Every finding on record at Good Samaritan Society de Smet

Based on record review, interview, and policy review, the facility failed to protect the residents' rights to be free of unnecessary medications, specifically psychotropic medications (drugs that affect brain activities associated with mental processes and behavior), for three of four sampled residents (2, 23, and 46) who were ordered psychotropic medications without a usage order stop date or documented reasoning for the continuation of their as needed psychotropic medications beyond fourteen days. Findings include: 1. Review of resident 46's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 7/17/26 Brief Interview of Mental Status (BIMS) assessment score was 13, which indicated his cognition was intact. His diagnoses included depression (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and insomnia (a sleep disorder characterized by persistent difficulty sleeping). He had a 7/17/26 physician's order for Zolpidem Tartrate (a hypnotic medication used to treat insomnia) 5 milligrams (mg) to be administered by mouth once every 24 hours as needed at bedtime for insomnia. That physician's order did not have an end date. 2. Interview on 8/6/26 at 8:12 a.m. with contracted travel Minimum Data Set (MDS) coordinator/licensed practical nurse (LPN) F revealed she confirmed that resident 46's Zolpidem Tartrate was ordered on 7/17/26 as a PRN (as needed dose) and there was no documented end date for that medication. She acknowledged Zolpidem Tartrate was a psychotropic medication that should not be ordered as a PRN medication for longer than 14 days without the physician providing documented reasoning why the medication was to be administered longer than 14 days and identified a specific end date for that medication. 3. Review of resident 2's EMR revealed she admitted to the facility on [DATE]. Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) and depression. She had a 12/9/25 physician's order for lorazepam (an antianxiety medication) 0.5 mg to be administered every four hours as needed for agitation related to dementia. The physician's order did not have an end date. Resident 2's 7/15/26 consultant pharmacist monthly medication review indicated, Still has [an] order for PRN [as needed] lorazepam with no end date in [EMR]- resent note. 4. Review of resident 23's EMR revealed he admitted to the facility on [DATE]. His diagnoses included depression, senile degeneration of the brain (severe age-related mental decline), and dementia with anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). He had a 11/25/25 physician's order for lorazepam 0.5 mg to be administered every four hours as needed for agitation, restlessness, depression, senile degeneration of the brain, and dementia with anxiety. The physician's order did not have an end date. Resident 23's 6/9/26 consultant pharmacist monthly medication review indicated, [The resident's] PRN lorazepam order was okay'd for 6 months back in November. Resident 23's 7/15/26 consultant pharmacist monthly medication review indicated, No notation on lorazepam PRN duration- resent. 5. Interview and EMR review on 8/6/26 at 9:24 a.m. with director of nursing (DON) B revealed she was responsible for reviewing the pharmacist's recommendations to the physician. She tried to review the physician's responses to the pharmacist's recommendations to be sure all the pharmacist's recommendations were addressed by the physician. She was aware as needed psychotropic medications needed to have an end date of 14 days after the medication was prescribed. The physician could provide a rationale of why the medication end date was to be longer than 14 days after that medication was prescribed, and the end date would need to be indicated. She thought that when the as needed medications were reordered, the nurse who entered the physician's order into the resident's EMR did not enter the end date. She was not aware that residents 2 and 23 had a pharmacist recommendation that indicated there was no end date on the physician's order for lorazepam and the physician did not address the recommendation. 6. Review of the provider's 12/9/25 Psychotropic Medications policy revealed, PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on observation, interview, record review, and policy review, the provider failed to ensure expired medications and supplies were discarded for one of one resident medication refrigerator, two of two medication carts, one of one medication storage room, one of one supply room, and one of one shower room, and temperatures were monitored for one of one resident medication refrigerator. Findings include:1. Observation on 8/4/26 at 3:45 p.m. of the shower room in the 100-hallway revealed there was a brown wooden cabinet. In the cabinet, there were ointments and dressing supplies. There was a silicone bordered dressing that expired on 2/12/25. There were 20 alcohol prep wipes that expired on 11/30/25. There was a package of iodine swabs that expired on 6/5/25. There was an oil emulsion dressing that expired on 3/7/26. There was an open, partially used tube of silicone cream that expired in October 2018. There was an opened, partially used tube of Dermaceptin with Menthol barrier cream that expired in July 2021. There were two packages of collagen powder that expired in January 2023.Beside the shower there was a white and clear plastic three drawer storage container that contained an open partially used protective ointment that expired in August 2025, and an opened partially used Calzinc Oxide cream that expired in March 2024. 2. Observation and interview on 8/5/26 at 3:52 p.m. with certified nursing assistant (CNA) N in the shower room revealed she was the full-time bath aide. She checked for expired supplies in the whirlpool and shower rooms every couple of months. She verified there were expired supplies in the shower room. She stated she must have missed them when she last checked for expired supplies. She verified she was using the creams in the white and clear plastic container for residents after they showered. 3. Observation, medication refrigerator temperature log review, and interview on 8/5/26 at 1:04 p.m. of the medication storage room with registered nurse (RN) I revealed the resident's medication refrigerator contained a vial of opened partially used tuberculin (used for tuberculosis skin testing) solution that was dated as opened on 6/30/26. There were six syringes of influenza vaccine with an expiration date of 6/26/26. There was one high dose influenza vaccine syringe with an expiration date of 6/26/26.The August 2026 medication refrigerator temperature log indicated the temperatures were to be checked two times daily. There were no temperatures documented on the evening of 8/1/26 and 8/2/26, and in the morning on 8/2/26 and 8/3/26.RN I verified that the medication refrigerator temperatures were not documented as having been monitored for the above dates in August. She verified the tuberculin solution should have been disposed of 30 days after it was opened, and the influenza vaccine syringes were expired. 4. Observation and interview on 8/5/26 at 1:25 p.m. of the medication carts with RN I revealed that in the 300 hallway medication cart there was a petroleum gauze dressing that expired on 5/16/26. In the 100 and 200 hallways medication cart was resident 37's Debrox ear drops (used to remove ear wax) that expired in January 2026.RN I stated that the night nurse was responsible for checking for expired medications and supplies stored in the medication room, the supplies storage room, and the medication carts every Sunday. The night nurse was to sign the calendar on the medication storage room door that they checked the medications and supplies' expiration date.RN I verified the dressings and supplies in the shower room were for the residents. They were there in case a nurse was changing a resident's dressing and needed to apply a new dressing. 5. Observation on 8/5/26 at 1:35 p.m. of the supply room revealed four boxes that contained rolls of InterDry moisture-wicking fabric that expired on 3/17/24. There were eight, four inch by five inch Telfa dressings (a nonadherent dressing) that expired on 3/1/25, and ten 6 inch by six inch Telfa dressing that expired on 3/1/25. 6. Review of the provider's May 2026 through July 2026 medication refrigerator temperature log revealed the temperatures were to be monitored and documented in the morning and evening. There was no documentation that the temperatures were monitored in the mornings of 5/7/26, 5/9/26, 5/14/26, 5/27/26, 5/28/26, 5/29/26, and in the evenings on 5/26/26, 5/27/26, 5/28/26, and 5/29/26 in the month of May.In June 2026 there was no documentation that the temperatures were monitored in the mornings of 6/2/26, 6/3/26, 6/4/26, 6/7/26, 6/8/26, 6/11/26, 6/12/26, 6/16/26, 6/17/26, 6/18/26, 6/21/26, 6/22/26, 6/25/26, 6/26/26, 6/27/26, 6/30/26 and in the evenings on 6/1/26, 6/2/26, 6/3/26, 6/6/26, 6/7/26, 6/9/26, 6/10/26, 6/11/26, 6/15/26, 6/16/26, 6/17/26, 6/20/26, 6/21/26, 6/24/26, 6/25/26, 6/26/26, and 6/29/26.In July 2026 there was no documentation that the temperatures were monitored in the mornings of 7/3/26, 7/5/26, 7/6/26, 7/17/26 through 7/25/26, 7/28/26, 7/29/26, 7/30/26 and in the evenings on 7/1/26, 7/2/26, 7/4/26, 7/5/26, 7/8/26, 7/9/26, 7/10/26, 7/15/26, 7/16/25, 7/17/26, 7/18/26, 7/20/26 through 7/24/26, 7/27/26, 7/28/26, and 7/29/26. 7. Review of the provider's March 2026 through July 2026 medication storage room expiration dates checklist calendar revealed the medication storage room was to be checked for expired medications and supplies every Sunday night and signed that the checks were completed. The March 2026 calendar did not have a signature to indicate the medication storage room was checked for expired medications and supplies on 3/1/26, 3/8/26, 3/15/26, and 3/22/26. The April 2026 calendar did not have any signatures to indicate the medication room had been checked for expired medications and supplies.The May 2026 calendar did not have signatures to indicate the medication storage room was checked for expired medications and supplies on 5/3/26, 5/17/26, 5/24/26, and 5/31/26. The June and July 2026 calendars did not have any signatures on it to indicate the medication storage room was checked for expired medications and supplies. 8. Interview on 8/6/26 at 9:24 a.m. with director of nursing (DON) B revealed she expected the temperature of the medication refrigerator to be monitored and documented two times daily in the morning and in the evening. The nurses were responsible for monitoring and documenting the medication refrigerator temperatures. She was aware there was missing documentation to indicate the medication refrigerator temperatures were monitored. She acknowledged that without the refrigerator temperature documentation she could ensure the medications in that refrigerator were stored within the manufacturers' recommendations for safe storage.The night nurses were responsible for checking the medication storage room, medication refrigerator, and the medication carts for expired medications and supplies every Sunday night. She was aware there was no documentation to support that the nurses had checked for expiration dates and disposed of the expired medications and supplies every Sunday night. The calendars that the nurses used to document when they had checked for expired medications and supplies and disposed of any expired medications and supplies were given to DON B at the end of each month. She did not review the calendars to be sure the nurses had documented that they checked for, and disposed of the medications and supplies that were expired. She did not know who was responsible for checking for expired creams and supplies in the shower room. 9. Review of the provider's 3/30/26 Medications: Acquisition, Receiving, Dispensing, and Storage policy revealed, The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations. All medications will be stored in accordance with manufacturers' recommendations. Refrigerators holding medications (such as insulin, etc) will be kept between 36 [degrees] F [Fahrenheit] and 46 [degrees] F. Check refrigerator temperatures once in the morning and once in the evening. 10. Review of the provider's undated CMS [Center for Medicare and Medicaid Services] Requirements for Expiration Dates of Ophthalmic [eye] Products for Long Term Care Facilities resource revealed, TB [tuberculin] Solutions- Expires 30 days after opening.

Based on record review, interview, and policy review, the provider failed to ensure the staff educated two of five sampled residents (5 and 46) or their representatives of the risks versus benefits of medications or of alternative treatments, and to obtain consents from two of five sampled residents (5 and 23) or their representatives for the use of psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) before they were administered. Findings Include:1. Review of resident 5's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) assessment score was 2, which indicated her cognition was severely impaired. Her diagnoses included major depressive disorder (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), disorientation, and unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities) with unspecified severity with other behavioral disturbance. She had a 5/12/26 physician's order for hospice care. She had a 5/12/26 physician's order for 0.5 milligram (mg) of Lorazepam (a prescription medication that slows down the central nervous system to treat short-term anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), anxiety-related insomnia, and acute seizures, and to provide sedation before medical procedures) to be administered every four hours as needed for agitation, and a 7/21/26 physician's order for Lorazepam 0.5 mg to be administered every morning for agitation and anxiety. No documentation indicated that resident 5 or her representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 5. She had a 4/8/24 physician's order for 25 mg of Sertraline HCl (a prescription medicine that increases serotonin (a natural chemical messenger and hormone) activity in the brain to treat major depressive disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, social anxiety disorder, and premenstrual dysphoric disorder) to be administered every morning for major depressive disorder. No documentation indicated that resident 5 or her representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 5. 2. Interview on 8/6/26 at 9:03 a.m. with contracted travel Minimum Data Set (MDS) coordinator/licensed practical nurse (LPN) F revealed that the charge nurses obtained the psychotropic consents from the resident or the resident's representative when a new psychotropic medication was started. She expected the consents to be completed before the medication was administered to the resident. 3. Interview on 8/6/26 at 9:52 a.m. with director of nursing (DON) B revealed that she expected the charge nurses to obtain the psychotropic consents for all residents on psychotropic medications, including those receiving hospice care. She confirmed that resident 5 and her representative were not informed of the risks versus benefits of Lorazepam and Sertraline, alternative treatment options, or that they provided their consent for those medications to be administered. 4. Review of resident 46's EMR revealed he admitted to the facility on [DATE]. His 7/17/26 BIMS assessment score was 13, which indicated his cognition was intact. His diagnoses included depression, anxiety, and insomnia (a sleep disorder characterized by persistent difficulty sleeping). He had a 7/17/26 physician's order for Buspirone HCl (an anti-anxiety medication) 30 mg to be administered by mouth two times a day for anxiety and depression. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 46. He had a 7/17/26 physician's order for Chlorpromazine HCl (an antipsychotic medication; ) 100 mg to be administered by mouth at bedtime for anxiety. No documentation indicated that the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or provided their consent for that medication to be administered to resident 46. He had a 7/17/26 physician's order for Clonazepam 0.5 mg (a benzodiazepine medication used to treat anxiety) to be administered by mouth two times a day for anxiety. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication or alternative treatment options before that medication was to be administered to resident 46. He had a 7/17/26 physician's order for Duloxetine HCl (an antidepressant medication) 90 mg to be administered by mouth in the morning for depression. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication or alternative treatment options before that medication was to be administered to resident 46. He had a 7/17/26 physician's order for Olanzapine (an antipsychotic medication) 10 mg to be administered by mouth at night for anxiety. No documentation indicated that the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or provided their consent for that medication to be administered to resident 46. He had a 7/17/26 physician's order for Trazodone HCl (an antidepressant medication) 300 mg to be administered by mouth at bedtime for insomnia. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication or alternative treatment options before that medication was to be administered to resident 46. He had a 7/17/26 physician's order for Zolpidem Tartrate (a hypnotic medication used to treat insomnia) 5 mg to be administered by mouth as needed once every 24 hours as needed at bedtime for insomnia. That physician's order did not have an end date, and resident 46 needed to be seen by a physician to have that medication reordered on 7/31/26. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication or alternative treatment options before that medication was to be administered to resident 46. 5. Review of resident 23's EMR revealed he admitted to the facility on [DATE]. His diagnoses included depression, senile degeneration of the brain (severe age-related mental decline), and dementia with anxiety. He had a 11/25/25 physician's order for lorazepam 0.5 mg to be administered every four hours as needed for agitation, restlessness, depression, senile degeneration of the brain, and dementia with anxiety. Resident 23's 11/21/25 consent for the lorazepam did not indicate what the medication was to be administered for or alternative treatment options. He had a 12/24/25 physician's order for risperidone (an antipsychotic medication) 0.25 mg to be administered two times a day for dementia with anxiety. Resident 23's 12/24/25 consent for the risperidone did not indicate what the medication was to be administered for or alternative treatment options. He had a 1/21/26 physician's order for mirtazapine 15 mg to be administered one time a day for insomnia (inability to sleep) related to senile degeneration of the brain and dementia with anxiety. There was no documentation to indicate that the resident or the resident's representative was informed of the risks versus benefits of that medication, what the medication was to be administered for, alternative treatment options, or consent obtained before that medication was to be administered to resident 23. He had a 2/20/26 physician's order for fluoxetine (an antidepressant medication) 10 mg to be administered one time daily. Resident 23's 11/21/25 consent for the fluoxetine did not indicate what the medication was to be administered for or alternative treatment options. 6. Interview on 8/6/26 at 8:48 a.m. with LPN J revealed that the nurse who admitted a resident or received a resident's new psychotropic medication order was responsible for completing the psychotropic medications consent form. When she completed the psychotropic medication form, she went over what was on the form with the resident or the resident's representative, including the side effects, and why that medication was ordered. The psychotropic medications form did not include what the alternatives to the medication may be. She did not review alternatives to the medications with the resident or the resident's representative. 7. Interview on 8/6/26 at 9:24 a.m. with DON B revealed the psychotropic medication consents were to be completed by the nurse who admitted the resident. If a new psychotropic medication was ordered by the physician after a resident admitted to the facility, the nurse who received the physician's order for the medication was responsible for completing the psychotropic medication consent with the resident or the resident's representative. DON B expected the psychotropic medication consents to be complete. She expected the nurse who completed the psychotropic medication consent sign the form to indicate which nurse provided the education to the resident or resident's representative and obtained the consent for the administration of the psychotropic medication before it was administered. DON B did not know that the resident or resident's representative was to receive education about alternative treatment options before the psychotropic medication was administered. She stated she was unable to find a psychotropic consent for resident 23's mirtazapine, which would indicate the resident or the resident's representative was educated about the risk versus benefits of the medication, what the medication was being administered to treat, the alternative treatment options, and consent was obtained before the mirtazapine was administered to resident 23. 8. Review of the provider's 12/9/25 Psychotropic Medications policy revealed, If the reduction committee determines that initiating a medication is warranted, then the committee nurse will ensure the following is completed: .The reduction committee will ensure that the family/legal representative and [the] resident are notified of this change in treatment. A consent must be signed for the use of psychotropic medications.

Based on observation, interview, record review, and policy review, the provider failed to ensure an ongoing restorative nursing program was implemented for three of three sampled residents (4, 6, and 27) identified as at risk for declining in their range of motion (ROM) and one of one sampled resident (37) who expressed a desire for increased physical activity due to weight gain and a fear of losing his mobility. Findings include: 1. Observation and interview on 8/4/26 at 8:50 a.m. with resident 4 in his room revealed he was seated in a power tilt-in-space wheelchair (a specialty wheelchair that tilts the entire seat and backrest backwards as a single unit), had difficulty holding his head up, and had limited use of both hands. He felt he was not receiving the exercises he needed to maintain his strength or ROM, and was getting weaker. He stated he used to complete exercises at the facility where he previously lived, but no staff members at this facility came to assist him with exercises or ROM.2. Review of resident 4's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. He had a diagnosis of spastic quadriplegic cerebral palsy (a severe form of cerebral palsy, a permanent neuromuscular condition caused by damage to the developing brain before, during, or shortly after birth, characterized by extreme muscle stiffness, impact on all four limbs, and involvement of the torso and face). His 7/24/26 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated his cognition was intact.His care plan (personalized plan that addresses a resident's care needs, goals, and interventions) included a 12/26/25 focus area that he had an activity of daily living self-care performance deficit related to limited mobility E/B [evidenced by] contractures [a permanent or severe tightening and shortening of muscles] and weakness, and that he had a Cerebral Palsy diagnosis upon admission. His goal was to maintain [his] current level of functioning in eating, assisting with dressing, [and] assisting with [his] hygiene cares. His care plan also included a focus area that The resident expressed need for customized dining services R/T [related to his] diet, [and] adaptive dining equipment. The goal was Resident [4] will express his/her dining services needs are met, and he/she feels supported in dining decisions.His most recent quarterly 7/1/26 Minimum Data Set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) indicated he had a functional limitation in ROM in both lower extremities (hips, knees, ankles, and feet) and both upper extremities (shoulders, elbows, wrists, and hands), and he received no restorative nursing exercise programs.3. Interview on 8/5/26 at 9:16 a.m. with physical therapist (PT) S revealed that physical therapy did not assess resident 4's need for a restorative exercise or ROM program when he admitted to the facility because the facility did not offer a restorative program. She stated that the facility offered a walking program for residents who could walk to their meals and that physical therapy prescribed home exercise programs (HEP) for residents in the facility who could complete exercises independently or had family members who could assist them. Those exercise programs were taught to the residents and their family members, and the certified nursing assistants (CNAs) were not trained to or expected to assist the residents with them. Resident 4 did not have an HEP because he was unable to complete exercises independently. She did not know if resident 4 would benefit from a restorative program or HEP because she had not assessed resident 4.4. Interview on 8/5/26 at 9:26 a.m. with resident 4 revealed he felt he dropped more food when he ate his breakfast and that his eating muscles were stiffer and weaker than when he admitted to the facility. He stated that he remembered doing hand exercises with the staff members at the facility where he used to live, and that those staff members moved his arms and legs to prevent them from being stiff. He was frustrated that the staff members at this facility did not help him with exercises or ROM activities.5. Interview on 8/5/26 at 9:35 a.m. with certified occupational therapy assistant (COTA) R revealed that resident 4 was seen for occupational therapy (OT) services related to the safe driving of his wheelchair. OT did not assess resident 4's ability to use adaptive dining equipment or his need for a restorative exercise or ROM program because the facility did not offer a restorative program. She thought resident 4 brought his own adaptive equipment with him to the facility and that he was at his baseline when he admitted to the facility.6. Observation and interview on 8/5/26 at 10:07 a.m. with resident 6 in her room revealed that she gestured thumbs up and thumbs down, or nodded her head to answer most questions, and at other times used one-word answers to respond. She was lying in bed and could only move one arm. She indicated that no one came to assist her with ROM exercises and she felt stiff, and that she was losing her strength.7. Review of resident 6's EMR revealed she admitted to the facility on [DATE]. Her diagnoses included hemiplegia (the total or partial paralysis on one side of the body, affecting the arm, leg, and often the face) following a cerebral infarction (stroke) affecting her left non-dominant side. Her 6/5/26 BIMS assessment score was 7, which indicated her cognition was severely impaired.Her care plan included a 4/11/25 focus area that stated The resident has potential alteration in musculoskeletal status R/T [related to] immobility, risk for developing contracture of legs/feet. Her goal was to remain free of complications related to immobility, such as contracture formation, embolism. Interventions included Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT/OT.Her 10/27/25 Physical Therapy Discharge Summary recommendations stated, Husband provided with cervical, UE [upper extremity] and LE [lower extremity] HEP to continue completing independently. Restorative Program Established/Trained = Restorative ROM Program.Her most recent modification of the quarterly 6/4/26 MDS assessment indicated she had a functional limitation in ROM in one lower extremity and one upper extremity, and she received no restorative nursing exercise programs.8. Observation on 8/5/24 at 10:12 a.m. with resident 27 in her room revealed she sat in a Broda chair (a specialized positioning wheelchair), her hands were closed in fists, and she was unable to answer the surveyors' questions.9. Review of resident 27's EMR revealed she admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions). Her 6/2/26 BIMS assessment score was 1, which indicated her cognition was severely impaired. Her most recent modification of the quarterly 6/2/26 MDS assessment indicated she had a functional limitation in ROM in both upper and lower extremities, and she received no restorative nursing exercise programs. Her care plan included a 9/8/20 focus area resident [27] has arthritis. Resident will be/remain free of complications related to arthritis (contractures, joint stiffness, swelling, or decline in mobility). Interventions included Observe/document/report.complications of arthritis: Joint pain; joint stiffness, usually worse on wakening; swelling; decline in mobility; decline in self-care ability; contracture formation/joint shape changes; crepitus [cracking and popping sound in the joint]; pain after exercise or weight bearing.10. Interview on 8/5/26 at 10:45 a.m. with CNA O revealed that she did not assist residents with ROM or exercise programs. Some residents were provided with exercise programs by the therapy department and completed those exercises independently. She did not think residents 4, 6, or 27 had any exercise programs since they were unable to complete them themselves.11. Interview on 8/5/26 at 11:36 a.m. with administrator A revealed that there was no restorative program offered at the facility. There was no documentation related to recommendations for restorative programs or documentation that exercise programs or ROM exercises were completed for residents 4, 6, or 27. 12. Observation and interview on 8/5/26 at 1:40 p.m. with resident 37 in his room revealed that he sat in a recliner and used a four-wheeled walker (a mobility device to help maintain balance with a built-in seat). He stated he used his four-wheeled walker independently to walk to his meals. He had gained weight since he moved to this facility because he was unable to ride an exercise bike and was afraid that he was getting weaker. The dietitian recommended that he exercise to lose weight about a month ago. There was no plan for that, but he thought more exercise would be good for him. He stated that he used to complete exercises and ride an exercise bike at the facility where he previously lived, but he was told there was no exercise bike at this facility that he could ride.13. Review of resident 37's EMR revealed he admitted to the facility on [DATE]. His diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities). His 5/28/26 BIMS assessment score was 15, which indicated his cognition was intact.His care plan included a 6/13/25 focus area that he was at risk for falling related to the use of a walker for ambulation (walking), with a goal that he would be free of injury.A 6/13/26 focus area indicated that resident 37 had an unplanned weight gain R/T potentially overeating. The goal was that resident 37 would maintain weight WNL [within normal limits] for resident. Interventions included Review overall meal plan with resident/family and adjust goals and interventions to meet resident's preferences and weight goals.His most recent 6/30/26 dietitian assessment indicated he had gained 30 pounds since he admitted to the facility. Her recommendations included Encourage physical activity.14. Interview on 8/5/26 at 3:32 p.m. with administrator A revealed the facility did not have a restorative program since the COVID-19 outbreak due to a lack of staffing. Some residents walked with the staff to meals, and other residents were assessed by the therapy department as independent with their exercise programs. She expected the therapists to educate the resident on a HEP and provide the resident with a handout to complete those exercises independently. The nursing staff did not oversee those programs. Those exercise programs were only for residents who could complete them independently.Residents with cognitive issues did not participate in OT or PT because they could not understand the directions needed to participate. Residents with limited ROM or contractures, who required assistance, did not receive restorative therapy because there was no program or the staff to complete them. She did not expect the CNAs to complete ROM exercises with residents because there was no program established for them. She thought a restorative program would be beneficial, but they did not have the staff members needed to complete it.15. Interview on 8/6/26 at 10:31 a.m. with administrator A and director of nursing (DON) B revealed administrator A thought that OT and PT departments reviewed resident 4's admitting documents and determined that they did not think that he needed OT or PT because he was at his baseline and no restorative nursing program was available. She expected the CNAs to notify the nurse if any residents, including 4, 6, and 27, had any decline in their ability to get dressed or increased mobility issues so orders for a therapy evaluation could be requested. There were no preventative interventions in place for the residents who required assistance with ROM or exercises to ensure they maintained their highest level of function.She thought that resident 37's weight gain was because he ate too many snacks, and she did not think there was a decline in his ability to walk because he walked to his meals independently. There were group exercises provided by the activities department in the living room that he chose not to attend.She was unaware that resident 37 wanted to ride an exercise bike. There was an exercise bike in the therapy room, but he would have to be able to ride it independently. She did not think resident 37 was assessed to do that. Resident 37 was unable to ride that exercise bike if he required any assistance or supervision because the facility did not have a restorative program. Administrator A did not think the CNAs were trained to assist residents with ROM or exercise programs and that the residents who were able to complete exercises independently were given HEP's. She did not think that there needed to be services provided to the residents to maintain, improve, or prevent avoidable decline in ROM and mobility.16. Review of the provider's undated Certified Nursing Assistant job description revealed that the CNAs provide assistance with basic healthcare needs, including daily living activities that may include but are not limited to. range of motion and passive exercises.17. Review of the provider's reviewed 12/8/25 Restorative- Nursing Care Policy Implementation and Screening revealed Each resident will receive restorative nursing care to the extent possible, based on individual strengths, needs and problems as defined in nursing assessments. This restorative care will be outlined in the resident's nursing care plan. Care includes safe measures to prevent complications and contractures, maintain strength and self-care abilities including eating and dressing, promote mobility and a feeling of well-being. The goal of restorative nursing care is to attain and maintain the maximum possible and/or prevent rapid declines through their interventions for each resident. Implementation of Resident's Restorative Program. 2. The information is shared with interdisciplinary team members during the initial care planning process. The interdisciplinary team, including therapy, should communicate upon a resident's facility admission, regarding the initiation of the Restorative Nursing Assessment, exclusive of the resident's status with skilled therapy. It is the goal to include the resident in the development of the care plan goals and interventions to ensure a person-centered approach to care.Examples of conditions for implementation of a restorative nursing program included medical conditions that affect joint mobility, pressure ulcers, limited range of motion; disease processes, and prognosis; spasticity, contractures, or decreased sensation, resident's willingness to participate, motivation, fall reduction programs promoting strength, flexibility, endurance and balance.18. Review of the provider's 6/3/26 Facility Assessment revealed resources available to deliver care needed by the residents included restorative therapy.

Based on observation, interview, record review, and policy review, the provider failed to ensure the residents' care plans (a personalized plan that addresses a resident's care needs, goals, and interventions) were reviewed and revised to reflect the current care needs for one of four sampled residents (23) who were on psychotropic medications (drugs that affect brain activities associated with mental processes and behavior).Findings include: 1. Review of resident 23's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His diagnoses included depression, senile degeneration of the brain (severe age-related mental decline), and dementia (a group of symptoms affecting memory, thinking, and social abilities) with anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). He had a 11/25/25 physician's order for lorazepam (an antianxiety medication) 0.5 milligrams (mg) to be administered every four hours as needed for agitation, restlessness, depression, senile degeneration of the brain, and dementia with anxiety. His 8/5/26 care plan did not indicate he was on an antianxiety medication or have nonpharmacological interventions that were to be attempted before the as needed lorazepam was administered. He had a 12/24/25 physician's order for risperidone (an antipsychotic medication; (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) 0.25 mg to be administered two times a day for dementia with anxiety. His 8/5/26 care plan did not indicate he was on an antipsychotic medication or the nonpharmacological interventions that could be used by the staff for resident 23's symptoms or behaviors related to dementia with anxiety. He had a 1/21/26 physician's order for mirtazapine (an antidepressant medication) 15 mg to be administered one time a day for insomnia (inability to sleep) related to senile degeneration of the brain and dementia with anxiety. His 8/5/26 care plan did not indicate nonpharmacological interventions that the staff could use to help resident 23 with his insomnia. He had a 2/20/26 physician's order for fluoxetine (an antidepressant medication) 10 mg to be administered one time daily. His 8/5/26 care plan did not indicate nonpharmacological interventions that the staff could use to help resident 23 with his depression symptoms. 2. Interview on 8/5/26 at 3:36 p.m. with administrator A revealed that not all resident care plans reflected nonpharmacological interventions. It just depends on the resident and the intervention, she said. There is a list of interventions listed at the nurse's station that are not resident-centered, they're just general interventions for [the] staff to try. 3. Review of the list of interventions at the nurse's station revealed 29 nonpharmacological interventions for the staff to try when residents experienced behaviors, including redirecting the resident, reducing noise and overstimulation, and providing pet therapy or fake companion pets. The list did not include any resident names and did not indicate whether the interventions were successfully attempted with any residents. 4. Interview on 8/6/26 at 9:03 a.m. with contracted travel Minimum Data Set (MDS) coordinator/licensed practical nurse (LPN) F revealed that she began working at the facility on 6/15/26. She expected the resident's care plan or Kardex to list any psychotropic medications the resident took, including adverse behaviors to monitor and successful interventions for the staff to use to reduce the resident's anxiety or agitation. She said nonpharmacological interventions were usually documented in the nursing progress notes, but she did not know if CNAs were able to view the progress notes. If an intervention works, we put it in the task list for the CNAs to see, she said. 5. Interview on 8/6/26 at 9:20 a.m. with social services designee D indicated that the residents' care plans are geared more towards resident safety, like falls and wheelchairs to use, more so than [their] behaviors. 6. Interview on 8/6/26 at 9:32 a.m. with contracted travel CNA Q revealed that she started working at the facility three days ago. She did not yet know the residents very well but expected to be able to reference their care plan or Kardex (a report of the resident's care needs and interventions) to learn whether they should be monitored for adverse behaviors and interventions to be used. If she witnessed a behavior by a resident that was not referenced in their care plan, she would ask one of the nurses or another CNA to determine whether the behavior was unusual for that resident. 7. Review of the provider's 12/9/25 Psychotropic Medications policy revealed, Ensure that the order has clear parameters, i.e., severe agitation that does not respond to other care plan interventions. It is important to initiate other care plan interventions prior to the use of PRN psychotropic medications.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to provide adequate supervision and assistance to ensure the safety of one of one sampled resident (26) who fell while being transferred by former contracted travel certified nursing assistant (CNA) (P), who did not transfer the resident as directed in the resident's care plan (a personalized plan that addresses a resident's care needs, goals, and interventions). This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include:1. Review of the provider's 6/13/26 SD DOH FRI regarding resident 26 revealed that on 6/13/26 at 4:34 p.m., former contracted travel CNA P transferred resident 26 from her wheelchair to her bed using a hygiene sling (a specialized support accessory used with a patient lift). The report specified that although resident 26 required assistance from two staff members to transfer her with a total body lift (a mechanical lift and sling used to lift a person's full body), former contracted travel CNA P transferred the resident alone, using the wrong sling. When the resident was suspended in the sling, she lifted her arms, causing her body to shift position within the sling and fall, hitting her head on the floor. Resident 26 was evaluated at the emergency room and returned to the facility the same day with no concerns other than a small bump on her head. Former contracted travel CNA P and all nursing staff were immediately reeducated on the provider's Safe Resident Handling Program. Following resident 26's fall, administrator A and director of nursing (DON) B reviewed the care plans for all other residents using a mechanical lift and found that they all accurately listed the appropriate sling and lift to be used during transfers. Administrator A and DON B audited resident transfers for four weeks to ensure the care plan was followed. Former contracted travel CNA P was terminated from employment on 6/14/26. 2. Review of resident 26's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. She had diagnoses of progressive multiple sclerosis (a long-lasting disease of the brain and spinal cord where the body's immune system harms the protective cover of the nerve cells, slowing or blocking messages between the brain and body), muscle weakness, Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), and unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. She had a 6/11/26 Brief Interview for Mental Status (BIMS) assessment score of 4, which indicated her cognition was severely impaired. Her 3/13/26 fall assessment score was 12, indicating she had a medium risk of falling. Her 1/21/26 care plan indicated she required assistance from two staff members to transfer with a total body lift and a medium mesh or high-back yellow sling. Her 6/10/26 sit-stand-walk assessment indicated she required a total body lift, a medium full-body sling, and two employees to assist her with transfers. 3. Interview on 8/5/26 at 10:28 a.m. with CNA M revealed she referenced the resident's Kardex (a report of the resident's care needs and interventions) to determine how many staff members should assist the resident with transfers, and what type of lift and sling to use for the transfer. She said the resident's Kardex specified if they used a hygiene sling, which was reserved for transfers to the toilet or the shower chair. She said hygiene slings were never used to transfer a resident from their wheelchair to their bed. 4. Observation and interview of a total lift transfer on 8/5/26 at 3:45 p.m. of a supply closet with CNA L revealed that the staff were informed at the beginning of each shift if a resident's care plan was updated for a different lift or sling. The supply closet contained slings of various sizes and colors, stored next to the manufacturer's poster depicting how a sling was to be attached to the total body lift. CNA L confirmed that a hygiene sling was only used for transfers during toileting or bathing. He said resident 26 had always required the assistance of two staff members using a total body lift. 5. Interview on 8/6/26 at 9:32 a.m. with contracted travel CNA Q revealed she started working at the facility three days ago. During her first shift she received training on the types of lifts and slings used in the facility and was instructed to reference the residents' care plan or Kardex to determine the equipment and level of assistance the residents required during a transfer. She was also trained to perform a time out prior to transferring a resident, to ensure the sling was buckled and the color-coordinated straps were in the right place on the total body lifts. 6. Interview on 8/6/26 at 10:14 a.m. with administrator A and DON B revealed that all nursing staff received Safe Resident Handling Program (SRHP) training when they were hired and completed safe transfer competency skills testing annually. The SRHP training was also provided to contracted travel CNAs on their first shift, in addition to any training they received from their contracted travel agency. All nursing staff received safe transfer competency skills testing in June as part of the provider's mock survey preparations. Former contracted travel CNA P's competencies were completed on 4/7/26 and 6/5/26. The competency testing included a step to check the resident's care plan or Kardex before transferring a resident to determine the type of equipment to be used and the amount of staff assistance required. The nurses assessed each resident to determine the level of assistance required during transfers, and slings were assigned based on the resident's weight. Administrator A and DON B expected the nursing staff to follow the residents' care plans to safely transfer them using the specified sling and lift. DON B acknowledged it was her responsibility to ensure the staff followed the care plans. Administrator A said the charge nurses were also responsible for supervising the CNAs, who should keep their peers in check and come to us with questions. They acknowledged that resident 26's care plan accurately reflected the assistance she required at the time of her fall and stated it was unacceptable for former contracted travel CNA P to have transferred resident 26 without the assistance of another staff member, and to use the wrong type of sling. Administrator A and DON B continued auditing resident transfers through the end of July and were pleased to see the staff adhering to transfer instructions specified in the residents' care plans. All 40 nursing staff members completed SRHP training and competency testing, except seven staff members scheduled as-needed (PRN), who would receive the training when they returned to work. We didn't implement any system changes as a result of the audits, because all the transfers were done correctly according to the resident's care plan, administrator A stated. 7. Review of the provider's 7/7/25 Safe Resident Handling Program (SRHP) policy indicated that a total body lift required two staff members and should be used for residents who cannot sit upright on the side of the bed, do not have weight-bearing ability on at least one leg, and cannot pull themselves to a standing position requiring full weight-bearing support. The policy indicated that the nursing staff should follow the resident's care plan or Kardex to determine the type of mobility device, type and size of sling, and number of staff to safely transfer or position the resident. 8. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 8/6/26 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding mechanical lift policy and fall policy, mechanical lift competencies were completed for all caregiver staff, and audits were being completed and would be ongoing. Interviews with the nursing staff indicated they understood the education provided regarding those topics. Observations of mechanical lift transfers in the residents' rooms were conducted and confirmed the staff understood how to use mechanical lifts and transfer residents safely. The provider's audits would be reviewed at their August 2026 Quality Assurance and Performance Improvement (QAPI) meeting and would continue to be a part of their QAPI process for further review to advise the staff as needed. 9. Based on the above information, non-compliance at F689 occurred on 6/13/26, and based on the provider's 6/14/26 implemented corrective actions for the deficient practice confirmed on 8/6/26, the non-compliance is considered past non-compliance.

Based on interview, record review, and policy review, the provider failed to ensure the staff completed and documented controlled (medications with risk for abuse and addiction) medication supply counts by one of one registered nurse (RN) (I) who signed the controlled medication count book as completed before she completed the medication count with another nurse, and that a resident's narcotic (a broad term for habit-forming or illegal drugs that are strictly controlled) pregabalin (a narcotic medication that specifically treats nerve pain) medication was signed out of the controlled drug count book when it was administered to one of one sampled resident (14).Findings include: 1. Interview and controlled count book review on 8/5/26 at 1:26 p.m. with RN I revealed that she had signed for the 6:30 p.m. controlled medication counts in the controlled drug count book on 8/5/26 before counting the controlled medications. She confirmed that by signing the controlled drug count book, her signature indicated she had completed the count, and it was accurate. RN I stated that she was not aware of any missing medications. 2. Review of resident 14's electronic medical record (EMR) revealed that on 7/6/26 there was a nurse's progress note that indicated that at evening shift change, two nurses counted the resident's controlled medications, and found that resident 14 was missing a pregabalin from her a.m. medication bubble pack card. The nurse had signed the medication as administered in resident 14's medication administration record (MAR) but did not verify that the number of medication capsules in the bubble pack card matched the number of pregabalin capsules in the medication count book. The nurse indicated in the progress note that she was unable to verify the count of pregabalin, before administration, or if she had given resident 14 two capsules of the medication in error. Resident 14's vital signs were not taken as the error was caught several hours later.3. Interview on 8/6/26 at 9:15 a.m. with director of nursing (DON) B regarding resident 14's missing pregabalin revealed DON B stated she was aware of the incident but did not that the medication was missing. She confirmed the nurse should have verified the medication count on the resident's medication bubble pack card when she signed the medication as administered in the resident's MAR and on the controlled drug count sheet.4. Interview on 8/6/26 at 9:24 a.m. with DON B regarding controlled medication counts revealed she expected the count to be done at every change of shift, by the oncoming nurse and the off-going nurse. After the count was completed and found to be accurate, she expected the staff members to sign the form in the controlled medication count book. She stated it was not acceptable for the controlled medication count book to be signed before the count was completed.5. Review of the provider's 6/30/26 Medications: Controlled policy revealed, The location will along with their consultant pharmacist will establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation that determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled and meets all state and federal requirements for controlled medications. Each time the keys that secure controlled medications change from one nurse/medication aide to another, the oncoming and off-going nurse/medication aide will work together to reconcile all controlled medications, including all discontinued controlled medications and document the same. If the physical count is NOT in agreement with the [Corporately used form] or Controlled Substance Bound Book the error must be found or an incident report must be completed prior to the end of the shift and reported to the director of nursing services before any staff administering medications for the shift leave the building.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, resource packet review, and facility assessment review, the provider failed to ensure sufficient caregiver staff were available to meet the needs of:*One of one sampled resident (1) who relied on staff assistance for repositioning and developed a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone) after she admitted to the facility.*One of one sampled resident (2) who relied on staff assistance for toileting and incontinence care and reported certified nursing assistant (CNA) H turned off the resident's call light without assisting the resident with toileting, which contributed to the resident being incontinent, remaining in wet garments overnight, inability to sleep, and expressed feeling of distress.Findings include:1. Review of the provider's 10/13/25 SD DOH FRI regarding resident 2 revealed:*On 10/13/25 at 7:21 a.m., resident 2 reported concerns about the care provided during the overnight shift, which included:-Certified nursing assistant (CNA) H had responded to her call light multiple times, but no assistance was provided.-CNA H turned off resident 2's call light and exited the room without assisting her, which led to an episode of incontinence.*Resident 2 expressed distress related to that incident.*The provider does not have the capacity to generate a call light usage and response time report.*On the night of the incident there was a CNA and an RN [registered nurse] on duty [to care for] 38 residents.*Based on the findings of the [providers] investigation, the allegation of neglect was unsubstantiated [by the provider]. There was no conclusive evidence that the CNA failed to provide care or turned off the call light without assisting the resident. 2. Observation and interview on 10/23/25 at 11:21 a.m. with resident 2 and her daughter in her room revealed:*Resident 2 was assisted by two CNAs to use the bedpan and then was assisted to her recliner using a total body lift (a mechanical lift and sling used to lift a person's full body).*Resident 2 recalled a recent night when she had called for staff assistance, became incontinent, remained wet all night, and was unable to sleep.-On that night, she turned her call light on to ask for assistance, but the staff member was busy, shut off her call light, and did not come back to her room to help her. Resident 2 was occasionally incontinent and stated she couldn't hold it and was awake and wet all night.*Resident 2's daughter washed her mother's laundry and recalled that when she arrived at the facility that day (10/13/25), she found her mother's pajamas were soaking wet, both the top and bottoms.*Resident 2's daughter took her mother's pajamas and a bag of bedsheets that were left in her mother's room to her home to wash, and recalled being shocked at how wet they were.*Resident 2's daughter stated that resident 2 used a bedpan when staff responded quickly enough to prevent an incontinent episode. She noticed her mother's pajamas were wet more often over the past month, and she questioned if they had enough staff working at the facility to assist her mother at night or if her mother was having more frequent episodes of incontinence. 3. Review of resident 2's electronic medical record (EMR) revealed:*She admitted to the facility on [DATE].*Her 9/17/25 Brief Interview for Mental Status (BIMS) score was 13, which indicated her cognition was intact.*Her updated 10/14/25 care plan indicated she was incontinent at night, wore an incontinence garment, and wanted to be woken up at night for assistance with her toileting needs. 4. Review of the 10/17/25 anonymous complaint intake report regarding resident 1 revealed:*Resident 1 had been admitted to the facility on [DATE], after a surgery to place a rod in her left leg. She was in a full-length cast and was dependent on staff for repositioning and pain medication.*Resident 1 developed worsening pain in her left leg starting on 10/11/25 and burning in her back and bottom throughout the night.*She was admitted to the hospital on [DATE] with a pressure ulcer that measured four inches by six inches and was deep. The rod in resident 1's left leg had broken away, and requiring an additional surgery. 5. Review of resident 1's electronic medical record (EMR) revealed:*She admitted to the facility on [DATE].*Her 10/9/25 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact.*Her diagnoses included infection due to an internal left knee prosthesis (artificial joint), Type II Diabetes Mellitus (a condition involving disruptions in how the body regulates blood sugar), Chronic Kidney Disease Stage 3 (kidneys do not effectively filter blood and have moderate damage), and adjustment disorder with mixed anxiety and depressed mood.*Her 10/9/25 physician orders indicated:-She was on a diabetic diet.-She was non-weight-bearing (unable to put pressure) on her left leg.- Prevera [Prevena] wound vac (a device that uses negative pressure to remove excess fluid and debris from a wound to promote healing). Leave in place. Will be removed at follow up appointment.-She was to receive Triad Hydrophilic Wound Dressing Paste (a wound treatment cream) to her right and left buttocks two times a day for skin breakdown.-She received DAPTOmycin [an antibiotic] Intravenous Solution Reconstituted once daily, related to an infection in her left knee.*Her 10/9/25 Braden Scale (a tool used to assess the risk of developing pressure ulcers) indicated:-She was confined to bed and needed moderate to maximum staff assistance with moving.-The ability to complete lifting to boost resident 1 in bed without sliding against the sheets was impossible.-She frequently slid down in bed and needed frequent repositioning with maximum assistance.-Her Braden Scale score was 15, which indicated she was at risk for developing pressure ulcers.*A 10/10/25 Skin Observation assessment indicated resident 1 had a Large area on [her] bottom [that was] red, flaky, [and] macerated [softening of skin due to prolonged exposure to moisture] present on admission, and that resident 1 was on an air mattress.-The Care Plan for Skin section listed several potential focus areas, goals, and interventions to select if applicable. The care plan section had not been completed.-The Education section listed potential education provided, potential barriers, and potential persons educated to select if applicable. The education section had not been completed.*Her 10/10/25 physical therapy evaluation indicated resident 1 needed moderate staff assistance for rolling in bed, and the use of the total body lift (a mechanical lift and sling used to lift a person's full body) when being transferred.*Resident 1's Roll left and Right task documentation included:-On 10/9/25, one rolling task was documented as Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or illness.-On 10/10/25, the rolling task was documented, at 11:36 a.m. and again at 9:59 p.m., as dependent or requiring the assistance of two caregivers.-On 10/11/25, the rolling task was documented: at 1:59 p.m., as refused and at 9:59 p.m., as dependent or requiring the assistance of two caregivers.-On 10/12/25, the rolling task was documented at 1:59 p.m., as dependent or requiring the assistance of two caregivers. *Resident 1's 10/9/25 care plan did not include resident 1's full-length left leg cast, wound vac (a medical treatment to promote wound healing) to her left leg, urinary catheter (flexible tubing inserted into the bladder to drain urine), transfer or weight-bearing status, assistance needs to complete activities of daily living such as toileting and repositioning, risk for developing pressure ulcers, or interventions to prevent acquiring a pressure ulcer. 6. Review of resident 1's 10/9/25 through 10/12/25 progress notes revealed:*On 10/9/25 resident 1 was admitted at 2:20 p.m., was fully oriented, was in significant pain and any movement was difficult.*On 10/10/25 resident 1 was pleasant and cooperative, refused to allow staff to remove her catheter due to her decreased mobility and increased pain, and had remained in bed since [her] admission yesterday.*On 10/11/25 resident 1 continues to remain in bed since admission, continues to have red, flaky macerated skin to buttocks/coccyx area, that staff attempts to relieve pressure to area with repositioning as res [resident 1] allows, and that resident 1 tends to lean often to [her] R [right] side due to pain from her LLE [left lower extremity].*On 10/12/25 PN resident 1 had reported her back and bottom are on fire, the nurse (LPN D) went to put cream on her bottom, resident 1 did not want the creams for [her] back and bottom; did not want to be touch[ed]/repositioned, and at 12:05 p.m., resident 1 was sent to the emergency room due to being inconsolable with increased pain to LLE. 7. Interview on 10/22/25 at 1:57 p.m. with registered nurse (RN) F revealed:*RN F completed resident 1's admission skin assessment on 10/9/25. Resident 1 was admitted to the facility with an area to her right and left buttocks that was approximately four inches by six inches wide and was bright red and excoriated. RN F stated the area was not bleeding and did not look like a pressure area, but rather appeared like an area associated with moisture where the top layer of skin was broken down.*RN F faxed the resident's physician for an order for Triad cream because RN/wound nurse C and director of nursing (DON) B were not at the facility that day.*RN F did not complete resident 1's baseline care plan. She expected that DON B would complete that care plan when DON B returned to work.*RN F repositioned resident 1 during her admission assessment and stated that resident 1 required the assistance of two staff members with rolling the resident due to her left leg cast and she was in a lot of pain. 8. Interview and staff schedule review on 10/22/25 at 12:43 p.m. with medical records (MR) staff member I revealed:*MR staff member I completed the staff schedules and would find additional staff to cover open shifts when needed.*During the overnight hours, there was to be one nurse scheduled from 6:00 p.m. until 6:30 a.m.*During the overnight hours, CNA staffing varied from one to two scheduled CNAs, depending on staff availability.-If two were scheduled, one CNA shift was from 10:00 p.m. until 6:30 a.m., and a second CNA shift was from 11:00 p.m. until 7:30 a.m.-The goal was to have two CNAs on duty for the overnight shifts, but that was not always possible.-She felt it was harder to staff two CNAs for the overnight shifts on the weekends because staff were not always available.*There were six overnight shifts during the two week period from 10/5/25 through 10/18/25, where one CNA and one nurse worked the overnight shift. -One nurse and one CNA worked the overnight shifts on Saturday, 10/11/25, and on Sunday, 10/12/25.*When DON B was out of the facility, the charge nurse would be the person in charge, and DON B would be available by phone, if needed. 9. Interview on 10/22/25 at 3:25 p.m. with CNA H revealed:*She had worked at the facility since 10/1/25 and typically worked the overnight shifts.-Sometimes two CNAs worked during the overnight shifts, and sometimes she was the only CNA for those shifts.-She felt that it was really hard when she was the only CNA working the overnight shift, but she was getting used to it.*She typically had 40 residents that she cared for during the overnight shift. She was responsible for answering the residents' call lights and doing rounds (checking on residents' status and assistance needs), by going room to room and checking on the residents.-She referred to the resident's care plans to know how much assistance residents required at night, but was unsure how many residents were incontinent, or how many required the assistance of two staff members.*She thought that she completed rounds and changed residents' incontinence products about four times each night.*She worked on 10/10/25 from 7:00 p.m. until 10/11/25 at 6:30 a.m. and again on 10/11/25 from 6:00 p.m. until 10/12/25 at 6:30 a.m.*She stated that on both of those days that she worked, there was one nurse and three CNAs on duty from 7:00 p.m. until 10:30 p.m., and from 10:30 p.m. until 6:30 a.m., CNA H and one nurse were on duty.*She could ask the nurse for assistance with the residents when the nurse was not busy with other tasks.*She felt that some nurses were more helpful than others with answering resident call lights and changing residents' incontinence products.*On the night resident 2 had reported concerns about not being assisted and having an incontinence episode, CNA H was the only CNA on duty, was very busy assisting another resident who was in the end of life process, and she thought that she may have missed one set of resident rounds.*She recalled that resident 1 had a catheter and that she emptied the urine from the resident's catheter at the end of her shift on 10/11/25. She did not know if resident 1 wore an undergarment or how much assistance she required for rolling or repositioning.*During the above worked shifts, she entered resident 1's room when resident 1 turned on her call light to request pain medication or water. She could not recall if she had repositioned resident 1 during those times.*She stated her interactions with resident 1 had been limited, and she thought that the nurse would have assisted resident 1 when she went into her room to provide her with medications. 10. Interview on 10/23/25 at 9:09 a.m. with medical doctor (MD) E revealed who participated by phone revealed:*He was resident 1's orthopedic surgeon for several surgeries involving resident 1's left knee and was familiar with her medical history.*Resident 1 was admitted to the hospital on [DATE] from the nursing home (provider) with fractures above and below the rod that had been surgically placed. The resident also had a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her buttocks/coccyx and associated moisture-related skin damage to her perineum (the area between the genitals and anus) that was not present when he discharged resident 1 from the hospital on [DATE].*He felt that the fractures around the rod in resident 1's left leg could not have been prevented and could have occurred with very little force or movement due to her poor bone quality and multiple complicating medical factors.*He felt that resident 1's pressure ulcer on her buttocks/coccyx and the soft tissue skin damage to her perineum were preventable.*Resident 1's pressure ulcer required her to be transferred to a specialty hospital for further care and treatment. 11. On 10/23/25 at 9:10 a.m., administrator A was requested to provide a call light audit report for resident 1 and resident 2 from 10/9/25 through 10/12/25 to review. Their call light system did not have the capability to provide reports, and no call light audits were available for review. On 10/23/25 at 9:10 a.m., administrator A was requested to provide video surveillance footage for the overnight hours from 10/10/25 through10/13/25 for review. Their video monitoring system only monitored the exit doors, and no video surveillance was available for review. 12. Interview on 10/23/25 at 10:20 p.m. with licensed practical nurse (LPN) D revealed:*She had completed a skin assessment on resident 1 after resident 1 had a bed bath on the morning of 10/10/25. Resident 1's bottom was red, excoriated, and had areas of flaky skin. The area was large but was not open.*Resident 1 allowed CNAs to provide her care and roll her slowly and carefully. Her movements were guarded, and she allowed them to place pillows under her leg to make her more comfortable.*Resident 1 would at times refuse to be repositioned if she was comfortable.*LPN D recalled that on the morning of 10/12/25, resident 1 was in significantly more pain, allowed CNAs to provide her with a bed bath, reported that her butt and back were on fire, and allowed CNAs to put a pillow under her leg. Resident 1 refused to allow LPN D to put the cream on her back and bottom that morning.*LPN D called the on-call medical provider, and the decision was made to send resident 1 to the emergency room for evaluation due to uncontrollable pain in her left leg. 13. Interview on 10/23/25 at 10:53 a.m. with LPN G revealed:*She worked the overnight shift on 10/10/25 at 6:00 p.m. until 6:30 a.m. on 10/11/25.-There typically was one CNA and one nurse who worked the overnight shifts to provide care to all the residents.*She remembered resident 1 was in a lot of pain when she had arrived at work on 10/10/25 and that she had given resident 1 PRN (as needed) pain medication and her scheduled evening medications.*LPN G called DON B that evening because resident 1's left leg pain was not controlled and was advised by DON B to contact the on-call medical provider. LPN G called the on-call medical provider, who approved LPN G to provide resident 1 with an early dose of her pain medication that day.*LPN G recalled that resident 1 must have slept all night, because she did not recall giving resident 1 any additional pain medication or having gone into resident 1's room again after giving her that pain medication. She could not recall if she assisted CNA H on 10/10/25 or 10/11/25 with repositioning resident 1.*She had not worked the night shift on 10/12/25 when resident 2 had reported being incontinent overnight.*She felt that when she worked with CNA H, CNA H became overwhelmed and frustrated at times, and would need to take short breaks.*LPN G felt that it was harder to meet the needs of the residents when there was just one CNA on duty on night shifts, but stated she felt that they did the best they could and the staff were always busy.*LPN G stated that she helped with repositioning residents and changing the residents' incontinence products when the night CNA requested her assistance, but those tasks were typically done by the CNA. She could not recall if she had assisted CNA H on 10/10/25 or 10/11/25 with repositioning resident 1. 14. Interview on 10/23/25 at 12:50 p.m. with RN/wound nurse C revealed she:*She was not present at the facility while resident 1 resided there and did not provide any of the resident's care.*Was the provider's wound nurse, and typically provided monitoring and interventions for residents who admitted with skin wounds, were identified as at risk for wounds, or developed a wound.*Would assess a resident identified by the nursing staff as at risk for a pressure ulcer, complete a Wound Data Collection form, obtain physician's orders if treatment was needed, and implement interventions to decrease the likelihood that a resident would develop a pressure ulcer. *Expected that the nurse who completed resident 1's admission assessment, or DON B, would have implemented and care planned interventions due to resident 1's skin condition on admission and her identified risk for developing pressure ulcers because she was bedbound. She expected those interventions to have included frequent repositioning, skin care to prevent moisture, and offloading of bony prominences like her heels.*Was aware that resident 1 had an air mattress. 15. Interview on 10/23/25 at 1:03 p.m. with administrator A and DON B revealed:*Administrator A stated that staffing levels were determined based on resident care hours and the number of staffing hours she was allowed by the facility's corporate management.*Their current night staffing was for one nurse and one or two CNAs on duty to care for all residents, depending on staff availability. They were trying to hire more night shift staff and depended on contracted travel staff to work extra shifts when they were able.*The average facility census was 38-40 residents in the past month.*Administrator A felt that one nurse and one CNA on duty from 10:30 p.m. until 6:30 a.m. was sufficient to care for the current residents' needs.*Administrator A and DON B were aware of resident 2's concerns about not being assisted and having an incontinence episode on the morning of 10/14/25, and had suspended CNA H while they completed an investigation.-They concluded that no abuse or willful neglect had occurred related to resident 2's concerns, DON B provided education to all staff, and CNA H had returned to work on the evening of 10/14/25.*Administrator A and DON B were not aware that resident 1 had developed a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer after she admitted to the facility on [DATE] and prior to her discharge on [DATE].*DON B worked recently as a CNA on the night shift with one nurse and stated, It can be done, and it's not easy. She added she felt exhausted after completing that shift.*The caregiver workload depended on many factors, such as how much assistance the residents required, if a resident needed care during the end of life process, how experienced the staff were, and if the staff worked as a team to ensure that all the residents were cared for.*DON B confirmed that she was out of the facility from 10/9/25 through 10/13/25.*Administrator A confirmed that RN/wound nurse C had been out of the facility from 10/6/25 through 10/14/25.*Administrator A and DON B agreed that several staffing factors could have contributed to resident 1 developing a pressure ulcer, and resident 2's reported care concerns regarding the weekend from 10/11/25 through 10/13/25, but felt that the staff worked hard to care for the residents. 16. Review of the provider's updated 7/7/25 Staffing and Scheduling Resource Packet revealed:*.You want to make sure you have the necessary staff to fulfill the needs of the customers you serve.*Managing schedules requires attentiveness and responsiveness of census fluctuations.*The resource packet did not address the provider's current staffing levels or census. Review of the provider's 8/5/25 Facility Assessment revealed:*The facility assessment was used to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.*The question How do you staff on all shifts, including nights and weekends, to meet acquity [acuity] & [and] needs of residents? was answered, We staff by a per diem basis. We listen to feedback from our staff when they feel they could use more support, and what times of the day they could use support. We also listen to feedback from residents and families. Part of our assessment of whether or not we are meeting residents' needs and have appropriate staffing is by reviewing our quality measures and outcomes.*There was no documentation of the current staffing levels.

Based on complaint intake report review, record review, interview, and resource packet review, the provider failed to develop and implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (1) identified at risk for developing pressure ulcers, and dependent on staff assistance with repositioning, who developed a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone) after she admitted to the facility.Findings include:1. Review of the 10/17/25 anonymous complaint intake report regarding resident 1 revealed:*Resident 1 had been admitted to the facility on [DATE], after a surgery to place a rod in her left leg. She was in a full-length cast and was dependent on staff for repositioning and pain medication.*Resident 1 developed worsening pain in her left leg starting on 10/11/25 and burning in her back and bottom throughout the night.*She was admitted to the hospital on [DATE] with a pressure ulcer that measured four inches by six inches and was deep. The rod in resident 1's left leg had broken away, and requiring an additional surgery. 2. Review of resident 1's electronic medical record (EMR) revealed:*She admitted to the facility on [DATE].*Her 10/9/25 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact.*Her diagnoses included infection due to an internal left knee prosthesis (artificial joint), Type II Diabetes Mellitus (a condition involving disruptions in how the body regulates blood sugar), Chronic Kidney Disease Stage 3 (kidneys do not effectively filter blood and have moderate damage), and adjustment disorder with mixed anxiety and depressed mood.*Her 10/9/25 physician orders indicated:-She was on a diabetic diet.-She was non-weight-bearing (unable to put pressure) on her left leg.- Prevera [Prevena] wound vac (a device that uses negative pressure to remove excess fluid and debris from a wound to promote healing). Leave in place. Will be removed at follow up appointment.-She was to receive Triad Hydrophilic Wound Dressing Paste (a wound treatment cream) to her right and left buttocks two times a day for skin breakdown.-She received DAPTOmycin [an antibiotic] Intravenous Solution Reconstituted once daily, related to an infection in her left knee.*Her 10/9/25 Braden Scale (a tool used to assess the risk of developing pressure ulcers) indicated:-She was confined to bed and needed moderate to maximum staff assistance with moving.-The ability to complete lifting to boost resident 1 in bed without sliding against the sheets was impossible.-She frequently slid down in bed and needed frequent repositioning with maximum assistance.-Her Braden Scale score was 15, which indicated she was at risk for developing pressure ulcers.*A 10/10/25 Skin Observation assessment indicated resident 1 had a Large area on [her] bottom [that was] red, flaky, [and] macerated [softening of skin due to prolonged exposure to moisture] present on admission, and that resident 1 was on an air mattress.-The Care Plan for Skin section listed several potential focus areas, goals, and interventions to select if applicable. The care plan section had not been completed.-The Education section listed potential education provided, potential barriers, and potential persons educated to select if applicable. The education section had not been completed.*Her 10/10/25 physical therapy evaluation indicated resident 1 needed moderate staff assistance for rolling in bed, and the use of the total body lift (a mechanical lift and sling used to lift a person's full body) when being transferred.*Resident 1's Roll left and Right task documentation included:-On 10/9/25, one rolling task was documented as Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or illness.-On 10/10/25, the rolling task was documented at 11:36 a.m. and again at 9:59 p.m., as dependent or requiring the assistance of two caregivers.-On 10/11/25, the rolling task was documented at 1:59 p.m., as refused and at 9:59 p.m., as dependent or requiring the assistance of two caregivers.-On 10/12/25, the rolling task was documented at 1:59 p.m., as dependent or requiring the assistance of two caregivers. 3. Review of resident 1's 10/9/25 care plan revealed it did not include the resident's full-length left leg cast, wound vac (a medical treatment to promote wound healing) to her left leg, urinary catheter (flexible tubing inserted into the bladder to drain urine), transfer or weight-bearing status, assistance needs to complete activities of daily living such as toileting and repositioning, risk for developing pressure ulcers, or interventions to prevent acquiring pressure ulcers. 4. Review of resident 1's 10/9/25 through 10/12/25 progress notes revealed:*On 10/9/25 resident 1 was admitted at 2:20 p.m., was fully oriented, was in significant pain and any movement was difficult.*On 10/10/25 resident 1 was pleasant and cooperative, refused to allow staff to remove her catheter due to her decreased mobility and increased pain, and had remained in bed since [her] admission yesterday.*On 10/11/25 resident 1 continues to remain in bed since admission, continues to have red, flaky macerated skin to buttocks/coccyx area, that staff attempts to relieve pressure to area with repositioning as res [resident 1] allows, and that resident 1 tends to lean often to [her] R [right] side due to pain from her LLE [left lower extremity].*On 10/12/25 PN resident 1 had reported her back and bottom are on fire, the nurse (LPN D) went to put cream on her bottom, resident 1 did not want the creams for [her] back and bottom; did not want to be touch[ed]/repositioned, and at 12:05 p.m., resident 1 was sent to the emergency room due to being inconsolable with increased pain to LLE. 5. Interview on 10/22/25 at 1:57 p.m. with registered nurse (RN) F revealed:*RN F completed resident 1's admission skin assessment on 10/9/25. Resident 1 was admitted to the facility with an area to her right and left buttocks that was approximately four inches by six inches wide and was bright red and excoriated. RN F stated the area was not bleeding and did not look like a pressure area, but rather appeared like an area associated with moisture where the top layer of skin was broken down.*RN F faxed the resident's physician for an order for Triad cream because RN/wound nurse C and director of nursing (DON) B were not at the facility that day.*RN F did not complete resident 1's baseline care plan. She expected that DON B would complete that care plan when DON B returned to work.*RN F repositioned resident 1 during her admission assessment and stated that resident 1 required the assistance of two staff members with rolling the resident due to her left leg cast and she was in a lot of pain. 6. Interview on 10/22/25 at 3:25 p.m. with certified nursing assistant (CNA) H revealed:*She worked overnights on 10/10/25 from 7:00 p.m. until 10/11/25 at 6:30 a.m. and again on 10/11/25 from 6:00 p.m. until 10/12/25 at 6:30 a.m.*She stated that on both of those days, there was one nurse and three CNAs on duty from 7:00 p.m. until 10:30 p.m., and then from 10:30 p.m. until 6:30 a.m., CNA H and one nurse were the only caregivers on duty.*She recalled that resident 1 had a catheter and that she emptied the urine from the resident's catheter at the end of her shift on 10/11/25. She did not know if resident 1 wore an undergarment or how much assistance she required for rolling or repositioning.*During the above worked shifts, she entered resident 1's room when resident 1 turned on her call light to request pain medication or water. She could not recall if she had repositioned resident 1 during those times.*She stated her interactions with resident 1 had been limited, and she thought that the nurse would have assisted resident 1 when she went into her room to provide her with medications. 7. Interview on 10/23/25 at 9:09 a.m. with medical doctor (MD) E revealed who participated by phone revealed:*He was resident 1's orthopedic surgeon for several surgeries involving resident 1's left knee and was familiar with her medical history.*Resident 1 was admitted to the hospital on [DATE] from the nursing home (provider) with fractures above and below the rod that had been surgically placed. The resident also had a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her buttocks/coccyx and associated moisture-related skin damage to her perineum (the area between the genitals and anus) that was not present when he discharged resident 1 from the hospital on [DATE].*He felt that the fractures around the rod in resident 1's left leg could not have been prevented and could have occurred with very little force or movement due to her poor bone quality and multiple complicating medical factors.*He felt that resident 1's pressure ulcer on her buttocks/coccyx and the soft tissue skin damage to her perineum were preventable.*Resident 1's pressure ulcer required her to be transferred to a specialty hospital for further care and treatment. 8. Interview on 10/23/25 at 10:20 p.m. with licensed practical nurse (LPN) D revealed:*She had completed a skin assessment on resident 1 after resident 1 had a bed bath on the morning of 10/10/25. Resident 1's bottom was red, excoriated, and had areas of flaky skin. The area was large but was not open.*Resident 1 allowed CNAs to provide her care and roll her slowly and carefully. Her movements were guarded, and she allowed them to place pillows under her leg to make her more comfortable.*Resident 1 would at times refuse to be repositioned if she was comfortable.*LPN D recalled that on the morning of 10/12/25, resident 1 was in significantly more pain, allowed CNAs to provide her with a bed bath, reported that her butt and back were on fire, and allowed CNAs to put a pillow under her leg. Resident 1 refused to allow LPN D to put the cream on her back and bottom that morning.*LPN D called the on-call medical provider, and the decision was made to send resident 1 to the emergency room for evaluation due to uncontrollable pain in her left leg. 9. Interview on 10/23/25 at 10:53 a.m. with LPN G revealed:*She worked the overnight shift on 10/10/25 at 6:00 p.m. until 6:30 a.m. on 10/11/25.-There typically was one CNA and one nurse who worked the overnight shifts.*She remembered resident 1 was in a lot of pain when she had arrived at work on 10/10/25 and that she had given resident 1 PRN (as needed) pain medication and her scheduled evening medications.*LPN G called DON B that evening because resident 1's left leg pain was not controlled and was advised by DON B to contact the on-call medical provider. LPN G called the on-call medical provider, who approved LPN G to provide resident 1 with an early dose of her pain medication that day.*LPN G recalled that resident 1 must have slept all night, because she did not recall giving resident 1 any additional pain medication or having gone into resident 1's room again after giving her that pain medication. She could not recall if she assisted CNA H on 10/10/25 or 10/11/25 with repositioning resident 1. 10. Interview on 10/23/25 at 12:50 p.m. with RN/wound nurse C revealed she:*She was not present at the facility while resident 1 resided there and did not provide any of the resident's care. *Was the provider's wound nurse, and typically provided monitoring and interventions for residents who admitted with skin wounds, were identified as at risk for wounds, or developed a wound.*Would assess a resident identified by the nursing staff as at risk for a pressure ulcer, complete a Wound Data Collection form, obtain physician's orders if treatment was needed, and implement interventions to decrease the likelihood that a resident would develop a pressure ulcer. *Expected that the nurse who completed resident 1's admission assessment, or DON B, would have implemented and care planned interventions due to resident 1's skin condition on admission and her identified risk for developing pressure ulcers because she was bedbound. She expected those interventions to have included frequent repositioning, skin care to prevent moisture, and offloading of bony prominences like her heels.*Was aware that resident 1 had an air mattress. 11. Interview on 10/23/25 at 1:03 p.m. with administrator A and DON B revealed:*DON B was not at the facility from 10/9/25 through 10/12/25 and did not meet resident 1.*DON B was contacted by phone on 10/10/25 and again on 10/11/25 regarding resident 1's left leg pain. She instructed the two nurses who called her those days to call the on-call medical provider for additional guidance on how to address resident 1's leg pain. *DON B confirmed that a Wound Data Collection form had not been completed because RN/wound nurse C had been on vacation and DON B was not at the facility during resident 1's stay.*DON B stated she completed all of the residents' care plans, but she did not complete a care plan for resident 1, and there were no documented interventions to prevent resident 1 from developing a pressure ulcer.-She had planned to complete that documentation when she returned to work on 10/13/25, but resident 1 had been discharged to the hospital on [DATE].*DON B expected that resident 1 would have been provided frequent repositioning, thorough cleaning of her perineum area, pain medications as needed, and the physician ordered Triad wound cream to prevent skin breakdown.*Administrator A and DON B were unaware that resident 1 developed a pressure ulcer after she admitted to the facility on [DATE] and prior to her hospital readmission on [DATE].*They expected that the nurses on duty would have implemented interventions to prevent resident 1 from developing a pressure ulcer when DON B and RN/wound nurse C were not available at the facility. 12. Review of the provider's updated 7/7/25 Pressure Ulcer/Wound Care Resource Packet revealed:*The provider's wound care programs, pressure guidelines and protocols have been developed and implemented to provide quality services to our residents.*Programs may include. A comprehensive management program to prevent [the] development of pressure ulcers or other skin conditions (Braden, following interventions identified on care plan, nutritional intervention, specialty surfaces.).*Promotion of healing, pain management and prevention of complications is extremely important, as well as accurate assessment and documentation.* Wound Data Collection UDA [user defined assessment] completed by a licensed nurse and is required for documenting daily monitoring, is required at least weekly when skin integrity is impaired.*.The facility must ensure 1. A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable.

Based on interview, record review, and policy review, the provider failed to complete a baseline care plan within 48 hours of her admission to the facility, for one of one newly admitted sampled resident (1) who developed a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone) after she admitted to the facility.Findings include:1. Review of resident 1's electronic medical record (EMR) revealed:*She admitted to the facility on [DATE].*Her 10/9/25 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact.*Her diagnoses included infection due to an internal left knee prosthesis (artificial joint), Type II Diabetes Mellitus (a condition involving disruptions in how the body regulates blood sugar), Chronic Kidney Disease Stage 3 (kidneys do not effectively filter blood and have moderate damage), and adjustment disorder with mixed anxiety and depressed mood.*Her 10/9/25 physician orders indicated:-She was on a diabetic diet.-She was non-weight-bearing (unable to put pressure) on her left leg.- Prevera [Prevena] wound vac (a device that uses negative pressure to remove excess fluid and debris from a wound to promote healing). Leave in place. Will be removed at follow up appointment.-She was to receive Triad Hydrophilic Wound Dressing Paste (a wound treatment cream) to her right and left buttocks two times a day for skin breakdown.-She received DAPTOmycin [an antibiotic] Intravenous Solution Reconstituted once daily, related to an infection in her left knee.*Her 10/9/25 Braden Scale (a tool used to assess the risk of developing pressure ulcers) indicated:-She was confined to bed and needed moderate to maximum staff assistance with moving.-The ability to complete lifting to boost resident 1 in bed without sliding against the sheets was impossible.-She frequently slid down in bed and needed frequent repositioning with maximum assistance.-Her Braden Scale score was 15, which indicated she was at risk for developing pressure ulcers.*A 10/10/25 Skin Observation assessment indicated resident 1 had a Large area on [her] bottom [that was] red, flaky, [and] macerated [softening of skin due to prolonged exposure to moisture] present on admission, and that resident 1 was on an air mattress.*Her 10/10/25 physical therapy evaluation indicated resident 1 needed moderate staff assistance for rolling in bed, and the use of the total body lift (a mechanical lift and sling used to lift a person's full body) when being transferred.*Nursing progress notes from 10/9/25 through 10/12/25 indicated resident 1 had frequent complaints of pain in her left leg. 2. Review of resident 1's 10/9/25 care plan revealed:*It did not indicate that resident 1 had a full-length left leg cast, a wound vac (a medical treatment to promote wound healing) to her left leg, a urinary catheter (flexible tubing inserted into the bladder to drain urine), or that she received intravenous antibiotics.*It did not indicate resident 1's transfer or weight-bearing status, the level of assistance she required to complete her activities of daily living, including toileting and repositioning, her risk for pressure injuries, the location or management of her pain, or interventions necessary to care for her or reduce the risk of her acquiring a pressure ulcer.*There was no documentation that indicated a baseline care plan was completed within 48 hours of her admission to the facility. 3. Interview on 10/23/25 at 9:09 a.m. with medical doctor (MD) E who participated by phone revealed:*He was resident 1's orthopedic surgeon for several surgeries involving resident 1's left knee and was familiar with her medical history.*Resident 1 was admitted to the hospital on [DATE] from the nursing home (provider) with fractures above and below the rod that had been surgically placed. The resident also had a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her buttocks/coccyx and associated moisture-related skin damage to her perineum (the area between the genitals and anus) that was not present when he discharged resident 1 from the hospital on [DATE]. 4. Interview on 10/23/25 at 1:03 p.m. with administrator A and director of nursing (DON) B revealed:*DON B stated she typically completed resident baseline care plans within 48 to 72 hours after a resident admitted to the facility.*DON B was not at the facility from 10/9/25 through 10/12/25 and did not complete resident 1's baseline care plan.-She planned to complete that care plan documentation when she returned to work on 10/13/25.*Administrator A expected that baseline care plans would be developed and completed within 48 hours of a resident's admission to the facility by DON B.-No other nurses were trained on how to complete the residents' baseline care plans.-Administrator A expected DON B to complete resident 1's care plan when she returned to work on 10/13/25, but resident 1 discharged to the hospital on [DATE].*DON B stated that nursing staff used the baseline care plan to know how to care for a resident until the comprehensive care plan was completed. Without a written baseline care plan, she expected nursing staff members to pass along important information in their nursing report (staff verbal communication of residents' status) at the beginning and end of each shift.*Administrator A and DON B were unaware that resident 1 had developed a pressure ulcer after she admitted to the facility. 5. Review of the provider's updated 12/2/24 Care Plan policy revealed:*Baseline care plan- Includes instructions needed to provide effective and person-centered care to the resident that meet professional standards of quality care.*A baseline care plan will be developed upon admission according to federal and state regulations. The location [facility] must provide the resident and resident representative with a written summary of the baseline care plan.*The resident/family or legal representative will have the opportunity to participate in the planning of his or her care to the extent practicable.

Based on observation, interview, and policy review, the provider failed to follow standard food safety practices for: *Two of two observed cooks (I and P) who had not changed their gloves or washed their hands while serving resident food items to prevent potential contamination. *One of one observed dietary aide (DA) (H) who had not performed hand hygiene (hand washing) while serving resident food items to prevent potential contamination. Findings include: 1. Observation on 5/19/25 at 5:17 p.m. with DA H in the main dining room revealed she served a plate of food to a resident, touched the items on the table to make room to set the plate down, wiped her right hand on her right leg, returned to the serving area, touched the meal tickets, touched a tray on the counter, touched dirty tongs that were used to retrieve cookies from a container, and without completing hand hygiene she served another meal plate to another resident. 2. Observation on 5/19/25 at 5:23 p.m. with cook I while serving resident meals revealed he: *Wore a pair of disposable gloves. While wearing those gloves he: -Wiped his hand on a white cloth on the edge of the serving line. -Touched the menu slips on the counter. -Touched the top surfaces of plates as he placed food on them. -Wiped his gloved hands on his white apron. -Went into the kitchen, opened the microwave, heated a bowl of soup, rested those gloved hands on the counter, and with those same gloved hands, he returned to the serving line and continued to prepare plates of food for residents. *Was not observed to have changed his gloves or to have washed his hands. 3. Observation on 5/19/25 at 5:34 p.m. of the hand-washing sink in the dining room revealed: *There was a handwashing sink next to a beverage machine behind the serving line. *A pump container of Thick-It (a food-safe thickening agent) was to the right of that beverage machine. *A meal service tray that contained several discarded used paper towels, straw wrappers, used plastic cup lids, a plastic container that held metal knives and forks, tea bag wrappers, and other waste items was located directly under the spout of the Thick-It pump. *Staff who washed their hands placed their discarded paper towels on that tray. *There was no trash receptacle observed near that hand-washing sink for staff to discard their used paper towels. 4. Observation on 5/19/25 at 5:37 p.m. with cook I revealed he retrieved a cup of ice cream from the kitchen, delivered that to a resident and had not used hand hygiene prior to placing gloves on his hands and serving other residents' food. 5. Observation on 5/19/25 at 5:45 p.m. of the dining room revealed: *One bottle of hand sanitizer on the counter next to the menu slips. *One container of Sani Wipes sanitizing hand wipes on the counter in front of the food serving line. *One hand sanitizer dispenser on the wall in the back room of the dining room. 6. Observation on 5/20/25 at 12:16 p.m. with cook P while serving residents meals revealed: *She retrieved a clean ladle from the kitchen with the same gloved hands that she was observed wearing while previously serving food to residents. *She returned to the serving line and touched a clean plate and a baked potato with those same gloved hands. *Wearing those same gloves, she retrieved a clean knife from the kitchen, returned to the serving line, and then continued touching clean plates and food for other residents. *She was not observed to have changed her gloves or to have washed her hands. *She went to kitchen, opened the microwave, heated a bowl of soup, touched the menu slips that were on the counter, and with those same gloved hands, she returned to the serving line and continued to prepare plates of food for residents. *A resident's visitor requested a menu to order a meal for herself, cook P touched a menu slip handing it to the visitor and then returned to serving plates of food with those same gloved hands. 7. Interview and observation on 5/20/25 at 3:09 p.m. with certified nursing assistant (CNA) E revealed she: *Had not used hand hygiene while assisting residents eating. *Should had used hand sanitizer in between assisting residents in the dining room but did not due to not having any sanitizer readily available to use. 8. Interview on 5/22/25 at 12:30 p.m. with director of nursing (DON) B and registered nurse (RN)/ Infection Preventionist (IP) D revealed they expected staff to complete hand hygiene in between assisting residents with eating in the dining room. 9. Interview on 5/22/25 with administrator A revealed: *She was the acting dietary manager (DM). -It is her expectation that Employees follow our policy on hand hygiene. 10. Review of the provider's revised 6/13/24 [NAME] Policy Enterprise: Rehab/Skilled & Long Term Care: Hand Washing and Glove Use-Food Nutrition Services policy revealed: Purpose: To provide guidelines regarding hand hygiene and glove use to reduce risk of cross-contamination when serving highly susceptible population. Procedure: Hand Washing: When to wash hands: *Before, between and after resident contact. *After touching any contaminated object (face, hair, body or clothing; garbage or dirty utensils, dirty dishes, phone, linen or money.) *Before and after use of gloves. Proper Use of Gloves: *Hands are washed thoroughly before putting gloves on and after taking gloves off. Note: The use of gloves does not eliminate the need for proper hand washing or good hygiene. *Gloves are worn when the employee: Is handling ready-to-eat foods and completing a single task. *Gloves are changed as follows:' *Before handling ready-to-eat foods. *When coming in contact with something that may be contaminated, such as handling pots/pans/tray/utensils, opening a trash can or touching a doorknob or faucet. *Whenever [an] employee changes an activity, the type of food being worked with or whenever he or she leaves the workstation. *After touching hair, skin or clothing. *Do not use food contact gloves for non-food tasks such as handling money, garbage removal, sanitizing surfaces, dish or ware washing, etc.

Based on record review, interview, and policy review, the provider failed to maintain the resident's rights and ensure: *Advance directive code status (an individual's desire to be resuscitated with cardiopulmonary resuscitation (CPR), specific limited interventions, or not resuscitated (DNR) if their heart stopped) wishes were identified accurately on the physician's orders and the care plans for two of five sampled residents (12 and 86). *The resident or the resident's representative participated in the determination and periodic review of advance directives related to the resident's code status for four of five sampled residents (18, 28, 30, and 86). Findings include: 1. Review of resident 12's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her [DATE] Brief Interview of Mental Status (BIMS) assessment score was 14, which indicated she was cognitively intact. *A [DATE] physician's order indicated, Okay for DNR, daughter has informed us also. *Her care plan indicated, Code Status: FULL CODE [to provide life-saving measures]. -Her code status on her care plan did not match her code status in the EMR. Interview on [DATE] at 2:04 p.m. with resident 12 revealed: *When she was admitted to the facility a couple of months ago, she had hoped to get better and return home, and at that time, she had wanted staff to initiate CPR if her heart stopped. *She stated that she had recently been admitted to hospice, had changed to a DNR code status, and was happy with that decision. *Her daughter was her power of attorney (POA), knew her wishes, and helped her with her medical decisions. 2. Review of resident 86's EMR revealed: *He was admitted on [DATE]. *His [DATE] BIMS assessment score was 13, which indicated he was cognitively intact. *A [DATE] physician's order Advance Directive: Limited - Do not intubate, Do not use ambubag. *His care plan indicated, Resident is DNR. -It had not reflected the additional directives in the [DATE] physician's order. *A [DATE] social services progress note indicated resident 86's wife was contacted and Re-affirmed DNR code status of DNR for [resident 86]. She [wife] indicated that she had no legal documentation regarding this but [it] was a mutual decision between herself and her husband. -There was no documentation that resident 86 had participated in a discussion about his advanced directives or code status. Interview on [DATE] at 11:01 a.m. with resident 86 in his room revealed: *He recalled having a discussion in the hospital about his advanced directives and code status, and he wanted everything except the tube. *He thought that his wife knew his wishes because they had discussed it before he was admitted to the facility. 3. Review of resident 28's EMR revealed: *She was admitted on [DATE]. *Her [DATE] BIMS assessment score was 9, which indicated she was moderately cognitively impaired. *Her POA was listed as her husband. *A [DATE] physician's order indicated, DNR. *There was no documentation that indicated a code status in resident 28's care plan. *There was no documentation that indicated that resident 28 or her POA had participated in the decision of the resident's advance directive related to her code status. Interview on [DATE] at 8:27 a.m. with administrator A and director of nursing (DON) B regarding resident 28's POA and code status revealed: *Resident 28 had a physician's order for DNR. *They had not contacted resident 28's POA regarding the resident's advance directives because he was living in an assisted living facility. 4. Review of resident 30's EMR revealed: *She was admitted on [DATE]. *Her [DATE] BIMS assessment score was 3, which indicated she was severely cognitively impaired. *Her POA was listed as her husband. *A [DATE] physician's order indicated, DNR. *There was no documentation that indicated a code status in resident 30's care plan. *There was no documentation that resident 30 or her POA had participated in the decision of an advance directive related to resident 30's code status or that her code status had been periodically reviewed with the resident or her POA. 5. Review of resident 18's EMR revealed: *She was admitted on [DATE]. *Her [DATE] BIMS assessment score was 11, which indicated she was moderately cognitively impaired. *Her POA was listed as her son. *A [DATE] physician's order indicated, DNR. *There was no documentation that resident 11 or her POA had participated in the decision of an advance directive related to resident 11's code status or that her code status had been periodically reviewed with the resident or her POA. 6. A request was made on [DATE] at 11:35 a.m. to administrator A for documentation that residents 18, 28, 30, and 86, or their representatives, had participated in the formulation of advance directives related to the residents' code status. 7. Interview on [DATE] at 11:48 a.m. with social services director (SSD) C regarding residents' advance directives revealed: *He had a conversation with residents when they were admitted to the facility, and the resident would verbally tell him what they would like their code status to be. *He asked for legal documentation of advance directives and information regarding the resident's POA during those conversations. *He would then confirm the information the resident provided with the resident's family to ensure that they were in agreement. *He provided the resident's code status information to the director of nursing (DON) B, and she records it, and DON B obtained the physician's order. *He did not document the conversations he had with the resident or the resident's family regarding the resident's code status. *He did not assist the resident in developing their advanced directives, but reviewed information on advance directives in the admission packet with the resident when they were admitted . *He expected the resident's code status would be documented in the resident care plan by himself or DON B. 8. Interview on [DATE] at 8:20 a.m. with DON B regarding residents' advance directives related to their code status revealed: *The facility followed what the hospital orders had listed for a resident's code status. *They only reassessed that hospital order if a family member had a concern or questioned it. *She expected the resident's medical provider or physician to discuss a resident's CPR code status with the resident on rounds. -She did not expect the medical provider or physician to discuss a DNR code status. *She would document in a progress note if the physician had discussed a resident's code status with the resident during those rounds. *She did not think that a DNR would need to be reviewed with the resident, the resident representative, or the medical provider. 9. Interview on [DATE] at 9:27 a.m. with administrator A revealed that she confirmed there was no documentation that residents 18, 28, 30, and 86, or their representatives, had participated in the formulation of advance directives related to the residents' code status. Review of the provider's [DATE] Advanced Directives including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) policy revealed: *To provide each resident the opportunity to make decisions related to medical care and select a proxy. To define a process to make resident decisions known. *Residents have the right to formulate advance directives. *The verbal declination of CPR by a resident, or if applicable a resident's representative, should be witnessed by two staff members. *Advance directive orders are to be reviewed with resident/healthcare decision-maker at each care plan meeting to ensure no changes are needed. Document this discussion in the PN [progress note]-Care Conference note. *The BIMS measures the mental status of a resident. If changes are noted in the BIMS score, the physician may need to be notified. It is important that throughout the resident's stay, the resident is assessed for the capacity to make or revoke healthcare decisions.

Based on interview, observation, record review, and policy review, the provider failed to complete a baseline care plan and provide a written summary of the baseline care plan to the resident or their representative for eleven of eleven recently admitted sampled residents (5, 12, 18, 25, 27, 28, 29, 30, 31, 32, and 86) within 48 hours of their admission to the facility. Findings include: 1. Observation and interview on 5/20/25 at 9:50 a.m. with resident 86 in his room revealed: *A Continuous Positive Airway Pressure (CPAP) machine (a machine that uses air pressure to keep breathing airways open) was on the nightstand next to his bed. *He stated his wife brought his CPAP from home, and he wore it every night. Interview on 5/21/25 11:01 a.m. with resident 86 revealed he had not received a list of his medications or a copy of his baseline care plan when he was admitted to the facility about two weeks ago. Review of resident 86's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 5/14/25 Brief Interview of Mental Status (BIMS) assessment score was 13, which indicated he was cognitively intact. *His baseline care plan did not indicate his use of the CPAP. *There was no documentation that indicated his baseline care plan was reviewed with him or that he had been provided or offered a copy of his baseline care plan within 48 hours of his admission. *A 5/16/25 progress note (PN) indicated resident 86's wife had been notified, Reported that baseline care plan for [resident 86] was ready and we could send her a copy if desired. -There was no indication if the content of that baseline care plan was discussed, if she had indicated that she wanted a copy, or if a copy had been sent. 2. Interview on 5/21/25 at 2:04 p.m. with resident 12 revealed: *She had been told there would be a meeting about her care and to develop a plan, but she had not attended a meeting. -She thought they would probably have it this week. *Her daughter was her power of attorney (POA) and helped her with her medical decisions. *She did not recall having been provided a baseline care plan or a medication list when she was admitted to the facility a few months ago. Review of resident 12's EMR revealed: *She was admitted on [DATE]. *Her 3/3/25 BIMS assessment score was 14, which indicated she was cognitively intact. *There was no documentation that indicated the resident's baseline care plan was developed and reviewed with her, her representative, or that she had been provided or offered a copy of her baseline care plan within 48 hours of her admission. 3. Review of resident 30's EMR revealed: *She was admitted on [DATE]. *Her 3/20/25 BIMS assessment score was 3, which indicated she was severely cognitively impaired. *Her POA was listed as her husband. *There was no documentation that indicated the resident's baseline care plan was developed and reviewed with her, her representative, or that they had been provided or offered a copy of her baseline care plan within 48 hours of her admission. 4. Review of resident 28's EMR revealed: *She was admitted on [DATE]. *Her 5/7/25 BIMS assessment score was 9, which indicated she was moderately cognitively impaired. *Her POA was listed as her husband. *There was no documentation that indicated the resident's baseline care plan was developed and reviewed with her, her POA, or that they had been provided or offered a copy of her baseline care plan within 48 hours of her admission. *A 5/2/25 PN indicated that resident 28's grandson had been contacted to clarify her emergency contact information and that resident 28's son was to be listed as the first emergency contact and her grandson as the second emergency contact and, He was informed that [the] resident's care plan could be sent to him if he desired and that it was available anytime. Interview on 5/21/25 at 8:27 a.m. with administrator A and director of nursing (DON) B regarding resident 28's POA and baseline care plan revealed: *Resident 28's son was the first emergency contact, however, the grandson had been contacted. *She confirmed that the resident or her POA had not been provided a copy of resident 28's baseline care plan and that they had not had contact with the POA because he was living in an assisted living facility. *She expected that the baseline care plan information would have been shared with the resident and her POA within 48 hours of her admission. 5. A request was made on 5/21/25 at 11:35 a.m. to administrator A for documentation that baseline care plans had been developed and the resident or their representative was offered a copy for newly admitted residents 5, 18, 25, 27, 28, 29, 30, 31, and 32. 6. Interview on 5/22/25 at 9:27 a.m. with administer A revealed: *There was no documentation that care plans had been developed or provided to the resident or their representative for the above-listed residents. *They had recently started a performance improvement project in their quality assurance and performance improvement plan regarding baseline care plans, but she was unaware of the documentation needed to support that they were being completed, and a summary of the baseline care plan had been provided to the resident and their representative. *She expected that the baseline care plan information would have been shared with the residents and their representative or POA within 48 hours of the resident's admission to the facility. 7. Interview on 5/22/25 at 1:12 p.m. with administrator A and DON B regarding baseline care plans revealed: *The baseline care plan was initiated upon a resident's admission to the facility by DON B or Minimum Data Set (MDS) registered nurse RN S. *The baseline care plan and the comprehensive care plan were not separate documents; the baseline care plan rolled into the comprehensive care plan when more information was added. *The care plan indicated the date the care plan was initiated, but there was no documentation of when the baseline care plan had been completed. *If a family member or representative was at the facility or came to the facility in person, they would be offered and provided a copy of the care plan. *If a family member or representative was not at the facility when the resident was admitted , they would have called and offered to mail a copy of the care plan. *A voicemail would have been left if a family member or representative was not contacted to indicate that they should return the call if they want to review the care plan. *Administrator A expected that the phone call to have been documented in a progress note and completed within 48 hours of the resident's admission to the facility. Review of the provider's 12/2/24 Care Plan policy revealed: *Baseline care plan- Includes instructions needed to provide effective and person-centered care to the resident that meet professional standards of quality care. *A baseline care plan will be developed upon admission according to federal and state regulations. The location must provide the resident and resident representative with a written summary of the baseline care plan. Use the PN Care Conference Note . to document that the meeting occurred with the resident and representative and any significant discussion that occurred. *The resident/family or legal representative will have the opportunity to participate in the planning of his or her care to the extent practicable.

Based on observation, record review, interview, and policy review, the provider failed to ensure care plans were reviewed and revised to reflect the current care needs for three of twelve sampled residents (12, 28, and 86). Findings include: 1. Review of resident 12's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *A 5/16/25 physician's order indicated, Okay for DNR [do not resuscitate], daughter has informed us also. *Her care plan indicated, Code Status: FULL CODE [to provide life-saving measures]. -Her code status had not been updated to DNR in her care plan. 2. Observation and interview on 5/19/25 at 2:56 p.m. with resident 28 in her room revealed: *There was a thick blue fall mat folded up next to her bed. *There was a mechanical sit-to-stand lift sling (a fabric safety harness used with a mechanical lift that requires the resident to bear weight on at least one leg when assisted from a seated position to a standing position) on her bed. -That lift sling had an unreadable, faded tag, and was labeled 506. *She stated that staff had used a machine to transfer her because she had not been strong enough to get up alone. Review of resident 28's EMR revealed: *She was admitted on [DATE]. *Her 5/7/25 BIMS assessment score was 9, which indicated she was moderately cognitively impaired. *Her care plan indicated TRANSFER: Resident requires extensive assist [assistance] x1 [by one staff member] with pivot transfers. STS [sit-to-stand] [lift] as needed. -The lift sling size to be used to transfer resident 28 was not addressed in her care plan. *A 5/18/25 progress note indicated, Bed is in low position with fall mat in place. *Her care plan did not address that resident 28 required the use of a fall mat. Interview on 5/22/25 at 10:01 a.m. with certified nursing assistant (CNA) R regarding transfers with resident 28 revealed CNA R: *Had used the mechanical sit-to-stand lift to assist resident 28 out of bed into her wheelchair that morning. *Stated she had used the lift sling that was in resident 28's room and had known which lift slings to use when transferring resident 28 because the lift sling size was listed in resident 28's care plan. Interview on 5/20/25 at 3:03 p.m. with director of nursing (DON) B regarding fall mats revealed: *Thick blue fall mats were used as a fall intervention. *The need for a resident to have a fall mat next to their bed was determined by the team, and when a fall mat was to be used, it should have been care planned. *It was not the facility's policy to require a formal assessment or a physician's order for a fall mat. *She clarified that staff should have known when to use a fall mat because it should have been in the resident's care plan. Interview on 5/22/25 at 1:06 p.m. with DON B and administrator A regarding the lift slings revealed: *Lift slings came in a few different sizes and were based on a resident's weight. The DON or Minimum Data Set (MDS) RN S would assess each resident who required the use of a lift for the correct size sling. *DON B or the MDS RN S should have documented the lift sling size in the resident's care plan. *Administrator A expected the CNAs to know which lift sling to use when transferring a resident because it should have been listed in the resident's care plan. *DON B was unaware that the lift sling size was not included in resident 28's care plan and expected that it would have been because the care plan had indicated the use of the sit-to-stand lift as needed. 3. Observation and interview on 5/20/25 at 9:50 a.m. with resident 86 in his room revealed: *A Continuous Positive Airway Pressure (CPAP) machine (a machine that uses air pressure to keep breathing airways open) was on the nightstand next to his bed. *He stated his wife brought his CPAP from home, and he wore it every night. Review of resident 86's EMR revealed: *He was admitted on [DATE]. *His 5/14/25 BIMS assessment score was 13, which indicated he was cognitively intact. *His care plan did not indicate his use of the CPAP. *A 5/14/25 physician's order Advance Directive: Limited - Do not intubate, Do not use ambubag. *His care plan indicated, Resident is DNR [do not resuscitate]. *A 5/20/25 social services progress note indicated resident 86's wife was contacted and Re-affirmed DNR code status of DNR for [resident 86]. She indicated that she had no legal documentation regarding this but [it] was a mutual decision between herself and her husband. *The code status in his care plan did not match his physician's order or the resident's wishes. Interview 5/21/25 at 4:25 p.m. with DON B and administrator A regarding resident 86's CPAP revealed DON B expected that his use of the CPAP would have been indicated on resident 86's care plan. 4. Interview on 5/20/25 at 8:45 a.m. with CNA K revealed: *She was a contracted traveling CNA and had worked at the facility for approximately six months. *She used the residents' care plans in the EMR to learn how to care for each resident. *The care plan would tell her how a resident should have been transferred, which size sling to use if they transferred with a mechanical lift, any special equipment the resident required, and other resident-specific information. *She reviewed resident care plans every day she worked because things always change. 5. Interview on 5/20/25 at 11:48 a.m. with social services director (SSD) C regarding advance directive revealed that he expected a resident's code status would be documented in the resident's care plan by himself or DON B and the care plan to be updated if there had been a change. 6. Interview and record review 5/21/25 at 4:32 p.m. with DON B and administrator A regarding care planning revealed: *DON B confirmed that resident 12's care plan indicated that she was a full code. The resident had started to receive hospice services on 5/16/25, and her code status had changed to DNR but her care plan was not updated. -She expected resident 12's care plan to have been updated when that code status had changed. *DON B confirmed that resident 86's physician's order for his code status and his care plan did not match. -She expected that resident 86's care plan would match the physician's order and the resident's wishes. *Administrator A and DON B expected that residents' care plans would be updated whenever a significant change occurred so that the care plan accurately reflected the resident's current care needs. Review of the provider's 12/2/24 Care Plan policy revealed: *Purpose- To develop a comprehensive care plan using an interdisciplinary team approach. *Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables . *The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. *Care plans also will be reviewed, evaluated and updated when there is a significant change in the resident's condition.

Based on interview, record review, and policy review, the provider failed to ensure expired medications and supplies were discarded in a timely manner in one of one nurse supply storage room and one of one nurse's station storage area. Findings include: 1. Observation on 5/21/25 at 9:40 a.m. of the nurse supply storage room revealed: *Five of five cases (24 containers in each case) of Benecalorie 44 ml (milliliter) packages expired 6/30/24. *Two of two Mepilex border post-op bandages expired 3/28/24. *One of three central line dress change kit expired 9/24/24. *Five of five Coloplast interdry moisture wicking fabric expired 3/17/24. 2. Observation on 5/21/25 at 3:10 p.m. of the nurse's station storage cabinets revealed: *Twenty-seven of twenty-seven COVID AgCard Covid tests expired 12/26/24. *Four of four Covid home test kits expired 11/17/24. *Eight of eight sterile gloves packages expired 2/1/25. *Two of two Phazix pill swallowing gel 500 ml bottles expired 11/30/23. *Approximately 300 Modudose 0.9% sodium chloride 5 ml doses expired 11/1/24. *More than 100 Filter needles (for drawing up medications) expired 7/31/21. 3. Interview on 5/22/25 at 11:00 a.m. with registered nurse (RN) D revealed: *There was no formal process for removing expired medications and supplies from the facility. *Night shift staff would usually discard expired medications and supplies. 4. Interview on 5/22/25 at 1:55 p.m. with director of nursing (DON) B revealed: *There was no formal process for removing expired medications and supplies from the facility. *It was her expectation that expired medications and supplies would be removed and discarded. 5. Interview on 5/22/25 at 4:13 p.m. with administrator A revealed it was her expectation that expired or outdated medications and supplies would be removed and discarded and would not have been kept for use in the facility. Review of the provider's 03/2025 Medications: Acquisition Receiving Dispensing and Storage policy revealed The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations.

Based on observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were followed: *For the cleaning of one of one soiled utility rooms. *To ensure enhanced barrier precautions (EBP) were used according to the provider's policy for one of one sampled resident (16) on EBP by not wearing a gown and gloves when providing direct care. Findings include: 1. Observation and interview on 5/20/25 at 8:53 a.m. with certified nursing assistant (CNA) E in the soiled utility room between the 200 and 300-hallways revealed: *A hopper (a specialized sink flushing device used to rinse soiled items and linens of bodily fluids) did not have a spray shield. -The inner edges were soiled with a brown, unidentified material. -The floor under the hopper was splattered with what appeared to be a mineral buildup. -The pipes behind the hopper were rusted. -There was white splatter on the wall behind the hopper and areas of peeling paint. *A paper sign with rolled edges, that read Disinfectant Wipes and Spray Bottles inside, was taped to the white cabinet and was an uncleanable surface; it did not contain gowns or face shields. *CNA E wore gloves and used that hopper to rinse soiled linen without putting on a gown or face shield. *CNA E stated she did not know if there should have been a splash shield on the hopper and confirmed that it was dirty. -She did not know who was responsible for cleaning the hopper. 50915 2. Observation on 5/21/25 at 5:00 p.m. of licensed practical nurse (LPN) G while administering medications to resident 16 revealed: *Resident 16 was on EBP, which required personal protective equipment (PPE)(gown and gloves) while providing direct care to the resident. *LPN G entered resident 16's room without putting on a gown or gloves. *LPN G administered resident 16's nebulizer (breathing medication) treatment. -During the nebulizer treatment, LPN G used her stethoscope to listen to resident 16's lungs from the resident's right side. -LPN G was in direct contact with resident 16. -LPN G then leaned over the resident to listen to his lungs on his left side. Her chest came in direct contact with the resident's chest. 3. Interview on 5/22/25 at 12:18 p.m. with registered nurse (RN)/infection preventionist D revealed: *She had been the facility infection preventionist for the past several years. *She expected staff to wear appropriate personal protective equipment (PPE) while providing cares for a resident on EBP. *LPN G should have worn a gown and gloves while providing cares for resident 16. 4. Interview on 5/22/25 at 12:30 with DON B revealed she expected LPN G to wear a gown and gloves while providing cares for resident 16. Review of the provider's 4/2025 Standard, Enhanced Barrier, and Transmission-Based Precautions, All Services Lines-Enterprise policy revealed: *Enhanced barrier precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. Review of the provider's 12/2/24 Infection Prevention and Control Program policy revealed: *Purpose- To establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. *The facility utilizes standard precautions for all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Standard precautions may include, but is not limited to: a. Hand hygiene; b. Proper selection of personal productive equipment .

Based on record review, interview, and policy review, the provider failed to accurately document correct doses of tube feedings for one of one resident (31). Findings include: 1. Review of 31's electronic medical record (EMR) revealed: *She had a physician's order to administer Bolus [a concentrated dose] Jevity [liquid nutritional formula] 1.5 Cal. [calorie] to give 237 milliliter [ml] (1-8 fl oz. [fluid ounce] container) via PEG [percutaneous endoscopic gastronomy feeding tube] tube 5x/day [5 times per day]. May hold post-meal bolus if 50% [of the] meal [was] consumed. *On 5/12/25, Jevity 1.5 Cal became unavailable to the provider. A physician's order was obtained for May use Jevity 1.2 cal to give 237ml (1-8 fl oz. container) via PEG tube 5x/day until Jevity 1.5 is available again. When Jevity 1.5 is available, stop use of Jevity 1.2 cal. May hold post meal bolus if 50% meal is consumed. *Both orders remained active in resident 31's EMR as of 5/21/25. *On 5/13/25 at 10:00 a.m., licensed practical nurse (LPN) G documented resident 31 received 237 ml of Jevity 1.5 cal, although it had been unavailable. *On 5/15/25 at 10:00 a.m. and 2:00 p.m., LPN G documented resident 31 received 237 ml of Jevity 1.5 cal, although it had been unavailable. *On 5/16/25 at 10:00 a.m., registered nurse (RN) D documented resident 31 received 237 ml of Jevity 1.5 and 237 ml of Jevity 1.2 cal. *On 5/21/25 at 10:00 a.m., it was documented in resident 31's EMR that she ate between zero and twenty-five percent of her morning meal, indicating she should have received her Jevity through her feeding tube, but RN N documented resident 31's Jevity 1.2 cal was not given because she consumed greater than 50% of her morning meal. 2. Interview on 5/21/25 at 5:13 p.m. with LPN G revealed: *Resident 31 should have had her tube feedings administered if she consumed less than 50% of her meals. *She would determine how much of resident 31's meal had been consumed by checking documentation in the EMR, then administering her tube feeding when appropriate. 3. Interview on 5/22/25 at 12:30 with director of nursing (DON) B revealed: *The order for Jevity 1.5 calorie should have been placed on hold when it became unavailable on 5/12/25 to eliminate confusion and the likelihood of error by staff administering the formula. *It was her expectation staff would administer resident 31's tube feeding based on the physician's order. -If the resident were to refuse her tube feeding, there should have been documentation to reflect her refusal. Review of the providers 4/2025 Physician/Practitioner Orders policy revealed: *Purpose. To provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. *A physician, physician's assistant, nurse practitioner or clinical nurse specialist must provide orders to the resident's immediate care, consistent with the resident's present physical and mental status needs.

Based on observation, record review, interview, and policy review, the provider failed to ensure: *Proper infection control practices had been followed for the cleaning and storage of oxygen equipment for two of two sampled residents (18 and 29) who required the use of continuous oxygen. *Proper infection control practices had been followed for the cleaning and storage of nebulizer masks (a mask worn when using a nebulizer machine that converts liquid medication into an inhalable mist) for two of two sampled residents (18 and 29). *One of one sampled resident (86) who required the use of a Continuous Positive Airway Pressure (CPAP) machine (a device that uses air pressure to keep breathing airways open) had a current physician order for the use of a CPAP machine and that the CPAP was addressed on the resident's care plan. Findings Include: 1. Observation and interview on 5/20/25 at 10:13 a.m. with resident 18 in her room revealed: *She had an oxygen (O2) concentrator (a medical device that purifies room air into concentrated oxygen) next to her recliner chair, which contained: -An undated, long O2 tubing and nasal cannula tubing (flexible tubing that delivers oxygen through the nose) that allowed her to receive O2 when she used the bathroom. -An undated humidifier bottle. -A filter on the right side of the concentrator with a thick gray dust that dispersed into the air when the filter was touched. -Unidentified particles that appeared to be food and dust covered the top of the concentrator. *The over-the-bed table next to her chair contained: -A long, undated, coiled-up O2 tubing. -An undated nasal cannula (NC) tubing that was not attached to anything and hung towards the floor. -A nebulizer machine (a machine that converts liquid medication into an inhalable mist) with an attached mask dated 5/11/25, covered in small white spots and was stored in a plastic emesis basin. *A small table next to her chair had two open half half-full, undated jugs of distilled water on the shelf. *An open, undated jug of purified water was on the floor next to the window. *A bag on the back of her wheelchair contained a portable O2 tank and an undated NC tubing. Observation on 5/21/25 at 4:49 p.m. with director of nursing (DON) B and administrator A in resident 18's room revealed: *The O2 tubing on the over-the-bed table marked with a date of 5/19/25 was not being used *DON B confirmed: -The NC tubing, long O2 tubing, and humidifier attached to the concentrator used by resident 18 were undated. -The nebulizer mask dated 5/11/25 remained connected to the nebulizer machine, contained a small amount of residual medication, and was spotted with white residue. -The two jugs of distilled water and the one jug of purified water were opened and undated. -The O2 concentrator was dirty, and the filter contained a thick gray dust. *DON B thought that resident 18's daughter may have brought in the jug of purified water and extra oxygen tubing. Review of resident 18's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included emphysema (a chronic lung disease) and heart disease. *A 2/21/22 physician order Oxygen via nasal cannula 1-4 liters per minute continuously for dyspnea, hypoxia (O2 saturation less than 88%) or acute angina. every day and night shift related to EMPHYSEMA. *A 6/29/24 NURSING ORDER: Change 02 tubing weekly. Put the date on the tubing when it is changed. Wipe down oxygen concentrator and clean oxygen concentrator filter. every night shift every Sat [Saturday] related to EMPHYSEMA, was documented as completed in May on 5/3/25, 5/10/25, and 5/17/25. *A 11/30/24 NURSING ORDER: Change oxygen tubing on portable concentrator weekly. Date tubing when changing it. every night shift every Sat related to EMPHYSEMA, was documented as completed in May on 5/3/25 and was discontinued on 5/10/25. *A 11/30/24 NURSING ORDER: Change nebulizer tubing/mask/supplies weekly and date with day of change. Clean off nebulizer machine. every night shift every Sat related to EMPHYSEMA, was documented as completed in May on 5/3/25, 5/10/25, and 5/17/25. 2. Observation and interview on 5/20/25 at 9:50 a.m. with resident 86 in his room revealed: *A CPAP was on the nightstand next to his bed. *The CPAP mask hung over the back of the nightstand towards the floor *The CPAP humidifier was more than half full. *He stated his wife brought his CPAP from home, and he wore it every night. Observation and interview on 5/21/25 at 11:01 a.m. with resident 86 in his room regarding his CPAP machine revealed: *The CPAP machine remained on the nightstand with the mask attached. *There was no distilled water in his room or bathroom. *He stated he wore his CPAP every night, to help him sleep better. *Since arriving at the facility last week, he had relied on the staff to help him put the CPAP mask on and to care for the machine. *He asked his wife to bring in distilled water for the humidification, but did not see a jug in his room. -He stated, I hope they aren't putting tap water in it. Review of resident 86's EMR revealed: *He was admitted on [DATE]. *His diagnoses included obstructive sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may become partially or fully blocked) and morbid (severe) obesity. *His 5/14/25 Brief Interview of Mental Status (BIMS) assessment score was 13, which indicated he was cognitively intact. *There was no physician's order for the use of his CPAP in his EMR. *There was no documentation in his EMR that indicated his CPAP mask and tubing were being cleaned. *His care plan did not indicate his use of the CPAP. Interview on 5/21/25 4:42 p.m. with DON B and administrator A regarding resident 86's CPAP revealed: *DON B was unaware that resident 86 had brought his CPAP from home and was using it. *DON B expected that there would be a physician's order for the use of the CPAP and a nursing order to ensure that the CPAP was cleaned between uses. *Administrator A stated that the jugs of distilled water were provided by the facility. Those should have been dated when opened and stored in the resident's room. 51471 3. Observation and interview on 5/19/25 at 4:30 p.m. with resident 29 in her room revealed she: *Had an O2 concentrator in her room. -Had nasal canula NC tubing attached to the O2 concentrator that the resident was actively using that was not dated. -Could not verify how long she had been using that NC tubing or how often she received a new one. *Had a coiled NC tubing in a plastic bag that was opened and lying on the floor. -Could not verify if the NC tubing on the floor was new or where it had come from. Review of resident 29's EMR revealed she: *Was admitted on [DATE]. *Had a BIMS assessment score of 3, which indicated she was severely cognitively impaired. *Had a diagnosis of heart failure. *Had a terminal prognosis and was receiving Hospice care. *Had an order in her care plan with a date of 3/19/25 to indicate that she had been receiving oxygen therapy. -May use O2 at 1-5 liters per minute per NC for comfort measures. -Had been monitored for signs and symptoms of respiratory distress and staff were to report to her health care provider as needed. Observation on 5/20/25 at 8:35 a.m. in the dining room revealed: *Resident 29 had been using an O2 concentrator labeled #8. *The NC tubing resident 29 had been using was not labeled to identify which resident it belonged to or what date the tubing was issued. Observation on 5/20/25 at 4:33 p.m. revealed resident 29 was being pushed in her wheelchair to the dining room for the supper meal by nurse G and she did not have an 02 concentrator or NC tubing. 4. Observation on 5/19/25 at 4:52 p.m. in the dining room revealed: *An O2 concentrator machine labeled #13 had NC tubing connected to it and coiled up inside of a plastic bag that was attached to the machine. -The end of the NC tubing was resting on the floor. *An O2 concentrator labeled #8 had NC tubing coiled up and tucked under the handle on the top of the concentrator. *There was no label attached to either of the NC tubings to indicate which resident the tubings belonged to. -There was no date noted on either of the NC tubing to have indicated what date the tubing was opened. *The filters on the back of both O2 concentrators had visible buildup of dust noted on them. 5. Interview on 5/21/25 4:42 p.m. with DON B and administrator A revealed: *DON B expected: -The nebulizer mask, nasal cannulas, and oxygen tubing to have been changed and dated weekly and documented in the resident's EMR medication administration record (MAR) by the nurse. *The nebulizer mask was to be rinsed out and cleaned after each use. -The oxygen concentrator and the filter were to have been cleaned weekly and documented in the EMR. *Administrator A expected that the cleaning of the oxygen equipment was being completed and documented. 6. Review of the provider's 7/8/24 Oxygen Administration policy revealed: *Purpose- To keep oxygen equipment clean and maintained in good condition . *All oxygen therapy equipment will be clean, safe and functional at all times. *Follow the manufacturer's recommendation for cleaning the concentrator unit and filters. *Document cleaning of concentrator and filters where appropriate. *Disposable equipment should be changed weekly or according to the manufacturer's instructions and marked with date and initials. *Oxygen concentrators are assigned to an individual resident and should not be shared without proper cleaning between residents. Best practice is to label each concentrator with the resident's name. Review of the provider's 10/30/24 Non-Invasive Respiratory Support policy revealed: *Purpose- To provide guidance to location staff when caring for residents using noninvasive respiratory support technology. *CPAP - Continuous Positive Airway Pressure. CPAPs are titrated to blow air at a constant set pressure that will keep air passages open. They are the most common way to treat sleep apnea. *Provider orders must be obtained . *Cleaning: Follow the manufacturer's recommendation for cleaning and maintaining equipment. Review of the provider's oxygen concentrator Operator's Manual revealed: *Cleaning the Cabinet Filter . Remove each filter and clean at least once a week depending on environmental conditions.

Based on observation, interview, record review, and policy review, the provider failed to initiate preventative interventions for one of one sampled resident (1) who was at risk for and developed a pressure ulcer to her left heel after fracturing her left lower leg during a fall. Findings include: 1. Observation on 1/2/25 at 2:45 p.m. of resident 1's room revealed: *Two light blue padded heel protector boots were on the bed. *An air mattress was present and inflated on the bed frame. *Resident 1 was seated in her wheelchair listening to an audiobook with her back towards the door. *There was a gait belt, pillow, and hangers on the recliner seat. Observation and interview on 1/2/25 at 3:02 p.m. with certified nursing assistant (CNA) F revealed: *She exited resident 1's room with a full-body lift. *She stated resident 1 had needed to be transferred with a full-body lift since she started working at the facility. *She was a travel CNA who had been working at the facility since the end of October. *She stated resident 1 had needed to be transferred with a full-body lift (a mechanical lift and sling used to lift a person's full body) since she started working at the facility. Observation and interview on 1/2/25 at 3:10 p.m. with resident 1 revealed: *She was seated in the recliner with her feet elevated. *A black knee immobilizer (splint) was present on her left leg. -The splint extended from her lower calf to her mid-thigh and was secured in place with Velcro. *When asked about her fall, she stated that she had broken her leg during the fall. *She indicated that she had been seeing a specialist and she was told that she was now able to do therapy on her leg. Review of resident 1's medical record revealed: *She was admitted on [DATE]. *Her 10/18/24 Brief Interview of Mental Status assessment score was 15, which indicated her cognition was intact. *Her diagnoses included: fracture of her left lower leg on 10/23/24, Type 2 diabetes, macular degeneration, and folate deficiency. *Her physician orders included: -A 10/24/24 non-weight bearing to her left lower extremity (LLE). -An 11/5/24 when resident 1 was in her wheelchair her left foot pedal needed to be elevated in the highest position and immobilizer to LLE was to be on at all times, when she was in bed the brace could be open to help with skin integrity. *Her 1/2/25 care plan included: -A 6/1/22 focus that she had the potential for pressure ulcer development R/T [related to] impaired mobility. --Interventions imitated on 6/1/22 and revised on 12/10/24 included provide pressure relief cushion in wheelchair and recliner. Pressure reducing mattress on bed. -A 10/24/24 focus that she was at risk for falls related to weakness, poor activity tolerance and impaired mobility evidenced by a history of falls with the most recent fall being 10/21/24. --Interventions for this focus included remind resident to call for assistance to reposition in wheelchair and lock brakes prior to attempting to rise from wheelchair and Reminded resident if feeling tired to call staff to sit in recliner to nap. -A 11/11/24 focus that she had a deep pressure injury to her left heel. --The goal for this focus included Resident will have no complications R/T [related to] non-pressure wound to L foot through the review date. --Interventions initiated on 11/7/24 included to elevate her heels off bed, to use heel protectors, and provide an air mattress. Review of resident 1's 10/16/24 Braden Scale (an assessment used to predict pressure sore risk) score was a 15.0 which indicated she was at mild risk for developing a pressure ulcer. Review of resident 1's skin observations assessments revealed: *On 11/7/24 she had a Stage 1 (red non-blanchable skin area) pressure ulcer (PU) on her left heel that measured 1.5 cm (centimeters) by 1.3 cm. -Her left leg was to be elevated as she had a brace on her left lower leg due to a fracture. -A note that indicated a heel cushion and air mattress would be added to her care interventions. *On 12/16/24 her left heel was a scabbed area and classified as a Stage I PU. -Her left leg was to be elevated as she had a brace to her left lower leg due to a fracture. -A note that indicated to Float heel on pillow and she had an air mattress on her bed. *12/30/24 the PU on her left heel was noted to be a Stage I. --A note that indicated Float heel on pillow and she had an air mattress on her bed. Interview on 1/2/25 at 5:02 p.m. with DON B regarding resident 1 revealed a Braden Scale assessment should have been done when she returned from the hospital, but it was not done. Interview on 1/2/25 at 6:05 p.m. with RN/WCN D and DON B regarding resident 1 revealed: *A significant change assessment was not completed when she returned from the hospital. -She was not reassessed for a potential change in pressure ulcer risk when returned from the hospital. *Preventative measures in place to prevent pressure ulcers prior to the development of resident 1's documented pressure ulcer were a daily multivitamin with zinc, and nutritional supplements. *The provider's process for completing skin assessments was that was to be completed weekly by a nurse or the wound nurse on bath day. *On 11/7/24 when resident 1's skin wound was found, the wound was measured, documented, and the provider was notified. -At that time the air mattress and heel protectors were added as pressure relieving interventions. * The expectation after a skin wound was identified was: -The dietician was to be notified. -The area was to be measured and documented weekly until the wound was healed. *The skin assessment on 12/16/24 and 12/30/24 identified a stage I PU to resident 1's left heel. -RN/WCN D stated she had never identified the wound as a stage I PU, she had always documented it as a suspected deep tissue injury (SDTI). --A SDTI wound indicates damage to deep tissue under the skin and may appear purple or maroon. Skin can be firmer or soft (boggy), and warmer or cooler than surrounding tissue. A blood-filled blister with a dark wound bed may also be present. --After reviewing the documentation on both assessments she stated she felt the documentation was probably copied and pasted. *RN/WCN D stated that the SDTI wound was documented as healed on 12/26/24. *DON B stated her expectation would be that the skin be assessed rather than copied from the previous assessment. -She confirmed copying information from a previous assessments was not an acceptable form of documentation of an assessment. Observation and interview on 1/2/24 at 6:16 p.m. with resident 1, RN/WCN D and administrator A revealed: *Resident 1's posterior left heel had an approximate one-half cm (centimeter) by one cm reddened non-blanchable area. -RN/WCN D stated that the current reddened area appeared to be in a different area than the original wound. *She stated the first wound had started as a flat area, red in color with some purplish areas. -She stated that the first wound was a SDTI. -She stated that the SDTI had progressed to look like a scab, that was dry and loose around edged. *Then one day she could not find it. *RN/WCN D stated she thought at first the wound may have been caused by her brace but the brace was higher up and could not have caused the wound. Review of the provider's 4/26/24 Skin Assessment Pressure Ulcer Prevention and Documentation Requirements policy revealed: *Purpose -To systematically assess residents regarding risk of skin breakdown -To accurately document observations and assessments of residents -To appropriately use prevention techniques and pressure redistribution surfaces on those resident at risk for pressure ulcers. Residents who are unable to reposition themselves independently, as indicated on the Sit-Stand-Walk Data Collection Tool UDA (user defined assessment), should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnoses, mobility and observation of the resident's skin over a period of time. Notify the physician/practitioner of the ulcer and resident's condition to obtain orders for a treatment. -Inquire whether physician/practitioner believes it is clinically necessary to see resident. *Notify resident and/or family representative of the pressure ulcer, orders and planned interventions. *When a pressure ulcer is present, complete the Wound Data Collection UDA daily, documentation should include the following: -An evaluation of the ulcer, if no dressing is present -An evaluation of the status of the dressing; if present (whether it is intact and whether draining, if present, is or is not leaking) -The status of the area surrounding the ulcer (that can be observed without removing the dressing) -The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection -Whether pain, if present, is being adequately controlled. 51472

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the facility failed to protect the resident's right to be free from neglect when one of one sampled resident's (1) physician orders following a left lower extremity (LLE) fracture were not followed to promote healing. Findings include: 1. Review of the provider's 10/23/24 SD DOH FRI regarding resident 1 revealed: *On 10/21/24 resident 1 was being transferred with a sit-to-stand lift (mechanical lift used to assist from a seated to a standing position) and she was lowered to the floor. -CNA E assisted her up from the floor with a full body mechanical lift to the wheelchair. -Resident 1 complained of left leg pain that afternoon. -Orders were received for an x-ray and a doppler (ultrasound) for her left leg from her primary care provider. --The primary care provider did not feel these tests were urgent. -Radiology was not able to schedule the tests until 10/23/24. *On 10/23/24 the provider received a fax from x-ray that indicated resident 1 had a fracture of her left lower leg. -The primary care provider recommended emergency room (ER) consult for orthopedic care. -Resident 1 was transferred via ambulance to the ER. *On 10/24/24 resident 1 was discharged from the hospital with orders that no surgery was needed and a stabilizer was placed on her left leg. -She was non-weight bearing to her left leg and needed a full body mechanical lift (mechanical lift and sling used to lift a person's full body) for all transfers. *CNA E stated she had immediately reported the incident to registered nurse (RN) C. Observation and interview on 1/2/25 at 3:10 p.m. with resident 1 revealed: *She was seated in her recliner with her feet elevated. *A black knee immobilizer was present on her left leg from mid-thigh to mid-calf and was secured with Velcro. *When asked about her fall, she stated that she had broken her leg during the fall. *She indicated that she had been seeing a specialist and she was told that she was now able to do therapy on her leg. *She stated she didn't know how much to share, but her daughter could give more information. Phone interview on 1/2/24 at 4:12 p.m. with resident 1's daughter revealed: *Regarding resident 1's fall on 10/21/24, and she stated she Only knew what nursing home folks told me [what] mom told me, but she [resident 1] was confused at the time. *She was told by resident 1: -A certified nursing assistant (CNA) was transferring her. -She told the CNA that it [the lift] didn't feel right. -The CNA told her; it would be alright and continued the transfer. *Resident 1's daughter stated that she did not think that resident 1 had fallen, but when she talked to her mother on 10/21/24 it was unclear. *She was aware that the provider was notified, and an x-ray was ordered after the fall. *She stated the x-ray could not be scheduled for three days. *She talked to the nurse, and it didn't seem to her that the nurse thought it was serious. *She felt there was some minimization of the situation, and they should have taken her mother to the hospital right away. *On 10/22/24 she noticed that resident 1 was confused. *She stated, when she saw resident 1 on 10/23/24 at the hospital, she was concerned that resident 1 had been miserable in pain for three days. *A urine test at the hospital showed she had a urinary tract infection (UTI). *On 10/24/24 resident 1 was discharged from the hospital and returned to the facility. *Her discharge orders included resident 1 was to always wear the leg immobilizer and keep her leg elevated. *When the facility staff picked up resident 1 from the hospital the staff was given those instructions by the hospital staff. *She stated she felt the management staff understood the instructions but did not feel it was being followed by the CNAs. *At resident 1's two-week follow-up appointment she witnessed: -The knee immobilizer was below resident 1's knee, when it should have been placed mid-thigh. -Her pants were over-the-knee immobilizer. -Her knee was bent at a 90-degree angle and not elevated. *She stated, that after the appointment, it took another two weeks before the staff cared for her leg properly. *She and her sister had posted pictures on resident 1's wall regarding the care of her leg. *Her sister had come to the facility daily and educated the CNAs on the care of resident 1's leg. *At resident 1's second follow-up appointment with the orthopedic (bone specialist) surgeon resident 1's daughter was told that unless the leg was cared for as he instructed, the bone would not heal. *She indicated that resident 1 had told her that if she tried to tell the CNAs about the care of her leg the CNAs would dismiss her. *Resident 1 reported to her that a CNA had left the immobilizer off her leg when she was placed in bed. -She told the CNA that the immobilizer needed to be on, and the CNA stated she did not need it on in bed. *Resident 1 had told her daughter that she felt that the staff did not like her because she kept getting the staff in trouble. Review of resident 1's medical record revealed: *She was admitted on [DATE]. *Her 10/18/24 Brief Interview of Mental Status assessment score was 15, which indicated her cognition was intact. *Her diagnoses included: fracture of shaft of tibia (10/23/24), urinary tract infection (10/23/24), Type 2 diabetes, macular degeneration, chronic kidney disease, arthritis, hearing loss, and folate deficiency (when the body does not have enough water-soluble B vitamin that is essential for cell growth and development, symptoms include fatigue and weakness). Review of resident 1's falls risk reports revealed: *On 10/7/24 she had slipped out of her wheelchair due to her wheelchair cushion. -Her fall risk assessment score was a 9, which indicated she was at a low risk of falls. *On 10/22/24 she had fallen from a mechanical lift and was referred to her medical provider. -Her fall risk assessment score was an 11, which indicated she was at a low risk for falls. Review of resident 1's nurses progress notes revealed: *On 10/21/24 she was lowered to the floor by a CNA while using a sit-to-stand mechanical lift. -An x-ray was ordered for her left lower leg. *On 10/23/24 Updated daughter in resident's increased confusion and requiring assistance with eating breakfast this morning. Daughter stated she noticed the confusion last night during her phone call. DON discussed with daughter about sending an order for UA [urinalysis] to rule out UTI as res [resident] has a hx [history] of UTI. Daughter thought this was a good idea and thanked DON for following up on this. -UA was obtained Resident tolerated well. Resident continues to be drowsy and has no remained in bed to rest. -The certified nurse practitioner notified the provider that the x-ray results indicated a fracture to resident 1's lower left leg, and to send her to the emergency room to be evaluated for increased confusion and diagnosis of urinary tract infection and to see the orthopedic specialist right away. -Her daughter was notified, and stated she would meet resident 1 at the hospital. -Resident left facility via gurney transport to the ER. -The ER notified the provider that there would be no surgery and they would be placing a stabilizer (brace) on resident 1's left leg. *On 10/24/24 resident returned .via facility van in facility w/c [wheelchair]. *On 10/28/24 she had been prescribed hydrocodone for left leg pain and she had increased confusion since starting this. -Her primary care provider (PCP) was notified. -On 10/29/24 her PCP stopped the order for hydrocodone related to her confusion. -He ordered to start tramadol 50 mg every 8 hours as needed for extreme pain. Review of resident 1's pain assessments revealed: *Between 9/16/24 and 10/17/24 her pain scores were a 0 on a 0 to 10 scale, which indicated she did not have pain. *On 10/21/24 her pain scores were six and four. *On 10/22/24 her pain score was a six. *On 10/23/24 her pain score was a nine. *Her physician orders included: -On 10/24/24 non-weight bearing to her left lower extremity (LLE). -On 11/5/24 when resident 1 was in her wheelchair her left foot pedal needed to be elevated in the highest position and immobilizer to LLE was to be always on, when she was in bed the brace could be open to help with skin integrity. --Make sure brace is over the knee and is put on over resident's pants per ortho [orthopedic specialist]. Review of resident 1's skin observations assessments revealed: *On 11/7/24 she had a brace to her left lower leg. -The brace may be open while she was in bed and was to be over her pants when she was up. -The leg needed to be elevated when she was sitting in her wheelchair, with a pillow on her leg for support. -A note that indicated a heel cushion and air mattress would be added. *On 12/16/24 and on 12/30/24 she had a brace to her left lower leg. -The brace may be open while she was in bed and was to be over her pants when she was up. -The leg needed to be elevated when she was sitting in her wheelchair, with a pillow on her leg for support. -A note that indicated her heel was to be floated on a pillow and she had an air mattress on her bed. Review of resident 1's orthopedic progress notes revealed: *On 10/24/24 she must be in straight leg brace at all times. -If resting in bed can have the brace open to help with skin integrity. *On 11/5/24 a note that included continue knee immobilizer at all times except skin care, and non-weight bearing left lower extremity. *On 12/12/24 a note that included non weight bearing to her left lower leg, continue knee immobilizer no standing. Interview on 1/2/25 at 5:02 p.m. with director of nursing B regarding resident 1 revealed: *Staff complete safe resident handling training and competencies during orientation and before they worked with residents. *Training is reinforced at staff stand-up huddles and staff meetings. *They had the provider come to the nursing home to see the resident. -The provider ordered an x-ray; the provider did not feel it was urgent. *Pain medication was given, and the resident's pain was managed. *The resident's cognition was intact and there were no cognitive changes at the nursing home. *Neither the resident nor the daughter demanded she be taken to the hospital. *The Nurse Practitioner gave orders to transport the patient to the emergency room after the X-ray results showed a fracture. * The facility transported her to the hospital. *The hospital tested and treated her for a UTI, they had felt the cognitive changes were related to her pain. *She was at the hospital for one night on observation and then discharged and transported back to the facility with the orthopedic physician's discharge orders for the non-weight bearing of the left leg, immobilizer brace, and to elevate her left leg. *The charge nurse received the orders and relayed them to the staff during shift change. *The only time she was aware of the immobilizer not being used correctly was when the daughter called her from the follow-up orthopedic appointment. *When the daughter and resident 1 voiced concerns to DON B regarding the care of resident 1's LLE fracture, DON B educated the staff. -She intermittently observed the placement of the brace and the elevation of resident 1's LLE to ensure proper care. *The resident was very good at expressing how her immobilizer should be placed and maintained on her leg. -DON B stated she felt the staff listened to resident 1. Review of the provider's 11/13/24 Abuse and Neglect Reporting policy revealed: *Definitions: -Neglect: Failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. *Policy: -The agency will comply will all applicable federal, state or local laws regarding abuse or neglect. Review of the provider's 7/22/24 Abuse and Neglect policy revealed: *Policy -The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Based on observation, interview, policy review, and record review, the provider failed to care plan appropriatley to prevent pressure ulcers from developing for three of ten sampled residents (1, 5, and 7). Findings include: 1. Observation on 8/16/11 at 1:20 p.m. revealed resident 1 had an open area located on the coccyx that was approximately 2.0 centimeter (cm) long by 0.5 cm wide and 0.5 cm deep or less. Review of residents 1's medical record revealed: *The resident's quarterly Minimum Data Set ((MDS) dated [DATE] stated he was not at risk for a pressure ulcer and had no pressure ulcers. *The resident's MDS dated [DATE] stated he was not at risk for a pressure ulcer and had no pressure ulcers. *The resident's MDS dated [DATE] stated he was not at risk for a pressure ulcer and had no pressure ulcers. *The resident's MDS dated [DATE] stated he was at risk for a pressure ulcer and had no pressure ulcers. *Review of the 7/20/11 Resident Care Area assessment stated his braden score was 15 putting him at mild risk for skin alteration. *The clinical monitoring/acute care flow sheet stated he had a stage II pressure ulcer documented on the right heel on 6/3/11. *It was healed on 7/8/11. *A head-to-toe assesment was documented in the interdiscipinary progress notes (IPN) on 7/15/11 at 8:15 a.m. stating the resident's skin had no open areas noted. *On 7/17/11 at 1:30 p.m. the IPN noted an open area to the coccyx. *It was noted in the IPN the open area was reported to the wound nurse. *On 7/19/11 at 7:20 a.m.it was noted in the IPN the open area measured 0.5 centimeters (cm) by 0.3 cm by 0.1 cm. *It was noted in the clinical monitoring/acute care flow sheet on 7/22/11 [MEDICATION NAME] ointment was being applied to the open area. *On 7/29/11 at 7:30 a.m. an IPN entry stated the pressure/open area to the coccyx had deteriorated significantly. *New orders were requested and received on 7/29/11 from the physician to address the deterioration of the open area. *On 8/5/11 at 7:15 a.m. the IPN entry stated the open area had deteriorated from the previous week. *On 8/12/11 at 8:30 a.m. the IPN entry stated the open area had improved from the previous week. Review of resident 1's 7/20/11 care plan identified problems revealed: *He had a potential for a "pressure area". *He had a potential for altered skin integrity. *A revision dated 8/15/11 that stated a "stage II to coccyx". Review of resident 1's 7/20/11 care plan goals for prevention of skin breakdown revealed: *A long term goal dated 7/20/11 stated his skin was to have remained intact through 10/20/11. *No other goals were entered for the above identified problems. *No goals had been entered that addressed evaluation and effectiveness of the interventions to heal the pressure ulcer. *There had been no goals entered that identified when the pressure areas or stage II pressure ulcer was to have been healed. Review of resident 1's 7/20/11 care plan interventions that addressed a pressure ulcer on the coccyx revealed: *A short term intervention dated 7/29/11 stated to apply [MEDICATION NAME] ointment to the pressure ulcer until it was resolved. *A short term intervention dated 7/29/11 for a nutrition supplement daily. *A short term intervention dated 8/15/11 for a pressure relieving mattress. *A long term intervention dated 8/15/11 stated documentation of the pressure area was to have been done by the nurse every day. Interview on 8/17/11 at 1:30 p.m. with the director of nursing (DON) confirmed: *The care plan for resident 1 had no measurable goals. *The specific treatments for the pressure ulcer had been entered on the current treatment sheets. *The care plan had not referred to the treatment sheets for the interventions listed. 2. Observation on 8/16/11 at 5:57 p.m. revealed resident 5 had an approximately 0.5 centimeter (cm) diameter superficial open area on his back. There was a cushion on the seat of the wheelchair (w/c). There was no cushioning on the back of the wheelchair. Review of the interdisciplinary progress notes from June 2011 until the August 2011 revealed a pressure ulcer had been identified on 7/7/11 and had developed in the facility. Review of the care plan dated 5/25/11 revealed resident 5 had: *A "Potential for altered skin integrity r/t (related to) decreased mobility." The long/short term goals indicated the skin would remain intact with the following plans and approaches: -"Reposition every 2 hours to prevent skin breakdown -Report chagnes (sic) in skin to nurse -House barrier oitment (sic) after each incontinent episode." The care plan indicated the above information had been sent to the certified nurse aides (CNA) hand held devices for them to be aware of the residents needs. The cushion on the w/c or the mattress on the bed was not addressed on the care plan. *"Altered nutrition r/t weakness, pain and (yellowed out) dehydration e/b (evidenced/by) low BMI (Body Mass Index), and (oral intake was hand written in) weight loss (and skin issues was hand written in with a date of 7/12/11). Long/short term goals indicated the resident "will weigh at or above 120 pounds" (this was yellowed out) and "Continue wgt (weight) loss may be unavoidable - skin will remain intact." (This was handwritten on 7/12/11 after the pressure ulcer developed.) The following interventions were in place prior to the development of the pressure ulcer: *Encourage fluids at the dining table. *Offer fluids when doing personal care. *Nutrition intervention program. The following interventions were added on 7/12/11 after the pressure ulcer had developed: *"Between meal supplements... *Nut (nurtition) @ (at) risk list for monthly RD (registered dietitian) review". Additional approaches were added on the back of the care plan after the pressure ulcer had developed: *"7/7/11 Stg (stage) 2 decub (pressure ulcer) mid-spine (0.8 x 0.5)[MEDICATION NAME] dsg (dressing) applied. Fax sent to provider (with) req. (request) for tx (treatment). *7/7/11 [MEDICATION NAME] (sic) to spine until healed... *8/9/11 Protective drsg (dressing) to stage 2 decub (decubti, pressure ulcer) mid spine - ? (check) daily & change q (every) 5 days or more often if needed until resolved then D/C (discontinue)." After the surveyor asked for clarification on the documentation the care plan was updated on 8/15/11 to include: "Daily Documentation of pressure area by nurse to include: *eval (evaluation) of ulcer *status of skin surrounding ulcer *status of drsg (dressing) if any *tx (treatment) *pain if any". There was no information on the care plan related to preventative strategies prior to the development of the pressure ulcer other than the repositioning. The following interventions were not indicated on the resident's care plan: *Review of the interdisciplinary progress notes (IDPN) dated 6/16/11 revealed: "PSLP (PrimaShear-Less Plus) mattress on bed, cushion in w/c. Interventions in place et (and) effective." *Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed resident 5 was at risk for pressure ulcers, did not currently have a pressure ulcer, had no previous history of pressure ulcers, a pressure relieving cushion was in his chair, and ointments were used. *Interview with the wound care nurse on 8/17/11 at 3:05 p.m. revealed all mattresses in the facility were PSLP pressure relieving mattresses unless a resident required something more specific. All residents upon admission were on pressure relieving mattresses. She documented her assessment and interventions in the IDPN. Review of the clinical monitoring/acute care flow sheet for resident 5 used for documenting wound assessments from 7/28/11 to 8/9/11 revealed documentation was missing for 8/5, 8/6, and 8/7. 3. Review of the admission nursing assessment dated [DATE] revealed resident 7 did not have any pressure ulcers. Review of the nutrition admission nutrition assessment dated [DATE] revealed resident 7 had an open area on her coccyx. She was placed on the nutrition risk list. There were no changes in her nutrition care implemented at that time. Observation on 8/17/11 at 8:05 a.m. revealed the pressure ulcer to resident 7's coccyx was healed. There was no scarring present. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed resident 7: *Required extensive assistance of two staff for bed mobility and transfers. *Was at risk for pressure ulcer development. *Had no history of pressure ulcers. *Had no venous or arterial ulcers. *Was not receiving any preventative treatment for [REDACTED]. Interview on 8/16/11 at 10:20 a.m. with registered nurse B revealed resident 7 had been independent with mobility prior to her admission to the facility. Due to her health she did not have any energy and spent a lot of time in her bed. She did come out for meals. Review of the Braden Scale for Predicting Pressure Sore Risk revealed resident 7 was as at mild risk with a score of 17 on the 6/28/11 (admission), 7/5/11, 7/11/11, and 7/19/11 assessments. Review of the care plan dated 7/13/11 revealed resident 7 had: *"Potential for altered skin integrity r/t (related to) decreased mobility." The long/short term goals indicated the skin would remain intact with the following plans and approaches: "-Reposition every 2 hours to prevent skin breakdown -Report changes in skin to nurse -House protective ointment after each incontinent episode." The care plan indicated the above information was sent to the certified nurse aides (CNA) hand held devices for them to be aware of the resident's needs. *"Potential for Altered nutrition r/t (related to) depression, [MEDICAL CONDITIONS],[MEDICAL CONDITION](crebral vascular accident), [MEDICAL CONDITION](hypertension). Long/short term goals indicated the resident "will weigh at or above 135 pounds. Will be free from dehydration." The following interventions were in place prior to the development of the pressure ulcer: *Regular diet. *Encourage fluids with all cares. *"Nut. (nutrition) @ (at) Risk List" (was handwritten in on 7/29/11). Additional approaches were added on the back of the care plan after the pressure ulcer had developed: *"7/21/11 Small Stg (stage) 2 open area to coccyx....[MEDICATION NAME] ointment bid (twice a day) to open area on coccyx until resolved, then d/c (disconinue). Family aware." That information was yellowed out. Review of the Clinical Monitoring/Acute Care Flow Sheet for resident 7 revealed: *On 7/21/11 open area 0.4 x 0.4 x less than 0.1. *On 7/29/11 open area 2.5 x 0.5 x less than 0.1 cm (centimeters). *On 8/4/11 open area 2.0 x 0.5 x less than 0.1 *On 8/12/11 resolved. Interview on 8/17/11 at 2:55 p.m. with the wound care nurse revealed she had completed weekly skin assessments on resident 7. If a resident was identified at risk the resident was given a cushion for the wheelchair. *Interview on 8/17/11 at 3:05 p.m. with the wound care nurse revealed: *She had completed an assessment on resident 7 on 7/7/11, and had implemented preventative measures. She did not have any documentation to confirm the interventions had been implemented or the assessment had been completed. *All mattresses in the facility were PSLP (PrimaShear-Less Plus) pressure relieving mattresses unless a resident required something more specific. All residents upon admission were on pressure relieving mattresses. *She documented her assessment and interventions in the interdiscpilinary progress notes (IDPN). 4. Review of the Duration of Stay Database Braden Scale for Predicting Pressure Sore Risk Policy dated December 2009 revealed: "Preventative measure must be implemented and addressed on the care plan." Surveyor The provider's revised March 2007 pressure ulcer policy revealed: *The purpose had been to assess and prevent pressure ulcers as well as provide treatment when needed. *Based on the resident's comprehensive assessment interventions would be utilized to ensure residents who entered the facility without pressure ulcers would not develop them. *A resident who had a pressure ulcer would have received treatment to prevent new pressure ulcers from developing. *If a pressure ulcer was unavoidable information would be documented in the resident's medical record to support that finding. The provider's revised January 2009 care plan policy revealed: *Each resident would have an individualized comprehensive care plan that included measurable goals and timetables. *The care plans were to be reviewed and updated at least quarterly. *The care plans were to be reviewed and updated when there was a significant change in the resident's condition. *The plan of care would be modified to reflect the care currently required for the resident.