Every finding on record at Good Samaritan Society Canton

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure the staff followed accident prevention interventions and safe device use for three of three sampled residents (8, 25, and 39) who needed to be transferred by staff with the use of a total body lifts (a mechanical lift and sling used to lift a person's full body) as directed in the residents' care plans and according to the lift manufacturer's sling sizing instructions by four of four observed certified nursing assistants (CNAs) (B, E, H, and K) who did not verify which sling size to use to safely transfer the residents before transferring those residents.Findings include:1. Review of the provider's 5/1/26 SD DOH FRI revealed that on 5/1/26, resident 39 was transferred from her wheelchair to her bed by CNA F who used a sit-to-stand lift. CNA F secured the sling's straps and chest strap clip. While transferring the resident, the strap on the right side of the sling came loose from the hook on the lift, and resident 39 fell backward. The chest strap clip broke, and she fell onto the floor on her right side. She was alert after her fall, had a skin tear on her right forearm, the right side of her face started to bruise, and the right side of her body was red. Registered nurse (RN) G completed a full body assessment on resident 39 and notified her physician, who advised RN G to send resident 39 to the emergency room (ER) for evaluation. The family was notified and agreed to send the resident to the ER for evaluation.CNA F transferred resident 39 according to her care plan, and no environmental hazards were identified that would have affected the mobility of the lift. The maintenance department evaluated the lift and lift sling and found the lift functioning appropriately. The lift sling did not have any rips, tears, or fraying, and the chest strap clip seemed to work before the chest strap clip broke during the transfer. The sling was discarded.Resident 39's ER evaluation and X-rays showed no acute findings or fractures. The only finding was a bruise on her right frontal scalp. The ER provider noted the resident was in no obvious distress, was resting comfortably, and aroused to open her eyes with minimal stimulation.Resident 39 returned to the facility with no new orders other than discontinuing a cranberry supplement. Resident 39's family member requested the resident to change from a sit-to-stand mechanical lift to a total body lift. Her care plan was updated with this intervention. The staff was educated at the facility huddle (a daily meeting where staff are updated on new information within the facility) and at shift change on the new intervention. Re-education was provided to the CNA's and nurses about safety mechanisms on the mechanical lifts, what to look for on the lift during the time-out (a time where the staff stop the transfer once tension is applied to the straps, but prior to the resident being lifted, to ensure the machine is working, the straps are placed correctly and securely), and what to assess on the slings before transferring a resident. All mechanical lifts with the same clip-type mechanism were inspected, in addition to the one involved in the fall, and routine scheduled preventive maintenance checks would continue as before. Three mechanical lift audits would be conducted weekly for four weeks to ensure the clip mechanism was checked after the sling was attached to the lift.2. Observation on 8/4/26 at 4:18 p.m. of resident 39 being transferred with the total body lift by CNAs B and K revealed they used a large sling, identified by a burgundy-colored border, and transferred resident 39 from the bed to her wheelchair. They completed the time-out to ensure the straps were secured to the total body lift prior to completing the transfer.3. Observation on 8/5/26 at 4:45 p.m. of EZ Way brand total body lift revealed there was a sling size identification color code system label on the total body lift for the staff to use to determine what sling to use for a resident based on the weight of the resident. That color code system indicated the correct size sling to use was small (grey) for residents at 70-100 pounds (lbs.) medium (beige) for 90-220 lbs., large (burgundy) for 190-320 lbs., (extra-large (green) for 280-450 lbs., 2 extra-large (black) for 400-600 lbs., and (3 extra-large (brown) for 600 lbs. and over.4. Review of resident 39's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 5/14/26 Brief Interview for Mental Status (BIMS) assessment score was 0, which indicated her cognition was severely impaired. Her diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions) with late onset, dementia (a group of symptoms affecting memory, thinking, and social abilities) with other behavioral disturbance, anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and muscle weakness.Her undated care plan included a focus area added on 1/5/23 that indicated her activity of daily living (ADL's) self-care performance deficit related to Alzheimer's disease and decreased strength, as evidenced by forgetfulness and confusion. On 4/27/23, an intervention indicated she was to be transferred using the sit-to-stand lift with a medium sling. If after two unsuccessful attempts at using the sit-to-stand, the staff were to use the total body lift with two staff members and a medium sling. An intervention was added on 5/2/26 to transfer her with the total body lift with the assistance of two staff members and a medium sling.Her 4/2/26 fall risk evaluation score was 12, which indicated that she had a medium risk for falling. Her 5/8/26 fall risk evaluation score was 14, which indicated she had a high risk for falling.Her 2/11/26 sit-stand-walk data collection tool indicated that the resident could not stand by pulling herself to a standing position and maintain that position. The data collection tool indicated using a sit-to-stand mechanical lift for her transfers. Her 5/2/26 sit-stand-walk data collection tool (a mobility assessment) indicated that the resident was resistant, rigid, and difficult to turn. She could not move from a lying or reclining position to sit on the edge of the bed, and she could not bear weight on at least one leg. These indicated the use of a total body lift. The sling size selected on the assessment was a medium, with two staff members to transfer her.Resident 39's 8/3/26 weight indicated she weighed 153 lbs.5. Observation on 8/5/26 at 8:55 a.m. revealed resident 39 was transferred with the total body lift and a large sling by CNA E and CNA H. She was transferred from her wheelchair to her bed.6. Observation on 8/5/26 at 4:15 p.m. of resident 8 was sitting in the hallway outside of his room in his wheelchair, and resident 25 was sitting inside her room across the hallway in her wheelchair. Both residents had large total body lift slings on, identified by burgundy borders.7. Review of resident 8's EMR revealed he admitted to the facility on [DATE]. His BIMS assessment score was 10, which indicated that his cognition was moderately impaired. He had a diagnosis of unspecified paraplegia (a condition where a person experiences paralysis of both legs).His undated current care plan indicated an intervention added on 7/8/24 directed that he was to be transferred using a total body lift, a medium and extra-large sling, and with the assistance of two staff members.His 4/12/26 fall risk evaluation score was an 8, indicating he had a low risk for falling.His 6/17/26 sit-stand-walk data collection tool indicated he was resistant, rigid, and difficult to turn. He could not move from a lying or reclining position to sitting on the edge of the bed, and he was not able to bear weight on at least one leg. These indicated that he was to use a total body lift when transferring, an extra-large sling, and the assistance of two staff members.His 8/5/26 weight indicated he weighed 234 lbs.8. Review of resident 25's EMR revealed she admitted to the facility 5/13/25. Her BIMS assessment score was 99, which indicated she could not complete the interview. Her diagnoses included vascular dementia (a form of dementia caused by reduced blood flow to the brain) and muscle weakness.Her undated current care plan indicated that on 1/29/26 she was to transfer using a total body lift with the assistance of two staff members. The care plan did not indicate the lift sling size to use.Her 1/29/26 fall risk evaluation score was a 13, which indicated she had a medium risk for falling.Her 6/17/26 sit-stand-walk data collection tool indicated she was resistant, rigid, and difficult to turn. She could not move from a lying or reclining position to sitting on the edge of the bed, and she was not able to bear weight on at least one leg. These indicated that she would need a total body lift, a large sling, and the assistance of two staff members when transferring.Review of her 7/31/26 weight revealed she was 167 lbs.9. Interview on 8/6/26 at 8:12 a.m. with CNA I revealed that she would look in the resident's care plan or Kardex (a report of the resident's care needs and interventions) to know how a resident transferred and what sling size they used. If she did not look in the resident's care plan, she stated I will just go off how it fits, if it's [the sling] in the room already.10. Interview on 8/6/26 at 9:15 a.m. with CNA C revealed that she would look in the resident's Kardex if she didn't know a resident's sling size, but if there was a sling already in the room, she would use that one. She examined the total body lifts before using them and made sure everything on the lift was working and that no parts were missing or broken.11. Interview on 8/6/26 at 12:31 p.m. with CNA F regarding resident 39's fall incident revealed CNA F transferred resident 39 from her wheelchair to her bed on 5/1/26. After CNA F used the sit-to-stand mechanical lift to stand resident 39 up and moved the lift towards CNA F, the right side of the sling came undone from the lift. As resident 39 fell, the chest strap clip broke, and resident 39 fell onto the floor onto her right side. CNA F turned on the emergency call light for other staff to assist her.Resident 39 had hit the right side of her head on the metal table, so CNA F moved that out of the way and waited for the nurse to come. After RN G completed her assessment, they used the total body lift to lift resident 39 off the floor and into her bed. RN G examined the skin tear on resident 39's right arm, then called the ambulance to take resident 39 to the hospital.DON A and CNA F examined the lift, and the metal clip on the right side that held the sling in place was loose. The sling did not rip or have any tears before that incident. CNA F knew what sling to use on the resident by looking in their care plan, or the resident usually had a sling in their room, and CNA F could just tell based on their [the residents] size what [sling] to use. She received verbal education after the incident on how to transfer a resident and what to watch for when using the lifts and the slings.12. Interview on 8/6/26 at 12:45 p.m. with contracted travel Minimum Data Set (MDS) coordinator J revealed that she expected the staff to refer to the resident's care plan or Kardex to know what size sling to use on the resident for a safe transfer.13. Interview on 8/6/26 at 12:55 p.m. with director of nursing (DON) A revealed that a sit-stand-walk tool was completed within the resident's EMR when a resident admitted to the facility, re-admitted to the facility, or for any changes in a resident's ADLs. If a mechanical lift was needed to transfer a resident, the staff were educated on the sling sizes during the education they received upon hire for safe resident handling and transfer assistance. The staff were to refer to and use the sling size indicated on the resident's care plan. She expected the sling size and the type of mechanical lift used for a resident's transfer to be indicated on their care plan. The maintenance department staff completed the mechanical lift audits on the lifts every month.14. Review of the provider's mechanical lift audits from 5/6/26 through 5/30/26 revealed that three observations of resident transfers were completed each week. The audits included observing that both straps were secured on the lift hooks, and both safety tabs/clips were closed all the way when the straps were on the hooks before transferring the resident.15. Review of the April 2026 through July 2026 monthly maintenance logs for the mechanical lifts revealed that each sit-to-stand and total body lift was being monitored for structural and functional maintenance monthly.16. Review of the provider's 6/2/26 Fall Prevention and Management policy revealed Proactive approach before a fall occurs (e.g., New Admit) Procedure 1. On admission or readmission, review the applicable documents (i.e., discharge summary from transferring agency, transfer record, history and physical, lab values, nursing admit/readmit data collection) and any additional admit information documentation for fall risk factors. 2. Complete the N Adv Fall Risk Evaluation [an evaluation used to determine the factors that a resident has for falling] UDA [user defined assessment] for fall screening and identifying fall risk factors. 3. Care plan the appropriate interventions, including personalizing all (specify) areas. 4. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-hour report, care plan and Kardex, daily-stand up meetings, and/or fall committee meetings. 5. Communicate any identified environmental changes and/or referral needs (e.g., maintenance, dietary, therapy).17. Review of the provider's 12/1/25 Care Plan policy revealed Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Residents Assessment Instrument (RAI) and review of the physician's orders. The comprehensive care plan will emphasize the care and development of the whole person, ensuring that the resident will receive appropriate care and services. It will address the relationship of items and services required and facility responsibility for providing these services.

Based on observation, interview, record review, and policy review, the provider failed to ensure there was documentation to support interventions had been implemented or offered to treat clinical signs of depression for one of one sampled resident (36) who had a diagnosis of major depression and recently lost a loved one. Findings include: 1. Observation and interview on [DATE] at 1:43 p.m. with resident 36 revealed: *He was in his room, sitting in his recliner, and his head facing down towards his chest. *His affect (observable expression of emotion) was expressionless, and his tone of voice was unanimated when responding to questions. *He answered questions but did not initiate any further conversation from them. *When conversing with him he: -Stated; No, I am not depressed. -Started to cry and stated, My wife died a few years ago. -Stated, I take some meds [medication] for depression but feel like I should feel better. *He did not confirm if he had received or been offered any counseling services to help with his depression and grief regarding the loss of his spouse. 2. Interview on [DATE] at 2:00 p.m. with social services designee (SSD) C regarding resident 36 revealed: *His wife's death had been unexpected, and he was not able to attend the funeral service in person. *She had sat with him during his wife's telephone bedside service that was provided. *She had not offered or implemented any other interventions to assist the resident with his grief and the loss of his wife. *She: -Was not sure, but thought he had taken an anti-depressant medication. -Stated, Oh, does he? when the surveyor commented on how sad the resident had appeared. -Thought they had offered counseling services to him or his family but they had declined. -Was not able to locate any documentation to support they had offered to assist him with counseling services or initiated interventions to further support his grief process from the loss of his spouse. 32355 3. Continued interview on [DATE] at 2:25 p.m. with SSD C regarding resident 36 revealed: *She confirmed he had a diagnosis of major depression and that his spouse had passed away on [DATE]. *She stated: -He had always refused to take anything [medication] for his depression. -He did have weepy episodes after his wife passed away and I believe we asked him and his family about an anti-depressant [medication] at that time. -He had refused and medication and so did his family. -His daughter said he had always been sensitive with mental issues and that behavior was not abnormal for him. -I'm pretty sure we've offered him counseling services too and that was declined also. *She had no documentation to support those conversations with the resident or his family had occurred. *She stated: We talk about these things all the time and it's discussed in our care conference meetings. *She agreed that if those conversations were not documented, there was no evidence to support that they had occurred. *She was not a licensed social worker (LSW) and required oversight by one. *The LSW worked in another sister facility, and she had traveled to meet with the LSW every three months. Those meetings were confirmed as having been scheduled on her Outlook calendar. *She had no documentation to support: -What was reviewed and discussed at those meetings with the LSW. -What guidance and education the LSW had provided for her during those meetings. -If resident charts had been reviewed to ensure appropriate processes had been followed to support their emotional well-being. 4. Review of resident 36's electronic medical record (EMR) revealed: *He had a diagnosis of recurrent major depressive disorder. *His [DATE] Brief Interview for Mental Status (BIMS) assessment score was 8, which indicated he had moderate cognitive impairment. *He had been on an anti-depressant in the past, but it was discontinued on [DATE] by the medical director based on a gradual dose reduction (GDR) recommendation by the pharmacist and was never resumed. *There were no orders that indicated he took any medications to help with his depression. *From [DATE] through [DATE] there was no documentation that indicated the interdisciplinary team had discussions with both the resident and his family regarding his depression and the capability for counseling or oral medication to assist him with his weepy episodes and the loss of his spouse. *The IDT had scheduled care conferences every three months from [DATE] through [DATE]. -He had declined to attend those meetings. -On [DATE] the IDT documented, Res [resident] wife passed this quarter and has had some tearful days. Resident has been opting to eat meals in his room more often but does still eat some meals in the dining room. -On [DATE] the IDT documented, Res does get tearful after outings when visiting his wife but doesn't last for long periods.-There was no documentation that indicated the resident had been offered counseling services or follow-up with the physician to evaluate and possibly resume his anti-depressant medication for his continued weepy and tearful episodes. 5. Review of resident 36's physician progress notes from [DATE] through [DATE] revealed: *On [DATE] the physician had documented, Nurses notes in PCC [point click care] reports resident was weepy (his spouse passed away 1 week ago). He reports [he is] tired, but feeling pretty good. *On [DATE] the physician had documented, Nursing staff notes that he has good and bad days. *There was no documentation that indicated the physician had visited with the resident about possibly resuming his anti-depressant medication or offering to order him counseling services to assist him with his depression and grieving process regarding the recent passing of his spouse. 6. Review of resident 36's [DATE] revised comprehensive care plan revealed: *A focus area initiated on [DATE] and revised on [DATE] indicated the resident had a potential for psychosocial well-being deficit related to recent confusion, change in his functional ability, and the loss of his wife on [DATE]. *A goal that the resident would have no indications of psychosocial well-being deficit by/through the next review date. -The interventions had not been updated since [DATE] to support how the provider would have helped him to achieve that goal. *There was no documentation that indicated he had been offered and refused assistance with his depression and weepy episodes through counseling, medication, or methods of supportive interventions. 7. Interview on [DATE] at 2:30 p.m. with registered nurse (RN)/Minimum Data Set (MDS) coordinator D regarding resident 36 revealed: *She was not able to locate any further documentation in the resident's chart to support: -The IDT or the nursing staff had visited with his family, the practitioner, or him about the possibility of resuming his anti-depressant medication to help with his weepy and tearful episodes. -Counseling services had been offered to the resident to help him with the grieving process from the recent loss of his spouse. *She stated they had talked to him and his family about his offered counseling and possible resumption of his depression medication, but they had refused. *She agreed that was an important piece of his care that was not documented but should have been. 8. Interview on [DATE] at 3:00 p.m. with director of nursing B regarding resident 36 revealed: *She was aware that resident 36 had recently lost his spouse, but was unaware about his diagnosis of major depression. *Most of her information that she received on the residents came from the 24 hour notes. -The leadership team reviewed those notes during morning huddle meetings. -She could not recall if they had discussed a concern with his mood and behaviors. *Most of the nursing documentation on a resident's mood and behavior was directed from [SSD name] and those assessments that she had done. *She would have expected whoever discussed these things with him or his family to have documented on it. *She agreed that if those conversations had not been documented there was no evidence to support that it occurred. 9. Interview on [DATE] at 3:15 p.m. with administrator A revealed: *He would have expected documentation of any conversation that occurred between resident 36 or his family regarding his mood and increase in his weepiness and the refusal of counseling or the potential use of an antidepressant medication. *He confirmed: -The SSD had oversight from an LSW from a sister facility. *He had no documentation of what the SSD and LSW had reviewed, what educational support was provided, or any guidance that SSD needed related to those meetings. 10. Review of the provider's revised [DATE] Documentation, Social Services - Rehab/Skilled policy revealed: *The purpose was to systematically and continuously collect information about the psychosocial status of the resident and to furnish documentary evidence of the care and services provided during a resident's stay. *Frequency of documentation will be determined depending on the condition and the plan of care of the resident. *When social work personnel provide intervention, evidence of the intervention will be documented. The provider was unable to find a mood/behavior or psychosocial policy by the survey exit date of [DATE].

Based on observation, interview, document review, and policy review, the provider failed to ensure appropriate infection control practices were followed by one of one observed housekeeper/laundry aide (E) when cleaning one of one sampled resident's (37) room who was on contact precautions for a highly infectious disease that had the potential to spread to others. Findings include: 1. Observation on 5/6/25 at 11:05 a.m. with housekeeper/laundry aide E revealed: *She had prepared to clean resident 37's room. *There was a sign on the resident's door that indicated she was on contact precautions and everyone must wear gloves and a gown when entering her room. Staff were to wash their hands with soap and water after assisting the resident. *The resident had been isolated to room for a diagnosis of Clostridium Difficile (C-DIFF) (a highly infectious disease that can easily spread to others). *Housekeeper/laundry aide E: -Sanitized her hands, put on gloves and a gown, and then entered the resident's room. -Took a spray bottle of toilet bowl cleaner and a container of bleach sanitary wipes into the resident's room and placed them onto the resident's dresser. *After housekeeper/laundry aide E finished cleaning the resident's room she: -Removed her gloves and gown, and placed the toilet bowl cleaner and the container of bleach wipes on top of an opened box of clean gloves. The box of clean gloves was on top of the housekeeper's cleaning cart that was located outside of the resident's room. *Housekeeper/laundry aide E: -Had not cleaned the toilet bowl spray bottle or container of bleach prior to taking it out of the resident's room and placing it on the opened box of clean gloves. -Left the resident's room without washing or sanitizing her hands. -Went to the soiled utility room that was approximately 25 feet from the resident's rooms, touched the door handle to open the door, and washed her hands. Interview on 5/6/25 with housekeeper/laundry aide E right after the observations above revealed: *She was not sure if supplies could have been brought out of the resident's room who was on contact precautions for an infectious disease. *She stated, I probably should have cleaned them with bleach wipes before I did that. *She had not realized that placing the supplies on top of the open box of clean gloves had contaminated them. *She stated: -Well, I can't wash my hands in the resident's room because we have to wear gloves and a gown in there. She's on contact precautions. -I guess I could sanitize my hands before I leave the room, but we were told to wash our hands. -I'm not sure what her actual diagnosis is, all I know is that she is on contact precautions, I have to use bleach, and she is last for cleaning [her room] on my list of rooms. *The housekeeping director had reviewed the process for cleaning resident 37's room which had included washing their hands with soap and water. -She was unsure, but thought they were supposed to leave the resident's room to wash their hands. *No one had watched them clean resident 37's room to ensure the correct processes were followed. *During the interview an unidentified staff person was observed going into the soiled utility room. *She stated, Well, I suppose I better go clean that door handle now. Interview on 5/7/25 at 10:00 a.m. with housekeeper/laundry aide F regarding the cleaning process of rooms for residents contact precautions revealed: *She would have put on a pair of gloves and gown prior to entering the resident's room. *The cleaning of that room would have been last to do on her list. *She would have taken the spray bottle of toilet bowl cleaner into the resident's room, it could not be left in the room, and she needed it to use in other residents' rooms. *She would have sanitized the spray bottle with a bleach wipe before taking it out of the room. *She would have left the room to wash my hands. *She stated: -Actually, I'm not sure how else I would do that. -I'm pretty sure that is what we were told to do. Interview on 5/7/25 at 10:20 a.m. with environmental services supervisor G regarding the above observation and interviews revealed: *She could not recall the last time that she had completed audits on the housekeeping staff while cleaning a room for a resident with an infectious disease. *She would have reviewed the process with the staff prior to them cleaning those rooms. *The housekeepers take the toilet bowl cleaner out of the residents' rooms because they could not leave chemicals in them. *She stated: -They should sanitize it [the cleaner] with a bleach wipe before bringing it out and they shouldn't be setting it down in the room. -This is why I have them park the carts right in front of the entrance, that way they are not leaving the rooms. -They are to wash their hands before leaving the [resident] rooms, not go down the hall to do it. *She could not recall the last time competencies had been completed on the housekeepers related to IC. *She stated, I think it was during COVID. That was the last time I did any competency checks. *She agreed the above processes were infection control concerns and had the potential to spread an infectious disease to others. Interview on 5/7/25 at 12:40 p.m. with director of nursing B regarding the above observation and interviews revealed: *She had been the previous infection control (IC) nurse and was still assisting the current IC nurse with some IC things. *She could not recall the last competencies that had been completed on all the staff related to IC. *She stated: -I believe it was with COVID. -I didn't do competencies on the housekeeping staff. I've always left that up to the director [housekeeping]. -But, yes, as the IC nurse, we probably should be involved with other departments to make sure they are following the correct processes. *The staff should not have taken anything into the resident's room that could not have been left in there. *Chemicals were not to be stored in resident rooms for safety purposes. *Any item that was brought out of a room where the resident had C-DIFF or an infectious disease, it should have been sanitized with bleach wipes. *Her expectations had been for the staff to wash their hands prior to leaving a resident's room where a resident was isolated with an infectious disease such as C-DIFF. -C-DIFF required hand washing versus sanitizing to kill the bacteria and stop the infectious disease from spreading to others. *She agreed the housekeeper's process observed above had created the potential for the infectious disease to spread to other residents. 2. Review of the provider's undated Housekeeping Resource packet revealed: *Role and Responsibilities of Environmental Cleaning in the Infection Control Program: -Environmental cleaning plays an important role in an infection control program.the spread of infections from contaminated surfaces is significant and supports the need for good procedures and practices related to cleaning and disinfecting of surfaces. -All staff members play a role and should be aware of the general principles of environmental cleaning and safety. *Procedure: If working in a resident room with a recent known infectious disease or if cleaning supplies or equipment have been used to clean blood or body fluids, the .cleaning equipment should be properly cleaned before storing. Review of the provider's October 2017 Clostridium Difficile (C-DIFF) policy revealed: *The staff should perform hand hygiene after removing gloves. Alcohol does not kill Clostridium difficile spores; therefore, the use of soap and water is more effective than alcohol-based hand rubs. *Refer to Environmental Services policies and procedures on the Web Portal regarding cleaning processes.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and policy review the provider failed to ensure the safety of one of one sampled resident (1) who was injured while being transferred by staff by staff with the use of a lift. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include: 1. Review of the provider's 1/9/25 SD DOH FRI for resident 1 revealed: *On 1/8/25 at 3:15 p.m. staff were transferring him with the use of a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position). *He complained of left shoulder pain and let go of the lift's handles. *His arms went above his head, and he slid below the sling. *Staff lowered him to the ground. *His vitals and range of motion were assessed and were within his normal limits. *He had a history of shoulder pain and did not report increased shoulder pain at that time. *He did not report increased shoulder pain on subsequent staff rounds on 1/8/25. *A fall intervention was initiated for him to be transfer with the use of a total lift (a mechanical lift and sling used to lift a person's full body) and the assistance of two staff due to his inability to safely use the sit-to-stand lift. *His physician performed a follow up visit on 1/9/25 and the resident had expressed increased shoulder pain. *The physician ordered x-rays for his left arm and shoulder. *The x-ray indicated he had an acute impacted traumatic fracture of the humeral head and neck. *His family was notified of the x-ray findings. *Director of nursing (DON) B interviewed the staff involved regarding the incident. -The sling used was the proper size. -A time out (paused to ensure all straps and belts were secure) was completed prior to mobilizing the lift. -The chest safety strap was not secured per protocol. *Education was initiated for all staff regarding the safe resident handling policy and hands-on competencies related to the lifts. *Audits regarding lift use were initiated and were to continue for four weeks, then monthly for six months to ensure continued compliance and staff competency of lift use and safe resident handling. 2. Observation and interview on 1/22/25 at 10:50 a.m. with resident 1 regarding 1/8/25 the incident with the sit-to-stand lift revealed:*He was sitting in his wheelchair in his room. *His left arm was in a sling. *He confirmed that he had a history of left shoulder pain. *He did not think he was injured that day when he was lowered to the floor. *His arm started hurting more the day after the incident. *His physician was making rounds that day and asked him how he was doing. *He mentioned that his left shoulder hurt more than usual. *His arm and shoulder were x-rayed and that was when he found out there was a fracture. *He stated that he still felt safe and that he was taken care of by the staff. 3. Observation and interview on 1/22/25 at 12:15 p.m. with certified nursing assistant (CNA) C and resident 2 while in her room regarding proper lift use and education revealed:*Resident 2 was being transferred from her wheelchair to a commode. *CNA C attached the sling to the sit-to-stand lift and used the appropriate loops. *She fastened the safety belt around resident 2's chest. *Once resident 2 was lifted off her wheelchair CNA C took a timeout (paused and ensured all straps and belts were secure). *Resident 2 was transferred to the commode. *CNA C stated lift safety was a current focus and staff had been retrained on lift use the week of 1/13/25. 4. Interview on 1/22/25 at 2:15 p.m. with director of nursing (DON) B regarding the incident with resident 1 and lift training revealed: *All residents received a transfer/lift assessment upon admission and quarterly. *The transfer/lift assessment was part of their safe resident handling program to ensure resident safety. *Direct care staff received training upon hire and annually for safe resident handling. *She completed the investigation for the incident when resident 1 was lowered to the floor. *The staff involved did not follow facility protocol by not ensuring the strap around his chest was secured. *She immediately re-educated the staff involved. *She implemented re-education for all direct care staff on safe resident handling and transfer audits were to be completed. *Resident 1's care plan was updated to reflect that staff were to use a total lift for his transfers. 5. Review of the provider's revised 12/23/24 Safe Resident Handling Program (SRHP) regarding resident transfers revealed: *Completes the GSS #670- Safe Resident Handling Equipment Competency Validation Checklist. *Performs a TIME OUT every time the appropriate mobility devices are used. *Reports to licensed nurse identified unsafe transfer process such as skin shearing, arm/shoulder injuries (chicken wing appearance), inconsistent weight bearing (rolling ankles, knee injury). The provider implemented actions to ensure the deficient practice does not reoccur was confirmed on 1/22/25 after record review revealed: *The provider followed the SRHP ensuring education and training was provided to all direct care staff. *The resident's care plan was updated to reflect his current transfer assistance needs. *Audits on safe resident handling and lifts had been completed on 1/10/25 and 1/16/25. *The audits were planned to be reviewed and discussed at the next quality assurance meeting. *Observations and staff interviews revealed the staff understood the education provided and the safe resident handling process. Based on the above information, non-compliance at F689 occurred on 1/8/25, and based on the provider's implemented corrective action for the deficient practice confirmed on 1/22/25, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, policy review, and manufacturer's guideline review, the provider failed to clean and disinfect one of one community shared blood glucose meter for four of four sampled residents (15, 31, 45, 46) resulting in a potential increased risk for bloodborne pathogen infections. Findings include: 1. Observation on 12/19/23 at 3:45 p.m. revealed: *Registered nurse (RN) E completed a blood glucose check for resident 46. *When RN E was asked what she used to clean and disinfect her blood glucose meter, she stated, I should have them with me, but I use the alcohol wipes. *After RN E performed a blood glucose test on resident 46 she cleaned the blood glucose meter with a 70% isopropyl alcohol wipe and placed the blood glucose meter back on the medication cart. Interview on 12/19/23 at 3:50 p.m. with RN E revealed: *She stated that eight residents share the blood glucose meter that she used for resident 46. *There was a blood glucose meter for every wing in the facility. *RN E was able to provide the manufacturer's cleaning instructions which stated the following: -The blood glucose meter was to have been cleaned with a lint-free cloth dampened with soapy water or isopropyl alcohol (70-80%). -The blood glucose meter was to have been disinfected with an EPA-registered disinfectant detergent, germicide wipe, or 1:(to)10 dilution of household bleach solution or 1:10 commercial bleach wipe. 2. Interview on 12/19/23 at 4:00 p.m. with director of nursing (DON) B regarding the blood glucose meter cleaning and disinfecting procedure revealed: * When questioned regarding the above observation and interview with RN E not disinfecting the blood glucose meter, DON B stated, Yes she does, I just watched her do it. *DON B returned to ask RN E how she cleaned and disinfected the blood glucose meters between residents and RN E stated that she cleaned the meter with the alcohol swab. *When asked when she used the disinfecting wipe, she said I do that at the end of the shift. *DON B then corrected RN E and stated No, you do it between every resident. *RN E stated, I didn't know, sorry, when educated by DON B about using a disinfectant wipe on the blood glucose meter after each resident's use. 3. Observation and interview on 12/19/23 at 4:15 p.m. with medication aide (MA) L revealed that she explained and demonstrated the correct process to clean and disinfect the blood glucose meter after each resident's use. 4. Record review on 12/20/23 of resident 31's electronic medical record revealed that he was admitted on [DATE] with a diagnosis of chronic viral hepatitis C. 5. Review of the provider's 9/22/23 Blood Glucose Monitoring Disinfecting and Cleaning-R/S [Rehabilitation/Skilled Care], LTC [Long-term Care] policy revealed: *The policy referred to CMS requirements and best practices, that blood glucose meters should have been cleaned and disinfected after each resident use whether the meter was assigned to a resident or was shared among residents. *The policy referred to the user manual for specific instructions for each meter. 6. Review of the provider's blood glucose meter User Instruction Manual revealed: *There were two options for cleaning and disinfecting the blood glucose meter. -Option 1 stated that cleaning and disinfection could have been completed using a commercially available EPA-registered disinfectant or germicide wipe. Two wipes should have been used; one to clean and the second to disinfect. -Option 2 stated to clean the outside of the meter with a lint-free cloth dampened with soapy water or isopropyl alcohol (70-80%) and to disinfect the meter by diluting 1 milliliter (mL) of household bleach in 9 mL of water to achieve a 1:10 dilution. Commercially available 1:10 bleach wipes were also acceptable for disinfection. 7. IMMEDIATE JEOPARDY The potential for blood-borne pathogen infections was increased due to RN E not following the provider's policy or the manufacturer's guidelines regarding the process of disinfecting the blood glucose meter after each resident's use. The blood glucose meter was shared between four residents on the 200-wing including resident 31 who had a diagnosis of chronic viral hepatitis C. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on 12/19/2023 at 5:39 p.m. to administrator A. An immediate removal plan was requested. IMMEDIATE JEOPARDY REMOVAL PLAN On 12/20/23 at 9:28 a.m., administrator A provided the survey team with a final written immediate jeopardy removal plan. The removal plan was approved by the survey team on 12/20/2023 at 9:41 a.m. with guidance from the long-term care advisor for the South Dakota Department of Health. The provider gave the following acceptable immediate jeopardy removal plan on 12/20/2023 at 5:39 a.m.: At 6:11pm on 12/19/23. DNS sent messages to all nurses and medication aides that competency on glucometer cleaning must be completed before next shift. Training to be completed by DNS or designee[.] - review of glucometer cleaning procedure - education of risk of BBP exposure if not cleaned properly. - nurse to complete demonstration of cleaning showing wiping all surface of meter. - verbalize dwell time IP or designee will audit 3 nurses daily x 2 to ensure compliance. Then weekly x4. Result to QA committee to determine ongoing monitoring and interventions. IP Nurse educated all nursing staff (nurses and medication aides) on the floor at 6:00 pm. A dedicated Glucose Monitor machine has been issued to resident (31) that has an infectious disease and labeled with resident name and is not to leave resident room. Care plan has been updated. All residents that utilize the glucometer were reviewed by DNS and IP Nurse on 12/19/23, and no other residents were found to be at known risk with diagnosis of Viral Hepatitis C. The medical director, [name of medical director], was notified of the incident on 12/19/23 at 8:26 p.m. Medical director was conferred with on review of case at 9:15 am on 12/20/23 and his recommendation is to not conduct lab test on residents. The immediate jeopardy was removed on 12/20/2023 at 12:57 p.m. after verification that the provider had implemented the removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was H.

Based on observation, interview, record review, and policy review, the provider failed to ensure the kitchen ceiling was free from peeling paint and the following kitchen equipment was free from frayed and broken parts, rust, dust buildup, particleboard breakdown, grime, and food particle buildup: *One of two convection ovens. *One of one dishwasher. *One of one door leading to the dishwasher room. *One of two particleboard cupboards in the dishwasher room. *All the handles on the cupboards in the dishwasher room. *All the table legs in the kitchen. *The lower shelving on one of three steel tables. *All the doors to the wooden cabinets. *The shelving inside the wooden cabinets. Findings include: 1. Observation on 12/19/23 from 8:35 a.m. to 9:00 a.m. during the initial kitchen walkthrough revealed: *The inner door seal on the top convection oven was frayed and there was exposed metal mesh. *There was a buildup of dust on the ceiling vest above the wooden cabinet. A nickel-sized clump of dust was observed falling off the vent. *That wooden cabinet was stained with what appeared to have been much oil from repeated hands touching the wood. *The shelves inside the wooden cabinet were stained with dried liquid and there were food crumbs. The cabinet contained pitchers, cloths, and other assortments of dishes. *All the steel legs on the tables, the three-compartment sink, and in the dishwasher room were rusted. *The lower shelving on the steel table across from the three-compartment sink was also rusted. There were mixing bowls and sheet pans stored upside down directly on the rusty shelf. *The ceiling paint in the dishwasher room and the food preparation area was peeling in several spots. *The handles on the particleboard cupboards in the dishwasher room were rusted. *The cupboard above the dirty dish area had particleboard exposed. There appeared to have been a buildup of moisture. Bits of wood fell off the cabinet when it was touched. *There was extensive rust on the cupboard hinges, the walls, and the door in the dishwasher room. *There was a thick buildup of grime and bits of food on the inside portion of the dishwasher doors. *There were two fans mounted to the walls in the dishwasher room. Both fan grates were rusty and had a buildup of dust. 2. Observation and interview on 12/21/23 at 11:23 a.m. with food service workers (FSW) G and H in the kitchen revealed: *The above equipment was in the same state. *To clean the dishwasher, FSW G stated she drained the dishwasher, removed the catch basket, sprayed that out, and sprayed out the inside of the dishwasher with plain water at the end of each shift. *FSW H stated he de-limed the dishwasher every month. *They both stated that they never scrubbed the inside or outside of the dishwasher. *There were several plastic scrub brushes located in the tall particleboard cabinet in the dishwasher room. They indicated they used those brushes to clean the sinks only. *They were not aware of the buildup of grime on the inside of the dishwasher. 3. Interview on 12/21/23 at 12:58 p.m. with dietary supervisor D about the above observations revealed *She confirmed neither she nor the other dietary staff scrubbed the inside or outside of the dishwasher. *The dishwasher company's technician visited monthly to inspect the dishwasher. *She confirmed that the dishwasher was de-limed monthly. *She was not aware of the buildup of grime and food particles in the dishwasher. *She was aware of the frayed parts on the convection oven, the stained cabinet doors, all the rust, the peeling paint, and the particleboard cabinets falling apart. *She stated she had been working at the facility for [AGE] years and it had always been like that. *An oven repair technician had previously visited the facility to fix the oven. She said that he was not able to fix the oven because it was too old. *She had requested new equipment over the past several years, and over the past several administrators, but it always gets pushed to the side. 4. Interview on 12/21/23 with administrator A about the above observations revealed: *He was aware of the state of the kitchen equipment. *They had repainted the ceiling several times before, but the paint continues to peel away due to the moisture and humidity coming from the dishwasher room. *He planned to compile a list of items in the kitchen that needed to be replaced or fixed so he could fit that into the budget. 5. Review of the past six months of kitchen cleaning checklists revealed that the dishwasher had been de-limed all the months except for November 2023. A request was made on 12/21/23 at noon for the dishwasher cleaning and maintenance policy and the kitchen cleanliness policy. Dietary supervisor D indicated there were no policies that she could locate.

Based on observation, interview, and record review, the provider failed to offer one of one sampled resident (45) a meal alternative when the resident expressed that she did not like what had been served. Findings include: 1. Observation on 12/19/23 at 11:10 a.m. in the dining room revealed the menu for lunch was cheesy tuna casserole, cucumber salad, bread, and apple crisp. Observation on 12/19/23 at 11:44 a.m. in the dining room revealed that a staff member was wheeling a cart of room trays out of the dining room. 2. Observation and interview on 12/19/23 from about 2:15 p.m. to 3:15 p.m. with resident 45 in her room revealed: *She was on airborne precautions due to her diagnosis of COVID-19 and was isolated in her room. *There was a Styrofoam plate on her overbed table. There was tuna casserole and green beans on her plate. She had not touched those food items. *She was disgusted by the meal because she didn't care for the casserole and the green beans were cold by the time her tray was delivered. *She indicated the cooked vegetables were usually cold by the time it was served. *No one ever gives me an option. You just get served whatever's on the board. *Since she was in isolation due to her diagnosis, she was not able to go to the menu board posted outside of the dining room to check on the menu. *She indicated the staff usually would deliver The Daily Chronicle that had the menu printed on it, but she had not received one for that day. *At around 2:30 p.m., certified nurse aide (CNA) F entered the resident's room and gave her a fresh cup of ice water. *Resident 45 informed CNA F that she did not care for the casserole or the beans. -CNA F did not ask the resident if she wanted anything else to eat. CNA F did not offer any alternative meal options. -CNA F said that they would pick up her lunch meal tray when supper was delivered. She left the plate of food sitting on the resident's overbed table. Interview on 12/19/23 at 4:06 p.m. with CNA F about the above observation revealed: *If a resident was not eating their meal, the nurse should have been notified. *She confirmed she had not yet notified a nurse about resident 45 not eating lunch. *She indicated she should have asked [the resident] if she wanted something else [to eat]. *She could not explain why she left the plate of food in the resident's room. *At times, she would have also spoken to her coworkers in the dietary department to see if there were any food preferences for that resident. *She confirmed she had spoken with a dietary employee to inform them that resident 45 had not eaten her lunch, that she was not happy with the menu option, and that she had not received The Daily Chronicle for 12/19/23. *She explained that there was no set alternative meal menu. If a resident did not like what was served on the main menu, staff were to ask the resident what else they wanted. -Usually, the alternatives were an egg salad sandwich, a bowl of soup, cold cereal, toast, or whatever the resident requested. 3. Interview on 12/20/23 at 3:47 p.m. with social services coordinator J and activities director K about menu alternatives revealed: *There usually was a second option for the vegetable. *If a resident did not like the main entree, they had the option to choose a sandwich, soup, or cold cereal. *The dietary staff were pretty accommodating and tried to make a food item that a resident would ask for, within reason. *If it's feasible, the kitchen will make whatever they [the residents] want. 4. Review of resident 45's meal intake records for 12/19/23 revealed that CNA I had charted that the resident ate 75 - 100% of her lunch. Interview on 12/21/23 at 12:58 p.m. with dietary supervisor D about the meal intake records revealed: *If the resident ate their meal in the dining room, the dietary staff were responsible for recording the resident's meal intake. *Nursing staff were responsible for recording the resident's meal intake if the resident ate their meal in their room. *She expected the nursing staff to check on the residents during and after their meals if they ate in their room. Interview on 12/21/23 at 1:22 p.m. with CNA I regarding resident meal intake records revealed: *The CNAs were responsible for recording the percentage of the meal intake if the resident ate their meal in their room. *When asked about how she would chart the percent meal intake for a resident who only ate the dessert and the bread but did not touch the main entree or the vegetable, she indicated she would have charted that as 0 - 25%. *She was not sure why she charted resident 45's meal intake for lunch on 12/19/23 as 75 - 100%. *She said at times, if she was on the computer charting, she would ask another CNA what the resident's meal intake was for a certain meal and would rely on their answer. -She indicated she should not have done that, and she should have charted the meal intake based on her observation. Interview on 12/21/23 at 1:57 p.m. with director of nursing services B about the above observations revealed: *If a resident was not eating their meal, it was her expectation that staff should have asked that resident if they would have liked something else to eat. *She also expected the staff to inform the nurse if a resident was not eating so the nurse could assess the resident to figure out why they were not eating. *She stated that CNA F should have offered a meal alternative or a snack to resident 45 and that the CNA should have taken the plate of food away rather than leave it in the resident's room. *It was her expectation for staff to chart meal intake based on what they saw rather than relying on another staff member's account. 5. A request was made on 12/21/23 at noon for the alternative menu policy, the menu for the food that was always available, the policy for documenting resident meal intake, and any policy or procedure for what the staff were expected to have done when they noticed a resident was not eating some or all of their meal. The requested items were not provided by the end of the survey on 12/21/23 at 4:00 p.m.

Based on observation, interview, and policy review, the provider failed to ensure: *A vital signs machine had been disinfected between use by one of one observed certified nursing assistant (CNA) F for four of four randomly observed residents. *Appropriate glove use by one of one registered nurse (RN) E while administering intravenous (IV) antibiotics to one of one sampled resident (35) receiving IV medication. Findings include: 1. Observation on 11/29/22 at 9:47 a.m. of CNA F using a vital signs machine revealed she had: *Obtained vital signs on four randomly observed residents in rooms [ROOM NUMBER]. *Not disinfected the vital signs machine between use on those four residents. Interview on 11/30/22 at 1:25 p.m. unlicensed assistive personnel G revealed the vital signs machine was to be disinfected between use with the wipes kept in the basket on the machine. Interview on 12/1/22 at 7:58 a.m. with CNA F regarding the vital signs machine revealed she should have disinfected the machine between uses and had not. Interview on 12/1/22 at 11:51 a.m. with director of nursing B revealed the vital signs machine was to be disinfected between uses. 2. Observation on 12/1/22 at 12:25 p.m. of RN E administering IV medication to resident 35 revealed she had worn gloves she had stored in her shirt pocket. Interview with RN E after the above observation revealed: *Her pockets were probably not clean because that is where she kept her pens. *The gloves she had in her pockets were not clean. Interview on 12/1/22 at 1:31 p.m. with director of nursing B revealed staff should not store gloves in their pockets. 3. A policy for cleaning of re-usable medical equipment and glove use policy was requested on 12/1/22 at 12:40 p.m. the policies provided had not addressed: *When or how to clean the vital signs machine. *How gloves were to be stored.

Based on observation, interview, record review, and policy review, the provider failed to ensure the nutritional status was monitored for one of one sampled resident (19) who had a significant weight loss. Findings include: 1. Observation on 11/29/22 at 11:20 a.m. of resident 19 sitting in a wheelchair at a table in the dining room revealed he: *Appeared thin. *Was eating a nutritional supplement. Review of resident 19's medical record revealed: *An admitted on 5/6/22. *His diagnoses included: chronic obstructive pulmonary disease, depression, hypertension, chronic heart failure, dementia, and muscle weakness. *His Abilify (medication used to treat depression) had been tapered starting 9/9/22 and discontinued at the beginning of October 2022. *On 09/15/2022, he weighed 130 pounds (lbs). *On 10/17/2022, he weighed 118.5 lbs. -An 8.85 percent weight loss. *On 10/31/22, he weighed 117.5 lbs. *A Mini-Nutritional Assessment (used to identify geriatric patients who are malnourished or at risk of malnutrition) had been completed on: -8/9/22, his score was 11 out of 14 indicating he was at risk of malnutrition. -11/11/22, his score was 8 indicating he was at risk of malnutrition. --The question for weight loss in the last 3 months was answered incorrectly. --If answered correctly his score would have been 6 indicating he was malnourished. *His 10/25/22 physician progress note stated: Appetite is fair and weight is stable. *No documentation his physician had been notified of weight loss until 11/3/22. *On 11/3/22 when the facility had notified the physician of the weight loss and his refusal to get up out of bed, he wrote new orders to restart the Abilify and increased his house nutritional supplement from two ounces to four ounces four times a day. *On 11/20/22 his physician saw him and wrote new order to increase the house nutritional supplement to six ounces four times a day for weight loss. *No documentation the dietician had been notified of his weight loss prior to the survey date. *No documentation of family notification until his care conference on 11/17/22. Review of resident 19's care plan revealed: *He had a nutritional problem related to his diagnosis and evidenced by his variable intakes and weight loss. *His goals had not been updated since is admission and included: -Resident will try to maintain weight without triggering a 5% weight loss/gain through the review date. - Resident will consume an average greater than 50% of meals through the review date. *His interventions had not been updated since the weight loss occurred. Interview on 11/30/22 at 4:12 p.m. with dietary manager (DM) C regarding resident 19's weight loss revealed: *She sent the doctor a fax to notify him of resident's weight loss on 11/4/22. *She reviewed weights on residents who are due for a minimum data set (MDS) assessment. *Tried to look at all resident's weights weekly. *The registered dietitian (RD)came monthly and sees the residents who are due for a MDS assessment, recently returned from a hospital stay, had wounds, on dialysis, had weight loss, or any other dietary concerns. *She made the list of resident's that needed seen by the RD each month. *Did not have resident 19 on that list for October. *The provider did not have a meeting to review residents who were at nutritional risk. Continued interview on 12/1/22 at 8:57 a.m. with DM C regarding resident 19 revealed: *He was receiving a magic cup (nutritional supplement) at dinner and supper and Breeze (nutritional supplement) at all three meals. *She stated the additional supplements were started in October 2022 but did not have documentation to show the addition of the supplements. *The consumption of these supplements was not documented. *There was no documentation that anything was done for his weight loss until November 2022. *She agreed her Mini-Nutritional Assessment completed on 11/11/22 was not answered correctly. -She should have answered Weight loss greater than 3 kg (6.6 pounds. Interview on 12/1/22 at 11:09 a.m. MDS coordinator D regarding resident 19 revealed: *DM C was to monitor residents' weights and let nursing know when a resident was loosing weight. *She noticed resident 19's weight loss when completing his quarterly MDS assessment in November 2022. *She notified DM C and faxed a note his physician. *Resident 19 should have been monitored more closely after his Abilify was stopped. *Provider does have morning meetings to discuss concerns but weights are not part of that meeting. Interview on 12/1/22 at 11:57 a.m. and at 1:28 p.m. with director of nursing B regarding resident 19 revealed: *She had done doctor rounds on 11/20/22 and had requested his house nutritional supplement be increased. *There had been no documentation the physician had been notified of the weight loss until 11/3/22. *There had been no documentation the RD had been notified of the weight loss prior to 11/30/22. *DM C monitored weights and let her know if a resident had weight loss. Review of the provider's 5/31/22 Identifying Resident With Impaired Nutritional Status and Nutritional Risk policy revealed: *The DM was to review resident weights monthly. *Residents with newly identified impaired nutritional status or nutritional risk are added to the Nutrition Risk List . and discussed at the next nutrition risk committee meeting.

A. Based on interview, document review, policy review, and infection control preventionist (ICP) and director of nursing services (DNS) job descriptions, the provider failed to ensure a consistent infection prevention and control program had been in place for staff and residents for: *Evaluating and tracking infection control trends and practices. *Conducting infection control meetings. *Reporting statistical information to the quality assurance performance improvement (QAPI) program to assist with establishing goals and objectives for infection control. *Five of five newly hired sampled employees (A, B, C, D, and E) had a health evaluation completed by a healthcare professional within fourteen days of being hired. *Five of five newly hired sampled employees (A, B, C, D, and E) had completed the two-step method for the Mantoux [MEDICATION(S)] (TB) skin test or TB screenings within fourteen days of being hired. Findings include: 1. Interview on 6/29/21 at 1:30 p.m. with the director of nursing services (DNS) A and registered nurse (RN) J regarding the infection control program revealed:*The provider had many staffing changes over the past year with multiple changes in the nurses' responsible for infection prevention and control. *Licensed practical nurse (LPN) L was certified as an ICP and had been in that role until October 2020. -She was now working as a night nurse and sometimes helped out with infection control. *From November 2020 through February 2021 the previous DNS RN J had taken over the job of infection control. *In February 2021 an interim DNS N took over the responsibility of infection control until May 2021. *RN K: -Accepted the position of ICP four weeks ago. -Was not yet certified as ICP. -Had not been trained. -Was not going to begin the job until she became certified. Continued interview with DNS A and RN J regarding the requested infection control program documentation for the last year revealed RN J provided the following information: *A graph indicating the monthly antimicrobial rate form June 2020 through May 2021. *A graph indicating the monthly infection rate from June 2020 through May 2021. *A Monthly Infection Summary from 6/22/20 through 8/7/20. That summary contained: -Residents' names. -Start date. -Date symptoms resolved had been identified for twelve of seventeen residents. -Type of infection. -The current status of the infection. -The antimicrobial used had been identified for six of seventeen residents. -Infection source. -Surveillance criteria met or not met. *A Monthly Antimicrobial Summary from 6/22/20 through 7/24/20. That summary contained: -Residents' names. -The name and antimicrobial class of the medication used to treat the infections. -The start date and end date of the medication therapy. -The route the medication was given. -The infection type had been identified for one of fifteen residents. RN J was asked to provide the monthly infection and antimicrobial summaries that related to the above graphs, any further tracking, trending, and other statistical information identified, infection control meeting minutes and education provided related to infection control. RN J had not provided any further infection control documentation for review. On 6/29/21 at 3:30 p.m. RN J stated: *There was no further infection control documentation because it had been given to the QAPI committee. *The infection control documentation had not been retained by the infection control nurse. *Infection control meetings were not held separately, because they were just part of the QAPI program. Interview on 6/29/21 at 3:35 p.m. with DNS A regarding the infection control program revealed: *Her expectation was for the infection control preventionist to maintain documentation of: -Evaluating and tracking infection control trends and practices. -Monthly infection and antimicrobial summaries and other statistical information. -Education provided to staff regarding current infection control concerns. -Infection control meeting minutes. -Any infection control statistical information that had been provided to QAPI. Surveyor: 2a. Review of the following employee personnel records revealed the following hire dates: *Employee A: 4/26/21 *Employee B: 5/26/21 *Employee C: 3/1/21 *Employee D: 4/23/21 *Employee E: 5/11/21 *There was no documentation in the above employee personnel files that a health evaluation had been completed, reviewed and signed by a health care professional to determine the employees were free of communicable diseases. Interview on 6/29/21 at 2:30 p.m. with administrator H revealed: *He confirmed there was no documentation in employee A, B, C, D, or E's personnel files that a health evaluation had been completed within fourteen days of being hired to determine they were free of communicable diseases. *He was aware that it should have been done and stated it had been missed. Surveyor: 2b. Review of the following employee personnel records revealed the following hire dates: *Employee A: 4/26/21 *Employee B: 5/26/21 *Employee C: 3/1/21 *Employee D: 4/23/21 *Employee E: 5/11/21 *There was no documentation in the above employee personnel files TB screening had been completed. Interview on 6/29/21 at 2:30 p.m. with administrator H revealed: *He confirmed employee's A, B, C, D, and E had not had a TB screening completed within fourteen days of hire and should have. *His expectation was for the state regulation to be followed for the TB screenings. Surveyor 3. Review of the provider's reviewed/revised December 2019 Infection Prevention and Control Program policy revealed: *The provider would maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment for residents, patients, children, families, visitors and employees and to help prevent the development and transmission of communicable diseases and infections. *The infection preventionist and the QAPI committee would direct the functions of the infection prevention and control program. *The system of identifying, reporting, investigating, and controlling infections and communicable diseases for all residents was to have been tracked where possible on the Infection and Antimicrobial Tracking Tool and reviewed by the QAPI committee who would keep a record of any corrective action taken. *The system of identifying, reporting, investigating, and controlling infections and communicable diseases for all employees, visitors and other individuals providing services would be tracked where possible on a Monthly Report of Infections in location - Employees, children, family and visitors. Review of the provider's reviewed/revised July 2020 Surveillance policy revealed: *Surveillance was to have been done to find, analyze, control, and prevent nosocomial infections. *Surveillance included collection, collation analysis of date and passing of information to those who needed to know and take action. Review of the December 2019 Infection Preventionist policy revealed the following responsibilities of the IP: *Coordination of an annual review of the infection prevention and control program and update as necessary. *Coordination of the antibiotic stewardship program. *Completion of the infection and antimicrobial tracking tool and use the information to report to the QAPI committee. *Become a member of the QAPI committee. *Investigate and report clusters of infections and unusual nosocomial infections and submit a monthly infection summary and Monthly antimicrobial summary and a monthly report of infections to the QAPI committee. *Work to prevent infections and implement improved resident care procedures. *Collect and catalog infection data, review the reports and recommend procedures to control additional cases. *Investigate and assist with employee health activities, including recording employee infection reports and information. *Provide infection control education to new employees and continuing education to all staff. *Continually monitor employee infection control practices. Review of the May 2021 director of nursing services job description revealed the DNS was responsible for: *The overall quality of care provided by the organization's nursing personnel. *Monitoring the compliance with regulations. *The overall responsibility for the day-to-day operations of the facility. *The quality of resident care. *Performing necessary delegation and coordination for clinical, operational, and managerial activities. *Effectively managing and directing the work of individuals and teams. B. Based on observation, interview, record review, and policy review, the provider failed to ensure one of three observed certified nursing assistant (CNA) (F) had maintained infection control technique during one of two observed sampled residents (40) personal care. Findings include: 1. Observation on 6/27/21 at 3:50 p.m. in resident 40's room with CNAs F and G revealed: *CNAs F and G had on gloves. *CNA F: -Assisted resident 40 to turn to her left side in bed. -Unfastened her wet brief and pulled it down, took a wet wipe from the package, and wiped one time in her front perineum area. -Removed the soiled brief and discarded it into the garbage. -Took another wet wipe from the package and wiped one time over her buttock area. *With the same gloves on, he put a clean brief on her and pulled up her slacks *CNAs F and G: -Assisted her with sitting up in bed. -Attached the mechanical stand lift sling around her and around her feet. *With the same gloves on CNA F touched the control switch on the mechanical lift and guided her to the wheelchair. *CNA F removed those gloves, discarded them into the garbage. tied up the garbage bag, and then went into the bathroom and performed hand hygiene. Review of resident 40's medical record revealed: *She had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *The 6/8/21 Minimum Data Set assessment had been coded she required extensive assistance of one staff member for toilet use, personal hygiene, and was incontinent of bowel and bladder. Interview on 6/29/21 at 10:20 a.m. with DNS A regarding CNA F and hand hygiene during resident 40's personal care revealed her expectations would have been after touching something soiled/dirty to remove gloves and perform hand hygiene, reapply gloves, and continue. CNA F should have removed his gloves and performed hand hygiene. Review of the provider's 4/6/21 Hand Hygiene and Handwashing policy revealed: *The purpose was to ensure appropriate hand hygiene technique for clinical use. *The goal for patient [resident] care was to prevent the spread of infection between residents. -Handwashing and changing gloves occurs after care is delivered to prevent the spread of organisms to other residents. -Sanitizers are used in patient care areas. *During patient [resident] care: -2. If hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub for routinely cleaning hands. -c. After having contact with body fluids, wounds or broken skin. -e. After removing gloves. Review of the provider's 4/16/21 Perineal Care policy and procedure revealed: *Purpose: -To prevent infection and odors in the perineal area. -To promote good perineal hygiene. -To observe perineal area. *Procedure: -3. Apply gloves. -4. Fold covers down and remove soiled pad. -5. Remove soiled gloves. Wash hands or use hand sanitizer before touching objects in environment. Re-glove to resume perineal care. -6. If resident is unable to spread legs and flex knees, turn the resident on the side with legs flexed. -7. Wet washcloth, apply a small amount of soap or peri-wash or use a disposable wipe. --For females:---a. -8. Turn resident (both male and female) on side to wash, rinse and dry anal area. --After removing soiled gloves use hand sanitizer or wash wit soap and water to cleanse hands. --Put on clean gloves to put on clean pad and/or clothing.

Based on interview, document review, and policy review, the provider failed to ensure an effective quality assurance and performance improvement (QAPI) had consistently been implemented to identify, track, and trend infection control concerns for residents and staff had been identified by a lack of documentation for infection control monitoring for tracking or trending of infections by the infection control preventionist for the first quarter of 2021. Findings include: 1. Interview on 6/29/21 at 10:30 a.m. with QAPI coordinator N regarding the QAPI program revealed: *The expectation had been for the QAPI committee to meet monthly or at a minimum quarterly to discuss identified concerns. *She took over as QAPI coordinator in January 2021. *Each facility department was to have reported quarterly on QAPI findings to the QAPI committee. Review at the above time with QAPI coordinator N of the QAPI committee minutes from 1/1/2021 through 6/29/21 of QAPI information brought to the meetings revealed she: *Was unable to find documentation of infection control statistics/tracking and trending of resident and staff infections. -Had attended QAPI meetings from January 2021 through June 2021. *Stated no infection control statistics had been added to the QAPI meetings for discussion at any of those meetings. *Her expectation was for infection control statistics to have been shared and discussed as part of QAPI. Interview on 6/29/21 at 1:25 p.m. with QAPI coordinator N regarding the missing Infection control statistics information confirmed: *The missing information could not be located, because there was no information or documentation to be found. *The current QAPI team were making good faith attempts to correct identified concerns. *She had not stated how long they had been making good faith attempts. Review of the provider's 2021 QAPI plan revealed: *The QAPI committee was to have ensured an effective QAPI program was in place and the program was adequately resource with time, personnel, training, equipment and financial resources. *The executive leadership was to have supported improvement work by ensuring the provider had a well-defined adequately resource QAPI program to address facility specific issues. *The provider's QAPI committee was to have met at least quarterly and as needed to address identified quality concerns. *The provider's administrator: -Was the leader of the QAPI committee with assistance of the QAPI coordinator. -Was responsible for the QAPI committee's effective operation. *The medical director was included as a member of the QAPI committee. *Each service line was responsible for tracking individual performance and report data to the QAPI committee. *Action plans were to have been presented to the QAPI committee for monitoring and to ensure improvement was sustained. Review of the administrator's April 2021 job description revealed the administrator was responsible for: *The overall leadership and management including meeting established goals and outcomes, ensuring regulatory and organization compliance, and directing and coordinating work, financial and operational stability, and demonstrating leadership. *Ensuring a QAPI program was in place. *Assigning responsibility to individuals for the daily management of QAPI. *Ensuring the leadership of monthly QAPI committee meetings. *Sponsoring performance improvement projects (PIPs) and reviews. *Providing access to information needed to support QAPI. *Provides equipment and supplies to support QAPI efforts. Review of the provider's May 2020 medical director job description revealed the medical director was identified as a leader and was to be responsible to collaborate with the provider's executive leadership, administration, and department leadership to develop and coordinate overall strategy for the reduction of healthcare associated infections. Review of the provider's December 2020 Associate Quality Strategist job description provided after a request for the QAPI coordinator job description revealed: *The associate quality strategist: -Role was responsibility for maintaining knowledge of current quality measures within value based programs and contracts. -Was to have the ability to collect and organize detailed information and review, analyze, and validate data reports. -Was to be willing to seek out new information and embrace new responsibilities and change. *Each service line was responsible for tracking individual performance and report data to the QAPI committee. *Action plans were to have been presented to the QAPI committee for monitoring and to ensure improvement was sustained. Refer to F880, findings A1, 2a, 2b, and 3.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled residents (30) with an indwelling catheter had received ongoing catheter care. Findings include: 1. Observation and interview on 6/27/21 at 3:30 p.m. with resident 30 revealed: *She had: -An indwelling Foley catheter due to [CONDITION(S)]. -Used a catheter almost two years after a hospitalization for a severe infection. -Been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . *When the surveyor asked her for permission to observe catheter care the following morning she stated: -She normally got up for the day around 9:00 a.m. -She had not received catheter care when the staff came to do her personal care. -The staff had not offered to complete the catheter care and she had not wanted to bother them, because they were busy doing other things. -Even when she was at the hospital the hospital (she had a cystoscopy done in November 2020 for blood in her urine) staff had asked if she received catheter care. She had told them she had not. -She had her catheter changed monthly and her catheter care was done at that time. Observation and interview on 6/28/21 at 9:30 a.m. of certified nursing assistant (CNA) I completing catheter care on resident 30 revealed: *CNA I performed catheter care with good technique. *She thought catheter care was to have been completed twice daily. Interview on 6/28/21 at 5:15 p.m. with resident 30 regarding the catheter care she had received at 9:30 a.m. when questioned whether that was something she had received routinely she confirmed: *She had not been receiving that or any other catheter care except for the monthly catheter changes. *CNA I had completed the catheter care with good technique. Review of resident 30's medical record revealed: *A 5/4/21 annual Minimum Data Set (MDS) assessment indicated her Brief Interview for Mental Status (BIMS) examination score was 15 indicating her mental status was cognitively intact. *She had a urine culture done with positive results of infection on 3/31/21. *Her revised 5/17/21 catheter care plan revealed CNA to clean catheter. *The monthly CNA task documentation area for CNA documentation of resident care tasks had no area to remind staff to complete catheter care or document that the care had been completed. *The December 2020 through June 27, 2021 treatment administration records had no documentation to indicate catheter care had been completed. Interview on 6/29/21 at 1:45 p.m. with the director of nursing services (DNS) regarding resident 30's concern about the lack of catheter care revealed: *Resident 30 had reported to her on two occasions of not having catheter care done in the past, even though the DNS had completed catheter care for her when she had helped out with resident care. -There was no documentation of the catheter care she had provided. *She confirmed resident 30's cognition was intact. *She had discussed infection control issues with the nursing staff monthly the last two months since she began working at the facility. -There was no specific documentation to indicate catheter care had been a topic. *She: -Thought catheter care was part of CNA competencies. --Had not provided copies of those competencies when this writer had requested them at the above time of the interview. *Confirmed there was no documentation to indicate the catheter care had been completed. Review of the provider's May 2021 Catheter: Care, Insertion and Removal, Drainage Bags, Irrigation, Specimen policy about indwelling catheters revealed catheter care was to have been done with morning and bedtime cares and as needed.

Based on record review, interview, job description review, and policy review, the provider failed to thoroughly investigate an event for one of one sampled resident (1) who had a fracture identified after being assisted with a mechanical lift to rule out abuse and neglect. Findings include: 1. Review of the provider's 3/24/20 South Dakota Department of Health (SD DOH) Online Self Reporting form for resident 1's 3/24/20 injury from a mechanical lift event revealed: *The director of nursing (DON) had completed the form on 3/24/20. *The event occurred on 3/24/20 at 7:00 a.m., and it was considered a suspicion/allegation of abuse/neglect due to physical harm/injury. *The form indicated the resident was capable of providing an explanation of the event. *The brief explanation included: -CNA (certified nursing assistant) reports to nurse when transferring resident using the sit to stand resident's arms gave way/slipped causing him to slip and he was then lowered to the floor. CNA also stated resident did not hit his head during incident. Resident states 'my arms slipped.' Asked resident upon return from ER (emergency room ) visit about how he hurt his shoulder. Resident stated 'What do you mean, I didn't get hurt.' Unable to remember/explain incident today. Resident was assessed for injuries, VS (vital signs) and ROM (range of motion) done. VS are WNL (within normal limits). Resident c/o (complained of) severe pain to his right upper arm up to his right shoulder area. He is not letting nurse do ROM to that area. Other ROM to rest of his body is WNL. Notified Physician on call- (name), NP (nurse practitioner) and she ordered to have resident seen in the ER today. Family, (administrator name) and (DON name) notified. *The allegation involved CNA C with the section for previous disciplinary actions left blank. -She had been hired on 7/1/19. *The conclusionary summary statement of the facility investigation was: -During investigation it was noted staff was using sit to stand properly and following care plan. Staff member has been certified with proper lift use within the past 12 months. Staff stated that during transfer he was fine in the lift and then suddenly his arms gave out and he started to slip and staff lowered to the floor to prevent further injury. Last evaluation of transfer appropriateness was done by a nurse on 1/20/20 and sit to stand was appropriate at that time. No documentation noted that resident/staff had concerns with safety with transfers since assessment. -Intervention: Sent to ER and scapula fracture/dislocation. Care plan updated with Total lift with assist of 2 with transfers. Staff on floor currently notified verbally as well. -Emailed proof of Facility investigation notes - ER documentation - Care plan - Resident lift assessment completed in January 2020 - Last lift competency completed for aide involved. *No was selected for if abuse/neglect allegation was substantiated due to lift was used properly. *Action taken by facility was: -Care plan reviewed/revised. -Personnel education. *There was no mention of: -How the resident was gotten up from the floor and sent to ER. -If there were any concerns found with the mechanical lift that was used. -What personnel education was given. -If any other personnel were involved in the event. Further record review and interviews throughout the survey on 4/6/20 from 11:15 a.m. through 6:30 p.m. and on 4/7/20 from 7:30 a.m. through 2:30 p.m. revealed concerns with the provider's investigation into resident 1's incident on 3/24/20 involving staff and a mechanical lift including what occurred in response to it. *The resident was cognitively impaired and not able to participate in the investigation. *There was missing documentation to support the details surrounding the event and response. *CNA D who had been involved in the event had not been identified in the investigation or documentation. *There had been no follow-up with staff or re-education when they had not followed the provider's policies regarding notifying the nurse for assessment prior to moving the resident. *The concerns identified showed a thorough investigation had not occurred to rule out abuse or neglect. Refer to F600. Surveyor Review of the provider's July 2017 Falls-Mechanical Lift/Transfers policy revealed: *Manually lifting a fallen resident from the floor increases the risk of injury to both the resident and the caregiver. -To ensure safe transfer for a fallen resident, the following steps should take place: --2. The licensed nurse should evaluate the resident while on floor and determine if the resident has injuries that indicate the resident should not be moved. --3. Use the total lift to assist an uninjured fallen resident from the floor. Avoid manual lifting. Review of the provider's May 2019 Incident Report policy revealed: *Purpose: -To document resident and visitor incidents. -To conduct an investigation of each resident. -To gather objective information and identify root causes to prevent similar occurrences from happening in the future. Review of the provider's October 2018 Abuse and Neglect policy revealed: *Purpose: -To assure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations in the location. -To ensure that all identified incidents of alleged or suspected abuse/neglect are promptly investigated and reported. -To prevent future injuries. -To ensure that a complete review of existing incidents is documented. -To identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and to determine the direction of the investigation. Review of the provider's 8/16/16 Certified Nursing Assistant job description revealed: *Basic Responsibilities: -This position will be held accountable for complying with all related laws, regulations, company policies and procedures pertaining to his or her position. *Physical/Mental Requirements: -While performing the duties of this job, the employee will operate/activate/use/prepare/inspect/place/detect/position objects, tools, or controls. -The employee will frequently communicate/express/observe/assess/detect information relative to this position. -Must be able to effectively communicate in English, both orally and in writing. Review of the provider's 8/17/16 Director of Nursing job description revealed: *Responsible to lead management and monitoring/auditing of the EMR (electronic medical record) in the location; to include training, documentation, reports/dashboards and retrieval management and monitoring/auditing. -Assures plan of care and interventions are evaluated for effectiveness on an ongoing basis and adjusted and updated accordingly. -Assures residents are free of neglect and abuse. -Maintains thorough and accurate records for each resident. Review of the provider's 8/16/16 Charge Nurse-LPN (licensed practical nurse) job description revealed: Observes and documents observations and care given to residents. Review of the provider's undated Administrator job description revealed: *An Administrator for the Society is responsible for the overall leadership and management of the location, including meeting established goals and outcomes, ensuring regulatory and organization compliance, directing and coordinating work. *Manages Communication and Documentation: -Ensures documentation and reports are completed as required by regulations and/or policy and procedure. Interview and document review on 11/9/20 at 1:55 p.m. with DON B regarding the above information revealed: *They had not had any falls from lifts since the 4/7/20 off-site survey. *They had made changes in their investigation process since that incident. *Those changes had included: -The charge nurse had done the assessments. -The certified nursing assistants had been educated on the fall process. -There was a list of items staff were to do when a resident fell . -They had completed audits on falls and were found to be compliant. *They had followed their plan of correction from the 4/7/20 off-site survey. *The process was ongoing, and they were ensuring all pieces were completed.

Based on record review, interview, job description review, and policy review, the provider failed to ensure resident safety for one of one sampled resident (1) who had a fracture identified on 3/24/20 from a previous off-site complaint health survey done on 4/6/20 through 4/7/20 after being assisted with a mechanical lift by two of two certified nursing assistants (CNA) (C and D). Findings include: 1. Review of the provider's 3/24/20 South Dakota Department of Health (SD DOH) Online Self Reporting form for resident 1's 3/24/20 event revealed: *The director of nursing (DON) had completed the form on 3/24/20. *The event occurred on 3/24/20 at 7:00 a.m., and it was considered a suspicion/allegation of abuse/neglect due to physical harm/injury. *The form indicated the resident was capable of providing an explanation of the event. *The brief explanation included: -CNA reports to nurse when transferring resident using the sit to stand (mechanical lift) resident's arms gave way/slipped causing him to slip and he was then lowered to the floor. CNA also stated resident did not hit his head during incident. Resident states 'my arms slipped.' Asked resident upon return from ER (emergency room ) visit about how he hurt his shoulder. Resident stated 'What do you mean, I didn't get hurt.' Unable to remember/explain incident today. Resident was assessed for injuries, VS (vital signs) and ROM (range of motion) done. VS are WNL (within normal limits). Resident c/o (complained of) severe pain to his right upper arm up to his right shoulder area. He is not letting nurse do ROM to that area. Other ROM to rest of his body is WNL. Notified Physician on call- (name), NP (nurse practitioner) and she ordered to have resident seen in the ER today. Family, (administrator name) and (DON name) notified. *The allegation involved CNA C with the section for previous disciplinary actions left blank. -She had been hired on 7/1/19. *The conclusion summary statement of the facility investigation was: -During investigation it was noted staff was using sit to stand properly and following care plan. Staff member has been certified with proper lift use within the past 12 months. Staff stated that during transfer he was fine in the lift and then suddenly his arms gave out and he started to slip and staff lowered to the floor to prevent further injury. Last evaluation of transfer appropriateness was done by a nurse on 1/20/20 and sit to stand was appropriate at that time. No documentation noted that resident/staff had concerns with safety with transfers since assessment. -Intervention: Sent to ER and scapula fracture/dislocation. Care plan updated with Total lift with assist of 2 with transfers. Staff on floor currently notified verbally as well. -Emailed proof of Facility investigation notes - ER documentation - Care plan - Resident lift assessment completed in January 2020 - Last lift competency completed for aide involved. *No was selected for if abuse/neglect allegation was substantiated due to lift was used properly. *Action taken by facility was: -Care plan reviewed/revised. -Personnel education. *There was no mention of: -How the resident had been gotten up from the floor and sent to the ER. -If there were any concerns found with the mechanical lift that was used. -What personnel education was given. -If any other personnel were involved in the event. Review of resident 1's medical records submitted by the provider with the above report revealed: *His current care plan indicated: -He had been admitted in June 2017. -His [DIAGNOSES REDACTED]. --[MEDICAL CONDITION], history of a stroke, [MEDICAL CONDITION], arthritis, severe cognitive impairment, hearing loss, [MEDICAL CONDITION], behaviors, and a left foot nodule, and [MEDICAL CONDITION]. -Transfers had been revised on 3/24/20 to be completed with the total mechanical lift and two staff. --Previously it had been to use the sit-to-stand mechanical lift with one staff person since 7/23/19. -He had falls on 7/23/19, 7/26/19, and on 3/24/20. *The 3/24/20 ER visit notes, x-ray, and computed tomography scan results included: -He was seen for a fall with arm pain and diagnosed with [REDACTED]. -The physician's orders [REDACTED]. *The 3/24/20 incident report included: -The nursing and resident description were the same as the brief explanation in the above SD DOH Online Self Report. -No apparent unsafe condition was marked for predisposing environment factors. --Options that could have been marked included if equipment/assistive devices were involved. -The only predisposing physiological factors marked were impaired memory and confused. --Options that could have been marked included if the resident had a recent illness or recent changes in medications. -The only predisposing situation factor marked was Other (specify in Other information). --Options that could have been marked included if a mechanical lift or equipment was used. -Other information was: Resident's arms gave way/slipped when using sit to stand while transferring resident. -There were no witnesses identified or listed. -The form indicated the physician, resident's family, DON, and administrator were all notified on 3/24/20. *A 1/20/20 Sit-Stand-Walk Data Collection Tool indicated he would be transferred using the sit-to-stand mechanical lift with assistance of one staff person. -That had been completed by Minimum Data Set (MDS) assessment coordinator nurse F. *CNA C's Safe Resident Handling Equipment Competency Validation Checklist had been completed on 7/1/19. Phone interview and entrance conference review on 4/6/20 at 11:15 a.m. with administrator A and DON B revealed: *They confirmed they had reported resident 1's 3/24/20 fall that had resulted in a scapula fracture to the SD DOH on the day of the fall. -That one report had been the initial and final report combined. *The surveyors requested access to the resident's medical record, to interview the staff involved with that event, and for several other documents relevant to the investigation including: -Manufacturer's recommendations for the mechanical lift used in the incident on 3/24/20 with resident 1. -If CNA C had any prior disciplines or re-education and where she received her certification. -Who usually completed the transfer tool that was completed on 1/20/20. -Resident 1's restorative sheets from 3/1/20 through 3/24/20, if there were any therapist notes from 3/1/20 through 3/24/20, medication and treatment administration records from 3/1/20 through 3/24/20, physicians' orders from 1/1/20 through 3/31/20, and nursing progress notes from 3/1/20 through 3/31/20. -If resident 1 had any other falls in the past six months, if so to include the incident reports and/or any investigations. -If any other residents had falls from any mechanical lifts in the past six months. -Preventative maintenance plan: include documentation on when and how often mechanical lifts were checked for safety, and specifically the mechanical lift used in the incident on 3/24/20 with resident 1. -Documentation and sign-in sheet for all staff who operate a mechanical lift and include education material used and competencies completed. -Policies and procedures: mechanical lift (specific to the one used in the 3/24/20 incident), accident prevention, and falls. -Quality assurance performance improvement projects (QAPI) being monitored for past six months. Phone interview on 4/6/20 at 2:00 p.m. with MDS coordinator nurse F regarding resident 1's falls and assessments revealed: *She had been working at the facility less than a year and completed the residents' MDS assessments. *When asked about mechanical lift assessments for the residents she indicated she was not responsible and usually therapy drives that. *She confirmed she had completed the 1/20/20 Sit-Stand-Walk Data Collection Tool that indicated the resident should have been transferred using a sit-to-stand lift with one staff person for assistance. *The Sit-Stand-Walk Data Collection Tool was done quarterly, on admission or re-admission, and with significant changes for all residents. -She stated it was just a tool that was done by the nurse. --If there was a concern they would refer to therapy. *She stated there was a safe handling program, and therapy was involved. -Assessments should have been completed to ensure safe transfers. *She was unsure if resident 1 had seen therapy recently. -He was on a restorative nursing program for active ROM and transfers. *She worked as a floor nurse also and watched resident transfers to do the data tools. *She confirmed resident 1 had a history of [REDACTED]. -She was not aware of him having an affected side or weakness related to that. -She felt he was able to use both of his arms/hands to hold onto the lift and was able to bear weight on both of his legs. *She was not aware of: -His cognition changing throughout the day or if he had an change in condition prior to the 3/24/20 incident. -Him ever letting go of the lift prior to that fall or having any issues prior to that fall. -What occurred with his previous falls in July 2019. *She indicated she did not assist with incident investigations. On 4/6/20 at 2:56 p.m. an email was sent to administrator A requesting further information regarding resident 1's falls in July 2019; policies related to abuse, neglect, investigations; and the safe handling program. Review of resident 1's electronic medical record (EMR) revealed: *Sit-Stand-Walk Data Collection Tools had been done by nurses on the following dates: -4/24/19 quarterly: indicated for transfers to use a stand aid, if unsuccessful use sit-to-stand lift with one staff person assist. -7/18/19 quarterly: same as April. -7/23/19 change in condition: changed transfers to using the sit-to-stand lift with one staff person assist. -10/17/19 quarterly: same as July. -1/20/20 quarterly: same as July. *His interdisciplinary and nursing progress notes included: -On 7/23/19 at 4:25 p.m.: he fell when he let go of the stand aid while being assisted by staff. --The intervention was: Resident is to use the sit-to-stand with all further transfers. CP (care plan) updated. -On 7/26/19 at 12:15 p.m.: he had another fall when staff were using the stand aid to assist him with a transfer. --The intervention was personnel education on proper lift to use. -On 3/4/20: new orders to start on quetiapine 25 milligrams (mg) twice daily for [MEDICAL CONDITION] dementia with behaviors. -He started the medication that evening. -On 3/14/20: he was sleepy and hard to wake up for lunch. -On 3/15/20: he yelled out many times but his eyes were closed and he was resting in a recliner sleepy during lunch. -On 3/16/20: he was yelling out during the night with eyes closed. -On 3/18/20: --At 9:55 a.m.: Resident temp (temperature) earlier this am was 100.2. His O2 sats (oxygen saturation) are 89% RA (room air). LS (lung sounds) are diminished. No coughing noted --At 11:53 a.m.: quetiapine was discontinued due to excessive sleepiness and no improvement in moods. --A weight change note indicated he had a slight weight loss which was due to having flu like symptoms. -On 3/19/20: --At 1:18 p.m.: he was more alert and no longer had a temperature. --At 3:15 p.m.: the physician saw him on rounds with no new orders indicated. *There were no notes from 3/22/20 at 1:20 p.m. through the fall note on 3/24/20 at 10:35 a.m. that stated: -CNA reports to nurse when transferring resident using the sit to stand resident's arms gave way/slipped causing him to slip and he was then lowered to the floor. CNA also stated resident did not hit his head during. Resident states 'my arms slipped' Resident was assessed for injuries, VS and ROM done. VS are WNL. Resident is c/o severe pain to his right upper arm up to his right shoulder area. He is not letting nurse do ROM to that area. Other ROM to rest of his body is WNL. Notified Physician on call- (name) and she ordered to have resident seen in the ER today. Family, (administrator) and (name) DON. --The above was the same note as the brief description on the 3/24/20 SD DOH online report and in the 3/24/20 incident report. --There was no indication of what time the actual fall occurred, where he was at the time of the fall, if any concerns were identified with the mechanical lift or transfer, if he bumped anything during the fall, how he had been gotten up off the floor, or the timeline of the events that occurred during and after the incident. -On 3/24/20: --At 10:38 a.m.: resident left to the ER per provider transport. --At 11:34 a.m.: the consultant pharmacist note of .resident to hosp ER (hospital ER) today, Shoulder, arm pain. 3/19 MD (medical doctor) rounded, no med changes. Tried [MEDICATION NAME] (quetiapine) 3/4-3/18 for dementia with behaviors, discontinued, too sleepy. No recommendations. --At 1:03 p.m.: Received phone call at 1255pm from (name) and they report resident does have a fractured right scapula. He will be returning with a sling and new orders. --At 1:11 p.m.: the resident's son was notified. --At 2:24 p.m.: he returned from the ER with new orders for ice, [MEDICATION NAME] as needed for pain, and could apply sling for comfort. *In the above interdisciplinary notes there was evidence supporting he had: -Recent medication changes. -Experienced a change in condition with his sleepiness, weight loss, and flu like symptoms. -A history of falls related to staff transferring him with lifts or equipment. --The above items were not listed as predisposing factors on his incident report or the SD DOH report. Phone interview on 4/7/20 at 10:00 a.m. with CNA C regarding resident 1's incident on 3/24/20 revealed: *She was assisting him with morning care in his room that day. -He seemed to be his usual self. *She had his upper body dressed and was planning to dress his lower half while he was standing in the sit-to-stand mechanical lift, and then she would move him from his bed to his recliner using the lift. *She got him situated and hooked up to the lift according to her usual process. -She had not used the leg strap, because he normally had not had an issue with moving his legs. *She indicated sometimes she used the leg strap and sometimes she did not depending on the resident. *Usually he stood up in the lift appropriately and used both hands to hang onto the handles. *She stated that morning while he was standing up in the lift all of a sudden his legs went up in the air, his arms went up, and he started slipping down. *She indicated he did not fall out of the lift, but she had to lower him down with the lift and then all the way to the floor. *She had not seen him hit or bump anything when he was lowered to the floor. *While she was lowering him down to the floor CNA D came into the room. -CNA C had not called anyone for help yet, and she was unsure why CNA D had come into the room at that time. *She indicated CNA D helped her with the resident when she noticed what was happening. *CNA C stated she had called the nurse on the walkie-talkie, but the nurse was busy at the time, so the CNAs just got him up into his recliner. -She stated they used the total mechanical lift to get him up off the floor since he seemed very uncomfortable. *After the resident was up in his recliner the nurse came in to check on him and stated his arm was not right. -They assisted with getting his vital signs while the nurse called the physician. *The staff then used the total mechanical lift to get him into his wheelchair, and facility staff took him to the ER. *She indicated the resident appeared to be in pain when he was lowered to the floor and when he was on the floor. *When asked why they got the resident up off the floor and into the recliner without the nurse coming in to check him out first she stated because the nurse was busy. -Normal practice if a resident fell or incident occurred was for the nurse to assess them first before moving them. *She indicated there was an emergency call light they could have put on when there was an incident or a resident was on the floor. -They had not used that. *The decision to get him up into the recliner was made by the CNAs. -She was not sure if they had told the nurse he was in pain or not when they initially called her. *She stated he just seemed very uncomfortable and restless and wanted off the floor, so they did that. *She had not indicated she had been educated further on what occurred with the resident's incident or his safety. On 4/7/20 at 9:30 a.m. an email request was made to administrator A for further evidence related to resident 1's investigation for the 3/24/20 incident. At 10:00 a.m. that information was received and revealed: *It was signed by the DON, administrator, and social services designee on 3/24/20. *There was no evidence of CNA D having been involved at all. *There was no mention of how the resident was gotten up off the floor. *There were missing details to ensure a complete and thorough investigation had been done to rule out abuse or neglect and ensure the resident's safety. On 4/7/20 at 10:23 a.m. an email request was made to administrator A to set-up an interview time for CNA D to speak with the surveyors. Phone interview on 4/7/20 at 10:30 a.m. with licensed practical nurse (LPN) E regarding resident 1 revealed: *She had been working the day shift on 3/24/20 and was assigned the resident's unit that day. -There was another nurse working in the building also at the time of the incident. *She stated she found out about the incident when CNA D came to her and reported the resident had slipped from the sit-to-stand lift and was lowered to the floor. -CNA D told her in-person not over the walkie talkie. *When she found out about the incident she went in to check on the resident, and he was already in his recliner. *She stated no one had contacted her prior to moving him from the floor to the recliner. -She had not instructed them to get him up off the floor. -Usually staff got the nurse to assess the resident first prior to moving them. --She was unsure why they had not reported it to her right away, so she could assess him and possibly prevent further injury. *When she got to his room she completed an assessment including vital signs and ROM. -She had not done neurological checks, because she was told he had not hit his head. *During her assessment she noted something was wrong with his shoulder, and he had pain in his right arm. *She then sent a fax and called the clinic, and the practitioner indicated he should be sent to the ER. *The facility staff took him to the ER in their facility bus. *She had not seen any of the resident's transfers by the CNAs that day during or following the incident. -She thought they used a total lift to get him from the recliner back into his wheelchair. *His cognition varied, and he would not remember or be able to explain what happened that day. -At the time she assessed him he did complain of right arm pain. *It was policy for the staff to notify the nurse first when an incident occurred prior to moving the resident. -There was a risk for further injury to the resident without proper assessment. *She had told the CNAs that day they should not have moved him without telling her first, but she was unaware if they had further re-education. *She confirmed the documentation in his EMR had not supported: -The correct time of the fall or the timeline of events that morning. -How the resident had been gotten up from the floor. -Full details of what had occurred during the incident and following the incident regarding his safety. Phone interview on 4/7/20 at 11:00 a.m. with CNA D regarding resident 1's 3/24/20 incident revealed: *She had been working in the facility since 2013. -She worked primarily day shifts and did resident baths along with working on the floor. *On 3/24/20 she was working with giving baths and went to the hallway looking for another staff person to help her with a resident in the bathing room. *She went into resident 1's room since she knew a staff member was in there. *When she entered resident 1's room she saw him hanging by his arms on the sit-to-stand lift with his knees on the floor. -She stated CNA C asked her for help. *They lifted him up using his pants to get the hooks undone from under his arms, and then lifted him to his bed. -She stated they could not use the lift to move him up or down because of how he was hanging. --She stated he was not laid down or lowered to the floor other than when he was on his knees when she came into the room. *She stated he had been incontinent of bowel, so they cleaned him up. *Then they used the same sit-to-stand lift and moved him to the recliner from his bed. *After they had him sitting in the recliner she went to tell LPN E. *She could not tell if he was in pain when they were helping him other than when he was hanging in the lift. *She was unsure who made the decision to move him from the bed to the recliner, if it was her or CNA C. *When asked if CNAs normally made the decision of moving a resident after an incident she stated no. -She confirmed the CNAs had made the call to get him out of the lift, to the bed, and then to the recliner without telling the nurse until afterward. *She felt they just reacted. *Normally if a resident was on the floor the staff would have put the emergency light on and waited until the nurse got there to do the assessment. -They had not done that. *She was not in the room when the nurse assessed him and did not help with the other transfer after he was in the recliner. *The day of the incident only LPN E asked her what happened. -No one else followed-up with her after that until she was told the surveyors were going to talk to her. *The staff had walkie-talkies for communication, but she had not had hers with her at the time of that incident. -She was unsure if CNA C had hers that day. *They could have used the walkie-talkie to contact the nurse. *She was not aware if he had any concerns with using the lift prior to that incident. -Normally he was transferred using the sit-to-stand lift with one staff person. Phone interview on 4/7/20 at 1:30 p.m. with administrator A and DON B regarding the above concerns: *For investigations into resident incidents: -The immediate discussion/documentation was done by the CNAs and nurses or whoever was working at the time of the event. -After that the falls committee reviewed all incidents. --The falls committee included the DON, administrator, and social services designee. -The full investigations were done by the falls committee members. *DON B indicated for investigations she talked to the staff involved. *For the 3/24/20 incident with resident 1 she indicated: -LPN E did the education with CNA C. --DON B had not talked to CNA C about the event at all. -She had talked to LPN E and CNA D later that day. --Those verbal interactions were not specifically documented in the investigation records. *Regarding the 3/24/20 incident for resident 1 DON B stated she was told: -CNA C was transferring him with the sit-to-stand lift and during the transfer his arms went out. -He was on his knees and still attached to the lift when CNA D came into the room. -The CNAs pulled him up with his jeans onto edge of the bed, and then moved him to his recliner. -Shortly after that they told the nurse about the incident and she then came in to assess him. *She confirmed all those details above were not mentioned in the SD DOH report, incident report, EMR, or the investigation notes. *When asked about completing a thorough investigation into the incident she avoided the question. -She stated she was well aware of it happening. *She confirmed the full details were not documented in the investigation notes. *When asked about the completeness of the documentation in the EMR she did not answer. *The surveyors discussed the differences in the staff members' interviews related to the incident. -The parts that matched were the resident having an incident while in the sit-to-stand lift and the CNAs moving him to the recliner prior to the nurse being notified. *She was told he was on the edge of the bed, so they moved him right away. -She was not aware they assisted him with incontinence care prior to using the same lift he had just had an incident with to move him from the bed to the recliner. *When asked if the CNAs should have moved the resident without talking to the nurse first she did not answer. *When asked if staff had followed their policy for a resident who fell she stated they moved him right away from the edge of the bed to the recliner and would not answer the question directly. *She confirmed staff could have used walkie-talkies and/or the emergency light to get a hold of other staff or a nurse when they needed help. *Administrator A confirmed: -He was a part of the falls committee and was aware of the 3/24/20 incident for resident 1. -He stated the CNAs made a poor choice of judgement. -They missed some steps here when he was referring to the investigation and documentation. *DON B indicated she was aware staff had used the sit-to-stand lift to move him from the edge of his bed to the recliner which was after he had the incident of slipping down in it. -There was no re-education or discipline done for the staff involved. *They confirmed the facility had been cited during their last recertification survey in March 2019 for investigations. -They felt they had been doing well and still had falls as part of their QAPI process. *Administrator A felt the current situation in the nation and world could have impacted how this event was handled and investigated. *DON B felt the investigation had been complete, and she was not aware the staff had different versions of what happened during the event. -She felt her verbal interactions with them had covered what had occurred. *She confirmed CNA D was not listed anywhere as part of the investigation or incident reports. -She had not thought she should have mentioned CNA D as a witness or with the investigation. *After further discussion she confirmed CNA C, CNA D, and LPN E all should have been questioned through the investigation process as to what had occurred related to the event and the resident's safety. *They had not completed a thorough investigation of the entire event to rule out abuse and neglect and ensure resident safety during transfers using lifts. Surveyor Review of the provider's July 2017 Falls-Mechanical Lift/Transfers policy revealed: *Manually lifting a fallen resident from the floor increases the risk of injury to both the resident and the caregiver. -To ensure safe transfer for a fallen resident, the following steps should take place: --2. The licensed nurse should evaluate the resident while on floor and determine if the resident has injuries that indicate the resident should not be moved. --3. Use the total lift to assist an uninjured fallen resident from the floor. Avoid manual lifting. Review of the provider's May 2019 Incident Report policy revealed: *Purpose: -To document resident and visitor incidents. -To conduct an investigation of each resident. -To gather objective information and identify root causes to prevent similar occurrences from happening in the future. Review of the provider's October 2018 Abuse and Neglect policy revealed: *Purpose: -To assure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations in the location. -To ensure that all identified incidents of alleged or suspected abuse/neglect are promptly investigated and reported. -To prevent future injuries. -To ensure that a complete review of existing incidents is documented. -To identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and to determine the direction of the investigation. Review of the provider's 8/16/16 Certified Nursing Assistant job description revealed: *Basic Responsibilities: -This position will be held accountable for complying with all related laws, regulations, company policies and procedures pertaining to his or her position. *Physical/Mental Requirements: -While performing the duties of this job, the employee will operate/activate/use/prepare/inspect/place/detect/position objects, tools, or controls. -The employee will frequently communicate/express/observe/assess/detect information relative to this position. -Must be able to effectively communicate in English, both orally and in writing. Review of the provider's 8/17/16 Director of Nursing job description revealed: *Responsible to lead management and monitoring/auditing of the EMR (electronic medical record) in the location; to include training, documentation, reports/dashboards and retrieval management and monitoring/auditing. *Assures plan of care and interventions are evaluated for effectiveness on an ongoing basis and adjusted and updated accordingly. -Assures residents are free of neglect and abuse. -Maintains thorough and accurate records for each resident. Review of the provider's 8/16/16 Charge Nurse-LPN job description revealed: Observes and documents observations and care given to residents. Review of the provider's undated Administrator job description revealed: *An Administrator for the Society is responsible for the overall leadership and management of the location, including meeting established goals and outcomes, ensuring regulatory and organization compliance, directing and coordinating work. *Manages Communication and Documentation: -Ensures documentation and reports are completed as required by regulations and/or policy and procedure. Interview and document review on 11/9/20 at 1:55 p.m with DON B regarding the above information revealed: *They had not had any falls from lifts since the 4/7/20 off-site survey. *They had made changes in their investigation process. -The charge nurse had done the assessments. -The certified nursing assistants had been educated on the fall process. -There was a list of items staff were to do when a resident fell . -They had completed audits on falls and were found to be compliant. *They had followed their plan of correction from the 4/7/20 off-site survey. *The process was ongoing and they were ensuring all pieces were completed.

Based on observation, interview, and policy review, the provider failed to implement infection control practices to prevent and/or contain the potential for transmission of COVID-19 virus by: *Fans running in three of three resident hallways where COVID-19 residents resided. *Doors not closed and/or plastic curtains not covering doors that had been left opened on COVID-19 positive residents' rooms. *Peroxide bottles not labeled to identify contents. *Hand sanitizer was not readily accessible. *Personal protective equipment (PPE) was not readily available for staff use. *Disposal containers were not readily accessible for soiled linens and garbage. Findings include: 1. Observation and interview on 11/9/20 at 3:45 p.m. with director of nursing (DON) B while touring the facility revealed: *They had a current census of thirty-six residents with three residents in the hospital and thirty-three residents in-house. Of those residents in-house: -Twenty-eight residents were currently in isolation and on transmission based precautions for COVID-19. -Two residents were considered recovered from COVID-19. -Three residents had remained negative for COVID-19. *The most recent positive resident case had just been identified that day. *When the outbreak initially started they had moved residents to the north wing. *She indicated as additional cases kept happening they ended up leaving some of the residents in place and now had COVID-19 positive residents in all areas of the building. -The first resident case had been identified on 10/17/20. *Currently positive residents resided in all areas of the facility and were considered to be in red rooms. *The three negative residents were in rooms in the center south hallway in yellow rooms. -They had yellow tape on the door frames signifying their negative COVID-19 status. *She indicated they were now planning to move some residents back to their original rooms to even out the workload for the staff since there were positive cases throughout the facility. *They had discontinued the dedicated COVID-19 unit due to most of the residents had tested positive for COVID-19. *The three negative COVID-19 residents were intermixed with the positive COVID-19 residents. *The following room doors had not been closed and had COVID-19 positive residents in them: -203, 204, 212, 501, 506, and 507. *Fans in the hallways were on and moving air around in all the resident hallways that housed the twenty-eight COVID-19 positive residents and the three COVID-19 negative residents. *DON B was not aware fans had been on and agreed they should not have been. -She had heard of not using fans in COVID-19 positive areas due to the risk of further spreading [MEDICAL CONDITION]. *A spray bottle of an unlabeled disinfectant was located on the south center hallway. -DON B indicated that was Peroxide used for disinfecting face shields and should have been used after staff exited a COVID-19 positive resident's room. *She confirmed the bottle should have been labeled to identify what it was. Observation and interview on 11/9/20 at 3:50 p.m. with DON B in the south hallway revealed: *Resident 2 was on a gurney being wheeled back to his room by two unidentified emergency medical staff. *DON B indicated he had been at the emergency room and was returning to the facility. -He was COVID-19 positive. -He had a surgical mask on and was noted to be coughing while being wheeled to his room. *The emergency staff had on full PPE including gown, gloves, respirators, and face shields. *Certified nursing assistant (CNA) G was wearing a respirator and face shield already and put on a reusable gown and disposable gloves to enter the room -She went into his room to assist the other staff to transfer the resident into bed. *When they were finished the two emergency staff removed their disposable gowns and gloves and put them into a disposable container down the hallway. -They had not completed hand hygiene until further down the hallway. -They left their respirators and face shields on and were not observed disinfecting their face shields. -They walked through the area where the COVID-19 negative residents' rooms were as they left the facility. *When CNA G exited the room she: -Removed her reusable gown, balled it up carrying it half way down the hall to put it into the soiled linen container. -Then proceeded farther down the hallway to get hand sanitizer from the medication cart. -Was not observed disinfecting her face shield. *Outside of the resident room there was no soiled linen container, disinfectant for the face shield, and no hand sanitizer readily available for the staff to use. Observation on 11/9/20 at 3:55 p.m. of an unidentified staff member revealed they: *Had come out of a COVID-19 positive resident's room located down the hall with a bag of garbage. *Had to go most of the way down the hallway to find a garbage container for that garbage. *Then had to go even further to find hand sanitizer to use. Interview and observation on 11/9/20 at 4:00 p.m. CNA G regarding PPE and infection control concerns revealed: *She agreed: -The equipment and supplies needed for proper removal/disposal of PPE, hand hygiene, and disinfection of the face shield were not readily available and should have been. -It was important to follow proper infection control practices to prevent further transmission of infections. *There were two different containers of germicidal wipes on a stand outside the resident's room that were Sanicloth Plus and Sanicloth AF3 wipes. -She thought those were effective disinfectants against COVID-19 but was unsure. -Those wipes were not the disinfectant they were supposed to use to disinfect the face shields. *They were supposed to use a peroxide solution on the face shields. *There was no peroxide solution close to that residents' care area. -There were several other COVID-19 positive residents also residing on that hallway. Continued interview on 11/9/20 at 4:05 p.m. with CNA G revealed: *The opened doors and shower curtains should have been closed because those were COVID-19 positive residents' rooms. *The staff person who had been ensuring supplies were available was currently out due to illness. -She was unsure who was helping stock supplies while that staff person was out. *Staff should have had the necessary supplies readily available in order to follow appropriate infection control practices. Observation and interview on 11/9/20 at 4:15 p.m. with DON B regarding the above concerns revealed: *Opened doors and shower curtains covering opened room doors should have been closed for the COVID-19 positive residents' rooms to decrease potential transmission of [MEDICAL CONDITION]. *All supplies for appropriate infection control practices should have been readily available for staff to use. *When staff had to go a distance to get to supplies and/or get rid of soiled supplies it could have caused a potential for transmitting infections or viruses further. *She agreed it was important to follow proper infection control practices in order to potentially prevent further COVID-19 infections. Review of the provider's revised 4/14/20 Hand Hygiene and Handwashing policy revealed:*The purpose was to ensure appropriate hand hygiene technique for clinical use. *Regular handwashing with soap and warm not hot water is one of the best ways to remove germs, avoid getting sick and prevent the spread of germs to others. *The guidance on handwashing and glove use for patient (resident) care included: -Patient care: The goal is to prevent the spread of infection between residents. Handwashing and changing gloves occurs after care is delivered to prevent the spread of organisms to other residents. Sanitizers are used in patient care areas. Review of the provider's revised February 2018 Putting on and Taking off Personal Protective Equipment (PPE) Donning and Removing policy revealed:*1. The Good Samaritan Society location will provide, at no cost to the employee, the following appropriate personal protective equipment for all employees considered at risk for occupational exposure: -a. Gloves, gowns, masks (or shields) -b. Eye protectors -c. Mouthpieces, resuscitation bags, pocket masks or other ventilation devices, if appropriate to the location. -The administrator, director of nursing services, senior living manager, environmental services director, child daycare services director or designee should be responsible for ensuring appropriate PPE is available for all employees. *3. It is the location's responsibility to ensure that appropriate personal protective equipment is readily accessible and that employees use it. *4. The location is responsible for cleaning, laundering, disposal, repair and replacement of required personal protective equipment. *5. Personal protective equipment will be removed before leaving the work area and placed in an appropriately designated area or container for storage, washing, decontamination or disposal. If any garment is penetrated by blood or other potentially infectious materials, it will be removed immediately or as soon as feasible. *Masks/Eye Protection/Face Shields: -a. Masks, eye protection and/or face shields should be worn whenever splashes, spray, spatter or droplets of blood or other potentially infectious materials might occur and contaminate the employee's eyes, nose or mouth. Select masks, eye protection, face shields and combinations of each according to the need anticipated by the task performed. Examples of when to use masks or eye protection could include plunging toilets, emptying fluids, use of hoppers/sprayers, suctioning residents/patients or working where there is risk for blood splashes. -b. This equipment should be discarded after use or placed in an area where it will be washed with soap and water. *Gowns -a. Wear a gown, appropriate to the task being performed, to protect skin and prevent soiling or contamination of clothing during procedures and resident/patient care activities when contact with blood, body fluids, secretions or excretions is anticipated. -b. Wear a gown for direct resident/patient contact if the resident/patient has uncontained secretions or excretions. A gown should be selected that is appropriate for the activity. If fluid is likely to be encountered, a long-sleeve impermeable gown is to be used. -c. Remove gown (perform gown removal per any isolation requirements) and perform hand hygiene before leaving the contaminated area.

Based on interview, record review, and policy review, the provider failed to ensure one of one sampled resident (1) had complete documentation in his medical record related to an incident with a mechanical lift. Findings include: 1. Review of resident 1's medical record revealed incomplete or missing documentation related to the mechanical lift incident with resident 1 that occurred on 3/24/20 and the details surrounding it including: *The time when the incident actually occurred was not mentioned. -There was documentation at 10:35 a.m. which was an overall summary to cover the fall and notifications. *There was no mention of how he had been assisted related to the above incident such as how he was gotten up. *The 10:35 a.m. documentation had not supported: -When the nursing assessment had occurred following the fall. -How the resident was doing from the time of the fall until he was sent to the ER. -When the family, physician, and others were notified and follow-up orders/responses were received. *The documentation addressed at 10:38 a.m. he was taken to the emergency room by facility staff. Review of the South Dakota Department of Health 3/24/20 online self-report, the 3/24/20 incident report, and other investigation notes regarding resident 1 revealed: *The mechanical lift incident with the resident had occurred at 7:00 a.m. on 3/24/20. *There were missing details to support a complete and thorough investigation had occurred and was documented. Review of phone interviews during the off-site survey on 4/6/20 from 11:15 a.m. through 6:30 p.m. and on 4/7/20 from 7:30 a.m. through 2:30 p.m. confirmed there was missing documentation regarding the incident with resident 1 and the mechanical lift incident. Refer to F600 and F610. Surveyor Review of the provider's May 2019 Incident Report policy revealed: *Purpose: -To document resident and visitor incidents. -To conduct an investigation of each resident. -To gather objective information and identify root causes to prevent similar occurrences from happening in the future. Review of the provider's October 2018 Abuse and Neglect policy revealed: *Purpose: -To assure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations in the location. -To ensure that all identified incidents of alleged or suspected abuse/neglect are promptly investigated and reported. -To prevent future injuries. -To ensure that a complete review of existing incidents is documented. -To identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and to determine the direction of the investigation. Interview and document review on 11/9/20 at 1:55 p.m. with DON B regarding the above information revealed: *They had made changes in their investigation process. -The charge nurse had done the assessments. -The certified nursing assistants had been educated on the fall process. -They had completed audits on falls and were found to be compliant. *They had followed their plan of correction from the 4/7/20 off-site survey. *The process was ongoing and they were ensuring all pieces were completed.

Based on observation, interview, record review, and policy review, the provider failed to ensure interventions were implemented and updated for two of two sampled residents (8 and 16) who had multiple falls. Findings include: 1. Review of resident 8's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Major [MEDICAL CONDITION]. -Anxiety. -Dementia. -Type two diabetes. *She had falls on the following dates: -7/12/18: She was found on the floor in front of her roommate's recliner. -12/2/18: Her roommate had called for help, and she was found on the floor halfway between her bed and the bathroom. -12/15/18: She was found lying on her back on the floor with her head towards the bed. -3/7/19: She tripped over the call light and hit the right side of her head causing a superficial cut. She also had a skin tear to her right elbow. Review of resident 8's 10/9/18 annual Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) score was eight indicating her cognition was moderately impaired. *She had wandered one-to-three days during the assessment period. -That had worsened from the prior assessment. *She required limited assistance of one staff person for bed mobility, dressing, and personal hygiene. *She required extensive assistance of one staff person for toilet use. *She required supervision of one staff person for transferring, walking, and eating. *She was occasionally incontinent of bowel and bladder. *She was not receiving any therapies. *She had one fall with no injury since her prior 7/17/18 assessment. Review of resident 8's 1/2/19 MDS revealed: *Her BIMS score was five indicating her cognition was severely impaired. *She required limited assistance of one staff person for bed mobility, dressing, toilet use, and personal hygiene. *She had two or more falls with no injury since her prior 10/9/18 assessment. *She had one fall with injury since her prior 10/9/18 assessment. Observation and interview on 3/18/19 at 4:21 p.m. with resident 8 revealed: *She was sitting in her room in her rocking chair sleeping. *She woke up when surveyors knocked on the door. *She was pleasant but confused when responding questions. -When asked questions she would respond with answers that were not applicable to the question. -She said she loved the surveyors when they left the room. -She asked the names of the surveyors during the conversation after she had been given the information upon entry into her room. Observation on 3/20/19 at 9:08 a.m. of resident 8 revealed she was sitting in her rocking chair sleeping. Her walker was beside the chair, and the call light was hanging on the drawer handle within reach. Review of resident 8's 1/7/19 care plan revealed: *Focus area: The resident is at risk for falls, actual fall R/T (related to) weakness, hx (history) exit seeking behavior. Falls: 9/6/14, 11/30/17, 12/15/17, 7/12/18, 10/24/18, 12/2/18, and 12/15/18; revised on 1/2/19. -Interventions included: --Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; revised on 4/14/14. --Revision date 12/4/18: Ensure/provide a safe environment: Keep door open to room when unattended; gripper strips in front of bed, gripper socks at HS (bedtime). *There was no update to the care plan reflecting the 3/7/19 fall. Review of resident 8's discontinued care plan interventions between 4/14/2014 through 3/20/19 for falls included the above interventions with minimal changes to the wording. Her fall risk assessment tools were requested on 3/20/19 at 3:35 p.m. from the social services designee and had not been received by the end of the survey on 3/20/19 at 6:45 p.m. Interview on 3/20/19 at 10:39 a.m. with licensed practical nurse (LPN) A regarding resident 8 revealed: *She had days when she was more confused, and those days were when she had falls. *She forgot to take her walker when getting up to go to the bathroom or leave the room. *She had days when she was confused and wanted to go home and leave the facility. 2. Review of resident 16's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Dementia. -Contracture of bilateral hands. -Major [MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Generalized anxiety disorder. *She had falls on the following dates: -12/5/18: She was going to the bathroom. The seat alarm went off, and staff arrived in the room and lowered her to the floor. -12/14/18: She was found sitting on the floor in her bathroom. Staff had assisted her to the toilet and left her before she was done. -12/14/18: Staff observed her rise from her recliner. When the alarm went off she attempted to sit back down. She missed the recliner and slid to the floor in front of the recliner. She had a scrape to her right knee. -1/10/19: She was found on the floor of her room. Her wheelchair was on its side; she said she tripped over the pedals. She reported right and left leg pain. -1/13/19: She was found of the floor of her room. -2/16/19: She slid out of her recliner onto the floor. -2/17/19: She was found on the floor in her bathroom. -3/14/19: She was walking in her room and tripped over her wheelchair pedals. Review of resident 16's 1/22/19 quarterly MDS revealed: *She had a BIMS score of thirteen indicating she was cognitively intact. *She required extensive assistance of one staff person with dressing, transferring, bathing, and toileting. *She required limited assistance of one staff person with personal hygiene, moving on and off the unit, and walking in her room. *She was not steady and required assistance with balance during transitions and walking. *She was occasionally incontinent of bowel. *She used an alarm daily. *She did not receive any therapies. Review of resident 16's 1/22/19 quarterly MDS assessment revealed she had two or more falls since the 10/30/18 MDS assessment. There were no changes to the level of assistance she required for activities of daily living. Interview and observation on 3/18/19 at 3:34 p.m. with resident 16 revealed: *She fell a week and half ago getting something out of her closet. *She said she was supposed to ask for help when she wanted to get up. *She indicated she had some falls, and they had put a restriction on her. It was an alarm that went off when she got up off her chair. *She said she had [MEDICAL CONDITION], and she wanted to do things on her own. *She was sitting in her recliner with her feet up. *The call light was attached to the arm of the recliner. *There was a body pillow on the left side between her and the arm of the chair. *While in the room she stated she needed to use the bathroom. *She was asked if she could turn on the call light to notify staff. -She could not find the call light. -She was pointed to the call light pad that was attached to the recliner. -She indicated that was the call light; she did not push the button. -This surveyor physically moved the pad to under her hand and told her she could go ahead and push the button. -She said okay but appeared to be confused as to how to push the button, so this surveyor helped her push the button. -She waited three minutes for staff to come in and assist her. *There was no alarm on the recliner. Observation on 3/20/19 at 8:45 a.m. revealed she was sitting in the recliner with her feet up, the call light was on the arm of her chair, and her body pillow was on her bed. Review of resident 16's 1/23/19 care plan revealed: *Focus area: The resident is at risk for falls/actual fall R/T (related to) [MEDICAL CONDITION] Dx (diagnsosis), Gait/balance problems, History of frequent falls, Psychoactive drug use, Unaware of safety need, [MEDICAL CONDITION] d/t (due to) orthostatic [MEDICAL CONDITION], fall 1/1/18, 1/20/18, 1/31/17, 2/1/18, 2/2/18, 5/18/18, 5/19/18, 3/1/18, 3/3/18, 4/12/18, 4/15/18, 4/25/18, 4/29/18, 5/7/18x2, 5/8/18, 5/18/18, 5/19/18, 7/1/18, 7/6/18, 9/4/18, 9/18/18, 10/10/18, 10/25/18, 11/25/18, 12/5/18, 12/14/18, 1/10/19, 1/13/19; revised on 1/23/19. -Interventions included: --COGNITIVE: Encourage participation and plan diversional activities that are of resident's interest; revised 9/18/17. --Remind resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. Closet shelves height adjusted for resident ease; revised 3/8/18. --Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: RNP; revised 12/6/17. --Ensure resident is wearing appropriate footwear: gripper socks or shoes at all times; revised 1/25/18. --ENVIRONMENTAL/PERSONAL SAFETY: antiroll back to w/c (wheelchair), toilet resident and provide assistance with ADL's (activities of daily living) when resident finishes supper. Re check resident after supper for any further ADL needs, SMART ALARM; revised 5/22/18. *There was no revision to the care plan when the alarm was discontinued. *The care plan was not updated with the (MONTH) or (MONTH) falls. *There were no documented fall interventions after (MONTH) (YEAR). *Date of 1/31/17 for a fall is prior to her admission on 9/8/18. Review of resident 16's discontinued interventions between 9/14/17 through 3/20/19 for falls included the above interventions with minimal changes to the wording. Review of resident 16's falls tool assessment revealed she was at a medium and high risk for falls. There were thirteen assessments completed since 9/4/18 through this survey date. Interview on 3/20/19 at 10:48 a.m. with LPN A regarding resident 16 revealed: *She had an alarm she sat on, but she had started ripping it apart, so it was discontinued. *She was not happy with the alarm. *She wanted to be able to do things on her own. *She was trying to get things in her room, clean her room, and that was when she had fallen. *She did not like to ask for help, because she wanted to do things on her own. *She would use the call light sometimes but not always. 3. Interview on 3/20/19 at 2:00 p.m. with the social services designee and the director of nursing services (DNS) revealed: *There was a limited number of interventions they could select from when creating or updating care plans. *The options were general, and they had to go in and delete what was written to edit the interventions. -The interventions they selected were not individualized for each resident. *They could not identify the interventions that had been attempted since (MONTH) (YEAR) for resident 16. Interview on 3/20/19 at 4:08 p.m. with CNA B regarding residents 8 and 16 revealed: *Upon start of her shift she would pick up and drop off water to all the residents, so she did a visual check at that time. *She was unsure of how often residents were to be checked on but believed it was every hour. *Resident 8 did not use her call light often, and she felt it was due to the resident being confused. *She checked on resident 8 at least every two hours to see if she needed any assistance. *Resident 8 was independent when using the bathroom but needed assistance with thoroughness of cleaning her perineal area. *Resident 16 would use her call light for bathrooming occasionally. *Resident 16 would try to get up on her own, because she wanted to be independent and wanted to do things on her own. *Resident 16 had an alarm on her chair, but that was discontinued. *Resident 16 did not like the alarm and started tearing it apart. *She checked on resident 16 more often than other more independent residents. *There was no documentation to determine how often residents were being checked on. Interview on 3/20/19 at 5:12 p.m. with the DNS revealed she: *Agreed resident 16 was a high fall risk. *Agreed resident 16 should not be left in the bathroom alone due to her fall risk. *Agreed interventions were not documented. *Stated she was aware falls were a problem, and she was working on coming up with ways to decrease the number of falls. *She currently had no plan in place. Reviewed of the provider's (MONTH) (YEAR) Fall Prevention and Management policy revealed: *Purpose stated: -To promote resident well-being by developing and implementing a fall prevention and management program. -To identify risk factors and implement interventions before a fall occurs. -To prevent further injury. *All falls should have been documented on a form GSS#409 to start the investigation. *Complete a Falls Tool UDA. *Procedure number 18 stated: Continue to monitor condition and the effectiveness of the interventions.

Based on observation, interview, record review, and policy review, the provider failed to ensure resident safety and interventions were put in place during six resident-to-resident altercations involving one of one sampled resident (7). Findings include: 1. Review of resident 7's medical record revealed: *She had been admitted on [DATE]. *She had been discharged to a behavior unit on 3/13/18. -She had returned to the facility on [DATE]. *Her Brief Interview of Mental Status score of three indicated she had a severe cognitive impairment. *Her [DIAGNOSES REDACTED]. *She had six incidents of resident-to-resident altercations on the following dates: -3/5/18. -4/26/18. -9/27/18. -12/1/18. -1/24/19. -3/13/19. Review of resident 7's 3/20/19 Medication Review report revealed: *A physician's orders [REDACTED].>-[MEDICATION NAME] 10 milligrams (mg); give one tablet daily for dementia. Start date 9/12/18. -Aripiprazole 5 mg; give a half tablet one time a day for major [MEDICAL CONDITION]. Start date 3/20/18. -[MEDICATION NAME] 100 mg; give one tablet daily in the morning for anxiety related to anxiety disorder. Start date 3/20/18. -[MEDICATION NAME] 15 mg; give one tablet at bedtime for mood related to major [MEDICAL CONDITION]. Start date 3/20/18. *Gradual dose reduction for the above medications had been recommended in (MONTH) (YEAR) by the pharmacist. -Physician had disagreed related to the severity of her dementia and behavioral issues. Observation on 3/18/19 at 5:29 p.m. of resident 7 in the dining room revealed: *She had been sitting at a table where residents required assistance with eating. *She required cueing with meals. *She had been grabbing at residents' silverware that were sitting to her left and to her right. -She had been trying to replace their silverware on the napkins. -The resident to her right kept telling her That is not your silverware, don't touch that. *Certified nursing assistant (CNA) B had to keep reminding her that was not her silverware. -(Resident name) do not touch that, (resident name) please do not touch those, they are not yours. *She received her food and began eating. -She no longer grabbed at the other residents' silverware. *When she finished her meal she left the table. Interview on 3/20/19 at 1:40 p.m. with the director of nursing (DON) and the social service designee (SSD) regarding resident 7 revealed: *She had several resident-to-resident incidents over the last year. *She exhibited other behaviors such as: -Urinated in places other then the bathroom. -Wandered into other residents' rooms. -Wandered throughout the facility. *She had been sent to a behavior unit (MONTH) (YEAR). -Medication adjustments and changes had been made so she could return to the facility. *She continued to have behaviors since returning and despite the interventions. *Her behaviors were inconsistent and did not follow a pattern or specific resident. *Many suggestions for interventions had been made to the family. -The family would not allow: --Medication increases or adjustments. --They did not want a psychologist involved. --They did not want a counselor to see her. --They had refused any form of help. *Did not have family cooperation. *In (MONTH) 2019 the ombudsman had been contacted for assistance. -He had not yet made it to the facility. *A family care conference had been scheduled for Thursday 3/28/19, they were hoping the ombudsman would attend. *Family had refused to attend care conferences in the past. -The daughter worked at the facility. -After discussions with the family the DON and SSD were shunned by the family member during work hours. *They were fearful for the resident's safety and the safety of all the residents. Interview on 3/20/19 at 4:20 p.m. with licensed practical nurse A regarding resident 7 revealed: *She was confused and wandered. *Most of the time she had been sweet and easy to get along with. *Had to redirect her in the dining room on occasion. -She liked to tidy up. -Would try to clear the table before residents were done eating. *On occasion direct care staff would report she spit or kicked at them during care. *She had not been aggressive with her. Interview on 3/20/19 at 4:36 p.m. with CNA B regarding resident 7 revealed she: *Had gotten angry about things. *Would talk calmly to her and then she could be redirected. *Would ram her walker into the CNA during redirection. -I would just calmly ask her to move in a direction and guide her. -She would start moving in that direction. -No more anger or trying to hit me with the walker. *If she was not ready to do something, she left her and went back later. -If she was not ready for bed, I would go in her room and lay out her pajamas. -Leave the room and when I would come back later she would be trying to get her pajamas on. -I would assist her with getting her pajamas on and she would go to bed. *She would try to clean up after meals. -Some staff let her help to keep her from getting upset. *She enjoyed folding towels and napkins. *She seemed to do better when the same group of staff cared for her. *She would just get upset/angry at times. -Not sure of the reason. -Did not last for a long period of time. -She redirected easily. Interview on 3/20/19 at 4:44 p.m. with the activity director regarding resident 7 revealed: *She was possessive and did not like her things being touched. *It did not seem to be a certain resident or time of day that caused the behaviors. *Behaviors were instant and impulsive. -Did not last more than a few minutes. -Did not seem to harbor feelings. --She was angry and had her outburst that was usually physical. -Then she would go about her day. --Would not try to hit or be mean to the resident she just had the altercation with later in the day. --Or even minutes later after the incident. *Easily redirected. *Had never been aggressive or mean to her. Review of resident 7's following incident reports revealed: a. On 3/5/18 at 1:30 p.m. she had an incident with resident 31 during an activity. *She had not wanted resident 31 to touch the napkins she had been folding. -She hit resident 31 with a closed fist. *The two ladies had been separated. *Resident 31 was taken to the nurse to be evaluated. *Incident had been reported to the charge nurse. *No injury had been noted to either resident. *Activity staff were to keep the residents separated to prevent future similar incidents. b. On 4/26/18 at 6:15 p.m. an incident with an unidentified resident's husband. *She had been in another resident's room holding that resident's blanket. -The resident and her husband entered the room. -The husband hollered at the her to put the blanket down and leave the room. *She approached him and kicked him in the shin. -He attempted to close the door to separate them when staff approached. *She left the resident's room without saying a word and walked toward the dining hall. *She was to be watched and redirected when found entering other residents' rooms. -Care team was to discuss incident with the psychologist during her visit on 5/3/18. c. On 9/27/18 at 8:30 a.m. an incident where she had been hit by another resident. *She had been at the table in the dining room. -She grabbed the unidentified resident's silverware. -He took his fist and hit down on her hand. *Incident had been witnessed by staff. *The unidentified resident had been removed from the table. -He had been asked to eat in his room. -He had been informed that kind of behavior was not appropriate. -He had been given options to sit at a different table. d. On 12/1/18 at 11:00 a.m. an incident with resident 31 in the hall. *Resident 31 had been standing in a doorway visiting with the dietary manager. *Resident 7 approached trying to enter the office. *Resident 31 grabbed resident 7's walker to keep her from coming in. *Resident 7 hit her with an opened hand on the left arm. *Resident 31 then hit resident 7 with an opened hand to the right arm. *The two residents were able to hit each other open handed approximately three to four times before staff were able to separate them. *No apparent injuries to either resident. e. On 1/24/19 at 7:00 p.m. an incident with an unidentified resident during Bingo. *She had swatted open handed at the unidentified resident when the bucket on the table was moved. -The unidentified resident stated she moved the bucket, and resident 7 was letting her know she was not happy about it. *No apparent injury to either resident. *Monitor more closely during activities. *Intervene as soon as possible. f. On 3/13/19 at 3:00 p.m. an incident with resident 40 before church services. *Resident 40 had been greeting residents before church by the doorway. *Resident 7 came to the doorway and would not move. *Resident 40 asked her to move out of the doorway nicely, and she would not move. -The second time he asked her to move she turned toward him. -With a closed fist she hit him in the upper arm while swearing and cussing at him. *The incident had been witnessed by the activity manager but it had not been reported to the charge nurse. *Resident 40 stated that he had not been hurt. Review of the providers (MONTH) (YEAR) Abuse and Neglect policy revealed: *The purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including, but not limited to other residents. *To ensure that all identified incidents of alleged or suspected abuse/neglect are promptly investigated and reported. *To prevent future injuries. *To intervene in any situation in order to protect residents. *Remove any individual from the location if necessary for the protection of residents or employees, including but not limited to employees, visitors, contractors, or family members. *The abuse/neglect policies and procedures cannot and do not guarantee that abuse will never occur. -To prevent such occurrences, all reasonable measures within their control will be taken. *If it is an allegation of resident-to-resident abuse, the residents will be separated immediately and both ensured a safe environment. *The physician and family will be notified regarding the facts of the situation. *The social worker and other employees, as appropriate would provide ongoing support and counseling to the resident and family as needed.

Based on observation, record review, interview, and policy review, the provider failed to ensure a baseline care plan was completed and available to staff to meet the needs for one of two newly admitted sampled residents (197). Findings include: 1. Observation and interview on 3/18/19 at 3:37 p.m. with resident 197 revealed he: *Had recently been hospitalized for [REDACTED]. *Had dressings on his right leg and right foot. *Had blackened toes on that foot. -Stated he was told by his physician it was too soon to determine if they would need to be amputated. *Had right leg pain that would worsen when that leg was repositioned and when the dressings were changed. *Was not able to stand on his own at that time. -Too painful to bear weight on his right leg. -had a history of [REDACTED]. Review of resident 197's medical record revealed he: *Was admitted on [DATE] after hospitalization for blood clot treatment. *Had skin wounds on his right leg and foot that were healing. Those areas were cleaned and covered with gauze dressings two times a day. *Took pain medication twice a day and as needed that provided relief. *Required the use of a mechanical lift and the assistance of two staff when transferred from one surface area to another. Review of resident 197's 3/14/19 computerized care plan revealed: *A focus area: The resident has an ADL self care performance deficit R/T (SPECIFY) E/B (SPECIFY). -It was computer generated and had not been changed to be specific for this resident. *Goal area was blank. *The following interventions: -AMBULATION: non ambulatory. -BED MOBILITY: Position Up in Bed: Assist of 1 with left side assist bar. -BED MOBILITY: Turn from Side to Side: independent with left side assist bar. -BED MOBILITY: Lying to Sitting: assist of 1 with side assist bar. -BED MOBILITY: Sitting to Lying: independent with left side assist bar. -TRANSFER - Transfer Between Surfaces: total lift (M) with assist of 2. *No further interventions. Interview on 3/20/19 at 3:49 p.m. with the director of nursing services (DNS) regarding the initial care plan process revealed: *The DNS, social services designee (SSD), or a nurse would routinely fill out a paper baseline care plan form on the day of admission or within forty-eight hours. -That would be kept in a binder at the nurses' station for nursing and certified nurse aide (CNA) reference. *A care plan was entered into the electronic medical record for the CNAs to use right away. -Those care plans routinely only included transfer needs and fall prevention. *A bio (summary) on new admissions would be completed and posted in the nurses' station or placed in the CNA communication binder for staff to review prior to resident's admission. *Staff would be educated for resident specific needs or new skills. *She was unable to locate his baseline care plan or his bio/summary at the nurses' station. They were found in the SSD's office. Review of resident 197's undated paper baseline care plan, bio/summary, and continued interview with the DNS revealed: *The disease/illness management section of his baseline care plan was check marked for post-surgical care, pain, weakness; it had polio LLE (left lower extremity) written on it. *The safety care section of his baseline care plan indicated he: -Had problems with ambulation and transfers. -Used a brace/splint and a wheelchair. -Needed the assistance of two staff with transfers. -Was to be encouraged to weight bear on his right leg. *It did not address: -He had wounds and blackened toes on his right foot, -Where his pain was located, -Pain management interventions, -He was unable to bear weight on either leg, -He required a mechanical lift. *His bio/summary stated: -He had been in the hospital and was treated for [REDACTED]. -He had pain and weakness in that leg. -His left leg had been nonfunctioning since he was a child d/t (due to) Polio. -He used a stand aide or slide board for transfers. -Lower leg/feet wounds/keep elevated AMAP (as much as possible). *It did not address interventions for pain management, wound care, or that he had blackened toes. *The DNS agreed his baseline care plan and bio/summary were not available for staff reference and did not accurately reflect his needs. Review of the provider's revised (MONTH) (YEAR) Care Plan policy revealed: *A 24-hour care plan will be developed upon admission. The location must provide the resident and resident representative with a summary of the 24-hour care plan. *The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. *It will address the relationship of items or services required and facility responsibility for providing these services.

Based on record review, interview, and policy review, the provider failed to ensure falls were thoroughly investigated and documented for one of two sampled residents (16) who had multiple falls. Findings include: 1. Review of resident 16's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Dementia. -Contracture of bilateral hands. -Major [MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Generalized anxiety disorder. *She had fallen on 12/5/18, twice on 12/14/18, 1/10/19, 1/13/19, 2/16/19, 2/17/19, and 3/14/19. Review of the above fall investigation reports revealed they were not complete or thorough and had been missing some or all of the following information: *The date and time the incident was reported. *Corrective actions to prevent recurrence of that incident. *Who was to complete the corrective actions that were selected to prevent recurrence of another fall incident. *The last time toileted. *Date of the investigation. *Name of the witness, caregivers, or employees for the last seventy-two hours. *No results of the investigation were noted. *Staff action that included: -The name of the last staff member that had contact with the resident. -The time between last staff member contact and fall. *No picture or diagram of the fall scene. *Medications within the last eight hours. -The form was to be completed by the charge nurse by the end of her shift. *No comments indicating the potential root cause of the fall and interventions taken to prevent another fall. *Resident action indicating what the resident said they were doing before the fall. *Missing signatures of the director of nursing services (DNS) and the social services designee. *The fall scene huddle worksheet had an area to mark if the care plan was updated. -It had not been checked on any of the above reports as an action that had been taken. Interview on 3/20/19 at 5:00 p.m. with the DNS revealed she agreed the above investigations had not been thorough or complete. Review of the provider's (MONTH) (YEAR) Abuse and Neglect policy revealed: *To ensure that all identified incidents of alleged or suspected abuse/neglect are promptly investigated and reported. *To ensure that all identified incidents involving injuries of unknown origin are promptly investigated to determine probable cause of unknown origin injuries. *To ensure that a complete review of existing incidents is documented.