Every finding on record at Fountain Springs Healthcare

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure the safety of a resident regarding the use of devices according to the care plan when one of one sampled resident (1) who needed to be transferred with a stand aid lift (a mechanical device used to assist from a seated to a standing position) while using a gait belt and pivot transfer (after assisting a resident to a standing position without a lift, the resident then turns their body to move to another surface). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:1. Review of the provider's 1/15/25 submitted SD DOH FRI final report regarding resident 1 revealed:*On 1/15/26, the physical therapy (PT) staff reported to administrator A and director of nursing (DON) B that resident 1 reported that certified nurse assistant (CNA) C transferred her to the bed the night before on 1/14/26 without using the stand aid lift. Resident 1 complained of increased pain to her left knee due to that transfer. CNA C was suspended pending investigation of the event.*The resident's care sheet (a personalized document that addresses a resident's care needs) included transfer instructions that the staff were to use the sit-to-stand lift for transferring resident 1.*CNA C admitted to moving her from the commode seat to the bed with a gait belt and a pivot transfer instead of using the stand aid lift. Resident 1 complained of pain in her left knee after the transfer. CNA C notified the nurse who then provided resident 1 with pain medication.*CNA C received disciplinary action for not transferring a resident in the manner that was indicated on that resident's care sheet. CNA C completed individual education on following the resident care sheets regarding how a resident was to be transferred. She was then allowed to return to work.*The provider performed weekly audits on the staff when they transferred residents and provided education to the staff regarding following a resident's care sheet and how to use a stand aid lift. 2. Review of resident 1's electronic medical record (EMR) revealed:*She was admitted to the facility on [DATE]. Upon admission, she was able to transfer with the assistance of one staff and used her walker for ambulation (walking). *Resident 1 fell on 1/11/26. She reported to staff that she was trying to transfer herself into her recliner without staff assistance. She denied pain after the fall and had no signs or symptoms of an injury.*On 1/12/26 resident 1 complained of pain and rated it an 8 out of 10 (using the 10 point scale) to her left leg. She was transferred to the emergency room for evaluation after her provider and power of attorney (POA) were notified. She had an x-ray (a non-invasive form of medical imaging to check for bone injuries) that did not show any new injuries.*After returning to the facility, resident 1 was re-evaluated by a physical therapist on 1/13/26 who recommended using a stand aid lift for safe transfers.*Resident 1 was re-evaluated by her medical provider on 1/13/26 and started on a Lidocaine 5% patch [a pain-relieving patch] and Tramadol 25mg as needed up to three times daily [a pain medication] for increased pain to her right knee and leg.*Resident 1 was transferred the next day on 1/14/26 by CNA C without the use of the stand aid lift.*She was evaluated by her medical provider again on 1/15/26 with no new orders. She would continue with a Lidocaine 5% patch, Tramadol, and ice compresses for pain control.*Physical therapy evaluated her on 1/15/26 and updated her transfer status to a full body lift (a mechanical lift and sling used to lift a person's full body) due to pain in her left leg. 3. Interview on 2/12/26 at 9:27 a.m. with resident 1 revealed:*She occasionally had sharp pains in her left knee.*She did not remember the incident where CNA C transferred her to the bed without using the stand aid lift.*She felt safe with the staff. 4. Interview on 2/12/26 at 9:32 a.m. with resident 2 revealed:*She could not walk and relied on a wheelchair for mobility.*Staff used a total body lift (a mechanical lift and sling used to lift a person's full body) to get her out of her wheelchair. She stated that she never felt unsafe while the staff has used the total body lift to transfer her. 5. Interview with registered nurse (RN) D on 2/12/26 at 8:58 a.m. revealed:*Staff used care sheets to keep track of the resident's information. That information included how they needed to be transferred, their diet, incontinence status (involuntary urine or bowel leakage), oxygen use, fall risk status, and if the resident had any pressure ulcers (skin and/or underlying tissue injury from prolonged pressure).*The care sheets were updated daily by management.*The staff used the care sheets for four of the five hallways within the facility. The fifth hallway used a new system called a Kardex (a report of the resident's care needs and interventions) that is generated from information entered into the resident's care plan (personalized plan in the EMR that addresses a resident's care needs, goals, and interventions). RN D stated that eventually the residents' care needs would be communicated to the staff through the Kardex system instead of the care sheets. 6. Interview on 2/12/26 at 9:19 a.m. with CNA's E and F revealed:*Residents were expected to be cared for based on the information on the resident's care sheet.*The care sheets were updated by management daily.*If a resident's conditions were to change, the staff would be responsible for notifying management so the resident's care sheet could be updated.*When a new resident was admitted to the facility they were evaluated by DON B or nurse manager G, who would verbally communicate the resident's needs to the staff, and then they would update the resident's care sheet. The PT department would assess the residents the next day and make new recommendations to perform safe transfers if that was needed. 7. Interview on 2/12/26 at 10:16 a.m. with director of PT H revealed:*The PT department would get a physician's order to evaluate a newly admitted resident. This evaluation would happen the day after the resident was admitted to the facility. The evaluation would include recommendations on how to safely transfer the resident. This information was communicated to DON B and nurse manager G, who would then communicate that information with the staff and update the resident's care sheet.*She remembered when resident 1 had her fall on 1/11/26 and when she had pain after her transfer on 1/14/26. She stated that resident 1 still had the ability to stand but they changed her to a lift due to anxiety about having pain after working with PT. 8. Interview on 2/12/26 at 10:25 a.m. with DON B revealed:*Staff were expected to follow instructions on the resident's care sheet for transfers.*She was aware that the care sheet was not a part of the resident's EMR. They were transitioning the staff to use the Kardex system as a reference for resident care information. 9. Review of the provider's March 2025 CNA job description revealed:*The CNAs were expected to perform duties for caring for residents in the community, consistent with the plan of care and established long-term care standards and community policies and processes. 10. The provider was unable to provide a policy for following residents' care plans, using mechanical lifts, or transferring residents. 11. The provider's implemented actions to ensure the deficient practice does not recur was confirmed on 2/12/26 after observations and interviews revealed the facility had followed their quality assurance process and:*Counseled CNA C regarding ensuring all residents are transferred according to their care sheets.*An all staff meeting was conducted on 1/15/26 regarding the need to follow the resident's transfer status on the care sheet. If staff could not attend in person, they were expected to review the information and sign the education sheet.*Audits were performed from 1/14/26 through the time of survey of staff performing resident transfers.*Reporting to the quality assurance committee the above audit findings. Based on the above information, non-compliance at F689 occurred on 1/14/26, and based on the provider's implemented corrective actions on 1/15/26 and additional corrective action plans, for the deficient practice confirmed on 2/12/26, the non-compliance is considered past non-compliance.

Based on observation, record review, interview, and policy review, the provider failed to ensure:*Proper infection control practices had been followed for the cleaning and storage of nebulizer masks (a mask worn when using a nebulizer machine that converts liquid medication into an inhalable mist) for two of two sampled residents (21 and 79).*Proper infection control practices had been followed for cleaning of the Continuous Positive Airway Pressure (CPAP) machine ( a device that uses air pressure to keep breathing airways open) for one of one sampled resident (16).*Proper infection control practice had been followed for cleaning and storage of oxygen equipment for three of three residents (16, 67, and 97) who required the use of oxygen. Findings included:1.Observation and interview on 9/16/25 at 2:07 p.m. with resident 21 in her room revealed: *A nebulizer machine (a machine that converts liquid medication into an inhalable mist) with an attached mask was lying on her bedside table. *The attached mask had a couple of small white spots on the inside. *Resident 21 stated she would receive her nebulizer treatment at night. *She stated the staff had not been cleaning the mask after her nebulizer treatments were completed. *She could not recall the last time the nebulizer mask had been cleaned following a treatment. 2. Review of resident 21's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. *Her 7/22/25 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *Her diagnoses included type 2 diabetes (a condition involving disruption in how the body regulates blood sugar), chronic respiratory failure with hypoxia (ongoing ability to maintain adequate oxygen levels), heart failure (a condition where the heart does not pump blood effectively), hypertension (high blood pressure), and pulmonary hypertension (high blood pressure that affects the lungs). *She had a 4/18/24 physician's order, Levalbuterol HCI Solution 1.25 MG/3ML (milligrams per 3 milliliters), 1 vial inhale orally via nebulizer at bedtime for SOB (shortness of breath)/wheezing. *There was no documentation for staff to clean or change her nebulizer mask. 3. Observation and interview on 9/16/25 at 1:47 p.m. with resident 16 in her room revealed: *There was a continuous positive airway pressure (CPAP) machine (machine that supplies continuous air pressure to keep your airway open while you sleep) on her bedside table. *The CPAP mask was lying on resident 16's bed under her pillow. *Resident 16 stated that the first six weeks she was in the facility her CPAP mask and tubing did not get cleaned by staff. *She stated she asked multiple times to have staff clean her CPAP mask and tubing weekly and was told that she could clean her mask as part of her therapy. -Therapy told her it was not part of her therapy routine but did help her clean it once. Observation on 9/18/25 at 8:21 a.m. of resident 16's room revealed her CPAP mask draped over the bed frame between the mattress and the headboard. 4. Review of resident 16's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 7/23/25 Brief Interview of Mental Status (BIMS) assessment score was 14, which indicated she was cognitively intact. *She had a 7/26/25 physician's order for CPAP cleaning to be done Q [every] Saturday. Use 1/2 part of vinegar and 1/2 part water and pat dry which ended on 8/11/25. *She had a 9/1/25 physician's order for Clean CPAP machine weekly- 1st thing in the morning so it has all day to dry per resident. 5. Observation on 9/16/25 at 2:43 p.m. of resident 67's room revealed: *There was an oxygen concentrator (a device that filters room air into purified oxygen) beside his bed. *The nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) attached to the oxygen concentrator was draped over his over-the-bed table with the nasal prongs lying on a hairbrush with gray hairs in it. 6. Review of resident 67's EMR revealed: *He was admitted on [DATE]. *He had a 6/16/25 BIMS assessment score with indicated he was severely cognitively impaired. *He had a 11/6/23 physician's order for O2 [oxygen] 1L [one liter] per NC [nasal cannula] at night. *He had a 11/15/23 physician's order to Change O2 tubing monthly at bedtime starting on the 15th and ending on the 15th every month. 7. Observation on 9/16/25 at 2:52 p.m. of resident 79's room revealed: *He had an oxygen concentrator beside his bed with the attached nasal cannula draped over his bed. *There was an assembled nebulizer (a device that converts liquid medication into an inhalable mist) mask hanging on the handle on the front of resident 79's bedside table. *There was a piece of tape secured to the tubing of the nebulizer mask that read 8/16. 8. Observation on 9/17/25 at 9:08 a.m. of resident 79's room revealed his nasal cannula draped over his unmade bed. 9. Observation and interview on 9/17/25 at 11:43 p.m. with resident 79 in his room revealed: *There was a nasal cannula attached to a portable oxygen cylinder on the back of resident 79's wheelchair that was draped over the wheel and seat of the wheelchair. *Resident 79 stated he received nebulizer treatments three to four times per day because of his cough. *He stated that when he finished with his nebulizer treatments, he hung the mask on the drawer handle on the front of his bedside table. *He did not rinse out his nebulizer masks after he used it, but stated staff did rinse it sometimes. *The nebulizer mask chamber was one-fourth filled with a clear liquid. *The bottom one-third of the nebulizer mask was hazy and had a rough texture inside the mask. 10. Observation and interview on 9/17/25 at 1:47 p.m. with resident 79 in his room revealed: *The nebulizer mask remained hanging on the drawer handle on the front of his bedside table. *He stated he had not received his afternoon neb yet. 11. Review of resident 79's EMR revealed: *He was admitted on [DATE]. *He had a BIMS assessment score of 11, which indicated he was moderately cognitively impaired. *Resident 79 had a 9/11/25 physician's order for Ipratropium-Albuterol Solution [ a medication used to open the air passages in the lungs to make it easier to breathe] 0.5 -2.5 (3) MG/3ML [milligrams per 3 milliliters] 3 ml inhale orally three times a day for pneumonia for 7 Days. *He had a 1/22/25 physician's order for Oxygen at 3L via NC to maintain [oxygen] saturations greater than 89% every night shift. *He did not have an order to change his nasal cannula or nebulizer mask on his TAR. 12. Observation on 9/17/25 at 9:47 a.m. of resident 97's room revealed: *There was a nasal cannula attached to a portable oxygen cylinder on the back of resident 97's wheelchair. *The nasal cannula was wrapped around the cylinder on the back of the wheelchair. *There was a plastic bag also hanging on the back of the wheelchair. *There was an oxygen concentrator near the head of the bed with a plastic bag hanging from the concentrator. *The nasal cannula that was attached to the concentrator was draped over resident 97's bed. 13. Observation and interview on 9/18/25 at 8:27 a.m. with resident 97 in her room revealed: *There was a nasal cannula draped over resident 97's oxygen concentrator with the nasal prongs touching the floor. *She was admitted to the facility for therapy to get strong enough to have surgery. *She was on oxygen before she was admitted to the facility but now, she required staff's assistance with her oxygen because she was unable to get out of bed or her chair without assistance. *She stated staff placed her nasal cannula on the oxygen concentrator that morning when she got out of bed. *She stated the staff usually just threw the nasal cannula on her bed or her recliner, but this morning had draped it over the oxygen concentrator. 14. Review of resident 97's EMR revealed: *She was admitted on [DATE]. *A BIMS assessment had not been completed. *She had a 9/15/25 physician's order for O2 at 1L per NC every shift. *She had a 9/15/25 physician's order to Change O2 tubing monthly at bedtime starting on the 15th and ending on the 15th every month. 15. Observation and interview on 9/17/25 at 3:39 p.m. with licensed practical nurse (LPN) H in resident 79's room revealed: *A resident's nebulizer mask and tubing were to be changed every two weeks, and it was to be dated when it was changed. *The CPAP masks and tubing were to be rinsed with vinegar water weekly and allowed to air dry. *Nasal cannulas were to be changed monthly. *LPN H stated when the nasal cannulas and nebulizer masks and tubing were changed it was documented in the treatment administration record (TAR) in the resident's EMR. *She agreed that if the tasks of changing of the nasal cannulas and nebulizer masks were not documented on the resident's TAR there would be no way to verify, they had been changed. *LPN H verified the changing of resident 79's nasal cannulas, nebulizer mask and tubing were not able to be documented on the TAR as there was no order to complete that task. *Nasal cannulas and nebulizer masks were to be stored in plastic bags on the oxygen concentrator or portable cylinder when they were not in use. *LPN H stated after a resident was administered a nebulizer treatment the nebulizer mask was to be disassembled, rinsed with water, allowed to air dry and then stored in a plastic bag when not in use. *LPN H had documented she administered resident 79's nebulizer treatment as having been administered on 9/17/25 at 1:02 p.m. *She stated after she administered resident 79's nebulizer she had rinsed his nebulizer mask, let it dry, and then reassembled the mask. She could not recall if he had a bag in his room that the nebulizer mask was stored in. *After LPN H observed resident 79's nebulizer mask medication chamber, which was one-fourth filled with a clear liquid she stated that he must not have finished his nebulizer treatment. *LPN H verified the nebulizer chamber attached to the mask was one-fourth filled with a clear liquid and the bottom one-third of the mask was hazy and the inside of the mask was rough to the touch, which was also documented as the condition of the mask on 9/17/25 at 11:43 a.m., prior to his last nebulizer having been documented as administered. *She stated she must not have cleaned it well after resident 79 was administered his 1:02 p.m. nebulizer treatment. *LPN H verified the tubing on the nebulizer mask was dated 8/16 and stated she would have considered resident 79's nebulizer mask as soiled and it should have been replaced. *LPN H verified resident 79's nasal cannula, which was draped across his bed was not store properly and stated it should have stored in a plastic bag, and she would consider it contaminated after laying on resident 79's bed and that would require the nasal cannula to be replaced. 16. Interview on 9/18/25 at 3:52 p.m. with director of nursing (DON) B revealed: *She expected nasal cannulas to be stored in a plastic bag when not in use. *If a nasal cannula became contaminated by touching the floor or other soiled surface, she expected staff to replace the nasal cannula. *She verified the nasal cannulas on the beds, floor, wheelchair, and hairbrush would have all been considered contaminated and would need to be replaced. *Nasal cannulas were to be replaced monthly, and the replacement was to be documented in the resident's TAR. *CPAP mask and tubing were to be cleaned weekly with a vinegar and water solution and then hung to air dry. *The cleaning of the CPAP mask and tubing was to be documented in the resident's TAR. *DON B verified resident 16's CPAP mask and tubing had not been documented as having been cleaned for three weeks in a row during the month of August. *The provider did not have a CPAP policy. *She expected nebulizer masks to be disassembled, rinsed, and placed on a towel to airdry after each use. *The nebulizer tubing was not scheduled to be changed on a specific schedule, but after review of the description of resident 79's nebulizer mask she verified she would have considered his mask to be soiled, and it would have needed to be replaced. 17. Review of the provider's November 2018 Respiratory Care: Equipment Care and Handling policy revealed: *Respiratory equipment is handled in a manner that maintains good working order and promotes proper infection control. *General equipment change guidelines will be observed unless otherwise specified by regulation or physician's order: -a. Plastic bags are not used for storage, as they promote bacterial growth. *Nebulizers -Recommended Change Frequency PRN [as needed], Discard and replace if heavily soiled. -Storage & [and] Waste Empty &Discard in regular waste. Store hand held nebulizer in mesh bag, paper sack, or in compartment/container between each use. *Nasal Cannulas or Face Mask -Recommended Change Frequency PRN [as needed], Discard and replace if heavily soiled. -Store in mesh bag, paper sack, or in compartment/container between use. Review of the 11/24/21 Tabletop Compressor Nebulizer manufacturer's instructions revealed: *After each use, disassemble medicine cup into 3 sections. Wash in warm soapy water and rinse well. Wipe with a paper towel and allow to air dry. *It is important that the cleaning instructions are carefully followed to ensure optimal operation. *The disposable nebulizer T-Piece kit should be replaced after a long period of time of inactivity, or if it is obstructed by dry medication, dust, etc. With normal use, the disposable nebulizer T-piece kit should last 1 month. Review of the undated ResMed AirSense 10 manufacturer's instructions revealed: *You should clean the device weekly as directed. Refer to the mask user guide for detailed instructions for cleaning your mask. -1. Wash the water tub and air tubing in warm water using only mild detergent. Do not wash in a dishwasher or washing machine. -2. Rinse the water tub and air tubing thoroughly and allow to dry out of direct sunlight and/or heat. -3. Wipe the exterior of the device with a dry cloth.

Based on observation, interview, record review, and policy review, the provider failed to ensure:The Emergency Kit (E-Kit, a secured storage container stocked with specific medications that were used for a resident during an unplanned medical emergency) controlled medications (medications regulated by the government due to their potential for abuse or addiction) had been routinely accounted for.Narcotic administration and narcotic counts for two of three sampled residents (31 and 98) were accurately documented, and any discrepancies in those counts had been identified and reconciled. The destruction of one of one sampled resident's medication (98) was documented and accurately accounted for after it was not administered.Findings include:1. Observation inside medication room (1) and interview on 9/17/25 at 4:20 p.m. with medical records/certified medication aide (CMA) T revealed: The medication refrigerator in that room contained an E-Kit. There was a numbered, plastic tag on the outside of the E-Kit that was broken to remove the medications from inside that box. A list of medications inside that E-Kit was affixed to the outside of that E-Kit. That E-Kit had contained insulin pens. There was a second secured storage container inside that same refrigerator. The following controlled substances that belonged to residents 11 and 77 were inside it: three ABH (Ativan, Benadryl, and Haldol) topical dispensers. There was also an unlabeled bottle of unopened liquid Ativan inside its original box within the second storage container. Medical records/CMA T stated the above bottle of Ativan was part of the E-Kit, but it was too big to store inside the E-Kit. He was not sure if the contents of that Ativan bottle were regularly accounted for. Administrations from the ABH dispensers for residents' 77 and 11's were accounted for each day on their individual narcotic sheets. Interview on 9/17/25 at 4:30 p.m. with director of nursing (DON) B regarding E-Kit accountability revealed that if the plastic tag on the above E-Kit was broken and insulin was removed, the removal was documented on the inventory sheet inside the E-Kit. That completed sheet was then faxed to the pharmacy provider. The pharmacy provider restocked the E-Kit and placed a different numbered tag on it. There was no process for regularly monitoring the tag number to know if any of the E-Kit contents had been removed without notifying the pharmacy, but DON B had thought the likelihood of insulin being diverted (the illegal redirection of prescription drugs for unauthorized use) was probably low. Continued interview with DON B regarding the above Ativan that was a part of, but not inside of the E-Kit, revealed there was also no process for accounting for the contents of that bottle. She agreed that if the Ativan bottle had been improperly accessed or removed from the refrigerator, it would have been difficult to identify that it was diverted. She thought the likelihood of Ativan diversion was higher than insulin diversion. 3. Review of the provider's January 2025 Emergency Pharmacy Service and Emergency Kits (E-Kits) policy revealed no mention that any emergency medications were to be stored outside of the E-Kit. 4. Review of resident 31's 8/19/25 through 8/25/25 oxycodone (a federally regulated narcotic pain medication) narcotic reconciliation sheet (page 21) and resident 31's August 2025 medication administration record (MAR) and interview on 9/18/25 at 2:30 p.m. with DON B revealed:The above reconciliation sheet was divided into the following columns: the date the medication was administered, the time the medication was administered, the administration dose, the signature of the person who had administered the medication, and the quantity of remaining tablets after the medication was administered.There were numbered lines for each time a medication was removed from a medication card for administration. The reconciliation sheet showed that on 8/19/25, there were eight 5-milligram (mg) tablets of oxycodone. On 8/20/25, two tablets were removed for administration, on 8/21/25, one tablet was removed for administration, and on 8/22/25, two tablets were removed for administration. That left three remaining oxycodone tablets. Resident 31's MAR supported that each of those oxycodone tablets had been administered.The date, time, dose, and signature on line 6 of that sheet were missing, but a 2 was written on that line for the quantity of tablets that were remaining. Line 7 indicated on 8/23/25, oxycodone was removed for administration at 4:40 p.m., but there was no documented dose or a signature of the person who had removed that oxycodone. A 1 was written on that same line for the quantity of remaining tablets. Resident 31's MAR indicated there was no oxycodone administered on that date. There was a discrepancy between the narcotic reconciliation sheet and the MAR.DON B stated that on 9/12/25, the above accountability error was brought to her attention by the pharmacy provider during an on-site visit. DON B had contacted licensed practical nurse (LPN) M, who had worked on 8/23/25. LPN M stated she had administered two oxycodone tablets to resident 31 on 8/23/25, but she had failed to document those administrations on the MAR. She had not fully completed lines 6 and 7 of the reconciliation form. There was no documentation in resident 31's electronic medical record (EMR), on her MAR, or on the reconciliation sheet to explain that reconciliation error.4. Review of resident 31's 8/25/25 through 8/28/25 oxycodone narcotic reconciliation sheet (page 22) and resident 31's August 2025 MAR and continued interview with DON B revealed:The narcotic reconciliation sheet showed that on 8/25/25, there were 30 oxycodone tablets. Between that date and 8/28/25, six oxycodone were documented as having been removed for administration to resident 14. Line 6 on that sheet showed 24, the amount of remaining oxycodone tablets the resident should have had after those administrations. Resident 31's MAR supported that six oxycodone were administered.Beneath the 24 on line 6 of the reconciliation sheet was the number 23 with a circle around it. Under that, there was a line through the remainder of the page and the words, Sent home 8/28/25. Further down the page, the quantity of oxycodone tablets that were released to the resident or their responsible party was 23. That form was signed by DON B.DON B was not able to explain the discrepancy between the number of oxycodone tablets resident 31 should have had at the time of her 8/28/25 discharge (24) and the number of oxycodone tablets that were released (23).5. Review of resident 98's 8/27/25 through 8/30/25 diphenoxylate (opioid pain reliever)-atropine (used to prevent abuse of a medication) narcotic reconciliation sheet (page 15) and resident 98's August 2025 MAR and interview on 9/18/25 at 2:40 p.m. with DON B revealed:The physician's order for diphenoxylate-atropine was: Give 2 tablets by mouth four times daily for 3 days. Those medication administrations were scheduled for 6:00 a.m., noon, 5:00 p.m., and 11:00 p.m. Line 3 of the reconciliation sheet showed that on 8/28/25 at 9:08 a.m., two of the above tablets were removed for administration. That left 18 remaining tablets.Line 4 of the sheet showed that on 8/28/25 at 9:08 p.m., two of the tablets were removed for administration. There was a line drawn through the 16 in the Quantity Remaining column, and a 15 with a circle around it was written beside it. Resident 98's MAR documentation on 8/28/25 indicated she was administered her 6:00 a.m. dose of the above medication and refused the noon dose. Her 5:00 p.m. dose was held (not administered) due to illness, and the 11:00 p.m. dose was refused. DON B had no explanation why the 16 had been drawn through and replaced with a 15. The narcotic sheet supported the removal of two medications for administration, so the medication count should have been 16. Since those medications were not administered, the remaining medication quantity should have been 16. There was no documentation to support that the same two medications had been destroyed after they were held and not administered to the resident. 6. Review of the provider's January 2025 Emergency Pharmacy Service and Emergency Kits (E-Kits) policy revealed:6. The emergency kit, along with the list of contents posted on the outside of the kit, is maintained at a designated locked area that is easily accessible in an emergency. 14. d. The provider pharmacy may require additional forms or procedures to aid in controlled substance accountability as appropriate per state regulation.Review of the provider's January 2025 Medication Administration General Guidelines policy revealed: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.Review of the provider's January 2024 Disposal of Medications policy revealed: Procedures: 2. If a controlled medication is unused, refused by the resident or not given for any reason, the disposal is documented on the accountability record on the line representing that dose with the required signatures.Review of the provider's January 2025 Medication Storage policy revealed:[ 15. Controlled drugs should be reconciled at the time of final disposition.

Based on observation, interview, and policy review, the provider failed to ensure:One of one observed certified medication aide (CMA) (F) had followed a physician's order for the administration of one of one sampled resident's (55) blood pressure medication.One of one observed registered nurse (RN) (E) had not split one of one sampled resident's (77) antipsychotic medication without first confirming this was an acceptable and safe practice.One of one observed RN (E) had documented the destruction of one of one sampled resident's (77) antipsychotic medication.One of one observed RN (E) had not documented that she had administered medications that were administered by one of one CMA (G). One of one observed CMA (G) had not administered medications to one of one sampled resident (77) that were prepared by one of one RN (E).One of one observed RN (D) had followed the manufacturer's instructions for use of an inhaler that was self-administered by one of one sampled resident (97).Findings include:1. Observation and interview on 9/18/25 at 7:30 a.m. with CMA F, preparing resident 55's medications for administration revealed: The resident's 4/15/25 physician's order for Metoprolol Succinate (a high blood pressure medication) had included the following parameters for administering that medication: hold [the medication] if SBP [systolic blood pressure-the pressure in the arteries when the heart contracts] is less than 110. CMA F administered the above medication to resident 55 and then took the resident's blood pressure. The resident's blood pressure was 142/73. The systolic number (142) was greater than 110. CMA F stated, [the resident's] blood pressure is usually high. I didn't see it [the parameter information below the medication order]. She confirmed she had not followed the physician's order for administering resident 55's blood pressure medication. 2. Observation on 9/18/25 at 9:05 a.m. of RN E preparing resident 77's medications for administration revealed:a. RN E reviewed the resident's medication administration record (MAR) to prepare the resident's morning medications for administration. Those medications included a packet of topical pain reliever gel and 2.5 milligrams (mg) of olanzapine (an atypical antipsychotic medication). RN E pulled a 5.0 mg olanzapine medication card out of the med cart for resident 77. The resident had orders to take 5 mg of olanzapine at bedtime. RN E split the 5.0 mg olanzapine tablet to make 2.5 mg without first contacting a pharmacist or the resident's medical provider to ensure it was appropriate to have done that. She discarded the other half of that 5.0 mg tablet into a medication destruction container, but she had failed to document that destruction. b. Continued observation of RN E and CMA G during that same medication pass revealed:CMA G was standing outside of resident 77's room, a short distance away from RN E. Resident 77 had COVID-19 and was in isolation in her room. CMA G offered to put on personal protective equipment (gown, gloves, and face mask) to enter the resident's room and administer the above medications.RN E handed CMA G the Biofreeze packet and the medication cup with the olanzapine inside of it. She instructed CMA G to apply the Biofreeze to the resident's back. RN E initialed on resident 77's medication administration record (MAR) that she had administered those medications, but she had not administered them.3. Interview on 9/18/25 at 9:07 a.m. with RN E revealed it was beyond her scope of practice to have determined it was acceptable to have split resident 77's olanzapine. She also had not accounted for the other half of the 5.0 mg olanzapine tablet that she had destroyed. She was also expected to have administered the above medications because she had prepared them. She should not have delegated that task to CMA G.4. Interview on 9/18/25 at 9:15 a.m. with CMA G regarding the above medication administration revealed that she should not have administered any medications that she had not prepared herself. 5. Observation on 9/18/25 at 9:30 a.m. of RN D preparing resident 97's inhaler for administration revealed:RN D carried the inhaler and a cup of water into the resident's room. She handed the resident her Trelegy Ellipta inhaler and resident 97 self-administered one puff according to the physician's order. RN D handed the resident the cup water. Resident 97 swallowed some of the water before setting the cup down on her bedside table.Review of the Trelegy Ellipta inhaler instructions for use and interview on 9/18/25 at 10:30 a.m. with RN D revealed Step 6. Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water. RN D confirmed she had not properly instructed resident 97 regarding how the resident should have used her inhaler. 6. Interview on 9/18/25 at 2:30 p.m. with director of nursing (DON) B regarding the above observations revealed:Licensed nurses and CMAs were expected to review the entire physician's order, including any instructions, before administering a resident's medication. Resident 97's inhaler order should have included instructions regarding the use of water in conjunction with her inhaler. Staff who prepared residents' medications for administration were expected to be the same staff who administered those medications. Medications were not expected to have been split without first consulting a medical provider or pharmacist. The destruction of any medication was expected to have been documented. 7. Review of the provider's January 2025 Medication Administration General Guidelines policy revealed,Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber .2. Obtain and record any vital signs as necessary prior to medication administration.If breaking tablets was necessary to administer the proper dose: Medication Preparation-4.a. The administration of partial tablets is clearly identified or highlighted on the resident's MAR.5. The person who prepares the dose for administration is the person who administers the dose.Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.8. Review of the provider's January 2024 Disposal of Medications, Syringes, and Needles Disposal of Medications policy revealed: 3. Documentation of non-controlled medication may be completed on a medication administration record (MAR), a medication disposition log or form (or record provided for that purpose) and shall be retained as per federal privacy and state regulations.9. Review of the provider's January 2023 Medication Administration Oral Inhalations policy revealed, 15. For steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (79 and 84) were assessed for the ability to safely self-administer medications, and had a physician's order to self-administer medications according to the provider's policy.Findings include:1. Observation and interview on 9/17/25 at 9:54 a.m. with resident 84 in her room revealed:*There was a plastic cup used for medication administration on her over-the-bed table.*There were pills in the plastic cup.*There were no staff present in her room or within eyesight of resident 84 or the medications.*Resident 84 stated that staff had left her morning medications on her over-the-bed table so she could take them slowly with breakfast because some of the medications upset her stomach.Observation and interview on 9/18/25 at 8:43 a.m. with resident 84 in her room revealed:*There was a plastic cup used for medication administration on her over-the-bed table.*There were four pills in the plastic cup.*Resident 84 stated she was waiting for her breakfast to arrive to take her medication.*There were no staff present in resident 84's room to be sure she took her medications.2. Review of resident 84's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She had a 7/9/25 Brief Interview of Mental Status (BIMS) assessment score of 12, which indicted she was moderately cognitively impaired.*The 7/9/25 progress note documented one of the reasons for admission to the facility was that she was non-compliant with taking her medications.*Resident 84 did not have a physician's order to self-administer medications.*There was no medication self-administration assessment to determine if resident 84 was able to safely self-administer her medications in her EMR.3. Interview on 9/18/25 at 9:33 a.m. with director of nursing (DON) B revealed that resident 84 had not been assessed to determine if she was safe to self-administer her medications.4. Observation and interview on 9/17/25 at 11:43 a.m. with resident 79 in his room revealed:*There was an assembled nebulizer (a device that converts liquid medication into an inhalable mist) mask wrapped around the handle of resident 79's bedside table.*The nebulizer mask had a clear liquid substance remaining in the chamber.*Resident 79 stated he received his nebulizer treatment three to four times per day.*Staff would set up his nebulizer treatment and then some staff stayed in the room while he took the medication, and others would leave the room.*He would hang the nebulizer mask on the handle on his bed side table when he had completed his nebulizer treatment.5. Interview on 9/17/25 at 3:39 p.m. with licensed practical nurse (LPN) H revealed:*She had administered resident 79's nebulizer after lunch on 9/17/25.*At times she would remain in the room while resident 79 was being administered his nebulizer medication, but other times she would go out into the hallway while he was receiving his nebulizer medication.*LPN H verified there was a clear liquid remaining in the chamber of the nebulizer mask.*She stated resident 79 must not have finished his nebulizer. She documented in his EMR as having administered the medication after lunch.6. Review of resident 79 EMR revealed:*He was admitted on [DATE].*He had a BIMS assessment score of 11, which indicated he was moderately cognitively impaired.*Resident 79 had a 9/11/25 physician's order for Ipratropium-Albuterol Solution [ a medication used to open the air passages in the lungs to make it easier to breathe] 0.5 -2.5 (3) MG/3ML [milligrams per 3 milliliters] 3 ml inhale orally three times a day for pneumonia for 7 Days.*There was no physician's order for resident 79 to self-administer medications.*There was no medication self-administration assessment to determine if resident 79 was able to safely self-administer his medications.7. Interview on 9/18/25 at 3:52 p.m. with DON B revealed:*If a resident asked to self-administer their medications the interdisciplinary team (IDT) would assess that resident to determine if they could safely self-administer their medications.*If it was determined by the IDT team that the resident was able to safely self-administer their medications, there would need to be a physician's order in place prior to the resident being able to self-administer medications.*There were no residents who had a self-administration assessment and physician's order for self-administration of medications in the facility at that time.*She verified leaving medications at bedside for a resident to take on their own would have been self-administration of those medications.*She verified leaving a resident's room while the resident was receiving a nebulizer treatment would have been considered self-administration of the nebulizer.8. Review of the provider's September 2017 Self-Administration of Medications policy revealed:* If the resident desires to self-administer medications, the Self Medication Evaluation is completed. This evaluation is completed before the resident is able to self-administer.* If it is determined the resident may self-administer medications, the nurse:-a. Obtains a physician's order for self-administration for the specific medication(s).-b. Initiates the Self-Medication Administration Care Plan.Review of the provider's January 2025 Medication Administration policy revealed:* Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care centers' Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulation.* The resident is always observed after administration to ensure that the dose was completely ingested.

Based on record review, interview, and policy review, the facility failed to ensure accurate documentation of the resident's wishes involving their advance directives (a legal document that expresses a person's health care wishes if they become unable to speak for themselves)/code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) for one of one sampled resident (5).Findings include:1. Review of resident 5's medical record revealed:*She was admitted on [DATE].*Her [DATE] Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact.*There was a banner display in her electronic medical record (EMR), which indicated that she did not want CPR (cardiopulmonary resuscitation, an emergency procedure to provide chest compression and often rescue breathing to preserve brain function and maintain blood circulation).-There was a [DATE] physician's order for DNR (do not resuscitate). *Her advance directive, which was signed on [DATE] and had been scanned into the EMR, indicated that she did want CPR. 2. Interview on [DATE] at 11:06 a.m. with resident 5 revealed:*She had changed her advance directive on [DATE].*She confirmed that she did want CPR. 3. Interview on [DATE] at 11:41 a.m. with licensed practical nurse (LPN) H about how staff would know a resident's code status revealed:*There were two places to find a resident's code status.-They kept a binder with the signed forms indicating residents' wishes at the nurses' station.-In the EMR, code status was indicated on a banner display and in physician orders.*If the paper form and the physician's order did not agree, she would follow the physician's order. 4. Interview on [DATE] at 11:46 a.m. with director of nursing (DON) B about the advance directive process revealed:*When an advance directive form is received, the binder in the nurse's station should be updated with that form to accurately reflect the residents' wishes.*The physician should be contacted for an order to reflect that code status.*She confirmed that resident 5's advance directive form indicated that she did want CPR.*She agreed that the physician should have been contacted for a new order to reflect the accurate code status for resident 5, and the EMR should have been updated. 5. Review of the provider's [DATE] Advance Directive policy revealed:* It is the policy of this facility that residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.* During the admission process, written information is given to the resident/representative regarding the resident's right to make decisions concerning medical care, including the right to request, refuse, and/or discontinue medical or surgical treatment, to participate in or refuse to participate in experimental research and the right to formulate an advance directive. This includes the right to revoke these decisions at any time.* During the admission process, the facility identifies if the resident has an advance directive or medical orders related to life sustaining treatment. If the resident does, a copy is requested and kept in the resident's medical chart, accessible to the physician and care staff.* During the development of the initial comprehensive assessment and care plan, quarterly, annually, when significant changes in condition occur, or at the resident's request, discussion and documentation of the resident's choices regarding future health care occurs. A review of the advance directive.is included in the discussion.* The resident's comprehensive care plan is reviewed and updated routinely in order to incorporate the resident's choices regarding these rights into treatment, care and services.

Based on record review, interview, policy review, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1 October 2024, the provider failed to ensure that one of one sampled residents (13) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment was accurately coded for the area of active diagnoses.Findings include:1. Review of resident 13's electronic medical record (EMR) revealed:*She was admitted on [DATE].*Her 7/23/25 Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated she had moderate cognitive impairment.*She had a 4/8/25 diagnosis of bipolar disorder (a chronic mental health condition characterized by extreme mood swings), anxiety disorder (a chronic mental health condition characterized by excessive and persistent worry, fear, and nervousness), and depression.*She had no physician orders related to bipolar disorder.*There was no documentation to support the diagnosis of bipolar disorder. 2. A request for documentation related to and supporting the diagnosis of bipolar disorder was submitted to director of nursing (DON) B on 9/18/25 at 7:45 a.m.-The facility was unable to provide documentation to support that diagnosis during the survey. 3. Interview on 9/18/25 at 11:46 a.m. with DON B about resident 13's diagnosis of bipolar disorder revealed, We have searched through everything and cannot find out how or why it got in her chart. 4. Interview on 9/18/25 at 1:58 p.m. with MDS coordinator, registered nurse (RN) C, about the diagnosis of bipolar disorder revealed:*She did not remember adding the diagnosis.*She did not know where the diagnosis came from and could not find any documentation to support it.*She stated, It was an error on the admission MDS. 5. The provider did not have an MDS policy to review. 6. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 October 2024 page I-7 revealed:* I: Active Diagnoses in the Last 7 Days (cont.)-Item Rationale--Health-related Quality of Life---Disease processes can have a significant adverse effect on an individual's health status and quality of life.--Planning for Care---This section identifies active diseases and infections that drive the current plan of care.--Steps for Assessment---There are two look-back periods for this section:----Diagnosis identification (Step 1) is a 60-day look-back period.----Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period (except for Item I2300 UTI, which does not use the active 7-day look-back period).---1. Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days.---Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered.---2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses.

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, and record review, the provider failed to ensure:*One of one sampled resident's (77) Wander Guard was not removed by one of one licensed practical nurse (LPN) R.*The presence and function of one of one sampled resident's (77) Wander Guard was accurately documented by two of two LPNs (M and R) and one of one registered nurse (RN) (Q).*Transport driver P securely fastened the four safety hooks to the resident's (60) wheelchair in one of three facility-operated buses before the transport driver started transporting the resident to another location. Failure to ensure the safety hooks were securely fastened potentially placed the resident at risk for harm or injury.This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incidents.Findings include: 1. Review of the provider's 6/30/25 submitted SD DOH FRI final report regarding resident 77 revealed: Her diagnoses included dementia, and her cognition was severely impaired. She was at risk for wandering behavior and elopement. The resident wore a Wander Guard (a wearable door alarming device) on her wrist and on her wheelchair. This device sounded if she attempted to open a secured and alarmed door. On 6/25/25 at approximately 5:45 p.m., a staff member opened the entrance door for a visitor to exit the facility. From behind the reception desk, staff were able to allow the door to open without activating the alarm. The visitor went out the door to his car in the parking lot. Resident 77 was sitting by the front door at that same time. When the visitor returned to the facility from his vehicle, he noticed resident 77 was now outside the facility. It was presumed she had gotten out of the door before the door had fully closed behind the visitor. The visitor notified a staff member after he was let back inside the facility that the resident was outdoors. The root cause of the elopement was that the resident's Wander Guard was removed about 5:30 a.m. on 6/25/25 by an overnight shift nurse before the resident was sent out of the facility for medical treatment. The nurse had not documented the removal of the Wander Guard, and she was not certain if she had communicated that information to the day shift nurse. The resident returned to the facility at 8:30 a.m. that same day. Her Wander Guard was not replaced at that time. Nursing staff had documented on resident 77's Treatment Administration Record (TAR) that her Wander Guard was on her wrist and working the day shift on 6/25/25, the overnight shift on 6/25/25 to 6/26/25, and the day shift on 6/26/25, even though she was not wearing the Wander Guard. Review on 9/22/25 at 11:30 a.m. of the provider's FRI binder revealed the process changes, disciplinary action, education, performance improvement plan (PIP), and audits referenced in the provider's 6/30/25 submitted SD DOH FRI final report had been documented and completed. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 9/22/25 after record review revealed the facility had followed their quality assurance process and: The Elopement binder at the nurses' station was updated to reflect resident 77's need for Wander Guards on both her wrist and wheelchair. Appropriate nursing staff were educated regarding the provider's expectations regarding the removal of and documentation of a resident's Wander Guard use. Caregiver education was completed on 6/27/25 regarding the expectations for Wander Guard use. A Wander Guard Performance Improvement Plan (PIP) was initiated on June 26, 2025, and monthly audits associated with that PIP have continued. Signage was posted on the main entrance doors regarding steps to mitigate the risk of resident elopement. Daily Wander Guard checks were added to the certified nurse aide (CNA) task list. Based on the above information, non-compliance at F689 occurred on 6/26/25, and based on the provider's implemented corrective actions on 6/27/25, for the deficient practice confirmed on 9/22/25, the non-compliance is considered past non-compliance. 2. Review of the provider's 7/31/25 submitted SD DOH FRI regarding resident 60 revealed: *On 7/30/25 at 4:30 p.m., resident 60 was being transported from the facility to an appointment. -During the transport, transport driver P made a turn, and resident 60's wheelchair tipped to her right side, where she hit her right arm against the lift. -Transport driver P pulled the transport bus over to the side of the road and went to the back of the bus, assessed the situation, and resident 60 told transport driver P that her right arm hurt, and she had a small scrape on her right elbow from the lift. -Transport driver P had acknowledged that she did not secure resident 60's wheelchair with the floor straps and immediately secured resident 60's wheelchair with the floor straps before continuing to resident 60's appointment. -When returning to the facility, transport driver P notified a nurse of the incident with resident 60. *Transport driver P was suspended 7/30/25 pending the outcome of the investigation. 3. Review of transport driver P's personnel records revealed she had completed her competence for loading wheelchair passengers on 5/18/25. 4. Review on 9/22/25 at 1:13 p.m. of the provider's FRI binder revealed: *Suspended transport driver P effective 7/30/25 pending the investigation. *Safety checks were completed on all facility-operated buses on 7/31/25. *TELS (internal communication system) updated to include safety checks on all three facility-operated buses weekly for four weeks, then monthly indefinitely. *All transport drivers completed loading wheelchair passenger, unloading wheelchair passenger, and safe driving competencies on all three facility-operated buses, or will complete before next time driving a facility-operated bus. *All transport drivers are assigned to [NAME] Ability Four Point Wheelchair restraint and will be completed before the next time driving a facility-operated bus. *Order obtained for {local counseling provider} for resident 60. Daily 1:1 social worker visit to continue until {local counseling provider} was available to have an initial visit. *Disciplinary action was completed with transport driver P on 8/1/25 and reinstated. *Audits were completed three times per week with four residents to ensure the two front and two rear tie downs are secured to the wheelchair, the resident is secured using the lap seatbelt and/or shoulder strap if applicable, and the seat belts and tie downs are in good working condition. *Each transport bus was now equipped with a reminder sign that displays a reminder to verify all safety straps are secured to the wheelchairs, seatbelts are in place, and the lift is raised. 5. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed after record review revealed the facility had followed their quality assurance process, education was provided to all transport drivers regarding loading and unloading wheelchair passengers, [NAME] Ability Four Point Wheelchair restraint, and safe driving competencies had been completed. Audits were completed with no negative findings and discussed in QAPI. Based on the above information, non-compliance at F689 occurred on 7/30/25, and based on the provider's implemented corrective action on 8/7/25, for the deficient practice confirmed on 9/22/25, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review the provider failed to complete a baseline care plan for one of one recently admitted sampled resident (38) within 48 hours of her admission to the facility.Findings include:1. Review of the 8/9/25 SD DOH FRI regarding resident 38 revealed:*On 8/8/25 resident 38's daughter had called the facility to report resident 38 had told her that on the evening of 8/7/25 a staff member was rough with resident 38 while performing cares.*Resident 38 was admitted on [DATE] after a repair of her right tibia (a bone in the lower leg) fracture.*Resident 38 was to be transferred with the use of a full body mechanical lift (a mechanical lift and sling used to lift a person's full body) according to her care plan.*On 8/7/25 at approximately 8:00 p.m. certified nursing assistant (CNA) N and CNA O were getting her ready for bed.*CNA N assisted resident 38 to transfer from her wheelchair to bed with the use of a slide board (a sturdy, smooth-surfaced transfer board as a bridge to move a person from one surface to another).*Resident 38 stated CNA N rushed her and was rough when she assisted resident 38 to lift her legs into her bed.*Resident 38 was not injured but stated the transfer was painful and she did not want CNA N to care for her.*Interview with CNA N revealed she had used the slide board to transfer resident 38 to bed at resident 38's request.*CNA N did not feel she was rough or had rushed resident 38.*CNA O stated she did not think CNA N had been rough but stated the transfer did not go well due to utilizing the slide board instead of the full body mechanical lift.2. Review of resident 38's electronic medical record revealed:*She was admitted on [DATE] and discharged on 9/12/25.*The admission progress note stated, staff assist of 2 with total body lift/ medium divided leg sling and medium toilet sling for transfers.*Resident 38 was non-weight baring on her right leg.*Resident 38's baseline care plan was initiated on 8/5/25 but was not completed until 8/8/25.*The intervention related to resident 38's weight baring restrictions, RLE NWB [right lower extremity nonweight baring] was initiated into the baseline care plan on 8/12/25.*The intervention related to how resident 38 transferred by Mechanical lift was initiated into the baseline care plan on 8/12/25. That intervention was not initiated until seven days after her admission.*On 8/5/25 the admission progress note, written by resident care manager (RCM)/ registered nurse (RN) I stated resident 38 and her daughter declined review of resident 38's care plan.3. Interview on 9/18/25 at 10:50 a.m. with licensed practical nurse (LPN) J revealed:*She referenced the residents' care plans to determine what care a resident required.*If she needed to determine how a resident transferred, she would reference the resident's care plan or the daily care sheet (a sheet printed daily that identified the cares and needs of each resident according to the resident's care plan).*She stated the care sheets were updated daily.4. Interview on 9/18/25 at 11:55 a.m. with RCM/RN I revealed:*She had completed resident 38's admission and baseline care plan.*The baseline care plan was developed within the admission Nursing Evaluation in the resident's EMR during the admission process.*RCM/RN I verified resident 38's baseline care plan had not been completed within 48 hours after admission to the facility.*She stated she reviewed the resident's care plan with new residents and the resident's representative during the admission process and then offered them a copy.*She stated most resident's and resident's representative refused a copy. She would document that it was offered in her admission progress note.*She verified resident 38's baseline care plan was not completed at the time she offered it to resident 38 and resident 38's daughter.*She would have completed it immediately and printed a copy for them at that time if they would have wanted a copy.*When asked how the staff would know what cares to provide a newly admitted resident if there was no baseline care plan to outline the resident's plan of care, she stated there was a care sheet for staff to reference that was updated daily.*She stated she was the primary person responsible for updating the daily care sheets but there were other management staff who were also able to update them.*Review of the 8/7/25 care sheet for resident 38 revealed she was non-weight-bearing to her right lower extremity, had a fall prior to admission to the facility which resulted in a fracture of her right tibia, and she was a Hoyer lift (full body mechanical lift) for transfers.5. Interview on 9/18/25 at 3:52 p.m. with director of nursing (DON) B revealed:*She expected a resident's baseline care plan to be completed within 48 hours after admission, and staff to follow the resident's care plan when they provided resident cares.*She verified resident 38's care plan was not completed within 48 hours after admission to the facility.*After review of resident 38's 8/5/25 admission Nursing Evaluation with DON B she verified within the Ambulation, Mobility, and Transfers portion of the evaluation it indicated resident 38's needs were:- Ambulation Assist: 1 Person-Mobility Device: Gait Belt-Mobility Device: Walker-Mobility Device: Wheelchair-Transfers: Assist: 2 Person-Transfers: Assist: Independent-Transfers: Total body lift -medium divided leg sling & [and] medium toileting sling were all selected to be included in resident 38's baseline care plan.*The provider did not have a policy related to baseline care plans. They referenced the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 October 2024.6. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 October 2024 revealed:* Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.* Within 48 hours of admission to the facility, the facility must develop and implement a Baseline Care Plan for the resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of care.

Based on record review, interview, and policy review, the provider failed to ensure that one of one sampled resident (13), who had a categorical convalescent period of 100 days (referring to a person recovering from an illness or operation) preadmission screening and resident review (PASRR) (a federally mandated program that screens individuals to ensure that those with a serious mental illness (SMI) or an intellectual or developmental disability (ID/DD) receive appropriate care in the correct setting), was rescreened when resident 13 stayed in the facility for over 100 days. Findings include:1. Record review of resident 13's electronic medical record (EMR) revealed:*She was admitted on [DATE].*Her initial preadmission screening from the hospital dated 4/7/25 indicated that she did not have a serious mental illness or developmental disability, and she had been approved for a period of 100 days.-The expectation was that the facility would rescreen the resident within the 100-day period for which she had been approved.*There was no documentation in the EMR to indicate that resident 13 had received any subsequent PASRR screening. 2. Documentation of all PASSR screenings for resident 13 was requested from director of nursing (DON) B on 9/18/25 at 7:45 a.m.-The facility was unable to provide documentation during the survey showing they had completed any PASRR screening for resident 13 after the initial screen on 4/8/25. 3. Interview on 9/18/25 at 11:46 a.m. with DON B revealed:*Social services director (SSD) S was responsible for completing the residents' PASRR screenings.-SSD S was not onsite during the survey.*She had reached out to SSD S to discuss the PASRR screening for resident 13.*SSD S had agreed that additional PASRR screening should have been completed for resident 13. 4. Review of the provider's 1/1/25 PASRR Process Policy and Procedure revealed:* Upon admission to the facility the Admissions Coordinator, Medical Records Director or designee validates a PASRR Level I is included in the admission paperwork. If there is no PASRR Level I, the Medical Records Director or designee contacts the hospital to obtain.* If a Level II Evaluation is indicated the Social Worker validates, within a timely period, that a LMHP [licensed mental health provider] is scheduled to evaluate.* Once the Level II Evaluation is complete, the Social Services Director will give to the Medical Records Director to be placed in the EHR [electronic health record]. * Social Services Director may keep a tracking log. If used, this log should include the following:-Resident admit date -PASRR I in the chart-Positive PASRR I has a referral for evaluation-Date the Level II evaluation is completed-Date the Level II is placed in the chart-Date an invalidation is placed in chart.* Follow up as needed per Federal PASRR rules. 5. Review of the 9/25 South Dakota Medicaid [NAME] and Policy Manual, Preadmission Screening and Resident Review (PASRR) revealed:* Federal Requirements- The PASRR process requires that all individuals applying to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have SMI or ID/DD. This is called a Level I screen. Those individuals who test positive at a Level I are then evaluated in depth, called Level II PASRR. The findings of this evaluation result in determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care.* Level I Process- Categorical Determination- Abbreviated Level II --This abbreviated process of PASRR is permitted because the individual meets certain categorical criteria. When an individual meets the criteria for one of these categories, it means that the evaluation of their SMI and/or ID/DD is not necessary at that time. However, the determination of meeting level of care for the nursing facility is still required. Some categories are time limited, meaning that the individual may be subject to a full PASRR Level II evaluation following admission.-- The current South Dakota categorical options are:--- The physician identifies the need for convalescent care following a hospitalization for a duration of less than 100 days. Requires documentation by a medical provider supporting the convalescent stay.* Resident Review/Status Change Process- Short Term/Categorical Concludes--When a categorical decision or short-term approval concludes, federal law requires that PASRR be involved to determine whether continued nursing facility care is appropriate if the provider believes that the individual's stay should extend beyond the authorized period.--- The nursing facility must submit a new Screening Form to Maximus, marking Resident Review.--- This must be completed by or before the last approved day after admission to the nursing facility.* Nursing Facility Responsibilities- To avoid non-payment for Medicaid recipients, nursing facilities have the responsibility to:-- Ensure that if a Short Term/Categorical stay needs to be renewed, the new PASRR is fully processed prior to the ending approval date.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure that allegations of abuse for one of one resident (1) were promptly investigated and reported. Failure to promptly investigate and report the allegation may have put all residents at risk for potential abuse. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's 1/28/25 submitted SD DOH FRI final report regarding resident 1 revealed: *A progress note indicated that on 12/29/24 at 1:00 p.m., resident 1 reported to licensed practical nurse (LPN) E, who was not assigned to care for resident 1 that day, that: -Resident 1 had asked certified nurse aide (CNA) G to stay out of her room, but CNA G continued to stay in her room. -CNA G used inappropriate language and gestures towards the resident. -CNA G had used her phone to take pictures of and record the resident. *Another progress note from 12/29/24 indicated that: -Registered nurse (RN) D, who was assigned to care for resident 1 that day, was notified by CNA F that resident 1 told CNA F that CNA G had been disrespectful to her while providing personal care. -RN D went to resident 1 with two unidentified staff members to find out what concerns the resident had with CNA G or the care she provided. -Resident 1 said she had no concerns. -It also indicated that CNA F wrote a statement about the incident that resident 1 complained to her about. *RN D and LPN E contacted the former assistant director of nursing (ADON) C, who was the manager on call, to notify her of the incident. -RN D reported to ADON C that resident 1 was having behaviors toward staff. -LPN E reported to ADON C that the resident had concerns about a CNA who had cared for her, but she did not provide specific details of what the resident had reported, only that resident 1 did not want that specific staff member in her room. -ADON C asked RN D and LPN E to document the interaction and not have that staff member provide care for resident 1. *On 12/30/24, the progress notes were reviewed by director of nursing (DON) B at the interdisciplinary team (IDT) meeting, and she asked social services director (SSD) H to speak with resident 1 to get more specific information. -SSD H spoke with resident 1, but no further information was elicited. *The incident was not reported to administrator A, law enforcement, or SD DOH, and no investigation was initiated at that time. *During a 1/21/25 discharge follow-up call by LPN I, resident 1 repeated the allegations of CNA G's use of inappropriate language and gestures towards her, and that CNA G had used their phone to take pictures and record her. -LPN I reported this information to administrator A, who initiated an investigation and reported the allegations to law enforcement and SD DOH in an initial report on 1/22/25. *That investigation validated the allegation of verbal abuse, and CNA G was terminated from working in the facility effective 1/24/25. Interview on 5/28/25 at 1:48 p.m. with CNA J revealed: *CNA J stated she would report any suspected abuse to a nurse, and if the nurse did not act on the allegation, she would report the information to the charge nurse and then the unit manager, if no action was taken. *She had recently received education on reporting potential abuse. *How to identify and report potential abuse was also discussed at a recent staff meeting. Interview on 5/28/25 at 4:37 p.m. with DON B revealed: *She confirmed that she failed to timely investigate and report the 12/29/24 incident that involved resident 1. *She felt that the staff was doing really well with the ongoing education that was being provided. *She stated she was much more diligent in investigating all potential concerns. Interview and record review on 5/28/25 at 3:15 p.m. with administrator A revealed the disciplinary action, education, interviews, and audits referenced in the provider's 1/28/25 submitted SD DOH FRI were completed and documented. The provider's implemented actions to ensure the deficient practice does not recur was confirmed onsite on 5/28/25 after record review revealed the facility had followed their quality assurance process and: *DON B received disciplinary action for failing to report and investigate in a timely manner. *DON B was assigned and completed education on abuse prevention on 1/22/25. *ADON C was educated to ask clarifying questions when staff called to report resident behaviors or resident requests to avoid specific caregivers being assigned to them. *LPN E was educated to report exactly what residents share with her, which could indicate potential abuse or neglect situations. *All nursing staff were educated to honor a resident's request to leave their room. *All nursing staff were educated to follow up with the administrator or DON if they reported an incident and had not received feedback from the administrator or DON regarding that incident. *All nursing staff completed a HIPAA confidentiality training course and reviewed the policy regarding video camera and phone use in the facility. *All nursing staff received education on the provider's Abuse Reporting and Response policy. *Audits were conducted by Administrator A for daily reviews of residents' progress notes over two weeks to ensure that all potential abuse or neglect events were reported and/or investigated in a timely manner. *Staff interview confirmed they understood the education provided. Based on the above information, non-compliance at F609 occurred on 12/29/24, and based on the provider's implemented corrective actions on 1/24/25, for the deficient practice confirmed on 5/28/25, the non-compliance is considered past non-compliance.

Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure: *A physician-ordered diet order was followed for one of one sampled resident (1). *Appropriate and timely emergency medical intervention was initiated for one of one sampled resident (1) who choked during a meal service. On [DATE] at 9:00 a.m., an Immediate Jeopardy was identified for a FRI related to the quality of resident care and treatment that occurred on [DATE]. The investigation revealed verbal and written education initiated on [DATE] removed the immediacy. Substantial compliance was confirmed on [DATE] after review of the provider's Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) minutes, documented staff education, competencies and audit information, personnel files, observation of the main kitchen and dining room, and multiple staff interviews. The provider was found to have past non-compliance at F684 related to the provider's failure to ensure a physician-ordered resident diet order was followed and appropriate emergency medical intervention was initiated timely. On [DATE] at 2:15 p.m. the Immediate Jeopardy template was electronically mailed to administrator A for reference. Findings include: 1. Review of the SD DOH FRI regarding resident 1 revealed: *She choked in the main dining room during a noon meal fed to her by her visiting sister on [DATE]. *Staff provided abdominal thrusts then administered cardiopulmonary resuscitation (CPR) after she became unresponsive. -She passed away at the facility after emergency medical personnel arrived and took over the chest compressions until an emergency room physician ordered to cease CPR. Review of resident 1's electronic medical record (EMR) revealed: *She was [AGE] years old and her date of admission to the facility was [DATE]. *Her diagnoses included: spastic hemiplegic cerebral palsy, Parkinson's disease, atrial fibrillation, depression, and anxiety. *A [DATE] physician's code status order to: DNR (do not resuscitate). *A [DATE] physician's diet order for: Regular texture, mildly-thick liquid consistency. Minced and moist meats and full supervision; NO straws. Add moisture to meats for diet. *Her [DATE] quarterly Minimum Data Set (MDS) assessment indicated she had no broken or loosely fitting dentures. The resident held food in her mouth during and following meals. She coughed or choked during meals. *Registered dietician E's [DATE] quarterly assessment indicated the resident required staff assistance to be fed. Her diet included mildly thick liquids and minced and moist meat. Interview, review of personnel files, and review of the certified nurse aide (CNA) job description on [DATE] at 10:20 a.m. with human resources (HR) manager C revealed: *The licenses or certifications for a sample of staff identified in the FRI (registered nurse B, CNA/certified medication aide G, and CNA H) were current. *Review of the updated [DATE] CNA job description revealed CPR certification was not a requirement of that position. *HR manager C stated: -Several CNAs became CPR-certified after the incident and another group of CNAs was scheduled to take a CPR course in [DATE]. The facility's goal was to have all CNAs CPR-certified. -Managers on duty were now expected to be CPR-certified. -A facility RN planned to become a CPR instructor for the facility. Interview on [DATE] at 10:44 a.m. with dietary manager (DM) D revealed: *Cook F failed to correctly prepare and plate resident 1's meal and was terminated from employment on [DATE]. *Resident 1's tray card indicated her meat was to have been minced and moist in consistency. -The breaded cod served to her on [DATE] was not put through the food processor and no moisture was added to it before it was served to resident 1. *DM D had documentation to support on [DATE] cook F was able to satisfactorily read and interpret recipes and verbalize the variations in therapeutic diets, modified diets, and liquids. Observation and continued interview with DM D in the kitchen revealed: *Information related to the International Dysphagia Diet Standardization Initiative (IDDSI-used to describe texture modified foods and thickened liquids) was found in the food prep area. -Various other modified diets and thickened liquid information was posted in other places in the kitchen. *Review of a random unidentified resident's tray card who received a minced and moist meat diet revealed: -A legible diet order was on one side of the card. -On the other side of the card in capital letters was MM (minced and moist) beside the description of the main entree for lunch that day (spaghetti). *The kitchen had an adequate supply of pre-thickened beverage options and pre-measured thickening packets to be used to thicken beverages such as coffee. -Any other beverage that required thickening was thickened by the dietary staff with other liquid thickening products. Interview on [DATE] at 12:15 p.m. with CNA H revealed: *She was assisting another resident at resident 1's table when the choking incident occurred. *Resident 1's breaded cod was chopped into pieces when it was served. -CNA H knew the resident received a modified diet but was not certain if the texture of the fish was correct or not. She had not asked another staff for clarification. *Since the incident: -All staff were re-trained on modified diet textures. CNA H now knew resident 1''s fish should have had a more pureed type look like wet cat food when it was served to her on [DATE]. -Thickener packets were removed from the beverage station and kitchen staff were expected to thicken resident beverages when indicated. *The FRI report interview with CNA H indicated: she [CNA H] went over and assessed [resident 1], and she thought resident 1 was blue so then she started yelling out. -CNA H had not administered abdominal thrusts to resident 1 because she received mixed responses from other staff who were present as to whether or not she was allowed to perform that maneuver. Abdominal thrusts can and should have been initiated by her or any other CNA for a choking resident. *She completed a lot of on-line learning and trainings (in-house) related to the FRI and verbalized an understanding of what she was expected to do moving forward. Interview on [DATE] at 12:30 p.m. with certified medication aide (CMA)/CNA G revealed she: *Was one of the first staff to arrive in the dining room after a call to help resident 1 was heard. *Provided the resident a few back blows in the dining room, then was instructed to move the resident out of the dining room before performing the first abdominal thrusts the resident received. CMA/CNA G was expected to have immediately started abdominal thrusts in the dining room rather than waiting to move the resident to another location before starting them. *Initiated chest compressions after resident 1 was moved to her room and after she was directed to do so by assistant director of nursing (ADON) I. CMA/CNA G was not CPR-certified at the time of the incident and should not have performed that intervention. *Stated A lot of refreshers [training] and education was provided regarding how staff were to respond to a similar situation should it happen again. Interviews on [DATE] at 11:15 a.m., 11:30 a.m., and 12:45 p.m. with director of nursing (DON) A regarding the FRI revealed: *In addition to the cook, caregivers were also responsible for ensuring residents received the diets per their physician's order. -Diet texture pictures are now posted at the kitchen serving window for caregivers to use to compare against the diet order on a resident's tray card. *The use of the abdominal thrust maneuver was taught in the CNA training curriculum and expected to have been performed by CNAs when indicated. *In most cases the execution of emergency medical interventions was not expected to have been interrupted or delayed by moving the resident to an alternate location(s) first. *ADON I was suspended and then terminated on [DATE] for directing CMA/CNA G to start CPR on resident 1. *A detailed plan of action was completed by the facility on [DATE] related to resident 1's choking incident. The plan was based on a Root Cause Analysis of the FRI and resulted in the development of multiple performance improvement plans. -These plans included systemic changes and actions such as staff education and re-training, audits, checklists, competencies, and personnel changes to ensure the deficient practice does not reoccur. The changes and actions were confirmed on [DATE] through observation, interview, and review of the provider's Plan of Correction binder. Based on the above information, non-compliance at F684 occurred on [DATE]. Based on the provider's implemented plan of correction for the deficient practice confirmed on [DATE], the non-compliance is considered past non-compliance.

Based on a facility reported incident (FRI) review, observation, interview, record review, and manufacture operator's instruction review, past noncompliance was confirmed for an incident occurring on 4/29/24. Findings include: 1. Review of the provider's 4/29/24 SD DOH FRI revealed: *On 4/29/24 certified nursing assistant (CNA) E did not use a standing frame mechanical lift as directed in the manufacturer's instructions and resident 2's care plan when she released the safety buckle while the resident was in the lift, and he fell . -Resident 1 was not injured. 2. The provider's implementation of systemic changes to ensure the deficient practice does not recur was confirmed after: record review revealed the facility had followed their quality assurance process, education was provided to all direct care staff regarding mechanical lift safety and following resident's care plan/care sheets, observations and interviews revealed staff understood how to correctly operate mechanical lifts according to each resident's individualized care plan/care sheet, a new device evaluation was completed regarding resident safety utilizing a standing frame lift, review of the appropriate sling sizes for each resident's mechanical lift needs, review of staff schedules confirmed staffing levels met resident assistance needs, and verifying certified nurse aide (CNA) competencies and audits were being performed. Based on the above information, non-compliance at F689 occurred on 4/29/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 5/22/24, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were followed by: *One of one licensed practical nurse (LPN) D during three of three dressing changes for one of one sampled resident (63) . *Two of two certified nursing aides (CNA) (E and F) during catheter care for one of two sampled residents (129). Findings include: 1. Observations and Interview on 4/2/24 at 3:02 p.m. with LPN D while changing 2 dressings on resident 63 revealed: *The resident was sitting in her wheelchair. - She had a dressing on her right foot and another one on her left hand. *LPN D: -Placed a plastic bag with wound dressing supplies in it on resident 63's bed. -Washed her hands and put gloves on. -Without placing a barrier between the resident's hand and her wheelchair, she remove a pair of scissors from her front pocket, used those scissors to remove the soiled dressing. -Opened the plastic bag and removed a bottle of wound cleansing spray and wound dressing supplies. -Did not wash her hands. -Put on a clean pair of gloves. -Opened an iodine packet, and cleaned the wound, removed wound packing and gauze from the plastic bag, and applied it to the wound. -With those same gloved hands, removed the wound wrapping from the plastic bag, and wrapped the wound. -She had cleaned the scissors at the nurse's station and placed them in her pocket before entering the room. -Her usual practice was to use a barrier between the plastic bag with wound supplies in it and the surface she places the plastic bag. *Removed those gloves, washed her hands and put on clean gloves. *Removed the resident's shoe from her right foot. *Removed the old dressing from the resident's foot, with those same unclean scissors. *Removed an iodine packet from the plastic bag and cleaned the wound. *With those same gloves on removed wound wrapping, from the plastic bag, wrapped the foot, and again removed supplies from the plastic bag. -Removed the soiled gloves and without washing her hands, secured the wound wrap with tape. *Would have usually changed gloves between soiled and clean dressings. *She should not have reached into the plastic bag and removed items with soiled gloves on. 2. Observation and interview on 4/2/24 at 3:25 p.m. with LPN D while changing resident 63's PICC line dressing revealed: *Resident 63 was sitting in her wheelchair and had a PICC line in her upper right arm. *LPN D washed her hands and placed the dressing kit for the PICC line dressing change kit on the bedside table with no barrier under the kit, opened the kit, removed a mask, and placed it on her face, leaving her nose exposed. -There was a second mask in the kit that did not get placed on resident 63. *She applied sterile gloves and removed the soiled dressing without placing a barrier between resident 63's arm and clothes. *She removed the soiled gloves and without sanitizing she applied sterile gloves. *She opened supplies from the kit and dropped them on the sterile field, touching resident 63's arm multiple times during the process to prevent her from touching her arm to her clothes. *With the Chloraprep applicator she cleaned the skin above the catheter site and then cleaned the top of the PICC line catheter. She did not clean around, under, or outside the area of the PICC line. *Without applying skin prep she placed the PICC line on resident 63's arm and secured it in place. *She grabbed the IV guard off the bedside table from under the sterile field, opened the sterile IV guard, placed it around the PICC line, applied a clear dressing onto the PICC line site, and secured it with tape above the IV access ends. *With the same gloves on she removed the PICC line access end from one of the PICC lines, replaced it with a new one without cleaning it. *She stated: -She did not have a second access end to change the second PICC line, and would change it later. -It had been a while since she had changed a PICC line dressing and was not comfortable doing it by herself. -She was taught to apply the new sterile access end to the PICC line as fast as she could. -Wiping the open PICC line before applying the new sterile access end with alcohol before applying a new sterile access end made sense to her. -She agreed she had removed the soiled gloves and did not wash her hands. -She would usually offer a mask to the resident after she put her mask on. 3. Interview on 4/4/24 at 1:24 p.m. with infection control nurse C regarding the above observation revealed she stated: *The above practice is not acceptable. *More wound and PICC line dressing change training was needed. *The director of nursing (DON) was responsible for educating nurses on wound and PICC line dressing changes. 4. Interview on 4/4/24 at 1:52 p.m. with DON B revealed she: *Was responsible for education on dressing and PICC line dressing changes. *Stated the above observation were not an acceptable. *Had recently educated staff nurses on dressing changes. 32332 5. Observation and interview on 4/4/24 at 10:10 a.m. of CNAs E and F while providing catheter care to resident 129 revealed: *Both CNAs performed hand hygiene and put on gloves. *CNA F removed several wet wipes from the package, placed them directly on the resident's bedside table, performed hand hygiene, and applied new gloves. -The bedside table had a drinking glass and other resident-use items on it. *CNA F had not: -Cleaned the table before placing the wet wipes on the table. -Removed the personal items from the bedside table. -Placed a barrier on the bedside table before she placed the wet wipes on it. *CNA E: -Left the bedside to locate a pair of pants for the resident. -Left her gloves on and moved about the room touching several surfaces with those same gloves on. -Returned to the resident and assisted the resident without changing her gloves.*CNA F stated she should have placed a clean barrier on the table before setting the wet wipes. *CNA E stated she should have performed hand hygiene and applied clean gloves before she returned to assist the resident. 6. Interview on 4/4/24 at 11:00 a.m. with infection control nurse C confirmed: *The bedside table should have had a barrier between the table and the clean wet wipes. *The CNA should have washed her hands and put on clean gloves before assisting the resident. 7. Interview on 4/4/24 at 12:30 p.m. with DON B confirmed: *The bedside table should have had a barrier between the table and the clean wet wipes. *The CNA should have washed her hands and put on clean gloves before assisting the resident. 8. Review of the provider's undated Giving Catheter Care Guidelines revealed:*Practice hand hygiene. *Use gloves. *Cover the over-bed table with paper towels. -Arrange items on top of them. [barrier] 9. Review of the provider's updated March 2018 Handwashing/Hand Hygiene policy revealed: *Personnel are trained and regularly in-service on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. *Use an alcohol-base hand rub or wash hands for the following situation: -b. Before and after direct contact with resident; -d. Before and after performing any non-surgical invasive procedures; -e. Before and after handling an invasive device (e.g. urinary catheters, IV access sites); -f. Before donning sterile gloves; -h. Before moving from a contaminated body site to a clean body site during resident care.; -i. After contact with a resident's intact skin; -k. After handling used dressings, contaminated equipment, ect.; -l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; and -M. After removing gloves. *-The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infection. 10. Review of the providers updated July 2014 Dressing Technique, Aseptic Competency form revealed: *3. Provide a clean surface, such as paper towel, to place treatment supplies in room and a plastic bag for disposal. Dressing supplies must be in sterile packages. *4. Wash hands and apply gloves. *6. Remove soiled dressings and dispose in plastic bag with gloves. *7. Wash hands if visibly soiled or use gel hand sanitizer if not. *8. Open dressing supplies, leave in sterile packages, and place on aseptic field. *9. Apply gloves. *10. Perform treatment as ordered. *12. Remove gloves and wash hands if visibly soiled or use gel hand sanitizer. 11. Review of the provider's 08/16 Dressing Change for Vascular Access Device (CVAD) policy revealed: *For Midline and all CVAD's: -1. Wash hands and don mask and clean gloves. -2. Assess insertion site for signs and symptoms of complications. -3. Remove existing dressing and any stabilization device. -4. Remove gloves. -5. Perform hand hygiene. -6. Don sterile gloves. -7. Using sterile technique, prep site with alcohol to remove skin oils, followed by the primary antiseptic (Chloraprep). Use a gentle scrubbing motion. Clean an area larger than dressing to be applied.

Based on observation, interview, record review, review of the facility-reported incident (FRI), and policy review, the provider failed to maintain a secured environment for one of one sampled resident (1) with a history of wandering and severe cognitive impairment who had eloped on 12/25/23 outdoors and into a fenced courtyard approximately 100-150 feet from the door he had exited from. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE] and currently resided at the facility. *His diagnoses included Alzheimer's dementia, psychosis, and a history of prostate cancer. *His 10/11/23 Brief Interview for Mental Status (BIMS) score was 3 indicating he had severe cognitive impairment. *He was able to ambulate independently. *He wore a Wanderguard (a system that alerts caregivers when a resident approaches and/or opens an alarmed door) on his wrist due to his history of wandering and exit-seeking behavior. *The Wanderguard was tested daily by staff in the morning and in the evening to ensure it was working properly. -That testing was documented on the resident's monthly Treatment Administration Record (TAR). Review of the FRI submitted by administrator A to the South Dakota Department of Health on 12/26/23 at 11:30 a.m. revealed: *On 12/25/23 at roughly 12:00 a.m. resident [1] was found outside of the building. -He was seen by staff inside the facility no less than 5 to 8 minutes prior to the event referred to above. *No door alarm had sounded when the resident exited the building. *The provider's 12/26/23 investigation of the incident revealed the following: -The door alarm battery was noted to be depleted [not functioning] when it was checked. -Door alarm checks had not been implemented on weekends or holidays and that was when the elopement occurred. -The speaker volume for the alarm activation system at the nurses' station was turned down. Review of the updated March 2018 Elopement/Wandering policy revealed for the use of door monitoring systems 2. The maintenance department or designee tests the monitoring system [of alarmed doors] on a daily basis using the manufacturer supplied device [as applicable] and documents the test. Interviews on 1/2/24 at 11:30 a.m. and 12:05 p.m. with director of nursing A and director of maintenance B revealed non-compliance at F689 was considered past non-compliance. The provider implemented corrective actions for the deficient practice by completing the following steps: *Having the maintenance director assume responsibility for monitoring and documenting weekday door alarm testing effective 12/30/23. -Weekday door alarm checks were completed by nursing staff prior to 12/30/23. -Director of maintenance B asked nursing staff for the results of door alarm checks completed the previous day and documented the results in the TELS system (computerized health care maintenance system) without validating those results himself. *Having the Activity Department assume responsibility for monitoring and documenting weekend and holiday door alarm testing on the Daily Door Alarm Test Log. -Test Log documentation between 12/30/23 and 1/2/24 was reviewed and verified by the survey team. *Re-setting the speaker volume on the alarm activation system at the nurses' station and securing the system with a keypad lock accessible only by management staff. *After activating a door alarm the survey team confirmed the following had occurred: -Staff appropriately responded to the alarm. -The speaker volume of the activation system was acceptable. The survey team determined there had been a deficient practice on 12/25/23 when resident 1 eloped. The survey team was able to verify the provider recognized the deficient practice, implemented corrective actions on 12/26/23 and was monitoring to ensure no re-occurrence of the previous deficient practice occurred.

Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were maintained for the following: *Proper hand hygiene for one of one certified nurse aide (CNA) I during a transition in personal care between two of two randomly observed residents (63 and 67). *Use of an uncleanable foam wedge by one of one sampled resident (21). *Proper gown use for one of one licensed practical nurse (G) (LPN) during wound care and two of two CNAs (H and I) during personal care for one of one sampled resident (21). *Cleaning of one of one mechanical lift by one of one observed CNA (L). *Routine cleaning of four of four medication carts. Findings include: 1. Observation and interview on 2/28/23 at 8:09 a.m. with CNA I revealed: *He entered resident 63's room without performing hand hygiene before obtaining her blood pressure and pulse oximeter reading. *Enhanced barrier precaution signage on her room door read: EVERYONE MUST: Clean their hands, including before entering and when leaving the room. *He exited her room and without performing hand hygiene and immediately entered resident 67's room. -Helped him transfer to a wheelchair, transported him out of his room to be weighed, returned him to his room, and assisted him back into bed. *He exited the room and performed hand hygiene. *There was enhanced barrier precaution signage on his room door. *Agreed he had not but should have performed hand hygiene after leaving resident 63's room and before entering resident 67's room. Review of the updated March 2018 Handwashing/Hand Hygiene policy revealed: 7. Use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -b. Before and after direct contact with residents; -n. Before and after entering isolation precaution settings; 2. Observation and interview on 2/28/23 at 1:44 p.m. with CNA I in resident 21's room revealed: *Enhanced barrier precaution signage on her room door read: Wear gloves and a gown for the following High-Contact Resident Care Activities that included changing briefs or assisting with toileting. *He transferred the resident out of the bathroom with a mechanical lift, lowered her into her wheelchair, removed his gloves, washed his hands, and left the room. *CNA I stated he had worn gloves while assisting the resident with toileting and washed his hands following that care. -Gowns were only worn if a resident received wound care. 3. Continued observation and interview with resident 21 revealed: *A rectangle shaped piece of foam on top of her bed. *She: -Used it at night between her upper legs to prevent skin to skin contact. -Tended to sweat and was incontinent of urine. -Had occasionally rinsed the wedge in water to clean it. 4. Interview on 3/1/23 at 9:20 a.m. with LPN G regarding resident 21's foam piece revealed: *The resident brought it from home when she was admitted a few months ago. *She used it between her legs for body alignment when she laid on her side. *There was no cover for the foam and the foam was uncleanable. 5. Observation on 2/28/23 at 3:30 p.m. of LPN G and CNA H in resident 21's room revealed: *LPN G wore a mask and gloves when she changed the dressing on the resident's left side wound. -Slight bleeding occurred after she had removed the dressing. *CNA H wore a mask and gloves when she assisted the resident to use the toilet after the wound care was completed. 6. Interview on 3/1/23 at 9:20 a.m. with LPN G regarding gown use with resident 21 revealed she: *Had known enhanced barrier precautions were followed during personal care with the resident. *Had not worn a gown during the wound care because she felt the incontinency pad she had placed between the side of the resident's wheelchair and underneath the resident's left leg was sufficient to absorb blood from her wound and keep that blood away from her. *Had not realized until after she read the enhanced barrier precaution signage on the resident's door that gown use was expected during wound care, changing briefs or assisting with toileting. 7. Interview on 3/2/23 at 12:20 p.m. with assistant director of nursing/infection control nurse D revealed: *Hand hygiene was expected to have been performed by CNA I upon entering and exiting residents' rooms. *Resident 21 had a history of a MRSA infection (8/30/22) and unspecified escherichia coli (E-Coli) (2/1/23). *The piece of foam she had been using was expected to have a cover on it that was cleanable. *Gown use was expected by LPN G, CNAs H and I during resident 21's wound care and toileting. Review of the July 2022 Enhanced Barrier Precautions policy revealed: 2. Enhanced Barrier Precautions requires use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDRO [multi-drug resistant organisms] to hand and clothing of healthcare personnel. 42558 8. Observation and interview on 2/28/23 at 8:15 a.m. of resident 171's transfer with a mechanical lift by CNA L revealed: *CNA L cleansed and gloved her hands, and was wearing a barrier gown. *CNA L placed the resident onto a mechanical lift sling and attached the sling to the mechanical lift that had been brought into his room from the hallway. -She placed his Foley urine catheter bag on his lap. -The resident then held on to the sling and was lifted off of his bed and was placed into his wheelchair. *During the mechanical lift transfer CNA L, with those same gloved hands, touched the mechanical lift's handles, sling bars, and the lift control screen. -CNA L then removed the sling from underneath the resident and placed it on the resident's bed. -Following the transfer, the mechanical lift was removed from the resident's room and placed into the hallway without being disinfected. *Following the above observation CNA L stated: *That was her normal routine for mechanical lift transfers. -The lift slings were for individual use and remained in the resident rooms. -The mechanical lift was used on multiple residents throughout the day. *Her normal cleaning routine for the re-usable mechanical lift was once per shift and if it was visibly soiled. Review of resident 171's care record revealed he: *Had been receiving intravenous antibiotics after becoming septic from a urinary tract infection and a lung infection. -Had a peripherally inserted central catheter (PICC) intravenous (IV) line in his left arm. --This PICC line gave access to the large central veins near his heart. -Had an indwelling urinary Foley catheter. *Staff should have been following enhanced barrier precautions for his protection during his personal care. Review of the provider's May 2015 Cleaning and Disinfecting Resident Care Items and Equipment policy revealed: *Procedure: -1.d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). -3. Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident. 9. Observation and interview on 3/1/23 from 11:40 a.m. through 12:33 p.m. of the medication carts on [NAME] and Watson hallways revealed: *The [NAME] and Watson hall carts had multiple small dried white and tan splash marks scattered over the exterior of the cart's drawers and brown flecks along the base of the carts. *Registered nurse (RN) M stated she cleaned the top flat surface of the medication cart at the start of her shift. Interview on 3/1/23 at 2:00 p.m. with director of nursing C revealed she was unsure if there was a medication cart cleaning schedule or a medication cart cleaning assignment task sheet. 10. Observation on 3/2/23 at 10:15 a.m. through 10:45 a.m. of the Watson, Garmin, and Dunn, medication carts revealed: *The same dried splash marks remained on the exterior of the Watson cart as was noted the day prior. *The Garmin and Dunn medication carts revealed multiple dried white and tan splash marks scattered over the exterior drawers and the interior drawers had scattered dried multi-colored particles stuck to the bottom surfaces. *The second drawer of the Dunn hall medication cart had multiple strands of hair laying inside the bottom of the drawer. Interview on 3/2/23 at 11:00 a.m. with resident care manager/registered nurse E regarding the above findings revealed: *She was unsure when the medication carts were to have been cleaned. *It was her expectation for the carts to be cleaned regularly. A medication cart cleaning policy was requested on 3/2/23 at 12:15 p.m. division director of clinical operations B stated there was no policy. Interview on 3/2/23 at 12:20 p.m. with assistant director of nursing/infection control nurse D regarding the above findings related to infection prevention and control revealed: *Her expectations for disinfecting mechanical lifts was, They are supposed to wipe down the handles and things between residents. *All staff had access to disinfectant wipes and personal protective equipment. *Her expectation was for the medication carts to be wiped down, inside and out, each shift.

Based on observation, interview, and policy review, the provider failed to ensure appropriate procedural techniques had been followed for: *One of one sampled resident (15) by one of one resident care manager/registered nurse (RCM/RN) (E) during the removal of her midline intravenous (IV) catheter used for medication administration. *One of one licensed practical nurse (LPN) G during inhaler medication administration for one of one sampled resident (38). Findings include: 1. Observation and interview on 3/1/23 at 1:00 p.m. with RCM/RN E during the removal of resident 15's IV catheter revealed she: *Performed hand hygiene, cleaned the top of the bedside table, laid a barrier on top of that cleaned table, and set her supplies down. *Put on a gown, performed hand hygiene, and applied a pair of gloves. *Had resident 15 seated upright in her wheelchair. *Removed the tape and dressing on top of the IV line in the resident's upper left arm. *Without changing her gloves or cleansing around the IV site, she had the resident exhale while she slowly removed the IV catheter. *Placed a dry gauze pad on the insertion site, and applied pressure until bleeding stopped. *Changed her right glove and placed a sterile dressing on top of the insertion site. *Stated it was not uncommon for the facility to care for residents requiring IV medication administration. -Needing to remove IV catheter access for those residents who completed their IV medication course occurred about once every other week. *Had not been trained at the facility to ensure the proper removal of an IV catheter. Interview on 3/1/23 at 3:45 p.m. with division director of clinical operations B and DON C revealed: *They had provided a copy of the revised August 2021 Pharmerica Vascular Access Devices and Infusion Therapy Procedures Catheter Removal policy that RNs were expected to follow for IV catheter removal. -Pharmerica was the pharmacy the provider used for resident medications as well as intravenous therapy needs. Interview and review of the Pharmerica policy referred to above on 3/1/23 at 4:00 p.m. with RCM/RN E and RCM/RN F revealed: *They had access to computer-based facility policies but had been unable to locate a facility policy for IV catheter removal. *They had never seen the Pharmerica policy referred to above and would not have thought to contact Pharmerica with IV catheter removal questions. *RCM/RN E had not followed the Pharmerica policy when she had discontinued resident 15's IV catheter. Interview, review of the catheter removal observation referred to above, and review of the Pharmerica policy referred to above on 3/2/23 at 9:15 a.m. with division director of clinical operations B and DON C revealed: *Staff would not have known to contact Pharmerica regarding infusion related questions. *The Pharmerica policy and procedure manual was located in the medication room. -That manual was found in the medication room unopened and still in its original sealed packaging. *For midline and PICC (peripherally inserted central catheters) removal RCM/RN E had not: -Placed the resident in supine flat or Trendelenburg position unless it was contraindicated. -Removed her gloves and performed hand hygiene after removing the old dressing. -Cleansed the insertion site with an appropriate antiseptic solution per policy prior to discontinuing the IV catheter. -Applied a sterile ointment or Vaseline gauze to the insertion site once the catheter was removed and the bleeding had stopped. 2. Observation and interview on 3/1/23 at 10:00 a.m. with LPN G administering resident 38's inhaler revealed she: *Entered his room and administered his Symbicort inhaler. *Brought no water for him to swish in his mouth or a cup to spit that water back into after he had used the inhaler. *The resident had his own mug of water with a straw through the lid on his over-bed table. *Provided the resident no instruction to swish and spit water after he inhaled the medication. *Knew swishing and spitting was expected after inhaler use but sometimes the resident had refused to do that. -Agreed she still should have offered him a means to properly rinse his mouth after inhaler use. Review on 3/1/23 of resident 38's physician order summary revealed: *A 2/7/23 order for a Symbicort inhaler. -Instructions for use included rinsing the mouth with water after use and not swallowing the water. Interview on 3/1/23 at 11:55 a.m. with resident 38 regarding inhaler use revealed he: *Had not used an inhaler prior to his admission on 2/2/23. *Would have swished and spit if he was asked to. *Used a Lifesaver or swallowed some water to rid his mouth of the taste of the inhaled medication. Interview on 3/2/23 at 9:05 a.m. with director of nursing (DON) C regarding resident 38's inhaler administration revealed she would have expected LPN G to: *Enter the resident's room with a cup of water for him to use to swish and spit after he used the inhaler. *Provide needed instruction and educated the resident about the reason for swishing and spitting after the inhaler use. *Document and report repeated resident refusals to swish and spit. Review of the updated November 2018 Guidelines for Administration of Aerosolized Care (Nebulizers and Inhalers) policy revealed the resident was expected to have been instructed to rinse their mouth after the last puff of medicine, spit out the water, and not swallow it.

A. Based on observation, interview, maintenance logbook review, and policy review, the provider failed to ensure privacy had been maintained for: *One of one sampled resident (21) whose window blind had been left open during her personal care. *Two of two random residents' rooms (111 and 349 B) with window blinds that were missing vertical slats and unable to have been completely closed. *One of one random resident's room (340 B) that had no window covering. Findings include: 1. Observation and interview on 2/28/23 between 3:45 p.m. and 4:15 p.m. with certified nurse aide (CNA) (H) and licensed practical nurse (LPN) G in resident 21's room revealed: *The resident was raised off the seat of her wheelchair by CNA H using a mechanical lift. *She faced the window and the vertical blinds on that window were opened. -A sidewalk was visible looking out the window as well as the north end of the facility's parking lot *LPN G lowered the resident's pants below her buttocks and pulled up her shirt exposing her abdomen. -She completed a dressing change to a wound on the resident's left side. *Both CNA H and LPN G agreed the resident's privacy had not been protected with the blinds that had been left open during the wound care. *CNA H stated even if the window blinds had been closed the resident's privacy still would not have been protected. -When the blinds were closed there were two center slats missing leaving an opening large enough to see inside and out of the window. *Other resident rooms including room [ROOM NUMBER] had vertical blinds that also had missing slats. *CNA H was unsure if maintenance director J had been made aware of the privacy issues. 2. Interview on 3/1/23 at 3:30 p.m. with resident 21 revealed she: *Had not noticed her blinds were left open during her wound care on 2/28/23. *Was aware her window blinds had missing center slats. 3. Observation on 2/28/23 at 4:30 p.m. of a semi-private room [ROOM NUMBER] A and 111 B revealed: *The blinds on the A side window of the room were missing four slats. -Three of those slats sat on the windowsill beneath the blinds. *The blinds on the B side window of the room were missing two slats. -One of those slats sat on the windowsill beneath the blinds. *There was a resident currently occupying the A side of the room but not the B. 4. Interview on 3/2/23 at 8:25 a.m. with maintenance director J regarding resident room maintenance revealed: *Resident rooms were checked monthly for maintenance needs. -That included looking at window blinds for something major wrong with them. *He had replaced quite a few of the blinds lately but had not known about the condition of the blinds in resident 21's room or in room [ROOM NUMBER]. *When he assessed window blinds during his room checks they were usually opened so he would not have seen any missing slats. *Staff were expected to have documented room maintenance issues in the maintenance log at the nurses' station. Review of the maintenance logbook entries between 1/1/23 and 3/1/23 revealed: *On 1/3/23: Put up blind standing by closet in room [ROOM NUMBER] B. *On 1/23/23: Son requests new blinds room [ROOM NUMBER] B. *On 2/24/23: Blinds on small window room [ROOM NUMBER]. Observation on 3/2/23 at 9:00 a.m. of rooms 349 B, 342 B and 340 revealed: *There were two center slats missing on the vertical blinds in room [ROOM NUMBER] B so they were unable to have been closed completely. *Window blinds in room [ROOM NUMBER] B had no missing slats and were able to have been completely closed. *There was no window covering in room [ROOM NUMBER]. 5. Interview on 3/2/23 at 9:10 a.m. with director of nursing C revealed she expected: *Blinds or privacy curtains to have been closed during residents' personal care. *Blinds were in good working order to ensure residents' privacy was protected. *Maintenance director J was promptly notified and there was immediate resolution for any issues regarding resident window coverings. A Privacy/Dignity policy was requested on 3/1/23 at 2:45 p.m. from administrator A however she indicated the facility had no policy. Review of an updated November 2016 EmpRes Healthcare Management, LLC Notice of Resident Rights Under Federal Law document found in the facility's resident admission packet revealed: *Residents have the following rights under Federal law: -14. The Resident has the right to a dignified existence and self-determination. -15. The Resident has the right to be treated with respect and dignity. -29. The Resident has the right to a safe, clean, comfortable, and homelike environment . 42558 B. Based on observation, interview, and policy review, the provider failed to ensure: *One of one sampled resident's (27) medical record was secured and not accessible to other residents, staff, and the public. *One of one medication cart was locked and medications were not accessible to other residents, staff, and the public by one of one licensed practical nurse (LPN) K during the morning medication pass. Findings include: 1. Observation on 3/2/23 at 7:44 a.m. of the Dunn hall medication cart computer revealed: *It was located in the Dunn hallway and there were no staff within view of the medication cart. *The medication computer screen was facing the hallway and was open to resident 27's medication record. *That record was visible to any resident, staff, or visitors passing by the medication cart. *It contained the following: -The resident's name. -Diagnoses. -Medications. -admitted and date of birth. -Current picture. -Medical provider. -Cardiopulmonary status. -Allergies. -Diet. -Room location. *An unidentified resident had been sitting in his wheelchair in a doorway directly across from the medication cart within view of the computer screen. 2. Continued observation on 3/2/23 at 7:45 a.m. of the same Dunn hall medication cart also revealed: *The medication cart had been unlocked, allowing residents, staff, and visitors, access to the drawers of the cart. *Upon surveyor inspection, the drawers had contained: -All of the Dunn hall residents' prescription medications. -Various over-the-counter medications. -Finger stick lancet needles and insulin pen needles. -Bandage scissors and skin treatment supplies. -Liquid and injectable medications. *The unattended medication cart was monitored for three minutes before licensed practical nurse (LPN) K came out of an adjacent room, which was not within view of the cart. Interview on 3/2/23 at 7:47 a.m. with LPN K regarding the above observations revealed: *Normally she would not have left the medication cart unlocked and the computer screen open to a resident's medication record. -She had been called away from the medication cart to assist a resident. *Agreed she should have locked the medication cart and computer screen to ensure the residents' information was kept confidential. *Agreed anyone could have had access to the contents of the medication cart. Interview on 3/2/23 at 7:48 a.m. with assistant director of nursing/infection control nurse D and resident care manager/registered nurse (RCM/RN) E regarding the above findings revealed: *It was their expectation the medication cart and the computer screen should have been locked every time a staff member left the cart unattended. *They had provided continued education to staff regarding securing the medication carts and resident's private information. -RCM/RN E voiced staff had been educated and re-educated. A medication cart policy regarding the above findings was requested on 3/2/23 at 12:15 p.m. from division director of clinical operations B. She indicated no such policy existed. Review of the November 2016 EmpRes Healthcare Management, LLC Notice of Resident Rights Under Federal Law document found in the facility's resident admission packet revealed: *Residents have the following rights under Federal law: -11. The Resident has the right to personal privacy and confidentiality, and security of his/her clinical records.

Based on interview, review of a South Dakota Department of Health complaint intake, grievance binder, resident council minutes, job description review, and policy review, the provider failed to ensure the facility was operated and administered by executive director (ED) A to ensure quality management and improvement processes had been implemented for all seventy-four residents in the facility. Findings include: 1. Interview on 11/9/22 at 5:15 p.m. and on 11/10/22 at 9:45 a.m. with ED A regarding the grievance process revealed: *Her current oversight of the grievance process was ensuring grievance forms were discussed during weekday morning stand-up meetings with department managers and identifying the most appropriate staff person to investigate that grievance. *There were two binders in a canvas bag on the floor of her office that held grievance tracking and trending reports. *That trending information was expected to be discussed during monthly Quality Assessment and Assurance (QAA) committee meetings. -The QAA committee had not met since February 2022. *Performance Improvement Projects (PIPs) were expected to be identified by the QAA committee for things that had driven quality of care and services like grievances. *There were informal PIPs for things like the use of [MEDICATION(S)] patches, medication administration, and skin care. -There was no formal process for determining if any changes made as a result of those PIP had been effective or sustained. 2. Review of the revised November 2016 Grievance policy revealed: *2. The Executive Director (ED), Social Services/designee oversees the grievance procedure and coordinates the Center system for collecting, tracking, and responding to grievances. *12. The ED reviews the Grievance Log at the Daily Stand-Up Meeting for needed resolution and/or follow-up. If a Grievance is not resolved in two business days, the ED reviews the Grievance daily at the meeting until resolution obtained. *13. Social Services/designee analyzes grievances monthly for tracking and trending. Identifiable trends are addressed through the QAPI [Quality Assessment and Performance Improvement] Committee. Review of the revised October 2018 QAPI plan policy revealed: *Governance and Leadership: -1. The Executive Director is responsible and accountable to the corporation to ensure QAPI is effectively implemented and integrated throughout the center. They are responsible for managing QAPI activities so they remain continuous, without lapses or interruptions. Also they are accountable to the governing body for requested documentation to be complete and submitted timely. *6. Leadership and Management Supported: -QAPI meetings are held on a monthly basis.

Based on review of a South Dakota Department of Health complaint intake, grievance forms, resident council minutes, interview, and policy review, the provider failed to: *Follow their process for resolving, tracking, and trending grievances. *Investigate and report back to the resident council findings for call light response time and staffing concerns they voiced during two of two resident council meetings. Findings include: 1. Review of the August-October 2022 grievance forms revealed: *Five reports of long call light response times in August, two in September, and four in October. *Administrator-in-training (AIT) B had investigated those reports. *Action taken in response to those grievances included: -Comparing the reported call light response time against a call light alarm report which showed the time a call light was activated and the time it was turned off. -Educating staff regarding expected call light response time (15 minutes), appropriate placement of the call light, asking for assistance if needed to respond to a call light, reminding staff not to turn a call light off before the resident's need was met, and having night shift carry a walkie talkie when working on an identified living unit where the automated system that identifies what room a call light has been activated cannot be heard. -Encouraging staff to ask residents following meals if they had any needs after dinner since that was a difficult time to be able to answer call lights promptly. Interview on 11/10/22 at 9:20 a.m. with AIT B regarding the grievances referred to above revealed he: *Was hired in May 2022 and his training on the grievance process had been a continuous education process with executive director (ED) A. -Worked together with her initially to learn the process and expectations, began completing them on his own after he gained sufficient experience, and continued to confer with her on an as needed basis. *Had not known if his grievance actions referred to above had any effect in decreasing the frequency of call light response time or reducing the time in which call lights had been responded to. *Had made the following observations regarding the call light grievances: -Residents admitted for short term rehabilitation seemed to use their call lights more frequently than long term care residents. -Residents who refused to leave their rooms for meals had a higher rate of reporting long call light wait times at mealtimes. -Call lights were often activated at shift changes, 6:00 a.m., 2:00 p.m., and 10:00 p.m. -The automated system that announced what room a call light had been activated cannot consistently be heard on the short term rehabilitation living unit. *Discussed grievances during the weekday morning stand-up meeting, but there was not a formal process for identifying a root cause for those grievances, developing an action plan to address those grievances, collecting and reviewing data to determine if an action plan had been effective. Interview on 11/9/22 at 5:15 p.m. and on 11/10/22 at 9:45 a.m. with ED A regarding the grievance process revealed: *Her current oversight of the grievance process was ensuring grievance forms were discussed during weekday morning stand-up meetings with department managers and identifying the most appropriate staff person to investigate that grievance. *There were two binders in a canvas bag on the floor of her office that held grievance tracking and trending reports. *Trending information was expected to be addressed through the Quality Assurance and Assessment (QAA) committee. -The QAA committee had not met since February 2022. Interview on 11/10/22 at 8:21 a.m. with social services director D regarding the grievance process revealed: *She was responsible for counting the total number of grievances each month, reviewing and identifying any trends or patterns related to them. *ED A e-mailed her each month for a report of her findings that were expected to be discussed during the QAA committee meeting. -ED A had last e-mailed her the beginning of August 2022 for her July 2022 grievance report. *There had not been a QAA meeting since about February 2022. Interview on 11/9/22 at 5:30 p.m. and on 11/10/22 at 9:20 a.m. with ED A regarding the grievance process revealed she: *Was responsible for ensuring administrator-in-training B and all department managers understood their departmental expectations regarding quality performance. *Was responsible for effectively overseeing the QAA committee and grievance processes, but that had not occurred. -She had made other responsibilities a priority. 2. Review of the August-October 2022 resident council minutes revealed: *New business for the 8/18/22 meeting included: Nursing care for the weekend is short handed at times. *Old business for the 9/15/22 meeting included: -No mention of follow-up regarding the weekend staffing concern identified at the 8/18/22 meeting. -Call lights-waiting a long time to answer-continues to still be a concern for the committee-new grievance form completed. *New business for the 9/15/22 meeting included: Call light times need to be attended to in a more timely manner. *Old business for the 10/18/22 meeting included no mention of follow-up regarding call light response time discussed at the 9/15/22 meeting or the weekend staffing concern identified at the 8/18/22 meeting. *ED A had signed off on, but not dated the August 2022 meeting minutes, signed and dated the September 2022 minutes on 10/20/22, and not signed off on the October 2022 resident council minutes. Interview on 11/10/22 at 11:20 a.m. with an unidentified resident revealed: *She tried to attend resident council meetings when she could. *She had not known if concerns expressed at those meetings by residents were followed-up on. -Call light response times still seemed too long at times. -Sometimes she heard staff complain they were short staffed. Interview on 11/10/22 at 1:00 p.m. with activity director C and ED A regarding resident council revealed: *Activity director C was responsible for coordinating and overseeing resident council meetings including: -Documenting concerns expressed by council members on grievance forms, investigating those concerns with the assistance of other interdisciplinary team members, and reporting back to resident council the outcome of those investigations. -Discussing resident council grievances during QAA committee meetings in order to identify opportunities for process improvements. *She had not completed the grievance form referred to above in old business from the 9/15/22 meeting nor had she completed any new grievances voiced by council members during the August 2022 and September 2022 meetings she facilitated. -That was her responsibility and it had not occurred. *She confirmed resident council minutes had not reflected if the council had been updated on actions taken regarding grievances expressed during the previous month's council meeting, but should have. *She was hired in July 2022 and stated it had been a learning process understanding the responsibilities of her role as the activity director. *ED A confirmed it was her responsibility to hold activity director C accountable for her departmental quality performance including the documentation, follow-up of resident council grievances, and sharing grievance follow-up with council members, but that had not occurred. 3. Review of the revised November 2016 Grievance policy revealed: *2. The Executive Director (ED), Social Services/designee oversees the grievance procedure and coordinates the Center system for collecting, tracking, and responding to grievances. *12. The ED reviews the Grievance Log at the Daily Stand-Up Meeting for needed resolution and/or follow-up. If a Grievance is not resolved in two business days, the ED reviews the Grievance daily at the meeting until resolution obtained. *13. Social Services/designee analyzes grievances monthly for tracking and trending. Identifiable trends are addressed through the QAPI Committee. Review of the revised January 2017 Resident Council policy revealed: *5. Concerns brought forth by the Council are resolved via the Center grievance policy. *7. The Center communicates a response and/or decisions to the Resident Council by the next meeting.

Based on observation, record review, interview, job description review, manufacturer's review, and policy review, the provider failed to assess and document the safest method of transfer for one of one sampled resident (5) who had a change in condition. Findings include: 1. Review of resident 5's medical record revealed she had: *Resided on the Dunn Hallway. *[DIAGNOSES REDACTED]. -That stroke had resulted in left sided weakness. *Been dependent upon the staff to assist her with all activities of daily living. *[DIAGNOSES REDACTED]. -That stroke had resulted in left sided weakness. *Been dependent upon the staff to assist her with all activities of daily living. *Dislocated her shoulder from a fall on 9/18/16. -That fall involved the use of an EZ Stand mechanical lift used by one staff member. *A Brief Interview Mental Status score of a fifteen per her revised 11/29/16 care plan. -That score had indicated her memory was intact. *Used an EZ stand lift with transfers prior to a fall on 9/18/16. -No transfer assessment had been completed to support that type of transfer. -No documentation on how many staff were required to assist her with the EZ stand lift. *A transfer assessment completed on 10/30/16 directed staff to use a Hoyer mechanical lift. -The staff whether licensed or unlicensed like the CNA staff could determine whether to use one or two staff during the transfers. *No transfer assessments had been completed prior to 10/30/16. Review of resident 5's CNA pocket care plan revealed: *From 9/1/16 through 9/18/16: -She had required the use of an EZ stand lift for all transfers. -No documentation on how many staff members were required to assist her with that transfer. *From 9/19/16 through 12/5/16 she had required the use of a Hoyer lift for all transfers. -No documentation on how many staff members were required to assist her with those transfers. Observation on 12/6/16 at 1:35 p.m. of CNAs A and Q with resident 5 revealed: *They had retrieved a Hoyer mechanical lift and entered the resident's room. *The resident had been sitting in her wheelchair (w/c) and was waiting for the CNAs to transfer her to the bed. *They applied the necessary sling underneath of the resident, hooked that sling up to the Hoyer lift, and transferred the resident into her bed. Interview on 12/6/16 at the time of the above observation with CNAs A and Q revealed: *Resident 5 had required the use of the Hoyer lift for the past two months. *The resident had used the EZ Stand mechanical lift prior to using the Hoyer lift. -She had fallen on 9/18/16 from that EZ Stand mechanical lift. *The staff had: -Been required to use two staff when transferring her with the Hoyer lift. -Used one or two staff when transferring a resident with the EZ Stand lift. --They could decide on how many people to use. *They used CNA pocket care plans to direct them for the type of transfer to use with each resident. -Those CNA pocket care plans had not always been specific on how many staff members to use with a transfer. Review of resident 5's progress notes from 9/1/16 through 12/5/16 revealed on the following: *9/16/16 at 10:15 a.m., registered nurse (RN) F documented: RT (restorative therapy) aide (staff initials), informed this author that resident was not able to hold onto the handles on the EZ stand and was having issues like she was sliding out of the sling. This RN spoke with resident there after and (resident name) stated that she wasn't feeling good. (resident name) stated that her acid reflux was acting up and she had some med from the nurse. Informed this information to the RT aide. *9/17/16 at 12:35 p.m., activity aide (AA) Z documented: I invited rsident to come to bingo and she attended and had good participation with a little help just to reach some numbers. *9/18/16 at 6:06 p.m., AA Z documented: I took a newspaper to (resident name) and visited for 5 minutes. *9/18/16 at 9:50 p.m., RN O documented: -Situation: Late entry: Resident being transferred to bed via EZY Stand Lift. Resident slid out of sling landing on top of bed. -Background: Resident slid out of sling of Stand lift on top of bed on left side with body on the bed and legs extended out to the floor. Bed in low position. -Assessment: Note red area to left knee, c/o left arm pain at the antecubital area. No redness or bruiding noted. Palpated left shoulder, no c/o pain at shoulder area. -Response: Resident repositioned in bed. Ice pak (pack) to left arm. Fall protocol initiated. Resident refused to be sent to the (hospital name) ER. Call to ADON and DON with voice message left. Physician to be faxed and POA to be contacted by day shift. *9/19/16 at 3:42 a.m., unidentified charge nurse documented: (hospital name) calls and informs resident is returning via ambulance. ED states Resident had a dislocated shoulder. It was placed back in and will need to wear immobilizer for awhile with limited mobility. *9/19/16at 7:57 a.m., LPN M documented: -Concerns/issues: 9:50 p.m. resident sustained [REDACTED]. She was being transferred from the bathroom to her bed. CNA reported that the lift had backed the resident to her bed. The resident was about to sit on the bed when she slipped out of the lift. Her feet were on the floor and her body fell on the bed and leaned on her left side, on the left arm. She complained immediately of pain in the biceps region of the upper arm. She repeated this pain at 11. Shortly thereafter she complained of the shoulder. In a lying position she could not tolerate laying her arm across her chest. The shoulder was markedly larger. No redness, skin was intact. The left arm laid in a semi external rotation. The palm of the hand was open in a prone position. ADON was contacted. She wanted the arm assessed prior to any other transfers. Vital signs had been taken prior to her departure to the ER at 1:00 a.m. -3:50 a.m: Resident returned to (facility name) post closed shoulder reduction. *No professional documentation: -Of any assessments or further monitoring of the resident between 9/16/16 at 10:15 a.m. until she fell out of the EZ stand lift on 9/18/16 at 9:50 p.m. and dislocated her shoulder. -Between the hours of 9:50 p.m. on 9/18/16 and 3:42 a.m. on 9/19/16 to support the documentation completed at 7:57 a.m. by LPN M. Review of resident 5's 9/18/16 Fall Scene Investigation Report completed by registered nurse (RN) O and CNA DD revealed: *Factors Observed at time of fall: -Clutter, furniture. -Clutter makes it difficult to maneuver resident in easy stand. *Fall summary: Fall to bed (witnessed) in resident's room. *She had been assisted per care plan. *The resident Slid out of sling from easy stand while being transferred. *Re-creation of last 3 hours before fall: Getting ready for bed - cooperative. Transferring to bed with easy stand. Slid out of sling falling down to bed landing on left side. Legs extended over bedside. *Root cause of this fall: Safety strap not in place. *Resident was being transferreed by CNA (not identified) from toilet to the bed. *What appears to be the root cause of the fall: One staff person (new CNA) (not identified) transferring resident. This resident needs to be a two person transfer. Recliner chair if no longer used needs to be out of room. *Fall team meeting notes: -Lay down mechanical lift with 2 people for transfers. -There was no documentation for the conclusion and additional care plan updates sections. -All of the facility department heads had signed and dated that form. Review of the 9/19/16 final Healthcare Online Self Reporting form documented by the director of nursing (DON) revealed: *The type of event being reported was Suspiciaon/Allegation of Abuse/Neglect. *The incident had occurred on 9/18/16 at 21:50 (9:50 p.m.). *Explanation of event being reported was: Resident 5 (BIMS = 15), was being transferred via a Stand-Lift in her room with a CNA present when she was not able to continue to hold on to lift when the bed was lowred. Resident's arm slipped out and she fell back onto her bed. Resident stated immediate pain in her left shoulder. Resident was assessed by the charge nurse on duty and was advised that she should be evaluated at (facility name). Resident initially refused and stated she did not want to go but finally did agree. Orders received from MD to transport resident for evaluation. Primary physician and family made aware. Resident was sent to (facility name) and per report from staff there, resident sustained [REDACTED]. Resident and staff educated on need to use Hoyer lift instead of Stand Lift. Care plan reviewed and revised. No abuse/neglect substantiated. Review of CNA DD's employee file revealed: *She had been hired on 5/17/16 to work in the housekeeping department. *On 9/9/16 she had passed her competency tests to become a CNA. -Those competency tests and training had included resident transfer training. *On 9/19/16 she had received coaching/education on use of the EZ Stand lift. -That training had included ensuring the safety straps for the legs and sling had been buckled. *Her last day of employment had been 9/30/16. Review of the provider's 12/1/16 CNA and nusring staff training/education meeting notes revealed: *Review: -Transferring residents. -Safe lifting and moving of residents. -Transers-Ambulation with transfer belt. -Mechanical lifts. *The Transfer with Mechanical Sit to Stand/lift competency form had been reviewed. -Components to observe during transfers had been: --Fasten safety belt around resident's waist. --If sit to stand has straps, affix straps across legs. --Mechanical lift (Two staff required for this procedure). *The July 2016 Mechanical lift policy had been reviewed. -The policy required the staff to use two staff with all mechanical lift transfers. *The staff training/educational meeting had not occurred until ten weeks after resident 5 had fallen from a mechanical lift. Interview on 12/7/16 at 1:30 p.m. with restorative aide (RA) H regarding resident 5 confirmed: *To her knowledge the resident had been cooperative with transfers. *She could not remember the resident refusing to wear the safety straps with transers. -She stated She wasn't able to always hold on to it. *The resident had a history of [REDACTED]. *She had assisted the resident on 9/16/16 with toileting. -That task required the use of the EZ stand lift. *The resident was not feeling well and had been hanging in the sling. -She stated: --I did report those issues and concerns to the nursing and therapy departments. --I believe she fell out of the lift shortly after that. Interview on 12/7/16 at 1:55 p.m. with RN F regarding resident 5 revealed: *She confirmed her documentation and assessment of the resident on 9/16/16. *The resident was alert, oriented, and capable of making her needs known to the staff. *The resident had a history of [REDACTED]. *She was not responsible for assessing the residents and determining the appropriate transfer type. -The therapy department and the unit managers would decide as a team on the appropriate transfer types used for residents. *To her knowledge she had not followed-up with the therapy department or the unit managers regarding the above conversation and assessment of the resident on 9/16/16. -She stated The resident is alert and told me she was not feeling well, and that is why she was slumped over in the lift. Nothing further was needed. *She had not considered the sliding out of a transfer sling and onto the bed as a fall. -She stated She fell on to the bed, not the floor. *She confirmed the resident had been injured and transferred to the hospital from that fall. *No comment was offered: -Whether the information and concerns about the health of the resident on 9/16/16 had been passed on to the charge nurses to monitor. -Regarding the professional assessments and documentation reviewed above. Interview on 12/7/16 at 2:15 p.m. with LPN I revealed she: *Confirmed the staff had the capability of using one or two staff with transfers. *Stated Depends on the CNA. The seasoned ones do better with the mechanical lifts. *Would have expected the staff to use two staff when transferring resident 5. -She stated She was a larger lady and difficult to transfer. Interview on 12/7/16 with physical therapist (PT) K revealed she: *Confirmed the therapy department had provided the staff with transfer recommendations for the residents. *Stated: -We will be asked to do a screen on a resident with transfer issues. -When we do a screen we cannot do hands on with the resident, it is only a recommendation. -We inform the unit coordinators, and they are responsible to let the other staff know. Interview on 12/7/16 at 3:40 p.m. with RN D revealed she: *Had been the unit coordinator for the transitional care units on Simpson and Garmann. *Confirmed: -The interview with PT K regarding transfers. -The department head team would have determined the transfer type for the residents. -The department head team was responsible to complete the residents' transfer assessments. Interview on 12/7/16 at 4:35 p.m. with RN O regarding resident 5 revealed she: *Worked between the hours of 6:00 p.m. and 10:00 p.m. only. *Worked all areas of the facility. *Confirmed: -She had been working the evening the resident had fallen from the mechanical lift on 9/18/16. -The resident had been assigned to CNA DD that evening. -CNA DD was new and had recently completed her CNA training. -CNA DD transferred the resident from the bathroom using the EZ Stand lift by herself. *She stated (Resident's name) should always be a two person transfer. *Confirmed the resident had been in and out of the hospital with pneumonia and was slowly declining. *Had not been able to remember receiving any information from the prior charge nurse regarding any health concerns with resident 5. *Had agreed for resident 5: -The concerns documented and assessed on 9/16/16 should have been addressed with the charge nurses to ensure continued monitoring. -There should have been documentation and assessmentes to support the nurse's charting at 7:57 a.m. on 9/19/16. *Had not been aware their transfer policy had required the use of two staff when using a mechanical lift. Interview on 12/7/16 at 4:35 p.m. with LPN M revealed she: *Worked between the hours of 10:00 p.m. and 6:00 a.m. only. *Worked all areas of the facility. *Confirmed: -The above interview above with RN O. -She had been working the night shift after resident 5 had fallen from the mechanical lift on 9/18/16. -She had been the one to further assess the resident and transfer her to the ER department. *Could not remember the exact times the resident had been transferred out of the facility and returned. *Had agreed regarding residetn 5: -There should have been continued monitoring of the resident after her assessment on 9/16/16. -There should have been documentation and assessments throughout the night to support her charting for the resident at 7:57 a.m. *Confirmed the CNAs could determine how many people to use with an EZ Stand lift. -She stated It would depend on the ability of the resident and physician orders. *Had not been aware their transfer policy requried the use of two staff with all mechanical lifts. Interview on 12/7/16 at 5:10 p.m. with LPN E revealed she: *Had been the unit coordinator for the long term care residents on Miller, Watson, and Dunn hallways. *Had several responsibilities that included updating the care plans, pocket care plans, and transfer assessments. *Could not recollect the incident on 9/18/16 with resident 5. -She stated I believe I was out on leave during that time. *Was not sure who had assumed her responsiblities and duties while she had been on leave. *Could not remember any specific medical concerns regarding resident 5. -She would have to look in the resident's record. *Had not completed daily rounds on any of the residents for the above hallways. *Confirmed: -She had been responsible for the transfer assessments and determining the method of transfers for the residents. --Those assessments were to have been completed quarterly and as needed with any changes. -She had completed the transfer assessment for resident 5 on 10/30/16. --She could not reflect on how she had determined the information documented on that assessment. --She stated repeatedly We gather the information as a team. *Had not been aware there were no further transfer assessments completed for resident 5 to support all of her past transfer types. *Did not know what their transfer policy was and how many staff were required when using a mechanical lift. Interview on 12/8/16 at 10:00 a.m. with CNA Q revealed: *She had assisted the residents with multiple different transfer types. *The CNA pocket care plan would have directed them on what type of transfer the residents required. *They had the capability of determining how many staff members were needed to transfer a resident. *She stated: -If the pocket care plan states one or two you can decide how many you need or the next shift might tell you how they did that day. -I'm comfortable determing whether to use a gait belt or Hoyer especially if I have worked with them for a while. Interview on 12/8/16 at 9:40 a.m. with resident 5 revealed: *She confirmed the staff had not been consistent on how staff they used to transfer her with the EZ Stand lift. -She stated They told me it took too much time to wait for help. *The staff had not consistently used the safety straps for her feet/legs. -She stated Some used them and some did not. *She confirmed the night she had fallen from the lift the CNA had not fastened the safety straps for the sling and her feet/legs. Interview on 12/8/16 at 2:00 p.m. with the director of nurses (DON) and the corporate nurse consultant revealed they: *Confirmed the above record review, employee file for CNA DD, and the education provided on transfers. *Had completed individual education on transfers and safety with CNA DD immediately following the fall with resident 5. *Were aware the staff training on transfers and safety had not been completed until over two months later. -The DON stated Education was delayed, because the other staff were long term employees.*Had not been aware resident 5 had not been feeling well on two days prior to her fall on 9/18/16. *Would have expected the staff to have assessed and monitored resident 5 for health concerns and appropriate transfer type between 9/16/16 and 9/18/16. *Agreed the nursing documentation had been incomplete the night resident 5 had fallen. *Confirmed the method of transfers for the residents had been determined as a team. -They would have expected the unit coordinators to have completed a full assessment of the staff assisting the residents during a transfer to ensure the transfer type had been appropriate. --Those assessments would have been used to complete the transfer assessment forms. *Expected the staff to have followed the CNA pocket care plans to assist them with their care for the residents. *Would not have expected the CNAs to be determining: -What type of transfer should have been used for a resident. -How many staff to use with a transfer. *Had not been aware their transfer policy required two staff members when using a mechanical lift. *Had no documentation to support competency reviews had been completed on the staff while assisting the residents with transfers. *Had no job descriptions for the unit managers. Review of the provider's 6/17/14 EZ Way Smart Stand Operator's Instructions manual revealed: The EZ Way Smart Stand was designed to be operated safely by one care give. However, depending on the situation, facility policy, and the patient's (resident) condition, two caregivers may be necessary. Review of the provider's July 2015 Mechanical Lift policy revealed: The portable lift is to be used by two (2) nursing assistants to perform the procedure. Review of the provider's 1/28/13 Resident Transfer Assessment policy revealed: *The mobility of residents will be assessed by nursing using the Resident Assessment Transfer form. This will be done upon admission to the facility and after a significant change in resident condition. *The RN or person completing the form will enter each resident's bed mobility and transfer status into the resident's care plan and inform the nursing staff. *The nursing staff will comply with the bed mobility and transfer recommendations based on the outcome of each resident transfer assessment. Review of the provider's undated Charge Nurse job description revealed: *Ensure that all nursing service personnel are following their respective job descriptions. *Make daily rounds of the Nursing Services Department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. *Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided and that they reflect the resident's response to the care. *Monitor your shift's personnel to assure that they are following established safety regulations in the use of equipment and supplies. *Ensure that nursing service personnel follow established departmental policies and procedures. Review of the assisted director of nursing's 7/9/15 job description revealed the same responsibilities as identified above for the charge nurse. Review of the provider's 11/9/04 CNA ob description revealed: *Implements nursing care following facility policies and procedures, under the supervision of licensed nursing staff. *Assists residents with activites of daily living following the resident care plan, resident ADL sheets and shift assignment sheet.