manager, and MDS [Minimum Data Set] Coordinator of skin care issues via email. (document notification in skin/wound note) -6. Recommended appropriate diet changes: Registered Dietician will perform a nutritional needs needs assessment/ (document notification skin/wound note) -7. Review resident's pain level (pain tool) and implement/revise/continue and individualized pan [pain] management program. (document pain level in skin/wound note) -8. Notify family/responsible person with condition changes. (Document notification in skin/wound note) -9. Daily and weekly narrative documentation is required (see criteria and examples for each.) Skin sheets will be completed if: a. The resident has a significant bruise b. The resident has an open wound or skin tear c. The resident has a suspected deep tissue injury d. The resident has any skin issues requiring follow-up or treatment -10. Document education given to family/resident and response to the education. -11. Notify PCP and family/resident at 14 days s/p [status post] no response to treatment. Change in treatment plan may be indicated if not improvement is observed. (Document notifications in the progress note under skin/wound note.)

Based on record review, interview, and policy review, the provider failed to ensure medications were securely stored and inaccessible to unauthorized individuals including: *Two of two unauthorized individuals (administrator A and maintenance director M) who had access to one of one medication room where controlled medications (medications at risk for abuse and addiction) were stored in an unsecured manner. *One of one certified nursing assistant (CNA)/certified medication aide (CMA) N who had not securely stored the keys to one of two medication cart and a drawer where controlled medications were stored for two of two observations. Findings include: 1. Observation on 4/7/25 at 2:40 p.m. of the medication carts near the nurse's station revealed: *The keys to open one of the two medication carts were stored on an open shelf on the side of the medication cart beside the water cups. -Those were accessible to visitors and unauthorized individuals. *There was no staff member present within sight of the medication carts. Interview on 4/7/25 at 2:43 p.m. with CNA/CMA N revealed: *She had left the keys on a shelf on the medication cart. *She verified those keys opened the north wing medication cart and that key ring also contained the keys to open the drawer where the controlled medications were stored. *She indicated it was not her normal practice to leave those keys unattended on the medication cart. *She indicated she usually kept the keys in her pocket. *She verified the keys were accessible to anyone when they were stored on an open shelf on the side of the medication cart. Observation on 4/8/25 at 8:36 a.m. of a medication cart in the west hallway revealed it was unlocked and there were no staff members in sight of the medication cart. 2. Observation on 4/7/25 at 2:57 p.m. of the medication room with licensed practical nurse (LPN) J revealed: *The medication room was secured with a coded keypad on the door. *The refrigerator in the medication room was not locked. *In the unlocked refrigerator there was a lock box that contained a bottle of liquid lorazepam (a controlled anti-anxiety medication). *That lock box in the refrigerator was not locked. 3. Interview on 4/7/25 at 4:33 p.m. with CNA/CMA N revealed the nurses, CMAs, administrator, and maintenance staff knew the code to enter the medication room where medications were stored. 4. Interview and observation on 4/8/25 at 8:17 a.m. with LPN F in the medication room revealed: *She indicated the nurses, CMAs, administrator, and maintenance staff knew the keypad code to enter the medication room where medications were stored. *She stated the code to the medication room had been changed one time, by maintenance, because the keypad needed to be changed. Prior to that the code was the same for years. *During the interview with LPN F, maintenance director M entered the medication room with the use of the keypad door code. *LPN F indicated maintenance director M previously had been in the medication room without the nursing staff being aware he was in there. *LPN F removed the lock box from the unlocked refrigerator in the medication room. *She verified the lock box was not locked, and that it contained lorazepam. 5. Interview on 4/9/25 at 7:30 a.m. with maintenance director M revealed: *He had changed the keypad codes to other doors within the facility but had never changed the code to the medication room's keypad. *He knew the keypad code to enter the medication room. *He went into the medication room to deliver pop for a resident, run water in the sink drain, and complete any maintenance required in the room. *He at times was in the medication room without another staff member present. 6. Interview on 4/9/25 at 11:39 a.m. with director of nursing (DON) B revealed: *She verified the nurses, CMAs, administrator A, and maintenance director M had access to the medication room where medications were stored. *Maintenance director M had keys to all the doors in the building, including the medication room, in case there was a fire, an emergency, or he needed to work on something such as plumbing or electricity. *She indicated administrator A also had access to every room in the facility. *DON B agreed administrator A and maintenance director M would have access to medications that were stored in the medication room. *She stated that the medications stored in the medication room were to be locked or in a medication cart except for the stock medications. *She indicated administrator A and maintenance M should not have access to controlled medications. *She was aware that the refrigerator in the medication room was not locked. *She was not aware that the lock box for controlled medications in the refrigerator was not locked. *She expected that lock box to be locked in order to secure the controlled medications from unauthorized access. *It was her expectation that the keys for the medication carts would be in the CMAs' or nurses' pocket or locked in the medication cart to prevent access from unauthorized individuals. *She would not expect the keys to be left unattended on an open shelf on the medication cart. 7. Review of the provider's undated Proper Storage, Usage and Documentation of Narcotics [controlled medications] policy revealed Access to narcotic is to be by a licensed staff and Director of Nursing ONLY! Review of the provider's undated Medication Storage and Labeling policy revealed Medications and biologicals will be stored in locations accessible only to designated staff. Review of the provider's undated Medication Management policy revealed: *During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. *The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on review of the provider's South Dakota Department of Health Facility Reported Incident (SD DOH FRI), record review, observation, and interview, the provider failed to follow professional standards to ensure a resident's physician ordered: *Fluid restriction was implemented effectively and accurately documented for one of one sampled resident (1). *Basic metabolic panel (BMP) laboratory (lab) test (a common blood test that measures levels of key electrolytes including sodium, glucose, and kidney function indicators) was not completed for one of one sampled resident (1) who had been diagnosed with a low sodium level (hyponatremia). Findings include: 1. Review of resident 1's electronic medical record revealed: *She was admitted on [DATE]. *Her 1/21/25 Brief Interview of Mental Status assessment score was 10, which indicated she had moderate cognitive impairment. *Her diagnoses included: hypertension (high blood pressure), hypo-osmolality (a condition where bodily fluids have a lower-than-normal concentration of solutes, such as sodium and other electrolytes), and hyponatremia (low sodium), constipation, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. *She had physician orders: -On 5/3/24 to be given Arginaid supplement every day and evening shift. -On 10/29/24 to be weighed twice weekly on Wednesdays and Saturdays. -On 3/26/25 to be placed on a fluid restriction of 40 ounces (oz) or 1200 cubic centimeters (cc) per day for her low sodium level. -On 3/25/25 a BMP lab (a basic metabolic panel, a common blood test that measures levels of key electrolytes including sodium, glucose, and kidney function indicators that was to be completed on 3/31/25. *Her care plan indicated she had dementia related cognitive impairments, was dependent on staff to assist her with her activities of daily living including bathing, repositioning, dressing, personal hygiene, oral care, bathroom use, and eating setup and received a dietary supplement. *Her fluid intake documentation included the following fluid intake amounts: -On 3/26/25 a total of 240 cc. -On 3/27/25 a total of 540 cc. -On 3/28/25 a total of 260 cc. -On 3/29/25 a total of 450 cc. -On 3/30/25 a total of 380 cc. -On 3/31/25 a total of 400 cc. -On 4/1/25 a total of 240 cc. -On 4/2/25 a total of 800 cc. -On 4/3/25 a total of 730 cc. -On 4/4/25 a total of 190 cc. -On 4/5/25 a total of 330 cc. -On 4/6/25 a total of 300 cc. *Those were all below her daily allowed fluid amount of 1200 cc. Observation on 4/9/25 at 8:45 a.m. of resident 1 at the breakfast table revealed: *She had an almost empty coffee cup and a half-empty glass of juice on the table in front of her. *She required staff to cue her to eat and drink. Observation on 4/8/25 at 3:40 p.m. of resident 1's over-the-bed table in her room revealed: *A half empty glass of orange juice. *A half empty pitcher of water without ice. Observation on 4/9/25 at 7:35 a.m. of resident 1's room revealed two unopened individual-sized containers of Jello on her bedside table. Interview on 4/8/25 at 1:44 p.m. with resident 1's daughter revealed resident 1 took a drink made up with something so her bed sores heal. Interview and record review on 4/8/25 at 2:51 p.m. with certified nursing assistant (CNA)/certified medication aide (CMA) N revealed: *She was aware of three residents who had fluid restrictions, resident 1 was one of the three. *Residents who required fluid restrictions had a physician order for the specific restriction. -Activity staff members would know [which residents had fluid restrictions]. -Dietary staff members would know [which residents had fluid restrictions], as [those residents were] only allowed so much [fluids] at breakfast, lunch, and supper. -Nursing did not document any fluids consumed by residents on fluid restrictions as they only give enough [fluid] to swallow [the] medication. *Staff were alerted to which residents were on fluid restrictions at staff huddles (meetings). *She thought resident 1 was on a 1500 cc fluid restriction. -She reviewed resident 1's EMR and then stated, She is on 40 ounces, 8 ounces with each meal and two 8 ounces outside of meals. Interview on 4/8/25 at 3:12 p.m. with dietary manager G regarding residents' fluid restrictions revealed: *The cooks were to document the resident's fluid intake during mealtimes. *CNA's were to document the residents' fluid intakes when they collect water pitchers, they measure [the amount consumed] and document. *Activities staff were to document consumed fluid amounts for residents on fluid restrictions also. Interview on 4/9/25 at 8:35 a.m. with CNA/CMA L revealed: *The water pitchers were passed to the resident rooms at 4:00 a.m. and 2:00 p.m. *The CNAs were responsible for documenting residents' fluid intakes not consumed at meals in the residents' EMR. *She was aware resident 1 was on a fluid restrictions since she returned from her most recent hospitalization. *Water pitchers were not to be provided to residents on a fluid restriction. *The nurses should have informed the CNAs how much fluid a resident may receive when on a fluid restriction. *Resident 1 received a supplement at 10:00 a.m. and it was to be documented as fluid intake in the EMR by the nurse. *She was not aware that Jello should be counted as a fluid, she indicated she documented Jello as a snack. Interview on 4/9/25 at 8:48 a.m. with CNA Q revealed: *If a resident was on a fluid restriction he would limit the resident's fluid intake. *He indicated resident 1 was on a fluid restriction. *When a resident was on a fluid restriction a water pitcher should not be provided in the resident's room. *He documented a resident's fluids intake consumed outside of meals in the resident's EMR. Interview on 4/9/25 at 9:39 a.m. with CNA/CMA N revealed: *Resident 1's Arginaid supplement was documented on the treatment administration record (TAR). *The nurse on duty was responsible for completing the TAR documentation. Interview on 4/9/25 at 9:50 a.m. with director of nursing (DON) B revealed: *Resident 1's fluid restriction information was passed on to staff during the nursing shift report. *There was no documentation to verify when or what resident information was passed on during those nurse shift reports. -Resident 1's 3/25/25 physician ordered BMP lab that was to be completed on 3/31/25 was not completed as ordered. Interview on 4/9/25 at 10:35 a.m. with licensed practical nurse (LPN) F revealed: *The nurses were responsible for completing the TAR documentation. *The kitchen would bring resident 1's Arginaid supplement to the nurse's station and the CNAs would distribute the supplement to the resident. -The nurses would document that the Arginaid was administered to the resident in their EMR, but the nurses would not administer it or document how much the resident drank. -The CNAs were responsible for documenting the resident's fluid intake that resulted from the administration of the supplement in the EMR. *She verified the nurses would document on the fluid restriction order in the resident's TAR. -She indicated that documentation of the resident's fluid restriction in the TAR was the nurse's acknowledgement that the resident was on the fluid restriction not that the nurse had monitored the resident's fluid intake. *It was her expectation that a resident on a fluid restriction only received a partial pitcher of water in the resident's room. Interview on 4/9/25 at 10:40 a.m. with CNA/CMA N revealed: *Resident 1 did not have a designated task in the EMR to document the amount she consumed of her Arginaid supplement. *She verified not all fluid intake was documented in the resident's EMR. *She verified CNA documentation of resident's fluid intake was inconsistent and on some days there was no CNA charting of resident fluid intakes. *She indicated a resident on a fluid restriction should not have a pitcher of water in the resident's room. *She stated there was no way for a CNA to know how much fluid intake a resident had consumed in order to determine if the resident had exceeded the maximum ordered fluid intake allowed for the day. A fluid restriction policy was requested from DON B but was not provided by the end of the survey.

Based on review of the provider's South Dakota Department of Health Facility Reported Incident (SD DOH FRI), observation, record review, interview, and policy review, the provider failed to ensure a thorough investigation was completed and reported to the SD DOH regarding a facial bruise of unknown origin for one of one sampled resident (1). Findings include: 1. Review of the provider's 3/25/25 SD DOH FRI regarding resident 1 revealed: *On 3/25/25 at 10:30 a.m. in the activity room resident 1 was found unresponsive, shaking, with a weak pulse and a blood pressure of 81/47. -She was transported to the emergency room by ambulance. *The emergency department performed a drug screen. -The drug screen indicated resident 1 had a benzodiazepine medication in her system. -Resident 1 was not on a prescribed benzodiazepine medication. *The SD DOH FRI did not indicate resident 1 had any injuries or bruises. Observation on 4/9/25 at 8:45 a.m. of resident 1 at the breakfast table revealed: *She was seated in a wheelchair. *A purple/yellow/green skin discoloration was noted just to the left of the center of her forehead that measured approximately 3 centimeters (cm) by 3 cm. Review of resident 1's electronic medical record revealed: *She was admitted on [DATE]. *Her 1/21/25 Brief Interview of Mental Status assessment score was 10, which indicated she had moderate cognitive impairment. *Her diagnoses included: chronic obstructive pulmonary disease (disease that restricts breathing), insomnia, emphysema (lung condition that causes shortness of breath), dementia without behavioral disturbance, psychotic disturbance (altered reality/thoughts), mood disturbance, anxiety, and respiratory failure. *Her care plan included: -A 10/28/24 focus area that indicated she was dependent on staff for meeting her physical needs related to cognitive deficits. -A 7/29/22 focus area that indicated she needed staff assistance with her activities of daily living. --Interventions for that focus area included she needed the assistance of a staff member for her bathing/showering, repositioning, dressing, personal hygiene/oral care, use of a toilet, and assistance with setup for eating. -A 10/28/24 focus area indicated that she had impaired cognition related to dementia. Review of resident 1's nurse progress notes revealed: *On 3/25/25 a note indicated Resident continues to have increased confusion. Resident was in bed calling out stating she was falling. Resident constantly taking of [off] oxygen tubing and using it as thread for sewing. Resident noted to have a bruise to the forehead. Resident assisted to bathroom with can [certified nursing assistant] report [of the resident having said] 'let me put on my new ankles.' -There was no additional information that indicated an assessment, or investigation was completed regarding the bruise on her forehead. *On 3/29/25 she was found on the floor in her room. -She had a bruise and bump on her left elbow. *On 3/29/25 her daughter was notified of the 3/29/25 fall and POA questioned about bruising on her forehead. This nurse researched through the notes. Notes read to POA. *On 3/29/25 a note indicated Review of resident 1's 3/25/25 ambulance transport report revealed it was noted that she had a 1 x 1 [one by one] square bruising above [her] left eye. Review of resident 1's 3/25/25 emergency room visit report revealed Noted small bruise to the forehead and a couple to her shins. Review of resident 1's skin assessments completed on 3/26/25 and on 4/2/25 had not indicated a bruise on her forehead. Interview on 4/7/25 at 4:33 p.m. with certified nurse aide/certified medication aide (CNA/CMA) N revealed: *She noticed the bruise on resident 1's forehead a few days ago. *She believed the bruise was from resident 1's fall on 3/29/25. Interview on 4/8/25 at 3:05 p.m. with director of nursing B regarding resident 1's forehead bruise that was identified as a bruise on 3/25/25 revealed: *She was not notified or aware of resident 1's forehead bruise. *She did not think administrator A had been notified of the bruise. *There was no investigation completed to identify a potential cause of the bruise. *She stated she had previously provided education, on various occasions, with staff regarding reporting resident injuries. Interview on 4/9/25 at 7:35 a.m. with CNA/CMA N revealed: *She would report any signs of abuse, bruises, skin issues, and resident concerns to the charge nurse. *If the charge nurse did not respond to her concerns, she would report her concern to the director of nursing or the administrator. Interview on 4/9/25 at 8:35 a.m. with CNA/CMA L revealed: *She would report any concerns such as bruises, skin issues, and resident concerns to the charge nurse. *She noticed the bruise on resident 1's face in March but did not recall what day. *She indicated she did not report the bruise to the charge nurse because she was told in shift report that the previous CNA had notified the charge nurse. Interview on 4/9/25 at 8:48 a.m. with CNA Q revealed: *He noticed the bruise on resident 1's forehead the day after she fell on 3/29/25. *He would report anything out of the ordinary for a resident to the charge nurse. -He verified that included skin issues, changes in condition, and resident concerns. Interview on 4/9/25 at 9:50 a.m. with director of nursing B revealed there was no documentation to verify when or what resident information was passed on by staff during the nurse shift report. Administrator A was not available for an interview during the survey. Review of the provider's undated Reporting Abuse to Facility Management policy revealed: *Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. *Reports of any suspected abuse or incidents of abuse must immediately be reported to the Social Services Director, Administrator, and the Director of Nursing. In the absence of those listed above, such reports may be made to the Nurse Supervisor on duty. *The Administrator, Social Services Director and Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator, Social Service Director and/or Director of Nursing must be called and informed of such incident. *When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. *A completed copy of documentation forms and witness statements, if any, must be provided to the Administrator within 24 hours of the occurrence of an incident of suspected abuse. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator within 5 working days of the occurrence of such incident. *Upon receiving information concerning a report of abuse, the Director of Nursing will request that Social Services monitor and document the resident's reactions to statements regarding the incident and their involvement in the investigation. *Unless the resident requests otherwise, the Social Service Director will give the Administrator and the Director of Nursing a written report of their findings. Review of the provider's undated Abuse Investigation policy revealed the following: *All reports of resident abuse, neglect, injury of unknown source and misappropriation of resident property shall be promptly and thoroughly investigated by facility management. *The individual conducting the investigation will, as [at] a minimum: -a. Review the completed documentation form -b. Review the resident's medical record to determine events leading up to the incident -c. Interview the person(s) reporting the incident -d. Interview any witnesses to the incident -e. Interview the resident (as medically appropriate) -f. Interview the attending physician as needed to determine the resident's current level of cognitive function and medical condition -g. Interview staff members who have contact with the resident during the period of the alleged incident -h. Interview the resident's roommate, family members, and visitors as needed -i. Interview other residents to whom the accused employee(s) provides care or services for -j. Review all events leading up to the alleged incident. *Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports. *The results of the investigation will be recorded on approved documentation forms. *The Administrator or his/her appointed member of management will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification Agency, the Local Policy Department, the Ombudsman and others as may be required by state or local laws, within (5) working days of the reported incident. Review of the provider's undated Mandatory Reporting policy revealed the following: *Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. *Willful means the individual intended the action itself that he/she knew or should have known could cause physical harm, pain, or mental anguish. *Do an investigation, review the findings, and revise the care plan as necessary. *Do an investigation and report per the appropriate timeline.

Based on interview and Arbitration Agreement review, the provider failed to ensure the provider's Arbitration Agreement: *Included the arbitration organization's name and how to contact that organization. *Provided for the selection of a neutral arbitrator agreed upon by both parties. *Provided for a location that was convenient for both parties for an arbitration dispute. Findings include: 1. Interview and record review of the provider's one-page arbitration agreement on 3/10/25 at 5:43 p.m. with administrator A revealed that the agreement had not included: *The arbitration organization's name and how to contact that organization. *For the provision of the selection of a neutral arbitrator agreed upon by both parties. *For the provision of a location that was convenient for both parties for an arbitration dispute. *Administrator A agreed with those findings above. Interview on 3/11/25 at 1:10 p.m. with administrator A regarding the arbitration agreement revealed: *The provider had no policy regarding arbitration agreements. *She agreed the arbitration agreement was poorly written.

Based on interview, Payroll Based Journal (PBJ) record review, employee timecard review, and policy review, the provider failed to ensure licensed nursing coverage for 24 hours a day for three federal fiscal quarters (Quarter 2, 1/1/24 through 3/31/24; Quarter 3, 4/1/24 through 6/30/24; and Quarter 4, 7/1/24 through 9/30/24). Findings include: 1. Interview on 3/9/25 at 2:08 p.m. with business office manager C during the entrance conference revealed the provider did not have any licensed nurse staffing waivers. 2. Interview on 3/9/25 at 3:42 p.m. with resident 5 revealed she had been told by staff members on multiple occasions they were short of nurses. 3. Review of the PBJ records submitted to the Center for Medicare and Medicaid Services (CMS) revealed the provider submitted the following for licensed nursing coverage not being covered 24 hours per day for: *Quarter 2, 2024 for 34 days. *Quarter 3, 2024 for 11 days. *Quarter 4, 2024 for 30 days. 4. Review of the provider's employee timecards revealed: *For Quarter 2, 2024; 24-hour licensed nursing coverage was unable to be verified on 1/1, 1/10, 1/11, 1/12, 1/31, 2/1, 2/2, 2/3, 2/9, 2/20, 2/24, 2/27,3/6, 3/7, 3/12, 3/13, 3/19, 3/20, 3/25, and 3/28. *For Quarter 3, 2024; 24-hour licensed nursing coverage was unable to be verified on 4/6, 4/13, 4/17, 5/27, and 6/21. *For Quarter 4, 2024; 24-hour licensed nursing coverage was unable to be verified on 7/13, 8/14, 8/22, 8/23, 8/24, 8/28, 8/29, 9/18, 9/19, 9/20, 9/21, 9/22, 9/25, and 9/27. 5. Interview on 3/10/25 at 6:03 p.m. with business office manager C regarding PBJ data submission revealed: *She was aware the PBJ reports indicated there were days of not having 24-hours of licensed nursing coverage. *She did not know how there was missing data because she always got an indicator that 100% of the information was submitted and every report had been accepted. *She stated she entered the travel staff manually into PBJ and the other staffs' times were pulled in from their timecards. Review of the provider's undated Nursing Staffing and Posting policy revealed The facility is required to provide licensed nursing staff 24 hours a day (except when waived), along with other nursing personnel, including but not limited to nurse aides.

Based on Payroll Based Journal (PBJ) reports, interview, staff timecard review, and policy review, the provider failed to ensure: *A registered nurse (RN) had been scheduled for eight consecutive hours of coverage for four days in quarter two (January 1 through March 31) of fiscal year 2024. *There was a full-time director of nursing (DON) for 16 randomly selected weeks between July and December 2024. 1. Interview on 3/9/35 at 2:08 p.m. with business office manager (BOM) C during the entrance conference revealed: *The provider did not have any nurse staffing waivers. *She stated the DON worked 36 hours per week. *The DON was paid hourly. 2. Review of the RN staff timecards for fiscal year 2024 revealed: *The DON timecard for 2/3/24 was not produced by the provider to verify hours worked. *RN coverage for eight consecutive hours could not be verified for 1/13/24, 1/14/24, and 2/17/24. 3. Interview on 3/11/25 at 6:00 p.m. with administrator A revealed: *The Minimum Data Set (MDS) nurse was scheduled from 8:00 a.m. to 5:00 p.m. Monday through Friday during quarter two of fiscal year 2024. *She was salaried. *The MDS nurse was a RN and would be considered to cover the requirement for an RN eight consecutive hours per day on the days she worked. *There was no RN scheduled for eight consecutive hours on 1/13/24, 1/14/24, and 2/17/24. *DON B had worked on 2/3/24. 4. Interview on 3/12/25 at 7:47 a.m. with administrator A revealed she thought DON B worked between 36 and 40 hours per week. Review of DON B's timecards revealed during 16 weeks of randomly selected timecards between July and December 2024, DON B averaged 23.125 hours per week. Review of the provider's undated Nursing Staffing and Posting policy revealed, The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on observation, interview, and record review, the provider failed to post the required daily nurse staffing information in a prominent location that was readily accessible to residents and visitors and to include the actual hours worked of nursing staff. Findings include: 1. Observation 3/12/25 at 8:00 a.m. of the posted nurse staffing information revealed: *It was posted on a board near the nurse's station. *It would not be readable to a resident or visitor in a wheelchair at the height it was posted. *There were three categories of staff listed on the sheet: RN (registered nurse), LPN (licensed practical nurse), and CNA (certified nursing assistant). *Under the LPN and CNA category the number of those staff scheduled for the day was listed by shift. *There were no numbers listed under the RN category. *There were no documented actual hours worked on the form for the nursing staff. 51816 2. Interview on 3/12/25 at 8:54 a.m. with director of nursing (DON) B about posting the daily staffing revealed: *CNA/certified medication aide (CMA) K was responsible for developing the schedule. *CNA/CMA K would then transfer information from the schedule onto a daily assignment sheet. *The night nurse would use the daily assignment sheet to fill out the daily staffing sheet for the following day and would post it in the morning on the board at the nurse's station. *DON B was unaware that actual hours worked by each nursing discipline should have been listed on the posted staffing sheet according to the requirements. *She stated that was an old form and it needed to be updated to include a column for recording actual hours worked of nursing staff. 3. Review of the provider's undated Nursing Staffing and Posting Policy revealed: *Posting of Staffing -It is the policy of [provider] to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. -The nurse staffing will be posted daily and will contain the following information: --Facility Name --The current date --Facility's current resident census --The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: ---Registered Nurses ---Licensed Practical Nurses/Licensed Vocational Nurses ---Certified Nurse Aides -The information posted will be: --Presented in a clear and readable format. --In a prominent place readily accessible to residents, staff, and visitors.

Based on observation, record review, interview and policy review, the provider failed to follow their policies for controlled medications (medications with risk for abuse, addiction, and potential theft) to ensure accurate and complete documentation for those medications related to their receipt, counts, administration details including the dates given and the resident names, and destruction process. Findings include: 1. Observation on 3/10/25 at 2:07 p.m. of the North wing medication cart revealed: *There was a three-ring binder labeled North Narcotic Binder on top of the medication cart that contained: -A March 2025 CONTROLLED DRUG COUNT RECORD. --That form had two columns for nurse initials labeled NURSE ON and NURSE OFF and rows numbered 1 through 31 which indicated days of the month. --There were no nurse initials for two nurses on 3/1/25 and 3/2/25 and only one nurse on 3/4/25. -Multiple forms labeled CONTROLLED DRUG RECORD Individual Patient's Narcotic Record. --Those forms included areas for the resident's name, medication name and strength, directions for administration of the medication, doctor, pharmacy, who the medication was received by, date received, and time received. *Those forms did not have a pharmacist signature and had only one signature of the individual who received the medication. 2. Observation on 3/10/25 at 2:11 p.m. of the three-ring binder labeled [NAME] Narcotic Binder on the west wing medication cart revealed: *The binder was set up the same as the North Narcotic Binder. *The [NAME] March 2025 Controlled Drug Count Record had no nurse initials for two nurses on 3/1/25 and 3/2/25 and one nurse on 3/11/25. *One Individual Patient Record belonged to resident 35, who had discharged from the facility on 3/9/25 and indicated: -30 tablets of Tramadol (a controlled pain medication) 50 milligrams (mg) received on 7/16/24. -The Tramadol had been signed out for administration to resident 17 three times, according to staff signatures and the medication count. -There were no dates documented for the three times the medication was removed for administration. 3. Observation and interview on 3/10/25 at 2:20 p.m. with Certified Medication Aide (CMA) Z revealed: *She entered the facility with a pharmacy bag that contained residents' prescription medications. -One of those medications was Morphine (a controlled pain medication) solution (liquid form). *She obtained a blank Individual Patient's Narcotic Record from the nurse's station and wrote the prescription information on the form. *She signed that she received the medication, dated it 3/10/25 and identified she received 30. -She did not identify if the 30 indicated tablets, milliliters, ounces, etc. *She then placed that Individual Patient's Narcotic Record in the North Narcotic Binder and put the Morphine in a locked compartment in the North medication cart. *She stated that she had gone to the pharmacy and picked up the medications for the newly admitted resident. *CMAs or nurses were to complete the Individual Patient's Narcotic Record when the medication was received from the pharmacy and put the form in the appropriate medication cart's binder. *She did not confirm the quantity of the morphine with another nurse or CMA. *The controlled drug count record was a different form used by staff to document who counted the controlled medications when they came on and went off their shifts to confirm counts of all controlled medications. *She indicated that the nurses worked from 6:00 a.m. to 6:00 p.m. and the nurse going off duty would count the controlled medications with the nurse coming on and document the counts on the controlled drug count record form. *The CMAs worked 7:00 a.m. to 5:00 p.m. so they would count with the nurse on duty when the CMAs arrived and when they left. *She verified there were not enough columns on the form to document all the controlled medication counts based on the changes in staff as she described. *She stated that sometimes the nurse and CMA would double sign in a column, but that did not always happen. *She verified she had already initialed for the 3/10/25 5:00 p.m. controlled medication count record which was prior to the count occurring. *She verified that there were three staff's initials documented for the 3/11/25 controlled medication count but the current date was 3/10/25. 4. Observation and interview on 3/10/25 at 2:32 p.m. with CMA Z in the medication storage room revealed: *The controlled medications stored in the medication storage room were to be counted by the nurses when they came on and went off their shifts. *The controlled medications stored in the medication storage room included: -Stock controlled medications. -Residents' controlled medication cards, when the pharmacy dispensed more than one card. The cards not in use would be stored in the medication room until it was needed. *The Controlled Drug Count Record for the medication storage room was set up the same as the medication carts. *The March 2025 Med Rm [medication room] Controlled Drug Count Record had no nurse initials for two nurses on 3/1/25, 3/2/25, 3/4/25, 3/7/25, one nurse on 3/10/25. 5. Review of the stock-controlled medication cards and the Individual Patient's Narcotic Record with CMA Z in the medication storage room on 3/10/25 at 2:40 p.m. revealed: *The Individual Patient's Narcotic Records identified the name of the medication and the dose. In the location designated for a resident's name was stock or Five Counties Stock. *There was card of Tramadol 50 mg (milligrams). -The card was received on 1/3/24 with 10 tablets. -There were six doses removed and signed out to be administered. --One of those doses did not indicate which resident it was removed for. --Four doses did not include the year the medication was removed for administration. *There were two cards of oxycodone (a controlled pain medication)10 mg. -Oxycodone card one was received on 3/6/23 with 16 tablets. --Nine doses documented as removed for administration did not indicate which resident it was for. --Four doses removed for administration did not include the year the medication was removed. --Two half-tablet documented destructions did not contain a second signature to indicate a licensed staff member witnessed the destruction. --Two times a CMA was identified as being the witness of the controlled medication destruction. -Oxycodone card two was received on 7/26/24 with 16 tablets. --One half-tablet was removed for administration with no documentation of what was done with the remaining half tablet. --There was one removal for administration that documented the other half was put in lock box for next admin [administration]. --Six administrations did not identify the resident the medication was removed for. -One time a CMA was identified as being the witness of controlled medication destruction. *There were three cards of lorazepam (a controlled anti-anxiety medication) 0.5 mg. -Lorazepam card one was received on 12/30/22 with 16 tablets. --One dose removed did not identify which resident it was administered to. --Four times a half tab was administered without documentation of where or how the remaining portion of the tablet was stored for the next administration. --Fifteen of fifteen of the documented removals for administration did not contain a year the medication was removed. -Lorazepam card two was received on 12/30/24 with 16 tablets. --Two of two removals for administrations had not identified the resident the medication was removed for. -Lorazepam card three did not have an Individual Patient's Narcotic Record. There was a plain white sheet of paper that had handwritten notes of Controlled Drug Record for Lorazepam 0.5 mg tablets Total 16 verified by with a signature following. --There was no date to indicate when the lorazepam was received. *There was an opened bottle of liquid lorazepam 2 mg/ml (milligrams per milliliter). -30 ml was documented as received on 2/20/24. -14 doses had been removed from the bottle. -There were three different residents identified that the lorazepam had been removed for. -Two doses did not indicate the resident the medication was removed for. 6. Review of the provider's February 2025 Controlled Drug Count Records revealed: *The [NAME] wing Controlled Drug Count Records had a squiggly line drawn through the documentation areas: -For three nurses' initials on 2/3/25. -For one nurses' initials on 2/13/25, 2/14/25, and 2/15/25. -For two nurses' initials on 2/30/25. *The medication room Controlled Drug Count Record had a squiggly line drawn through the areas for documentation for three nurses on 2/4/25 and two nurses on 2/9/25. 7. Observation and interview on 3/10/25 at 2:47 p.m. with assistant director of nursing (ADON) G in the medication storage room revealed: *She verified there were missing staff signatures on the March 2025 medication room's Controlled Drug Count Record. *The Individual Patient's Narcotic Records for the stock medications should have indicated which resident the medications were removed for. *She verified there were missing resident identifiers on the Individual Patient's Narcotic Records. *She expected the date the controlled medication was removed from the medication room for administration to be documented in the Individual Patient's Narcotic Records. *She stated that any nurse or CMA could check-in medications when they were received, including controlled substances. *The opened bottle of stock liquid lorazepam in the medication room did not have a date to indicate when it was opened. 8. Interview on 3/11/25 at 4:37 p.m. with consultant pharmacist N revealed: *His role in the facility included managing medication profiles, controlled medication disposal, and to answer staffs' medication related questions. *The provider received residents' medications from a local pharmacy. *It was his expectation that each resident's individual controlled drug record be initiated by the pharmacy dispensing the medication and it was to be sent with the medication to the facility. *He expected controlled medications be delivered by a pharmacist or picked up by a licensed nurse to ensure control and accountability of those high-risk medications. *It was his expectation that the controlled medications be counted at each shift change by the person coming on a shift with the person leaving a shift. *The signatures on the Controlled Drug Count Record would indicate the controlled medication counts had been completed and the counts were accurate. *He indicated the use of a stock supply of controlled medications should not be the process. -Each card of controlled medications should have been assigned to a specific resident because a hard copy physician prescription would be needed to dispense and administer the medication to the resident. *He expected that if a half-tablet of a controlled medication was unused it would have been wasted and documented as wasted by a licensed nurse or pharmacist. 9. Interview on 3/12/25 at 1:13 p.m. with director of nursing (DON) B revealed: *When a resident's-controlled medication was discontinued and was to be destroyed, she and consultant pharmacist N would reconcile the count of the controlled medication and document the medication to be destroyed. *Consultant pharmacist N destroyed the medications. *She did not watch the actual destruction of the controlled medications by consultant pharmacist N. *She thought the Individual Patient's Narcotic Record was initiated at the pharmacy. *It was her expectation that two staff verify the receipt of controlled medications and both sign the form in verification of that for an accurate count. *It was her expectation that the controlled medications be counted between each shift by the incoming and off going staff members. *The signatures on the Controlled Drug Count Record would indicate the counts were completed and accurate. *She would expect to be notified if there was an issue in the controlled drug counts. *She agreed there was no column on the Controlled Drug Count Record to account for the controlled medication count with the CMAs. *It was her expectation that two people witness the destruction of the controlled medications. *She would expect a date to be documented when controlled medications were removed for administration. 10. Review of the provider's undated Medication Management Policy revealed the following: *If breaking tablets is necessary to administer the proper dose ., the following guidelines are followed: -c. If using only one-half of the tablet from a unit dose package, the remainder is disposed of if not used within 24 hours according to facility procedure. If in a vial the half-tablet is returned to the vial. -Medications supplied for one resident are never administered to another resident. Review of the provider's undated Pharmacy Services policy revealed the following: *The facility will provide pharmaceutical services to include procedures that assure [ensure] the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. *The facility in coordination with the licensed pharmacist, will provide for: -a. A system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications; -b. Prompt identification of loss of or potential diversion of controlled medications; and -c. Determination of the extent of loss or potential diversion of controlled medications. *The facility will maintain a limited supply of medications for emergency or after-hours situations in accordance with facility policy and applicable state laws. *The pharmacist, in collaboration with the facility and medical director, may include other aspects of pharmaceutical services such as: -a. Development of procedures and guidance in relations to medication issues and/or adverse effects; -b. Development of processes for receiving, transcribing or recapitulation of medication orders; -c. Interaction with the quality assessment and assurance committee to develop procedures and evaluate pharmaceutical services. Review of the provider's undated Proper Storage, Usage and Documentation of Narcotics (controlled medications)-policy revealed the following: *When a narcotic is being accepted, please verify the correct drug and amount. The nurse who accepts the medication should add the count sheet to the narcotic book, notating the date and the time, along with any other needed documentation. *Access to narcotics is to be by a licensed staff and Director of Nursing ONLY! Scheduled II Narcotics are to be kept locked in a separate are from non-scheduled drugs such as the lock box. Refrigerated scheduled II Narcotics should be stored and locked separately. *Narcotics are to be counted every shift by nursing staff (AM, PM, NOC). They should not be assumed all accounted for, therefore the nurse going off her shift and the nurse coming on shift should count together and then sign that all narcotics are accounted for. *When administering narcotics the following should be done: -After pouring the narcotic, the count should be signed and verified for accurate county [count]. Signing the count sheet does not mean you gave the medication. It is only showing that the count is correct. -Any refused narcotics that have been poured should not be taped back into the card but should be wasted and disposed of properly. -There should always be a count sheet for ALL NARCOTICS. If one was not sent from the pharmacy, it can be requested. All count sheets should be used properly, and counts should be accurate. When they are complete the count sheet should be sent to medical records and kept for 3 years.

Based on observation, record review, interview, and policy review, the provider failed to follow standard food safety practices to ensure: *The mechanical dishwashers, refrigerator, and freezer temperatures were monitored and logged according to their policy. *Single-use food containers were not used to store leftover food. *Clean dishes were not stored on frayed cloth towels. Findings include: 1. Observation on 3/9/25 at 1:59 p.m. in the kitchen revealed the posted dishwasher temperature log for March 2025 was not completed for 3/4/25 through 3/7/25 and 3/9/25. *The dishwasher temperature logs for January, February, and March 2025 had no temperatures documented on 36 of 67 days. *The freezer temperature logs for February and March 2025 had no temperatures documented on 15 of 36 days for two of two freezers. *The walk-in cooler temperature logs for February and March 2025 had no documented temperatures on 8 of 36 days. *The satellite kitchen refrigerator/freezer temperature logs for February and March 2025 had no temperatures documented on 7 of 31 days. Interview on 3/11/25 at 4:40 p.m. with dietary manager (DM) D revealed: *She confirmed the logs were not complete. *She stated they were working on a new process for the temperature logs. *She agreed they were not monitoring and recording temperatures according to their policy. Review of the provider's 1/27/25 Dishwashing Machine Use policy revealed: *Temperature Records -The operator will check temperatures using the machine gauge with each dishwashing cycle, and will record the temperatures in a facility approved log. Review of the provider's 1/8/25 Refrigerator policy revealed: *Temperatures will be taken twice a day according to staff assignment. *Staff will record the temperature on a chart. Interview on 3/11/25 at 4:54 p.m. with administrator A regarding monitoring temperatures of dishwashers, freezers, walk-in coolers, and the satellite kitchen revealed: *She confirmed there were days the temperatures had not been logged. -She would have expected those to be completed and logged. *She confirmed their policies for monitoring the temperatures of dishwashers, freezers, walk-in coolers, and the satellite kitchen were not being followed. 2. Observation on 3/9/25 at 2:05 p.m. in the kitchen revealed: *The walk-in freezer contained several single-use containers with food items labeled with masking tape which included: -Two margarine containers labeled pork roast. --There was no date written on the masking tape. -A cottage cheese container labeled beef juice 2/17. -A margarine container labeled beef juice 2/28. -A vanilla ice cream container labeled chocolate chip cookies 3/3. *The walk-in refrigerator contained single-use containers with food items that were labeled with masking tape which included: -A sour cream container covered with cellophane that contained grapes. -A cottage cheese container labeled peaches 3/9. -A cottage cheese container labeled applesauce 3/4. -An additional seven other single-use containers labeled with leftover food items that were dated. Observation on 3/9/25 at 5:28 p.m. in the dining room revealed that single-use containers were being used to serve leftover food to residents in the dining room. Interview on 3/11/25 at 11:36 a.m. with DM D about single-use containers revealed: *She confirmed the containers were single-use containers and should not have been used to store leftover food items. *She stated she would re-educate staff on not using single-use containers to store leftovers. Interview on 3/11/25 at 4:51 p.m. with administrator A revealed she was aware that single-use containers were being used for leftover food storage and serving. Those single-use containers should not have been used. Review of the Administrative Rules of South Dakota (ARSD) 44:02:07:43 revealed: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food. Under normal use conditions materials must be safe; durable; corrosion-resistant; nonabsorbent; sufficient in weight and thickness to withstand repeated warewashing; finished to have a smooth, easily cleanable surface; and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. Review of the provider's 1/28/25 Refrigerator Policy revealed: *It is the intent of [provider] that our residents enjoy a home like atmosphere. We also take all measures to make sure the food they enjoy is safely stored. -The policy did not address food storage containers. 43844 3. Observation on 3/9/25 at 2:57 p.m. of the kitchen revealed: *A stainless-steel table was located at the clean end of the area of the dishwasher. On that stainless-steel table was the following: -A cloth towel that had frayed edges with two coffee carafes and a glass sugar dispenser with no lid stored upside down it. -There were what appeared to be water calcium spots on that table around the cloth towel. Observation on 3/11/25 at 11:29 a.m. in the kitchen revealed two frayed wet bath towels on a stainless-steel table with three empty ice-cream buckets and an empty glass sugar dispenser and the lid for it lying on top of the towels. -There was a clear liquid on the stainless counter that appeared to be water. Interview on 3/11/25 at 11:36 a.m. with DM D regarding the above observations revealed: *Towels were placed on the stainless-steel table to keep the water from the wet dishes from dripping onto the floor. -She agreed the towels were wet and would not have allowed the dishes to air dry. Interview on 3/11/25 at 4:59 p.m. with administrator A regarding the use of cloth towels in the kitchen revealed she was not aware that cloth towels should not have been used to store wet dishes on. Review of the Food and Drug Administration Food Code 2022 revealed: *Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: -Shall be air-dried or used after adequate draining -May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry. Review of the ARSD for Lodging and Food Service revealed: *Cleaned equipment and utensils must be stored as follows: -In a clean, dry location; -Where they are not exposed to splash, dust, or other contamination; -In a self-draining position that permits air drying; and -Either covered or inverted. *After sanitizing, equipment and utensils must be air-dried or may be used after adequate draining.

Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure the facility was operated and administered by administrator A, director of nursing (DON) B, and assistant director of nursing (ADON) G, in a manner that ensured quality of life and overall well-being for all 39 residents in the facility. Findings include: 1. Observations, interviews, record reviews, and policy reviews throughout the survey on 3/9/25 from 1:00 p.m. through 6:00 p.m., 3/10/25 from 7:30 a.m. through 6:15 p.m., 3/11/25 from 7:00 a.m. through 6:00 p.m., and 3/12/25 from 7:30 a.m. through 5:30 p.m., revealed administrator A, DON B, and ADON G, had not ensured the management, safety, quality of life, and overall well-being of all the residents who lived in the facility. Those were evidenced by: *A widespread system breakdown to ensure services provided: -Met professional standards as it pertained to: --Medication administration and storage. --Addressing and notifying the physician of the significant weight loss for one resident (36). --Identifying and addressing low blood sugars for one diabetic resident (5). -Met the requirements for sufficient nursing staff including: --Full-time DON. --Registered nurse coverage for eight hours each day. --Twenty-four-hour licensed nurse coverage. --The daily posting of nurse staffing. -Addressed trauma informed care. -Monitored for appropriate temperatures of mechanical dishwashers, refrigerators and freezers in the kitchen. -Addressed appropriate storage of leftover food. -Allowed for residents' and their representatives' right to make informed decisions and choices about important aspects of residents' health, safety, and welfare related to binding arbitration agreements to resolve disputes. -Included providing a written summary of the baseline care plan within 48 hours of a resident's admission. -Included a preventative maintenance program for the safe use of resident side rails. *Ensuring the proper Medicare notices were completed accurately for three residents (10, 33, and 41) prior to their discharge from Medicare Part A skilled services. *Responding to a resident's (5) concern with a staff member, certified nursing assistant R. *Ensuring privacy and signage had been maintained for two residents (9 and 21) with audio/video monitoring devices in their rooms. *Implementing an effective performance improvement plan and quality assurance program. 2. Review of the provider's undated job description for the administrator revealed: *Summary: Administers, directs and coordinates all activities of the care center to carry out its objectives as to the care of the individuals who need nursing care . *Essential Duties included: -Coordinates and integrates the total overall program of the facility. -Make sure residents are meeting their highest level of professional care needed. -Develops and monitors all departments within the facility to meet the standards put forth by the governing board, management, and state and federal regulations. Review of the provider's 10/30/15 job description for the director of nursing revealed: *Summary: This individual directs the licensed and non-licensed staff who provide health care and nursing services to residents of the facility. The Director of Nursing's primary responsibility is to ensure the provision of quality nursing care on a 24-hour basis to the residents of the care center in accordance with Federal, State and Local standards and regulations. *Essential Duties included: -Monitors the staffing levels of various nursing sections . -Develops and directs nursing services objectives, policies and procedures. -Assures that there is compliance with the regulations pertaining to care plans and resident assessments. -Collaborates with outside providers such as . pharmacy companies to enhance the quality of care for the residents. Refer to F582, F583, F610, F655, F658, F699, F700, F725, F727, F732, F755, F761, F812, F847, F865, and F909.

Based on observations, interviews, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being for all 39 residents in the facility. Findings include: 1. During the survey on 3/9/25 from 1:00 p.m. through 6:00 p.m., 3/10/25 from 7:30 a.m. through 6:15 p.m., 3/11/25 from 7:00 a.m. through 6:00 p.m., and 3/12/25 from 7:30 a.m. through 5:30 p.m., it was identified that the provider had not operated in a manner to ensure residents received quality care. Administrator A had not been assisted with her duties to ensure she was able to effectively provide guidance to staff to be able to provide quality care. Those were evidenced by: *A widespread system breakdown to ensure services provided: -Met professional standards as it pertained to: --Medication administration and storage. --Addressing and notifying the physician of the significant weight loss for one resident (36). --Identifying and addressing low blood sugars for one diabetic resident (5). -Met the requirements for sufficient nursing staff including: --Full-time DON. --Registered nurse coverage for eight hours each day. --Twenty-four-hour licensed nurse coverage. --The daily posting of nurse staffing. -Addressed trauma informed care. -Monitored for appropriate temperatures of mechanical dishwashers, refrigerators and freezers in the kitchen. -Addressed appropriate storage of leftover food. -Allowed for residents' and their representatives' right to make informed decisions and choices about important aspects of residents' health, safety, and welfare related to binding arbitration agreements to resolve disputes. -Included providing a written summary of the baseline care plan within 48 hours of a resident's admission. -Included a preventative maintenance program for the safe use of resident side rails. *Ensuring the proper Medicare notices were completed accurately for three residents (10, 33, and 41) prior to their discharge from Medicare Part A skilled services. *Responding to a resident's (5) concern with a staff member, certified nursing assistant R. *Ensuring privacy and signage had been maintained for two residents (9 and 21) with audio/video monitoring devices in their rooms. *Implementing an effective performance improvement plan and quality assurance program. Refer to F582, F583, F610, F655, F658, F699, F700, F725, F727, F732, F755, F758, F761, F812, F835, F847, F848, F851, F865, and F909.

Based on record review, interview, and Arbitration Agreement review, the provider failed to ensure seven of thirteen sampled residents (13, 21, 23, 24, 25, 36, and 142) and three of three recently admitted residents (38, 39, and 142) who had entered into an Arbitration Agreement upon admission to the facility: *Were not required to sign a binding arbitration agreement as a condition of admission to receive care at the facility. *Were explained the arbitration agreement in a form and manner including a language that the resident or his/her representative understood. *Were explicitly granted the right to rescind the agreement within 30 calendar day of signing it. Findings include: 1. Record review on 3/10/25 at 1:00 p.m. of the Resident List Report printed at 12:10 p.m. that day by administrator A revealed: *The report listed forty residents which included thirty-nine residents in the facility and one resident who was hospitalized . *A handwritten note by administrator A that indicated All residents have a signed arbitration agreement. No active disputes. 2. Interview on 3/10/25 at 4:28 p.m. with resident 38 in his room regarding the Arbitration of Disputes admission agreement addendum he had signed on 2/13/25 revealed: *He did not recall signing any admission documents and asked if he had signed it or one of his kids? *After showing him a copy of the signed one-page Arbitration of Disputes and asking him if he remembered signing that document he stated Not at all. -After reviewing his signature, he agreed he had signed that agreement. -He could not remember what the agreement was about. Review of resident 38's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 2/13/25 admission agreement was signed by resident 38, his son/durable power of attorney (DPOA)/DPOA healthcare (DPOA-HC), and administrator A. -The Admission Agreement Addendum included the one-page Arbitration of Disputes dated 2/13/25 that was signed by the resident. --The resident's son/DPOA/DPOA-HC had not signed this agreement. *His 2/18/25 brief interview for mental status (BIMS) assessment score was 12, which indicated his cognition was moderately impaired. 3. Review of resident 142's EMR revealed: *She was admitted on [DATE]. *Her 3/3/25 admission agreement was signed by her daughter/DPOA/DPOA-HC, and social services director (SSD) E. -The Admission Agreement Addendum included the one-page Arbitration of Disputes dated 3/3/25 that was signed by the resident's daughter/DPOA/DPOA-HC. *Her 3/4/25 BIMS assessment score was 14, which indicated she was cognitively intact. Phone interview on 3/10/25 at 4:50 p.m. with resident 142's daughter/DPOA/DPOA-HC regarding the Arbitration of Disputes admission agreement addendum she had signed on 3/3/25 revealed she: *Could not recall understanding the arbitration process and stated: -She would discuss anything that wasn't right with the provider. -I didn't think we were totally giving up the right to litigate in a court proceeding. *Had No idea [what she was signing] as that was a very stressful day. *Could not remember if her right to terminate or withdraw from the agreement within 30 days of signing had been discussed. *Stated admitting her mother to the facility had been a long day and there was a lot of paperwork. 4. Review of resident 39's EMR revealed: *She was admitted on [DATE]. *Her 2/26/25 admission agreement was signed by her daughter/DPOA/DPOA-HC, and SSD E. -The Admission Agreement Addendum included the one-page Arbitration of Disputes dated 2/26/25 that was signed by the resident's daughter/DPOA/DPOA-HC. *Her 3/4/25 BIMS assessment score was 13, which indicated she was cognitively intact. Phone interview on 3/10/25 at 5:04 p.m. with resident 39's daughter/DPOA/DPOA-HC regarding the Arbitration of Disputes admission agreement addendum she had signed on 3/3/25 revealed she: *Was at work, but was able to answer a few questions. *Could not recall what the arbitration agreement was about. *Felt it was a form that needed to be signed. 5. Review of resident 25's EMR revealed: *He was admitted on [DATE]. *His 8/29/24 admission agreement was signed by his niece/responsible party and SSD E. -The Admission Agreement Addendum included the one-page Arbitration of Disputes dated 8/29/24 that was signed by the resident's niece/responsible party. *His 9/5/24 BIMS assessment score was 8 which indicated his cognition was moderately impaired. 6. Review of resident 13's EMR revealed: *She was admitted on [DATE]. *Her 11/27/24 admission agreement was signed by her son/DPOA/DPOA-HC, and SSD E. -The Admission Agreement Addendum included the one-page Arbitration of Disputes dated 11/27/24 that was signed by the resident's son/DPOA/DPOA-HC. *Her 12/3/24 BIMS assessment score was 12 which indicated her cognition was moderately impaired. 7. Review of resident 36's EMR revealed: *She was admitted on [DATE]. *Her 1/28/25 admission agreement was signed by her daughter/DPOA and SSD E. -The Admission Agreement Addendum included the one-page Arbitration of Disputes dated 1/28/25 that was signed by the resident's daughter/DPOA. *Her 2/4/25 BIMS assessment score was 7 which indicated her cognition was severely impaired. 8. Interview on 3/10/25 at 5:10 p.m. with SSD E regarding the one-page Arbitration of Disputes form revealed: *The form was included in the admission agreement binder that included the paperwork the resident and/or representative signed upon admission. *She had not had anyone refuse to sign it. *She had no training on the form or how to discuss the agreement with the resident and/or representative on admission. *She had not ensured the person signing the form understood their right: -To refuse to enter into an arbitration agreement. -To rescind the agreement within 30 days of signing that form. *She stated she treated the form as informational acknowledgment and not as an agreement. *Her responsibilities included having the resident and/or representative sign the Admission Agreement paperwork. -For most admissions, while the resident was involved with the nurse's physical assessment, she would have the representative complete the admission paperwork. --That is what had happened with residents 39 and 142 noted above. -If she was unavailable, Administrator A would fill-in and complete the resident's admission agreement paperwork with the resident and/or representative. --She was not available on 2/13/25, when resident 38 had admitted to the facility. --Administrator A had completed the admission paperwork for resident 38's admission. Interview on 3/10/25 at 5:43 p.m. with administrator A revealed: *SSD E completed the admission paperwork with most of the residents' admissions. -She assumed SSD E discussed the arbitration agreement appropriately with residents and/or representatives. *She agreed she had completed the admission paperwork for resident 38 on 2/13/25. -She stated resident 38, his daughter, his son/DPOA/DPOA-HC, and his son's wife were all present when the admission paperwork was completed. -She confirmed that this admission agreement was signed by resident 38, his son/DPOA/DPOA-HC, and administrator A. -She stated resident 38's son/DPOA/DPOA-HC read the paperwork prior to signing. --Resident 38's family read the arbitration agreement and stated resident 38 could sign that agreement. --Resident 38 was not really interested in reading the arbitration agreement and had commented You just want my signature. Interview and record review of the undated one-page Arbitration of Disputes Admission Agreement Addendum on 3/11/25 at 8:24 a.m. with administrator A revealed: *The arbitration agreement was reviewed to ensure it clearly stated that the resident or his or her representative was not required to enter into the agreement as a condition of admission to the facility. -Administrator A agreed that was not clearly stated in the agreement. -Administrator A stated it was a poorly written agreement. Further interview that day with administrator A at 8:30 a.m. after reviewing the requested arbitration agreements for three residents (21, 23, and 24) and a handwritten note from SSD E revealed: *On 11/8/22, SSD E was provided notice to add the Arbitration of Disputes form to the Admission Agreement packet. *Administrator A confirmed that residents who were admitted to the facility prior to 11/8/22 had not entered into the arbitration agreement. Interview on 3/11/25 at 9:51 a.m. with SSD E regarding requested arbitration agreements revealed: *She confirmed that prior to 11/8/22 the residents admitted to the facility had not signed an arbitration agreement upon their admission. *Those residents had not been asked to sign the arbitration agreement after 11/8/22, when the arbitration agreement was added to the admission agreement packet. *A printed email, that she provided, indicated on 11/8/22 at 1:48 p.m. the administrator of the facility, at that time, had e-mailed the Arbitration of Disputes as an attachment with the message Please include this in your admission packet. -She confirmed that was her notice and that she had received no training on that form or the arbitration process. Interview on 3/11/25 at 1:10 p.m. with administrator A regarding the requested policy on arbitration agreements revealed the provider did not have such a policy.

Based on Payroll Based Journal (PBJ) record review, employee timecard review, and interview, the provider failed to submit PBJ data accurately for three of three federal fiscal quarters reviewed Quarter 2, 2024 (January 1 through March 31, 2024); Quarter 3, 2024 (April 1 through June 30, 2024)2024); and Quarter 4, 2024 (July 1 through September 30, 2024). Findings include: 1. Review of the PBJ records submitted to the Center for Medicare and Medicaid Services (CMS) revealed the provider submitted the following for licensed nursing coverage not being covered 24 hours per day for: *Quarter 2, 2024 for 34 days. *Quarter 3, 2024 for 11 days. *Quarter 4, 2024 for 30 days. 2. Review of the PBJ records submitted to CMS revealed the provider submitted the following for RN (registered nurse) coverage for 8 consecutive hours per day for: *Quarter 2, 2024 for 16 days. *Quarter 4, 2024 for 4 days. 3. Review of the provider's employee timecards revealed: *Quarter 2, 2024; 24-hour licensed nursing coverage was verified for 13 of the 34 days that were triggered for no 24-hour licensed nursing coverage and for 12 of the 16 days triggered for no RN coverage for 8 consecutive hours per day. *Quarter 3, 2024; 24-hour licensed nursing coverage was verified for 6 of the 11 days that were triggered for no 24-hour licensed nursing coverage. *Quarter 4, 2024; 24-hour licensed nursing coverage was verified for 16 of the 30 days that were triggered for no 24-hour licensed nursing coverage and for all the days triggered for no RN coverage for 8 consecutive hours per day. *The timecard information supported the PBJ records were not accurate. 4. Interview on 3/10/25 at 6:03 p.m. with business office manager C regarding PBJ data submission revealed: *She was responsible for submission of the PBJ data. *She stated she entered the travel staff hours worked manually into the PBJ and the other staff hours worked were transferred electronically from their timecards into the PBJ online reporting system. *She was aware there were days on the PBJ reports that indicated there was no 24-hour licensed nursing coverage and no RN coverage for 8 consecutive hours per day. *She did not know how there was missing data because with each submission she received an indicator that 100% of the information was submitted and the report had been accepted. -She was not aware that the indicator only provided notification that the information submitted was accepted at 100% and not if that data was accurate to actual hours worked by staff.

Based on observation, interview, record review, and policy review, the provider failed to ensure necessary care and services were provided for one of one resident (2) with a potentially avoidable weight loss. Findings include: Surveyor: 1. Observation and interview on 12/13/16 at 11:15 a.m. with resident 2 revealed: *He was lying on his bed receiving oxygen per canula. *He was wearing a button down shirt left open and a blanket pulled up to his waist. *He appeared tired but alert. *He spoke with pauses to take extra breathes during the conversation. *He stated: -He did not like to walk much, because he could not breathe very well. -He could only walk a short distance. -He would rather be home, but he knew he probably would not get to go home. *He revealed he: -Was not picky about food. -Would eat anything they brought him. -Had lost weight. -Now weighed 146 lb. -Did not like to do much outside of his room. Surveyor: Observation on 12/13/16 at 11:26 a.m. of licensed practical nurse (LPN) A revealed she administered three units of [MEDICATION NAME]to resident 2. Surveyor: Observation on 12/13/16 from 12:20 p.m. through 1:10 p.m. of resident 2 revealed: *He never left his room to go to lunch. *He laid in his bed with the lights off and his oxygen on. *No staff went to his room during the above time to try to get him to go to lunch. *No one brought him any food. Surveyor: 2. Interview on 12/13/16 at 3:00 p.m. with certified nurse assistants (CNA) B and C revealed: *They would give him a snack around 3:00 p.m. and at bedtime. *At 5:30 p.m. CNA B stated he would ask the resident to come out for supper. He would tell the resident he would take him his wheelchair and bring him back to his room as soon as he had finished eating. *That would usually work for him to get the resident to come out of his room and eat supper in the dining room. *If he refused to come out to the dining room for supper they would have given him a sandwich and string cheese from the bedtime snack cart. *They had never given him a tray of food from the supper steam table. *They had been told by the nurses he could only have the snack if he would not come out of his room for the meal. Surveyor: 3. Observation on 12/13/16 at 3:10 p.m. of resident 2 in his room revealed: *He was lying in bed with the lights off. *There was no sign of any leftover food or tray of food in his room. 4. Interview on 12/13/16 at 3:45 p.m. with LPN A regarding resident 2 revealed: *He could be very pleasant. *All he really wants to do was lie in bed. *He frequently refused to go to the dining room for meals. -He would agree to go then later change his mind. *She was unsure if he was lonely or not feeling well (in regards to his mood and non-compliance with staff requests). *She had been unaware of his weight loss. *She became concerned about him when told no staff had been observed bringing him lunch. -She was unaware no one had brought him any food for lunch. -She agreed he had received an insulin injection at 11:26 a.m. and should have had food within fifteen minutes. *She believed he was upset about his wife's health problems. -That had been around October when he started to refuse to ambulate more often. Interview on 12/13/16 at 4:30 p.m. with the certified dietary manager (CDM) regarding resident 2 revealed: *She was aware of his weight loss. *She thought his weight problems started because he was worried about his wife and her failing health. -It seemed to be the start of his increased refusal to ambulate to the dining room for meals and the weight loss. *He often refused to go to meals in the dining room. *They were not to bring him a room tray if he refused to ambulate to meals per the facility's meal tray protocol. *They were not supposed to push him to come out of his room for meals per the physician's orders [REDACTED]. -The physician wanted him to walk to meals to try to get him up and moving. *They did not give any meal trays to residents unless there had been special circumstances like they had an infection (flu) or were eating with family in their room. *He was on the dietary supplement Ensure three times a day because of his weight loss from refusing to go to the dining room. *He was very good about drinking the supplement shakes. *He would often ask for sandwiches after meal services were over. *She made sure to put sandwiches and cheese sticks on the snack cart for him. -He would wait for the snack cart to come around to eat. -The snack cart came around at 9:30 a.m., 3:00 p.m., and about 7:00 p.m. *An unidentified dietary employee who usually brought the evening snack cart around entered the room during the interview. When asked about resident 2 she stated: -If he is awake in the evening he will take a snack, usually a sandwich. -He would probably eat as much as I brought him. *The CDM felt by not giving him a room tray it was almost like bribing him to come out for his room. *She felt there was a better solution to his problem and weight loss. *She did not agree with not allowing him a meal tray in his room when he did not want to go to the dining room. 5. Review of resident 2's nurses' notes from 12/13/16 revealed he had told the nurse he did not want to go to the dining room for lunch. He had not gone to breakfast that morning. There was no documentation he had eaten anything so far that day. 6. Review of resident 2's complete medical record revealed: *He had been admitted on [DATE]. *He had [DIAGNOSES REDACTED].>-Right [MEDICAL CONDITION], major [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), muscle weakness, type two diabetes mellitus , gastro-[MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION] infarction, acute [MEDICAL CONDITION] with exacerbation, [MEDICAL CONDITION], and prostate disorder. *His weight record revealed: -9/11/16- 165 pounds (lb). -10/12/16- 155 lb. -10/19/16- 154 lb. -10/21/16- 156 lb. -11/15/16- 149 lb. -12/10/16- 146 lb. -From 9/11/16 to 10/21/16 he had a significant weight loss of over five percent (%) (-5.5%) in thirty days. -From 9/11/16 to 12/10/16 he had a significant weight loss of over 7.5% (-11.5%) in three months. *His most current Minimum Data Set assessment on 11/6/16 revealed he had been: -Coded as weight loss, not physician prescribed. -Coded as on a therapeutic diet. -Coded as no swallowing issues. -Scored as a fifteen on a Brief Interview for Mental Status (BIMS) indicating he was mentally intact. Review of resident 2's physician's orders [REDACTED]. *None of the orders stated he was not supposed to be given a room tray. *None of the orders specifically stated he was not supposed to get meals if he refused to walk to the dining room. *Following initial record review, a 10/15/16 verbal physician's orders [REDACTED]. -The physician clarification was Encourage resident to get up to meals. No meals in room per facility protocol. Supplements and snacks provided between meals when resident refuses to get up for meals. Review of the physician's visits and notes for resident 2 from 6/29/16 to 10/6/16 revealed: *6/30/16, he is aware that his wife had a coronary event last week. -Assessment .generalized weakness with persistent noncompliance with ordered activities. *8/24 visit-The staff reports he has been a little more cooperative in increasing his activity .hopeful that he can be discharged to home. -Plan .I explained to (resident name) that it seemed unreasonable to want to go home when his wife was still receiving assisted care from a daughter .My fear would be once home he would revert to his behaviors of last fall, winter, and leading up to his hospitalization . *10/5 visit-Nursing staff notes that he is frequently uncooperative with activities. Often times he refuses to go down for his meals. Due to his wife's declining cardiac situation, it was explained to (resident name) today that his wife is too ill for him to come home. -I told him that i didn't think he has shown enough ambition and drive in the nursing home to convince me that he would make a positive contribution at home. -At least for the foreseeable future he is going to have to remain in the nursing home. He needs to show more initiative. He needs to get stronger. Even if he does those things, I am still not sure that it would work out for him to be at home. *No notation stating he should not have been given normal meals or a room tray if he refused to ambulate to the dining room at meal times. *No notation of his significant weight loss or interventions. Review of resident 2's food and fluids intake records from 8/1/16 through 12/13/16 revealed the following documentation: *August: -No refusals of meals had been recorded. -One supper meal had zero meaning he ate nothing. -One meal , unavailable. *September: -Six meals refused. -Seven meals, zero. -Two meals, unavailable. -Two days, he either refused or ate nothing for all three meals. *October: -Twenty-six meals refused. -Six meals, zero. -Four meals, unavailable. -Three days, he either refused or ate nothing for all three meals. *November: -Fifty-six meals refused. --Fifty-three of those had been at breakfast and lunch. -One meal was marked zero. -Three days, he either refused or ate nothing for all three meals. *December 1 through 13: -Twenty-three meals refused. --Nineteen of those had been at breakfast and lunch. -Two meals were marked zero. -Two meals, unavailable. *Most of his other meal intakes had been recorded as a 3 meaning he had eaten 76% to 100% of his meal. Review of resident 2's nursing notes from 8/1/16 through 12/13/16 revealed: *8/12/16, dietary noted he ate over 75% of meals improved since he came in to nursing home. *8/15/16, Physician had told (resident name) he has to start doing more for himself or he won't discharge him. (Resident name) is capable he just chooses not to. *Almost daily in August it had been noted Resident ambulated from both meals, tolerated, very well, but needed a lot of encouragement to get started. *His refusal to walk to meals increased starting in September. *9/22/16, Did not eat breakfast asked for sandwich we can not feed him in bed. *9/24/16, Resident only ambulated after bkfst (breakfast) .doesn't like to walk at all. *9/26/16, he complained of nausea and refused to get up. He ate lunch but complained of shortness of breath after ambulating back to his room. *9/26/16, he refused to get up and walk multiple times. The nurse educated him on the importance of getting up to walk and not to lie in bed all the time. He refused to listen or get up. *9/27/16, he felt sick to his stomach and did not ambulate at all. *9/28/16, Tonight no matter what was said for encouragement he refused (to come out for supper). When he cussed I told him its his right. Usually he will come for me he told me tonight to eat his share. *10/2/16 and 10/3/16 he would only go out for meals if pushed in his wheelchair. *10/13/16, dietary noted his weight had been down 10 lb in one month, a 6% loss. -This is severe loss. He does not come to the dining room for many meals. The Nutrition Intervention Program is provided as possible to enhance daily intake, but he eats little so the main feature is meeting his preferences and encouraging intake .Recommend offer milk based supplement. *10/21/16, dietary noted Has had a 5% loss of weight over the last 30 days. This is an unplanned loss. He is not coming out for meals. We have put him on supplements BID (twice a day). *10/28/16, Resident flat out refused to come down to supper for evening. When CNA asked why resident was not going to come down, resident replies with 'Because I don't wanna. CNA informs resident their reply isn't satisfactory . *11/2/16, Continues to refuse to come out for meals. He is receiving supplements BID and offered when he does not come out for meals. He states 'I will eat when I go home,' I did tell him he needs to eat so he could go home . *11/8/16, .refused to get up for breakfast and dinner. Up for supper. Supplements given. Dr. to address tomorrow. -an order for [REDACTED]. *11/11/16, social services assessment stated .daily refuses to cares he can do things for himself but wants to lay in bed and be waited on. Staff and family have been encouraging him. (Resident name) states he is tired and has little energy. He appears where he is a person that you use the approach by saying time to get up not do you want to cause he is going to say no .this writer talked to him about the concerns we as a team had with him not eating and not getting out of his bed. He gets very verbal to staff . *11/11/16, dietary noted his weight loss and his refusals to come out for meals. -He states he wants to eat at home and wants to leave this place. *11/21/16, dietary noted in regarding his refusals and supplements He did say he would drink the supplements. He doesn't really like them but he will drink whatever we send into his room. When I visited with nursing staff I was informed he (resident name) is not willing to come out for breakfast or lunch and will become abusive to staff when they try to help him out. (Resident name) states that he just wants to go home. *11/22/16, a CNA charted .when he was done in the bathroom, to avoid going to breakfast he did not pull his light and he self transferred from toilet to chair and chair to bed. *11/28/16, dietary noted his weight loss was attributed to inadequate oral intake related to confusion and refusal to come out for meals. *12/7/16, he refused to go out to the dining room for lunch, because he just didn't feel like coming out. *12/8/16, Resident rang his light when lunch was over. When I went into his room he asked if he could have a sandwich. I asked why he didn't come out to lunch, and he said because nobody asked him. I reminded him the 3 CNA's and the nurse went in for breakfast and lunch and he refused both of them. He said he doesn't mean to be a burden on anyone and I told him he was not a burden we are here to care for him, but he has to come out for all meals so he can eat when everyone else eats .He agreed with me. *12/9/16, The resident did not what (want) to get up for lunch or breakfast and cna ask 4 to 5 times for each one but then he ask for food in room after breakfast and lunch so i told the nurse and the dir (director) of nursing to (too). *12/12/16, nursing noted He is refusing to eat at meal times. May at times other than meals, ask for a sandwich. -He also refused to go out to the dining room for meals twice that day cause I don't want to. Review of resident 2's careplan revised 11/14/16 revealed: *Focus area, At risk of poor control of his Diabetic (diabetes) due to refusing to come out for meals. -Goal, Will come out for 2 meals a day. -Interventions, Nursing will cue and encourage (resident name) to come out for meals and supplements will be given TID (three times a day) and will be documented by Nursing. *Focus area, Resistive to care r/t (related to) adjustment to nursing home and lack of motivation. -Goal, Resident will cooperate with care. -Interventions, Allow the resident to make decisions about treatment regime, to provide sense of control and if resident resists .leave and return 5-10 minutes later and try again. *Weight loss had not been included on his careplan. 7. Interview on 12/13/16 at 4:30 p.m. and on 12/14/16 at 8:45 a.m. with the director of nursing (DON) regarding resident 2 revealed: *She was aware of his weight loss. *The weight loss had been gradual. *She thought the biggest factor of him starting to refuse to go to meals was his wife's health and the physician flat out told him he wasn't going home. *After his wife's second health episode he really got worse (in regards to his refusals and weight loss). *He had never been offered a room tray when he refused to leave his room. *When questioned about why he had not been offered a room tray as an option since he did not want to come out of his room: -Facility protocol was room trays were not allowed on a regular basis. -She had been told staff had to supervise everyone that had a room tray because of choking risks. -She did not have enough staff to do that, so there were no residents that regularly received room trays. -He did not get a room tray due to protocol and verbal physician's orders [REDACTED]. -The physician had told them not to feed him in his room, because he wanted him to ambulate daily. -The physician had told them he would otherwise probably never come out of his room. *She agreed it was the resident's right to stay in his room if he wanted. *She agreed he had no swallowing problems. *She agreed he had a high BIMS score. *In regards to weight loss not being on his careplan, staff should have updated it day-to-day to reflect current needs, and it should have been on his careplan. *It was a tough dilemma to find a solution between his rights and the physician's orders [REDACTED]. *She was unsure if resident 2's rights had been brought up to the physician. The physician had not been available for interview during the survey on 12/14/16. 8. Review of the provider's In Room Meal protocol revealed For the safety of the resident (due to risk of aspiration or choking during unsupervised intake), in room meals will not be honored unless one of the following criteria is present: *The resident is bedbound and cannot leave their room. *The resident is on isolation precautions. *The resident wants to have a special meal with guests. *The resident is ill. *The resident is vomiting. 9. Review of the provider's Resident Handbook revealed: *Residents of the facility have the right to a dignified existence, self-determination, and communication with and access to person and services inside and outside the facility. *Residents had the right .to be free from interference, coercion, discrimination, or reprisal from the facility in exercising his/her rights. *The care planning team was responsible for .reviewing every resident on a regular and quarterly basis or more often if there is a significant change in resident status. -They were to assess residents nutritional needs, rehabilitation needs, psychosocial needs, medical status, functional abilities, strengths, and problems. -They were to .establish qualified objectives and goals of the highest level of resident function (based on assessment). -They were to develop those into a workable care plan that reflected the assessment, was oriented toward increasing resident's function level, managed risk factors, and built resident strengths. 10. Review of the provider's Weight Assessment and Intervention policy revised 12/13/16 revealed: *The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month-5% weight loss is significant; greater than 5% is severe. 3 months-7.5% weight loss is significant; greater than 7.5% is severe. *Prior to care planning conferences, a problem identification list shall be developed to assist the Care Planning/Interdisciplinary Team in developing and revising comprehensive care plans. *Each discipline will provide a written or oral report of the resident's problems, strengths goals, and approaches as outlined below: a. Problems-Any area of difficulty or concern that prevents the resident from reaching his/her fullest potential . c. Short-Term Goals-The desired outcome for the problem .must be resident oriented, behaviorally stated, measurable, and include a timeframe. d. Approach-The specific action(s) or intervention(s) that the staff will take to assist the resident in meeting/achieving the short-term goals.

Based on record review, interview, and policy review, the provider failed to thoroughly inquire about statements and further investigate the mistreatment, abuse, and neglect for two of two sampled residents (1 and 2). That failure put all residents at risk of mistreatment, abuse, and neglect. Findings include: 1. Review of resident 2's medical record and the provider's investigation of abuse towards her revealed they had not followed their abuse policies and procedures to ensure she and all residents would be free from abuse. 2. Review of resident 1's medical record and personnel reports of neglect revealed those reports had not been investigated and actions to prevent further neglect for all residents had been completed. 3. Refer to F223, F224, F226, F309, F490, F493, F501, and F520.

Based on record review, observation, interview, policy review, and job description review, the provider failed to ensure the facility was operated and administered in a manner that attained or maintained the highest practicable physical, mental, and psychosocial well-being of all forty-five residents. Findings include: 1. Interview on 3/3/15 at 11:00 a.m. with the administrator confirmed the overall operation and administration of the facility was his responsibility. He revealed: *He had been the administrator for about fourteen months. *He had no background in the healthcare industry. *He had not read or revised any policies or procedures since he had started at the facility. *Neither he nor the director of nursing (DON) kept a record of verbal warnings to the staff. *He had told the DON to keep a separate record on all the employees in the DON's office. He was not aware a separate file could not be kept on employees without their knowledge of what as in the file. *He had not disciplined the other two staff members (C and F) regarding the mistreatment of [REDACTED]. *He had not done his own investigation of the DON regarding the neglect of resident 1 as he did not want to lose the DON. He had not disciplined the DON for the same reason. *He relied on the DON to address any concerns with the nursing staff. *He had not completed any performance evaluations on the DON. Interview on 3/4/15 at 1:25 p.m. with a requested unidentified employee revealed: *The administrator was afraid of confrontation. *The administrator had his "pets" at the facility, and they were allowed to do what they wanted. *The administrator was not at the facility all the time. He regularly left the facility at 1:30 p.m. until 2:00 p.m. daily. Interview on 3/4/15 at 1:45 p.m. with two requested unidentified employees revealed they were aware of both incidents for residents 1 and 2. They were concerned and surprised the other two staff (C and F) involved in the incident on 11/16/14 were still employed at the facility. *They were surprised no additional training had been given to all employees after the 11/16/14 and 1/5/15 resident incidents. Interview on 3/4/15 at 4:45 p.m. with the DON revealed: *He was aware of both incidents that had occurred on 11/16/14 and 1/5/15. *He stated he had talked with the administrator and requested all employees involved with the incident on 11/16/14 be reprimanded and if needed dismissed from employment. He stated the administrator told him he was afraid of losing employees and did not want to confront the employees. *He stated he had investigated the incident in which he was involved in on 1/5/15. He had done that as the administrator had no knowledge of how to investigate an incident. The DON stated he had received no verbal or written warning regarding his involvement in the incident. *The DON revealed he talked with the administrator about several other concerns that included a registered nurse who had not fulfilled her duties as a charge nurse. The DON stated he had been told not to reprimand the RN as nursing staff were needed at the facility. *He stated when he had verbally reprimanded an employee they would go behind his back and talk to the administrator. After they would talk with the administrator nothing was done regarding that employee. Review of the undated job description for the administrator of Five Counties Nursing Home revealed: *"Essential Functions: -7. Establishes formal responsibilities and accountabilities of all members of the management and professional staff, and evaluates their performance regularly. -17. Ensure compliance with regulations governing the institution and the rules of accrediting bodes, by continually monitoring the institutions activities and initiating changes as required. -18. Formulates, establishes and enforces such procedures, rules and regulations as necessary to provide for the proper admission, care, safety and discharge of patients. *Expectations: The administrator/CEO (chief operating officer) is expected to follow and maintain established facility (Fire and Disaster Manual, Personnel Policy Manual, Standard of Performance) and department policies, procedures, and objectives." Interviews, observations, record reviews, and policy reviews throughout the course of the survey on 3/3/15 through 3/4/15 revealed the administration had not ensured all forty-five residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being. Refer to F223, F224, F225, F226, F309, F490, F493, F501, and F520.

Based on observation, record review, interview, and policy review, the governing body failed to ensure the facility was administered in a manner that ensured: *Two of two sampled residents' (1 and 2) incidents with mental and physical outcomes were thoroughly investigated. *Three of six staff members (A, C, and F) were reprimanded and retrained after the resident 1 and 2's incidents on 11/16/14 and 1/5/15. *One of one director of nursing (DON) had not investigated one of one sampled resident 1's incident that personally involved himself. *Abuse and neglect policies and procedures were used and implemented for two of two incidents on 11/16/14 and 1/5/15 that involved two of two residents 1 and 2. Findings include: 1. Interviews, observations, record reviews, and policy reviews throughout the course of the survey from 3/3/15 through 3/4/15 revealed the administrator and governing body had not ensured the safe management and overall well-being of all residents. Refer to F223, F224, F225, F226, F309, F490, F493, F501, and F520. 2. Interview on 3/4/15 at 5:30 p.m. with the DON revealed he had contacted one of the board members, G, concerning the overall management of the facility. He stated he had tried to talk with the administrator regarding staff members and their conduct in the facility. He revealed the administrator refused to "step-in" and reprimand or terminate employees. He stated the administrator told him he could not afford to lose any more employees. He revealed he had followed the chain of command and talked to a governing board member. He had been told by that board member to talk with the administrator. 3. Interview on 3/9/15 at 8:55 p.m. via email response with board member H revealed they had not been contacted by any employees regarding the status of the nursing home. 4. Phone interview on 3/10/15 at 10:00 a.m. with the president of the board revealed he had been out of contact with the governing board and the issues at the nursing home due to personal medical issues. He stated the vice-president had taken over the presidential duties the last few months due to those medical issues. The board president revealed the following: *He had never been in the healthcare business and trusted the administrator to keep the board informed of the day-to-day functions of the nursing home. *The administrator had been hired by the previous board president. He understood the administrator had been hired because of his master's degree in education. He also understood and was aware the administrator had no experience in the healthcare industry. *He and the board were happy with the administrator's performance. *He thought the DON and the administrator worked well together. *He was not aware nor had heard if the DON had contacted any of the board members to address concerns at the nursing home. *He was aware of the incident on 11/16/14 regarding resident 1. He stated he had heard the registered nurse had pushed the resident's wheelchair to an open door as a "joke." He gave no comment nor confirmed his knowledge of the incident on 1/5/15 regarding resident 2. *He stated he had wondered if opportunities were missed to retain or retrain employees who had left the facility. *He confirmed the interview of the administrator in which personnel and resident concerns were discussed in executive session. He stated if no action was taken in executive session, then no results were recorded. *He was not aware that not all of the incidents and concerns were reported to the governing board by the administrator. *He was not aware the quality assessment and performance improvement (QAPI) program had not been done correctly. *He confirmed the administrator only reported the last survey audits for the QAPI program. *He was not aware the administrator might not have been conveying all pertinent information to the board. He stated the administrator might have been afraid to report the concerns of the facility as it would be seen as the administrator was not doing his job. *He stated the administrator had a lot of patience and might have given employees involved in incidents and concerns a break in order to keep the employees. He also confirmed he had hoped the administrator would not keep anyone who had done harm or could do harm to a resident.

Based on record review and interview, the provider failed to ensure the medical director provided for the maintenance and collection of information of negative health care outcomes and incidents for two of two (one and two) sampled residents. Findings include: 1. Review of the provider's quality assessment and performance improvement (QAPI) meeting minutes from July 2014 through January 23, 2015 revealed the QAPI committee had only identified areas that included the tags from the survey conducted on 7/24/14. The medical director had attended all meetings but gave no input according to the documentation. Interview on 3/4/15 at 1:30 p.m. with a requested unidentified employee revealed she had contacted the medical director regarding the concerns and incidents at the facility. She stated he gave no concern for the day-to-day activities of the provider. He did state he had thought the provider should start a new fall assessment program. Interview on 3/4/15 at 5:00 p.m. with the director of nursing (DON) revealed he would like to set-up a meeting with the medical director. He stated he had discussed that with the administrator at least twice but had heard nothing back from the administrator. Interview on 3/13/15 at 9:00 a.m. by phone call with the medical director revealed: *He confirmed he had not been made aware of all incidents at the facility. *He had been following the administrator's progress. *He had been letting him "grow" into his position as he had only been there a little over a year. *Employees had told him the administrator lacked leadership and confidence. *He understood the surveyors concerns related to the complaint survey regarding the incidents involving residents 1 and 2. Those concerns had reflected the employee interviews. *He was going to start leadership, team building, and how to take control using "Mind Tools." *He was going to start more integrated meetings with all managers and create horizontal leadership. *He stated the administrator was timid and had no strong leadership role. He needed to relay to the administrator he could not always be a friend to the employees and needed to get on with the mission of the nursing home and the care of the residents. *He was aware the DON came from a military background. He tended to treat his staff "robotic" instead of equals to step up to the daily demands of the nursing home. *He was aware of the insubordination letter the DON had drafted. He was not aware the letter had gone out to all staff. He had thought the letter dealt with a registered nurse and her questioning of the DON's instructions involving a catheter (tube inserted into bladder to release urine). He was concerned the administrator had not diffused the situation and try to intervene to retain the nurse. He stated the letter gave him a better understanding of how the DON operated and interacted with the staff. *He was aware there were some nurses just "filling time." But, it was better to have open positions than bad employees. It would be better for the nursing home to have retention than new recruitments from outside agencies all the time. *He was not aware the DON had requested at least two meetings with him. He stated he is there every Friday for rounds and was upset no one had contacted him or kept him in the loop. He also stated he was concerned that when he did his rounds on Fridays the administrator's door was always closed, and the DON was never around. *There needed to be more construction instead of destruction among the employees, and he intended to work with the board of directors to ensure it would get done. According to the www. American Medical Directors Association (AMDA) on 3/13/15, the medical director is involved at all levels of individualized patient care and supervision, and for all persons served by the facility. The medical director serves as the clinician who oversees and guides the care that is provided, a leader to help define a vision of quality improvement, and an operations consultant to address day-to-day aspects of organizational function. According to an undated article by AMDA the following was a general guideline to be used for medical directors: *Coordination and evaluation of the medical care within the facility. To include: -Identification, evaluation, and addressing health care issues related to the quality of care and quality of life of residents. -Review of individual resident cases, as warranted, to evaluate quality of care or quality of life concerns or other problematic situations and take appropriate steps to resolve the situation as necessary and as requested. -Review, consider and/or act upon consultant recommendations that affect the facility's resident care policies and procedures or the care of an individual resident.

Based on record review, policy procedure book, and interview, the provider failed to ensure an effective quality assessment and performance improvement (QAPI) program had been maintained to: *Review residents' cares concerns, and plans. *Identify trends in the quality measures indicator. *Identify trends and tracing of infection controls. *Identify needs and issues with electronic medical records. *Review admissions and discharges for residents. *Discuss new and old policies and procedures. *Discuss the monthly pharmacist reports. *Discuss incident and safety reports. *Discuss staff concerns and needs. Findings include: 1. Review of the provider's QAPI meeting minutes from July 2014 through January 23, 2015 revealed the QAPI committee had identified areas that only included the deficiencies from the survey conducted on 7/24/14. Interview on 3/4/15 at 11:30 a.m. with the administrator revealed: *He was the responsible party for QAPI. *The QAPI committee met quarterly and included himself, the director of nursing, the medical director, and other employees. *The QAPI meetings had identified only the deficiencies written from the last survey on 7/24/14. *There were no other measurable goals or interventions. *The monthly resident council meeting minutes were not reviewed for issues. *None of the above listed topics from the above introduction statement were addressed in QAPI. The administrator revealed the provider had implemented a safety audit on the employees due to the high insurance premiums. He also stated he was trying to implement a better admission process and packet to let all departments know of a new admission. Phone interview on 3/10/15 at 10:00 a.m. with the president of the board revealed: *He was not aware the QAPI program had not been done correctly. *He confirmed the administrator only reported the last survey audits from the QAPI program to the governing board. Review of an undated quality assurance procedure book revealed no policy could be located regarding QAPI. Interview on 3/4/15 at 1:40 p.m. with the recording secretary for QAPI revealed there was no policy for QAPI. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, MO., 2005, p. 365, revealed " ...organizations must be responsible and accountable for evaluating and improving the quality of client care services being provided to all clients. This requires health professionals at all levels to critically evaluate their practices, to incorporate the latest scientific findings into client care, and to measure the success of meeting client outcomes on an ongoing basis." Refer to: F223, F224, F225, F226, F309, F490, F493, and F501.

Based on record review, observation, interview, and policy review, the provider failed to thoroughly investigate two of two incidents for abuse and neglect for two of two sampled residents (1 and 2). Findings include: 1. Refer to F309, finding 2. 2. Review of the undated abuse policy and procedure manual revealed: *"Abuse Prevention Program. -Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. 1. Our facility is committed to protecting our resident from abuse by anyone including but not necessarily limited to: facility staff.... 3. Comprehensive polices and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. B. Mandated staff training/orientation programs that include such topes as abuse prevention, identification and reporting of abuse, stress management, delaying with violent behavior or catastrophic reactions, etc. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; e. The development of investigative protocols governing resident abuse, theft/misappropriation of resident property, resident-to-resident a;abuse and resident-to-staff abuse; f. Timely and thorough investigations of all reports and allegations of abuse; g. The reporting and filing of accurate documents relative to incidents of abuse; h. An ongoing review and analysis of abuse incidents; and i. The implementation of changes to prevent future occurrences of abuse." "*Investigation Unexplained Injuries - An investigation of all unexplained injuries Including bruises, abrasion, and injuries of unknown source) will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our resident ha not been jeopardized." *"Preventing Resident Abuse -Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures,a training programs, system, etc., to assist in preventing resident abuse. 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: I. Monitoring staff on all shifts to identify inappropriate behaviors toward resident (e.g. using derogatory language, rough handling of resident, ignoring resident while giving care, ... j. Assessing, care planning, and monitoring resident with needs and behaviors that may lead to conflict or neglect; k. Assessing resident with signs and symptoms of behavior problems and developing implementing care plans to address behavioral issues." *"Protection of Resident During Abuse Investigations -Our facility will protect resident from harm during investigations of abuse allegations. 1. During abuse investigations, resident will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator." *"Recognizing Signs and Symptoms of Abuse/Neglect -Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor to the the Director of Nursing Services immediately. 1. Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. a. Signs of Actual physical Abuse: (8) Excessive exposure to heat or cold. 3. b.(6) Inadequate provision of care. 3.b.(7) Caregiver indifference to resident's personal care and needs." *"Reporting Abuse to State Agencies and Other Entities/Individuals - All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individual as may be required by law. 4. The individual(s) involved in the incident will be notified of such findings, and such individual(s) will be suspended, without pay, until the State Abuse Registry has investigated the claim ad found the allegations to be true or unfounded. 6. Records of all allegations will be filed in the accused employee's personal record..." Surveyor: 1. Refer to F309, finding 1. 2. Review of the undated abuse policy and procedure manual revealed: *"Abuse Prevention Program. -Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. 1. Our facility is committed to protecting our resident from abuse by anyone including but not necessarily limited to: facility staff.... 3. Comprehensive polices and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. B. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, delaying with violent behavior or catastrophic reactions, etc. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; e. The development of investigative protocols governing resident abuse, theft/misappropriation of resident property, resident-to-resident abuse and resident-to-staff abuse; f. Timely and thorough investigations of all reports and allegations of abuse; g. The reporting and filing of accurate documents relative to incidents of abuse; h. An ongoing review and analysis of abuse incidents; and i. The implementation of changes to prevent future occurrences of abuse." "*Investigation Unexplained Injuries - An investigation of all unexplained injuries Including bruises, abrasion, and injuries of unknown source will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our resident has not been jeopardized." *"Preventing Resident Abuse -Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, a training programs, system, etc., to assist in preventing resident abuse. 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: I. Monitoring staff on all shifts to identify inappropriate behaviors toward resident (e.g. using derogatory language, rough handling of resident, ignoring resident while giving care, ... j. Assessing, care planning, and monitoring resident with needs and behaviors that may lead to conflict or neglect; k. Assessing resident with signs and symptoms of behavior problems and developing implementing care plans to address behavioral issues."

A. Based on record review, interview, and policy review, two of five staff (C and F) failed to intervene to stop a registered nurse (A) from inflicting punishment to one of two sampled residents (2) with cognitive (thinking) impairment. Those two staff were still employed and had received no re-education on abuse prevention thus this had the potential to affect all residents. Findings include: 1. Review of the 11/18/14 allegation (accusation) of abuse of an elderly resident investigation report revealed: *The director of nursing (DON) had conducted the interviews of all staff involved in that allegation. *It had been alleged registered nurse (RN) A had propelled resident 2 in her wheelchair up to the patio door and had the door held open, as resident 2 had stated she wanted to go home. *Certified nursing assistants (CNA) B, D, and E had been asked by RN A to open the door for her. They had refused and stated "This isn't right." *CNA C and licensed practical nurse (LPN) F had held the door open while RN A positioned resident 2 partially out the door. *CNAs B, D, and E reported this to the Minimum Data Set (MDS) assessment and the DON was also called. *The DON started the investigation, and the administrator had also been notified. *During the investigation the DON and administrator had determined to suspend RN A until the investigation was completed. *RN A resigned before the investigation had been completed. *CNA C and LPN F were still employed, and there was no record of any disciplinary action or re-education for them. Surveyor: Interview on 3/3/15 at 11:25 a.m. with a CNA who wished to not be identified revealed: *She had been concerned after the above incident as CNA C and LPN F were still employed. *She was not aware of any education provided to any staff in regards to preventing abuse to residents. Interview on 3/3/15 at 11:00 a.m. with the administrator revealed he: *Had not disciplined the other two staff members regarding the mistreatment of [REDACTED]. *Relied on the DON to address any concerns with the nursing staff. Interview on 3/4/15 at 4:45 p.m. with the DON revealed: *He had completed the investigation on the incident with resident 2. *He had told the administrator that CNA C and LPN F should also have been suspended or terminated. *The administrator had told him he could not do that due to the lack of staffing. *LPN F was on maternity leave and had not returned to work after her maternity leave. *He was not aware LPN F was still considered an employee. Review of the provider's revised December 2009 Abuse Investigations policy included: *Employees who have been accused of resident abuse might have been reassigned to non-resident care duties or suspended from duty until the results of the investigation had been reviewed by the administrator. *The individual in charge of the investigation would consult daily with the administrator concerning the progress/findings of the investigation. *The administrator would have kept the resident and his/her representative informed of the progress of the investigation. Review of the provider's revised August 2006 Abuse Prevention Program policy included: *The abuse prevention program provided policies and procedures that governed, and as a minimum included: -Identification of occurrences and patterns of potential mistreatment/abuse. -The implementation of changes to prevent future occurrences of abuse. Review of the provider's revised December 2006 Preventing Resident Abuse policy included: *Training all staff how to resolve conflicts. *Assisting or rotating staff working with difficult residents. *Monitoring staff on all shifts to identify inappropriate behaviors toward residents. *Involving attending physicians and the medical director when findings of abuse had been determined. *Encourage all personnel, residents, family members, visitors to report any signs or suspected incidents of abuse to facility management immediately. B. Based on record review, interview, and policy review, nursing staff failed to adequately respond to and assess one of two sampled residents (1) after a fall. *That lack of response had caused the resident to have prolonged pain due to a fracture. *No investigation by the administrator had been completed when staff had provided both verbal and written concerns. Findings include: 1. Review of resident 1's medical record revealed he had been found on the floor in his room on 1/5/15 at 2:00 a.m. His physician had not been contacted until 10:06 a.m. He has not been transferred to the hospital until the afternoon of 1/5/15. He was later found to have suffered a left hip and a pelvic fracture. 2. Refer to F309, finding 1.

Based on record review, interview, and policy review, the provider failed to ensure all forty-five of forty-five residents currently residing in the facility were safe from potential neglect, abuse, and psychological harm. The provider had not followed their policies and procedures for abuse. Repercussion and training for two of two staff (C and F) had not been completed following two incidents of resident (1 and 2) abuse with psychological harm and neglect at the facility. NOTICE: Notice of immediate jeopardy was given to the administrator on 3/3/15 at 1:15 p.m. He was asked for a plan of correction for the following : *All residents to be free from abuse, neglect, and psychological harm. *All staff to have education on the provider's abuse and neglect policies. *A memo for all staff, contracted staff, and clinic employees on a zero tolerance for resident abuse. *A policy for the chain of command for reporting abuse and neglect. PLAN OF CORRECTION: "A. All Residents will be free from Abuse, Neglect, and Psychological Harm. B. All resident have the potential to be affected. C. All Staff on duty will be trained regarding the above area during their shift on 3/3/15 at the time of the announced immediate jeopardy. All other staff will be trained prior to their shift on 3/3/15 or their next planed work date. D. Training to remove the Immediate Jeopardy will include all of the following: Abuse Investigations, Abuse Prevention Program, Investigating Unexplained Injuries, Preventing Resident Abuse, Protection of Residents During Abuse Investigations, Recognizing Signs and Symptoms of Abuse/Neglect, Reporting Abuse to Facility Management, Reporting Abuse to State Agencies and Other Entities/Individuals, Reporting Suspected Cases and/or Incidents of Rape, Resident-to-Resident Altercations. E. A memo will be drafted to all employees, contracted employees, and clinic staff to ensure they are aware that Five Counties Nursing Home as a Zero tolerance for any resident abuse, neglect, or psychological harm. The Administrator, DON (director of nursing), and ADON (assistant director of nursing) will also be responsible for ensuring the attached memo is read and signed by all employees. --All of the above listed people who work for those entities will sign the memo to ensure they are aware of the memo and the policy. F. A new Chain of command policy will be implemented for any concerns, allegations, or incidents. This will be incorporated into the training identified in E. --All employees will sign a sheet to ensure they have read the new Chain of Command policy. G. Administrator, DON, or ADON will be responsible for reviewing, auditing and monitor staff providing care in regards to Abuse, Neglect, and Psychological Harm policies weekly X (times) 4 weeks then quarterly thereafter. Those reviews, audits, and monitoring reports (QAPI) (quality assurance performance improvement) will be compiled by the Administrator. QAPI results will be reported to the Administrator to the governing board weekly X 4 weeks then quarterly thereafter for 1 year." The plan of correction was accepted by the surveyors on 3/4/15 at 11:00 a.m., and the immediate jeopardy was removed: Findings include: 1. Review of resident 2's medical record and the provider's investigation of abuse towards her revealed they had not followed their abuse policies and procedures to ensure she and all residents would be free from abuse. 2. Review of resident 1's medical record and personnel reports of neglect revealed those reports had not been investigated and actions to prevent further neglect for all residents had been completed. 3. Refer to F223, F225, F226, F309, F490, F493, F501, and F520.

Based on record review, interview, and policy review, the provider failed to ensure two of two sampled residents (1 and 2) had been assessed and monitored for mental distress and physical pain. Findings include: 1. Review of resident 1's interdisciplinary progress notes revealed:*1/5/15 3:16 a.m. note by the DON (director of nursing) "Resident was found on floor in room at 0200 (2:00 a.m.) Head-to-toe assessment performed; resident is AAOX2 (alert and oriented to person and place) not time, in no apparent distress, pain and discomfort indicated; observed quietly laying on floor with eyes opened; v/s (vital sign) BP=(blood pressure) 129/66; HR=(heart rate) 71; Temp=(temperature) 96.1; RR=(respiratory rate) 16; O2 Sat=(oxygen saturation) 97% room air. No injury noted. Resident given Tylenol 1000 mg (milligram) PO (by mouth) q4hr (every 4 hours) PRN (as needed) for pain. Resident tolerated care well. POA (power of attorney) _____(name of POA) contacted today 1/5/15 at 2:40 a.m. message left of situation. No witness to fall. Resident states he was reaching to get in his wheelchair from his bed & fell . Resident was not wearing footwear. Resident assisted back to bed. Nurses continue to monitor. Call light within reach." *1/5/15 10:06 a.m. note by licensed practical nurse (LPN) I "Called and left a message for Md's (medical doctor) nurse regarding resident (1)." *1/5/15 at 11:19 a.m. note by LPN I "Received call back from MD nurse to transfer resident to _______(hospital name) for further evaluation. Called and notified residents RP (responsible party) and she agreed with the plan of care." *1/5/15 3:13 p.m. note by registered nurse (RN) J "Alert and oriented to self with some confusion. Presented with left hip pain and ecchymosis (bruise). Guarding his left hip and painful on movement. ____(hospital name) was called and order to send resident to ___(hospital name) was made. Resident was transferred to _____(hospital name) via stretcher ambulance. Family member _____(name of family member) was informed by ______(name of LPN I) that resident was transferred to _____(hospital name) with left hip pain and left hip ecchymosis. _____(name) RN from ______(hospital name) called at 1455 (2:55 p.m.) and reported that resident was been (being) transferred to _____(another hospital) with a broken hip and pelvic (pelvis)." Director of nurses and administrator aware." *1/5/15 at 5:36 p.m. note by the DON "D.O.N. discussed with POA today 1/5/15 at 17:30 hrs (5:30 p.m.) regarding resident status. POA states resident has history not communicating need for assistance. POA states she will be more involved with FCNH (Five Counties Nursing Home) regarding resident's ADLs (activities of daily living) and communication." *1/7/15 at 2:40 p.m. note by the dietary director ".....He does eat a very large breakfast but after fall he was said to be almost in tears and not consuming any food." *Review of the interdisciplinary progress notes revealed resident 1's physician had not been contacted until 1/5/15 at 10:06 a.m. Review of resident 1's 1/5/15 emergency room note/transfer summary by his attending physician revealed: *He had been found on the floor with left hip pain. *The fall had happened around 2:00 a.m.on 1/5/15. *"He was helped back to bed, but really wanted to lay on his left side in the fetal position, which is unusual for him." *He complained of a lot of hip pain. Review of a 1/5/15 handwritten note to the administrator and Minimum Data Set Assessment(MDS) coordinator from certified nursing assistant K regarding resident 1 revealed: *She had reported she had found the resident on the floor in his room on 1/5/15 at 2:00 a.m. *He had been in pain and holding his left leg. *She had asked the other CNA L who was also on duty to find the nurse on duty, who was the DON. *They looked for the DON, used the overhead paging system, and called on the telephone to reach him. *CNA L went to the second floor of the building and found the DON sleeping on the couch. *When the DON came down to assess resident 1 it had been over one-half hour. *CNA L stated to the DON that "______(resident 1) is in great pain." *"He (DON) told _____(resident 1) we needed to get him up and he needed to roll over on his back he put gait belt on and told us to help lift him up (roughly) into the w/c (wheelchair) and then onto bed." "_____(resident 1) was still in great pain." *"Ice pack was put on leg and thigh by ______ (CNA L)" *"I think _____(DON) gave him some pain med." *"_____(DON) was too rough and didn't thoroughly check him." Review of resident 1's January Medication Administration Record [REDACTED]. He had not received any other pain medication until his regular scheduled dose of Tylenol 1000 mg at 8:00 a.m. It was noted resident 1 had fell at 2:00 a.m. ,and the Tylenol had also been administered at 2:00 a.m. He had no physician orders for any stronger pain medication. There had been no documentation on what type of pain and how intense resident 1's pain had been. There had been no documentation the Tylenol had been effective. Interview on 3/4/15 at 5:45 p.m. with the DON revealed he: *Had been working the night shift on 1/5/15. *Confirmed he had been upstairs when resident 1 had fell . *Had done a "Cursory" (brief) assessment. *Had been upset with CNAs K and L as resident 1 had been soiled with bowel movement. *Had wanted them to clean resident 1 up first before he assessed him. *Had not felt resident 1 had been in a lot of pain after the fall. *Had not documented any more of his assessments for resident 1 for the rest of that shift. Review of the provider's revised April 2013 Falls - Clinical Protocol policy revealed the following: *The nurse should assess and document/report that included following: -Muscular function, observation for change in normal range of motion and weight bearing. -Pain. Review of the provider's revised October 2010 Pain Assessment and Management policy revealed to observe the following: *The resident during rest and movement for signs of pain. *Verbal expressions such as groaning, crying, or screaming. *Facial expressions such as grimacing, frowning, and clenching of the jaw. *Behavior such as resisting care, irritability, depression, decreased participation in usual activities. *Limitations in his or her level of activity due to the presence of pain. *Guarding, rubbing, or favoring a particular part of the body. *Difficulty eating or loss of appetite. *Increased blood pressure. *Increase heart rate. 2. Review of the 11/18/14 allegation of abuse of an elderly resident report regarding residet 1 to the South Dakota Department of Health revealed: *It had been documented by the DON, and he and the administrator had both signed it. *RN A had propelled resident 2 in her wheelchair to the patio door and had pushed her to the threshold of the door to have her stop asking to go home. *A nursing assessment of the resident had been conducted by the DON with CNA staff (who were not involved). No abnormal change in physical or mental status had been noted. *That assessment had not been documented in resident 2's medical record. Interview on 3/3/15 at 11: 25 a.m. with CNA E revealed: *She had witnessed and reported RN A to the MDS coordinator and the social services designee (SSD during the incident with resident 2. *She stated resident 2 was "Frantic" after the incident, and it took a long time to calm her down. *She stated resident 2 had always asked to go home. She was easily re-directed and had never gone outside without someone with her. *It was cold outside that day, and there was snow on the deck. Review of resident 2's following interdisciplinary progress notes revealed: *11/14/14 at 10:53 a.m. a physician progress notes [REDACTED]. She has periods where she just screams and has repetitive verbal behaviors." *11/16/14 at 3:49 p.m. a SSD note "Family member POA ____-(name) was contacted about an incident regarding ______(POA name) mother. Call made approximately around three o'clock pm." *There was no further documentation regarding the above incident. *There was no physical examination of resident 2 by a licensed nurse or a physician. *There was no documentation on resident 2's behavior after the incident or her state of mind. Review of the provider's revised September 2013 Reporting Abuse to Facility Management included findings of any physical examination should have been recorded in the resident's medical record. Surveyor: According to the National Weather Service the average high temperature for the week of November 9, 2014 through November 16, 2014 was 14 degrees Fahrenheit (F). Average low temperature for that same week was -10 degrees F. Average snow fall for November 2014 was one to two inches.