Every finding on record at Good Samaritan Society Luther Manor

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who eloped (left the facility without staff knowledge) through the front door after visitors entered the facility and walked a block and a half east of the facility, fell with his walker, and sustained injuries.Findings Include: 1. Review of the provider's [DATE] SD DOH FRI report revealed that on [DATE] at 10:45 a.m., police alerted the staff that resident 1 was in an ambulance due to falling outside of the facility. A neighbor called 911 after seeing the resident lying on the sidewalk 1.5 blocks away from the facility. The police officer called an ambulance due to resident 1 having abrasions (scrapes in the skin) to the bilateral (both) upper and lower extremities (upper and lower limbs of the body), and notified the facility of the resident's location and condition. Registered nurse (RN) F went to see the resident in the ambulance before he was transported to the emergency department (ED). She saw his walker next to him in the ambulance. RN F called his family, notified the director of nursing (DON) B, and administrator A. Administrator A arrived at the facility to investigate the elopement. The door codes were changed on the front doors. Education was sent out to staff and family members. Signage was posted at the doors for visitors about not allowing residents to leave when the door was alarmed. Elopement drills were performed. 2. Review of resident 1's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. He had a [DATE] Brief Interview for Mental Status (BIMS) assessment score of 8, which indicated his cognition was moderately impaired. His diagnoses included depression (mental health condition where a person experiences a persistent feeling of sadness or loss), altered mental status, insomnia (trouble falling or staying asleep), cognitive communication deficit (a person has trouble thinking skills that affect communication) and Sarcopenia (the gradual loss of muscle mass and strength, typically due to aging, which makes everyday activities tougher and increases the risk of falls). His [DATE] care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated interventions to cue, reorient, and supervise the resident as needed due to impaired cognitive function and impaired thought processes. The care plan identified a communication problem related to mild cognitive impairment and directed the staff to be aware of his location during groups, activities, and in the dining room to promote effective communication. The care plan indicated that resident 1 required staff supervision with ambulation (walking), a gait belt, and the use of a front wheeled walker (FWW). Resident 1 refused to wait for staff assistance with ambulation and was educated on the risks of ambulating alone and on safety awareness. On [DATE], his care plan identified a potential for elopement related to exit seeking behavior and a prior elopement incident. On [DATE], his care plan directed certified nursing assistants (CNAs) to walk resident 1 to the dining room. His elopement evaluations revealed that a score of 1 or higher indicated a risk for elopement. On [DATE], the resident's elopement score was 3, which indicated he was at risk for eloping. On [DATE], his elopement score was 0, which indicated he was not at risk for eloping. On [DATE], his elopement score was 2, which indicated he was at risk for eloping. On [DATE], his elopement score was 6, which indicated he was at risk for eloping. On [DATE], his elopement score was 2, which indicated he was at risk for eloping. His fall risk evaluations indicated that a score of 10 or higher indicated the resident was at high risk for falling. His [DATE], [DATE], [DATE], [DATE], and [DATE] fall risk evaluation scores were all above 10, which indicated he was at risk for falling. He had a [DATE] physician's order for a wander guard (a wearable door alarming device). Nursing progress notes indicated that on [DATE], resident 1 eloped from the building. A police officer notified RN F after responding to the resident, who had fallen outside the building. RN F observed the resident on the ambulance gurney with bleeding legs and arms from the fall. The resident's walker lay folded on the ambulance floor. The resident was alert but confused. The police officer stated he would call the resident's daughter. The ambulance transported the resident to the hospital for treatment. RN F called the daughter at 11:50 a.m., and the daughter called the physician at 1:00 p.m. about the elopement. RN F indicated in resident 1's [DATE] elopement evaluation at 11:23 a.m., No to the statement, Wandering behavior likely to affect the safety or well-being of self/others. She also documented resident 1's blood pressure, temperature, pulse, respirations, and pain level on [DATE] at 2:46 p.m., when resident 1 was transported via ambulance to the ED around 10:45 a.m. On [DATE], he returned to the facility from the ED at 6:00 p.m., and on [DATE] at 6:56 a.m., staff contacted the nurse practitioner regarding the observed him have physical and verbal aggression and personality changes. At 10:20 a.m., an order was written to transfer to the ED for further evaluation. He was admitted to the hospital on [DATE] due to his altered mental status (a person is not thinking, acting, or responding within a person's normal limits) and delirium (sudden change in a person's thinking and awareness), and was discharged on [DATE] from the hospital back to the facility. His [DATE] hospital records indicated that resident 1 was diagnosed with cellulitis (a bacterial infection of the deeper layers of skin and underlying tissue that causes redness, swelling, warmth, and pain in the affected area) of the left lower extremity, altered mental status due to hepatic encephalopathy (liver can no longer remove toxins from the blood), and acute kidney injury (AKI) (kidneys suddenly stop filtering waste from the blood causing waste to build up and fluid or electrolyte imbalances). The progress noted indicated had multiple bruises on his torso and extremities. 3. Review of the [DATE] camera footage of the facility's front entrance door revealed that at 10:21 a.m., resident 1 was standing at the doorway when a family entered the facility. Resident 1 then walked out past the first set of sliding glass doors. He was wearing his wander guard, and the device activated the door alarm. Another visitor entered the facility, and resident 1 walked out of the second set of sliding glass doors. At 10:25 a.m., a CNA /medication aide (MA) K walked to the front entrance, looked out the doors while standing by the door code keypad, and deactivated the alarm before leaving the camera's view. 4. Observation and interview on [DATE] at 10:58 a.m. with resident 1 revealed that he had Mepilex dressings (a soft foam bandage used to cover and protect wounds) on both of his knees, each labeled with a date and signature. Bruising was noted across his body. The bruising was on the bilateral lower legs and forearms. He was wearing shorts, knee-high socks, a thin jacket with arms pulled up to his elbows, and a t-shirt on top of that. This left his lower legs and forearms visible. The bruising was in various stages. The resident stated he was looking for his wife, but later referred to her as having been deceased for several years. The wander guard on his four-wheeled walker had a date of [DATE]. The resident indicated that the wander guard was a meter to tell you how far you go, referring to walking. He had an electric recliner and was able to demonstrate its use. He stated that the staff encouraged him to get up on his own. The resident stated that it was his first day at the facility. 5. Interview on [DATE] at 1:51 p.m. with Administrator A revealed that the code yellow (the overhead page for a possible resident elopement) was not initiated on [DATE] when resident 1 eloped out of the facility. 6. Review of the facility's Quality Assurance and Performance Improvement (QAPI) interdisciplinary (IDT) meeting on [DATE] revealed that the team identified the root cause of resident 1's elopement incident was a family member letting the resident out of the facility, and the staff not responding to the door alarm. The review indicated that resident 1 was wearing a coat, shorts, and shoes at the time of the incident, and the weather temperature ranged between 68 and 70 degrees on [DATE]. 7. Interview on [DATE] at 10:52 a.m. with contracted travel RN G revealed she was not aware of how the door alarms were turned off at each exit within the facility, but believed there was a code that the staff entered. The alarm panel at the nursing station displayed the location of an activated alarm so the staff could respond to that area, and displayed the alarms for the entire building. She did not know whether there was a process that the staff was to follow when there was a potential elopement. 8. Interview on [DATE] at 11:00 a.m. with RN F revealed she was aware of which residents were at risk for wandering because the resident's treatment administration record (TAR) identified which residents had a wander guard that the nursing staff checked to ensure it was on the resident or device used by the resident and that the wander guard was functioning. 9. Interview on [DATE] at 11:06 a.m. with certified CNA L revealed she was informed of which residents were at risk for elopement during report (information that one nurse gives to another staff member about a patient's condition, care, and any important events), by reviewing the resident's care plan, or by visibly seeing a wander guard on a resident or their assistive device such as a walker or wheelchair. 10. Interview on [DATE] at 11:11 a.m. with contracted travel licensed practical nurse (LPN) J revealed she did not know how to identify which residents in the building were at risk for elopement and that she would need to ask someone. If an alarm alerted the staff, she would check the alarm panel at the nurses' station and go to the alarming door. She was not aware of any process to follow when a possible elopement occurred. 11. Interview and observation on [DATE] at 11:34 a.m. with the supervisor of ancillary services (SAS) C at the front sliding door revealed that the door code to the facility's doors had to be changed immediately after an incident or concern. After opening the front sliding door, it remained open for approximately five seconds when closing without interruption. 12. Interview on [DATE] at 12:15 p.m. with the director of nursing (DON) B revealed that resident 1 was considered a very at risk resident for eloping, and he did not want to remain in the facility since his admission, as he did not understand why he needed to be there. DON B expected the charting completed by RN F on resident 1's [DATE] elopement evaluation to be accurate. He reported the response to the question, Wandering behavior likely to affect the safety or well-being of self/others, should have been Yes, as the resident had eloped from the facility earlier that morning. 13. Interview on [DATE] at 12:27 p.m. with RN F revealed she was the nurse assigned to care for resident 1 on [DATE]. She reviewed her charting from [DATE] at 11:23 a.m. and confirmed the answer to the statement, Wandering behavior likely to affect the safety or well-being of self/others, should have been Yes. 14. Interview on [DATE] at 4:13 p.m. with Administrator A revealed the facility did not complete staff education on code yellow procedures, and what residents are at risk for elopement for contracted travel staff. 15. Interview on [DATE] at 5:03 p.m. with DON B revealed the facility had a process in which all staff were expected to be aware of and use a yellow clipboard to identify the residents who may have potentially eloped. This clipboard contained the information and pictures of residents at risk for elopement. He confirmed the staff did not use this process as expected on [DATE]. 16. Interview on [DATE] at 9:31 a.m. with RN F revealed resident 1 did not return to the facility on [DATE] during her shift. She should not have charted his vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) at 2:46 p.m.as he was not in the facility. 17. Interview on [DATE] at 11:23 a.m. with CNA/MA K revealed he was working on [DATE] in the [NAME] Lane hallway. He heard the door alarm sounding and went toward the front door, where it was alarming. CNA/MA K entered the code on the keypad to turn off the door alarm and peeked out the door because he believed it was only an accidental alarm. He returned to his hallway and told his coworkers, It was the alarm going off by accident or misfiring. CNA/MA K then went on his break after turning off the front door alarm on [DATE], and then learned while he was on break that resident 1 was outside. Administrator A gave him education on elopement processes at the facility on [DATE] after the elopement had occurred. CNA/MA K identified residents at risk for elopement by visually observing whether they were wearing a wander guard. 18. Interview on [DATE] at 7:20 p.m. with DON B revealed he expected the nursing staff to review a resident's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) or Kardex (a report of the resident's care needs and interventions) to ensure they provided appropriate resident care. He did not expect the staff to chart vital signs on a resident who was not present in the facility. Resident 1 was never alert and oriented; he was consistently confused and did not understand the amount of assistance he needed from the staff. DON B thought resident 1's elopement could have been prevented if the facility had a better door system in place and acknowledged the facility had experienced previous elopements related to the doors. 19. Review of the provider's reviewed/revised [DATE] Elopement-Rehab/Skilled & Adult Day Services police revealed purpose to assess and identify residents/clients at risk for elopement. To clearly define the mechanisms and procedures for monitoring residents/clients at risk for elopement. To provide a system of documentation for the prevention of, and in the event of, elopement. To minimize risk for elopement through individualized interventions. Definition of elopement: when a resident/client who needs supervision leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The SNF location and each Adult Day Program will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring residents/clients at risk for elopement. These include identifying, evaluating and analyzing environmental hazards and risks; and implementing, monitoring, and modifying interventions as needed. 20. Review of the provider's reviewed [DATE] Nursing Services Philosophy and Care policy revealed committed to the advancement of the profession practice of nursing through safe, reliable, person-centered care, in a healthy work environment, inspiring innovation and leading discovery. This comprehensive care will be planned to prevent further disability, maintain strengths, and restore any loss of function when possible. Every attempt will be made to assist the person to achieve the independence necessary to transition to the place they desire to live in and call home. Nursing is a part of the interdisciplinary team that partners with the person to assess, plan, implement, and evaluate what is possible for the person. Objectives of Nursing Services 2. To cooperate with other team members and with the person/family using an interdisciplinary team approach in pre-admission, comprehensive care, and discharge planning, including the person/family in all phases of assessment, planning, teaching, and referral. 5. To provide the person with a relaxed, homelike, safe, and clean environment.

Based on South Dakota Department of Health (SD DOH) complaint intake report, record review, interview, and policy review, the provider failed to ensure the staff were educated on NPWT (closed drain system that relies on the presence of vacuum to withdraw accumulated fluid from around the wound bed into the collection device) treatments for one of one sampled resident (2) whose wound vac was placed incorrectly, which resulted in the resident developing red, irritate skin above his pressure ulcer on his buttocks. Findings include:1. Review of the 5/13/26 SD DOH complaint intake report, revealed that resident 2 had voiced some concerns with the care he received at the nursing facility where he resided while he was getting a suprapubic catheter ( flexible medical tube used to drain urine from the bladder) placed and a colonoscopy (diagnostic and preventative procedure to examine the lining of your rectum and colon) at the hospital. Resident 2 expressed that he did not want to the nursing facility following his hospitalization. Resident 2 was a quadriplegic (partial or total paralysis of all four limbs, (both arms, and both legs) and the torso) and was fully dependent on the staff for all care. He had multiple pressure wounds that were present upon admission to the hospital, including one on the ischium (lower and back part of the hip bone) that required a wound vac for healing. The resident and his wife voiced that the nursing facility was not meeting the resident's care needs. Resident 2 indicated that since he was on a bowel preparation for the colonoscopy procedure, he often sat in stool for an extended period (up to two hours), due to CNAs stating that they were not allowed to change the resident more frequently than every two hours. The resident stated that this prolonged contact with stool on his buttocks aggravated an existing pressure wound.Upon resident 2's arrival at the hospital, the staff discovered that his NPWT machine was not sent with him, despite the hospital's request to the nursing staff. As a result, the NPWT tubing remained attached to the resident's wound dressing but was not connected to the machine. According to the hospitals wound vac protocol, if a wound vac was not connected to the machine, the dressing and tubing must be removed. Resident 2 had reported that his primary physician recommended minimizing pressure to the wound area on his buttocks and was to use a commode (portable toilet) for bowel care. The staff at the nursing facility told him there was not enough space in the resident's assigned room to use a commode and that he had to use a bedpan ( a small, stationary receptacle to collect stool or urine while lying in bed). According to records from the hospital, the number and severity of resident 2's pressure wounds had increased since his facility admission. It further indicated that the resident had a total of seven wounds, one of which required a wound vac for healing. Resident 2 had reported an incident in which his NPWT machine's alarm sounded during the night, and the staff member who responded did not understand why the alarm was beeping; they shut the device off without troubleshooting or addressing the issue.The report indicated that resident 2 stated he was frequently left without access to his call light, and when he did have access, response times were prolonged period of times. Resident 2's representative had visited him regularly in the hospital and confirmed that the concerns regarding resident 2 were accurate. The nursing facility was not previously notified of resident 2's concerns until a care conference held on 5/1/26, during which the provider stated they were unaware of any problems with his care. As of 5/13/26, the nursing facility did not submit a facility reported Incident (FRI) regarding the allegations of neglect.Resident 2 did not return to the nursing facility following his medical procedures at the hospital. 2. Review of resident 2's electronic medical record (EMR) revealed that admitted on [DATE]. His 4/3/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. He had a diagnosis of injury at the C7 (damage at the seventh cervical vertebra at the base of the neck) incomplete lesion at the C4 (damage at the fourth cervical vertebra in the neck), quadriplegia (paralysis that causes total loss of motor and sensory function in all four limbs), C1-C4, neuromuscular dysfunction of bladder (neurological conditions interrupt nerve signals between the brain, spinal cord, and bladder muscles), neurogenic bowel (loss of normal bowel function due to nerve damage), and an open wound of the left buttock. His physician's wound care orders included care to his left and right heels, left and right ischium, medical coccyx, penis, and left buttock. His left buttock order was initiated on admission [DATE]) and indicated to have a NPWT with 125 millimeters of mercury (mmHg) of continuous suction, and a black foam dressing to be changed on Monday, Wednesday, Friday, and as needed.Resident 2's skin issues progress note, completed by DON B dated 4/23/26, that he measured the right gluteus as 0.6 centimeters (cm) long, 0.8 cm wide, with no depth. The left gluteal area measured 2.9 cm long, 2 cm wide, and 4 cm deep, with 2.3 cm of undermining (tissue under the wound edges dies or erodes).Resident 2's skin issues progress note, completed by registered nurse/minimum data set nurse (RN/MDS) H dated 4/29/26, indicated that the left heel measured 1.5 cm long, 1.3 cm wide, and 0.1 cm deep, with an area of 1.95 cm^2. The right gluteus measured 1 cm long, 1.5 cm wide, with no depth, and an area of 1.5 cm^2. The left gluteal area measured 3.5 cm long, 5 cm wide, and 6 cm deep, with an area of 17.5 cm^2 and no undermining.His undated care plan indicated he did not use the toilet and had a Foley catheter and bowel regimen at 7:30 every evening. Resident 2 had a nutritional problem related to wounds, obesity, and a history of diabetes mellitus, which increased his need for more protein and a nutritional supplement for wound healing. He had an order for a regular diet to encourage protein intake at meals, and Juven (nutritional supplement) twice daily, all initiated on 4/3/26. His weight was monitored weekly with no significant weight loss. 3. Interview on 6/4/26 at 4:35 p.m. with DON B revealed that on 4/29/26, RN/MDS H identified that the NPWT tubing for Resident 2 was placed incorrectly, which caused a reddened area above the open wound on his buttocks. After RN/MDS H identified this issue, DON B began training the facility nursing staff on NPWT procedures and care. The training was identified by DON B as needing to be completed because of the reddened area that was caused by the placement of the NPWT tubing. DON B points to the picture of the wound taken on 4/29/26, and said: This is why. RN/MDS H documented this reddened area in the skin issues progress notes dated 4/29/26.4. Interview on 6/4/26 at 6:45 p.m., with RN I revealed that over the last six months, the facility had cared for an increased number of residents receiving NPWT on the long term care side of the building. She explained that the nurses on that unit were less comfortable working with wound vacs than the rehabilitation nurses in the building.5. Interview on 6/4/26 at 7:02 p.m., with RN/MDS H revealed that on 4/29/26, she recalled the area above resident 2's buttock wound being reddened, where the black foam dressing was placed. She explained that the staff were expected to bridge the black foam (creating a pathway of foam from the wound to a separate area of healthy skin where it was safe to place the track pad) because the track pad (the adhesive connector that links the dressing to the vacuum machine) should not be placed directly on the wound. If the track pad were placed directly on the wound and the resident sat in his chair, the pressure would worsen the wound area. She added that the track pad and tubing should be positioned over the resident's hip.6. Review of the provider's reviewed 8/7/25 Nursing Services Philosophy and Care policy revealed committed to the advancement of the profession practice of nursing through safe, reliable, person-centered care, in a healthy work environment, inspiring innovation and leading discovery. This comprehensive care will be planned to prevent further disability, maintain strengths, and restore any loss of function when possible. Every attempt will be made to assist the person to achieve the independence necessary to transition to the place they desire to live in and call home. Nursing is a part of the interdisciplinary team that partners with the person to assess, plan, implement, and evaluate what is possible for the person. Objectives of Nursing Services 2. To cooperate with other team members and with the person/family using an interdisciplinary team approach in pre-admission, comprehensive care, and discharge planning, including the person/family in all phases of assessment, planning, teaching, and referral. 5. To provide the person with a relaxed, homelike, safe, and clean environment.7. Review of the provider's reviewed 7/7/25 Wound-Drain System: Open, Closed, and Negative-Pressure Wound Therapy policy revealed Negative pressure wound therapy: The negative pressure device removes excess wound fluids that may cause maceration or delayed healing and stimulates the growth of healthy granulation tissue. This should be used cautiously in residents taking anticoagulants. Negative pressure wound therapy (NPWT) Clinical Skill Checklist 18. Apply a new NPWT dressing or other appropriate absorptive dressing per the practitioner's order and following the manufacturer's instructions for packing. 22. Leave [the] resident comfortable.8. Review of the provider's reviewed 12/8/25 Pressure Ulcer/Wound Care policy revealed: promotion of healing, pain management, and prevention of complications is extremely important, as well as accurate assessment and documentation.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure that one of one sampled resident (1) was free from a significant medication error when his baclofen (a primary medication for managing involuntary muscle stiffness and muscle spasms in quadriplegia) was discontinued by registered nurse (RN) C without a physician's order which resulted in the resident being transferred to the emergency department (ED) for evaluation and treatment, and had a subsequent three-night hospitalization for observation of his condition. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include:1. Review of the provider's 3/21/26 SD DOH FRI regarding resident 1 revealed that on 3/20/26, he had a change in [his] mental status, face turning red, and was not acting himself. He was sent to the ED for evaluation at approximately 9:00 p.m. and was then admitted to the hospital from the ED at 10:52 p.m. He was diagnosed with acute encephalopathy (a critical syndrome characterized by rapid changes in brain function), likely due to baclofen withdrawal after abrupt discontinuation.The facility's investigation into the incident revealed that RN C received a Consultant Pharmacist Communication to Physician, in which the pharmacist asked the physician for clarification about the date that baclofen should be discontinued. The communication read, Baclofen and duonebs [an inhaled medication to treat lung diseases] have a stop date of 2/1/2027 on the MAR [medication administration record] - please clarify if these are supposed to be discontinued at that time or if they are ongoing. RN C did not notice the year 2027 and thought the medications should have been discontinued on 2/1/26. She did not wait for the physician's verification before discontinuing the order. RN C stopped resident 1's baclofen on 3/18/26.DON B provided education to RN C about the process of monthly pharmacy recommendations immediately after the incident was identified upon RN C's return to work on 3/23/26. The education included an explanation that pharmacy recommendations could not be acted upon without the physician's order to agree or disagree. RN C was encouraged to maintain a questioning attitude and was advised to seek clarification if she was unsure whether a medication had been discontinued. She was also instructed to use her unit manager and DON B as resources if she was ever unsure about a pharmacy recommendation or what action to take. RN C had no previous disciplinary actions or performance issues.The facility's plan to prevent future significant medication errors involves reporting the issue to its Quality Assurance and Performance Improvement (QAPI) committee. There was a process change, and moving forward, the QAPI nurse will be assigned to review monthly pharmacy recommendations as a second RN check and to serve as a resource for questions.Interview on 4/1/26 at 11:26 a.m. with RN C confirmed that DON B had recently provided her with education related to her role in the monthly pharmacy recommendation process, and she felt more confident in that role. She was also educated about the change in the process involving the QAPI nurse serving as a second RN check and as a resource.Interview on 4/1/26 at 11:50 a.m. with medical director K, who was resident 1's primary physician, revealed that she would have expected to be contacted before a medication was discontinued. She would have expected a nurse to get clarification on how a medication like baclofen should be discontinued to ensure it was done safely.Interview on 4/1/26 at 2:29 p.m. with DON B revealed she was providing oversight and reviewing the monthly pharmacy recommendations for all residents until the transition of those duties to the QAPI nurse was complete. She confirmed the incident was a significant medication error for resident 1 and stated it was discovered on Saturday, 3/21/26. On Monday, 3/23/26, she and clinical care leader (CCL) D and RN E reviewed all of the monthly pharmacy recommendations that RN C had been responsible for to ensure accuracy, and no additional errors were found. She stated that although not all nursing staff are responsible for handling monthly pharmacy recommendations, they will provide education to all nursing staff as an additional precaution in case they need to assist with coverage for that task.Interview on 4/1/26 at 3:41 p.m. with administrator A revealed that he expected a nurse to have a physician's order before discontinuing a resident's medication.The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 4/1/26 after record review confirmed the facility had followed their quality assurance process and:*DON B provided education to RN C about the monthly pharmacy recommendation process.*Interview confirmed that RN C understood the education provided.*RN C had no prior disciplinary actions or performance issues.*DON B implemented a new process to provide a second RN check by the QAPI nurse for monthly pharmacy recommendations.*DON B created an audit tool to be used to monitor monthly pharmacy recommendations.*DON B ensured monthly pharmacy recommendation audits will be reported at the next monthly QAPI meeting.Based on the above information, non-compliance at F760 occurred on 3/18/26, and based on the provider's implemented corrective actions on 3/23/26, for the deficient practice confirmed on 4/1/26, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, South Dakota Department of health (SD DOH) facility-reported incident (FRI) review, and policy review, the provider failed to ensure:*The front door code was changed following an elopement (when a resident who needs supervision leaves the premises or safe area without authorization or necessary supervision) from the facility for one of one sampled resident (2) who knew that door code and remained outside unsupervised for about 18.5 hours on 3/28/26 through 3/29/26.*Three of four sampled newly admitted residents (3, 4, and 5) were assessed for their elopement risk per provider policy. Findings include:1. Review of the SD DOH FRI initial report received on 3/28/26 revealed that resident 2 had been reported missing to director of nursing (DON) B at 8:00 p.m. on 3/28/26. Dietary staff told DON B that resident 2 was not at the evening meal which was unusual for him, and the last he was reported seen was by registered nurse (RN) F at approximately 5:30 p.m. that day when she offered him a diet coke. The building and grounds were searched by staff, but resident 2 was unable to be located. 2. Review of the provider's camera check timeline summary for resident 2's elopement investigation revealed that resident 2 had exited the building on 3/28/26 at 5:04 p.m. Earlier that day at 12:49 p.m., resident 2 can be seen in his wheelchair approaching the front door, pushing numbers on the keypad, watching the door open and close, then returning to his room. 3. Review of resident 2's electronic medical record (EMR) revealed that he was admitted to the facility on [DATE] and was assessed as a risk for elopement from his admission elopement risk screening. Resident 2 had a Brief Interview for Mental Status (BIMS) score of 11 meaning he had mild cognitive impairment. He had refused to have a wander guard (a wearable door alarming device) placed for his safety, so his care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was updated for staff to perform and document rounding (checking on residents' status and assistance needs) on him every three hours to verify his whereabouts. His last documented three-hour check on 3/28/26 was at 12:00 p.m. that day. He returned to the facility on 3/29/26 at 11:30 a.m. in a private vehicle. 4. Observation on 3/31/26 at 4:33 p.m. in the hallway near the front door revealed that a keypad was protruding from the wall to the right of the front door. A visitor was seen reading the top of the keypad, then entered a number to that keypad. The front door opened and that visitor exited the building. The laminated paper on top of the keypad read 7092 (BACKWARDS). 5. Interview on 3/31/26 at 4:42 p.m. with resident 2 in his room revealed that his room was the closest resident room located near the front door. Resident 2 stated that he would watch people leave through that front door and was able to figure out the code for the door from watching it being pushed by others on the keypad. He recalled testing the door code earlier in the day on 3/28/26 and waited until a time that staff was busy to wheel himself out of the building in his wheelchair. He did not know if the door code had been changed after he left the faciity on 3/28/26 evening, but he would continue to watch people and figure out the new code if it had been changed. 6. Interview on 4/1/26 at 9:34 a.m. with registered nurse (RN) I and licensed practical nurse (LPN) J at the nurses' station revealed that they both were aware that resident 2 was an elopement risk because he had made statements about leaving the facility on his own. They both stated that he was periodically confused but they both believed that he planned his elopement to a time when staff would be busy getting the other residents ready for the evening meal. 7. Interview on 4/1/26 at 10:10 a.m. with supervisor of ancillary services (SAS) G revealed that the same door code had been used for several years, and that administrator A asked him to change the code yesterday on 3/31/26. He confirmed that the code was the same from when resident 2 eloped on 3/28/26 until 3/31/26. SAS G stated that some residents knew the front door code and would use it to open the door and to sit outside on occasion, and that resident 2 was one of those residents. He acknowledged that a resident with intact cognition would be able to read the laminated door code sign and enter the code to leave the front door. 8. Interview on 4/1/26 at 11:26 a.m. with RN C revealed that she was responsible for performing the admission assessments on residents who were new to the facility. The provider used a system called Point Click Care (PCC) for the resident's electronic medical record (EMR). She stated that the elopement assessment for residents used to automatically open when a new resident admitted to the facility for the staff to complete in PCC. She explained that since the update to PCC in December 2025, the elopement assessment no longer automatically opened for the staff to complete for new resident admissions. RN C would only perform an elopement risk assessment if a resident verbally confirmed that they had a wish to leave the facility or if they had other clinical risk factors. RN C also explained that there was an admission checklist to perform on the admission assessment, but it was no longer accurate since the PCC upgrade, and she no longer filled out that checklist. 9. Interview on 4/1/26 at 1:48 p.m. with social services supervisor H revealed that resident 2 had been offered counseling previously for his wish to elope from the facility and declined it. His doctor wanted him to undergo a psychiatric evaluation (a series of tests to determine a person's decision-making ability) and he declined this as well. His discharge plan was to get a new pair of prosthetic legs and discharge either to the community or with his brother. 10. Interview on 4/1/26 at 2:29 p.m. with director of nursing (DON) B revealed that education on elopement risk residents was performed with staff after resident 2's elopement as well as at the March all-staff meeting. 11. Review of the residents admitted from 3/11/26 through 3/27/26 revealed that resident 4 was admitted on [DATE], resident 6 was admitted on [DATE], and residents 3 and 5 were both admitted on [DATE]. There were no documented admission elopement screening assessments for residents 3, 4, and 5 found in their EMRs. 12. Further interview on 4/1/26 at 2:29 p.m. with DON B revealed that she was aware that the assessment in PCC for elopement screens on newly admitted residents no longer automatically opened for staff to complete after the December 2025 update for PCC. She acknowledged that staff were only performing this assessment if a resident voiced a history of trauma, substance abuse, or actively wanted to leave the facility. She agreed that their policy stated that all residents were to be screened for elopement risk on admission and that a history of trauma or substance abuse was not an elopement screen. 13. Interview on 4/1/26 at 3:41 p.m. with administrator A revealed that he was not aware that newly admitted residents were not being screened for their risk for elopement. Screening all newly admitted residents for elopement risk was the expectation to determine their risk and implement safety interventions. He agreed that not changing the door code immediately after the elopement could have put resident 2 at risk for another elopement. 14. Review of the provider's 4/7/25 Elopement policy revealed that all residents would be assessed for their risk of elopement through the pre-admission and/or admission process to put measures in place to minimize the risk of elopement that are individualized to the resident needs and identified on the care plan. The staff would complete the elopement risk user defined assessments (UDA) (customizable electronic forms used for clinical documentation such as assessments) in PCC. That UDA would include resident/family education about needing to sign in and sign out of the building or to let a staff member know that a resident is leaving. During the resident's stay, elopement risk UDA would be completed again periodically, and the resident's care plan would be updated as needed.

Based on observation, record review, interview, and policy review, the provider failed to monitor and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (7) who was identified at risk for developing pressure ulcers and developed a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to his coccyx (tailbone), right buttock, and left buttock and one of one sampled resident (7) who was identified at risk for developing a pressure ulcer developed a stage II pressure ulcer to his right buttock. Findings include:1. Observation and interview on 3/3/26 at 10:58 a.m. with resident 7 in his room revealed:*He had a trapeze bar (a bar above the bed used to assist in repositioning and transfers) attached to his bed.*There was a pressure reduction cushion in his wheelchair and recliner.*He stated that he had a wound on his buttocks, but he thought it had healed.*He did not know if he had the trapeze bar attached to his bed or the pressure reduction cushions in his recliner and wheelchair before the wound developed on his buttocks.2. Review of resident 7's electronic medical records (EMR) revealed:*He was admitted to the facility on [DATE].*His 1/30/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated his cognition was intact.*His diagnoses included stage I (1; unopened non-blanchable skin redness, meaning the area remains red when pressed, caused by pressure) pressure ulcer and stage II pressure ulcer.*Resident 7's 1/10/25 Braden Scale for Predicting Pressure Sore Risk (a tool used to assess the risk of developing pressure ulcers) assessment score was 16, which indicated he had a mild risk for the development of a pressure ulcer.-The interventions recommended for that mild risk were, Frequent Turning (e.g., q [every] 2 hours), Maximal Remobilization, Pressure-Reduction Support Surfaces if Bed- or Chair-Bound, Protect Heels, Manage Moisture, Manage Nutrition, Manage Friction and Shear*If other major risk factors are present (advanced age, poor dietary intake of protein, diastolic pressure below 60, hemodynamic instability), advance to [the] next level of risk.*His 1/24/25 wound assessment indicated that resident 7's facility acquired stage II pressure ulcer to his coccyx measured 1 centimeter (cm) in length by 0.5 cm in width.-Resident 7 indicated to staff that he had pain related to the wound. There was no description of his pain or what intervention was used to decrease his pain level.*His 1/28/25 wound assessment indicated that resident 7's facility acquired stage II pressure ulcer to his coccyx measured 1.0 cm in length by 1.3 cm in width by 0.1 cm in depth and that the surrounding tissues were red. It did not indicate that resident 7's physician was notified of the increased size of that pressure ulcer.*His 2/4/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 1 cm in length by 0.5 cm in width by 0.1 cm in depth.*His 2/11/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 1.2 cm in length by 2.2 cm in width by 0.1 cm in depth. It did not indicate that resident 7's physician was notified of the increased size of that pressure ulcer.*His 2/18/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 3.1 cm in length by 3.6 cm in width by 0.1 cm in depth. It did not indicate that resident 7's physician was notified of the increased size of that pressure ulcer.*His 3/4/25 wound assessment documentation indicated resident 7's pressure ulcer on his coccyx measured 0.2 cm by 0.2 cm.*His 3/11/25 wound assessment indicated that resident 7 had a facility acquired stage II pressure ulcer to his left buttock. There were no measurements of that wound, and it indicated the current treatment plan was to continue.*His 3/18/25 wound assessment indicated that resident 7's facility acquired stage II pressure ulcer to his coccyx/left buttocks were healed.*His 3/25/25 wound assessment indicated that resident 7's facility acquired stage II pressure ulcer to his left buttock measured 0.9 cm in length by 0.9 cm in width by 0.1 cm in depth and was described as dried scabs.*His 3/26/25 wound assessment indicated that resident 7 had a facility acquired stage II pressure ulcer to his left buttocks. There were no measurements of that wound, and it was described as open.*His 4/8/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 1.4 cm in length by 1.9 cm in width. It did not indicate that resident 7's physician was notified of the increased size of that pressure ulcer.*His 4/16/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 0.2 cm in length by 0.8 cm in width.*His 4/29/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 1.0 cm in length by 1.0 cm in width. It did not indicate that resident 7's physician was notified of the increased size of that pressure ulcer.*His 5/06/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 1.2 cm in length by 1.0 cm in depth.*His 5/13/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 0.7 cm in length by 1.0 cm in width by 0.1 cm in depth.*His 5/20/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 0.4 cm in length by 0.2 cm in width.*His 5/27/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 0.6 cm in length by 0.3 cm in width.*His 6/03/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 1.6 cm in length by 1.5 cm in width by 0.1 cm in depth. It did not indicate that resident 7's physician was notified of the increased size of that pressure ulcer.*His 6/10/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 0.6 cm in length by 0.5 cm in width.*His 6/17/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 0.2 in length cm by 0.4 cm in width.*His 6/22/25 wound assessment indicated resident 7's pressure ulcer on his coccyx was red, dry, and intact with no open areas.*His 7/30/25 wound assessment indicated resident 7's pressure ulcer on his coccyx stated, left side 0.1x1.2 [0.1 cm in length by 1.2 cm in width] right side 2.2x1.6 [2.2 cm in length by 1.6 cm in width], sang drng [sanguineous drainage; bloody fluid that leaks from wounds].*His 8/05/25 wound assessment indicated resident 7's pressure ulcer on his coccyx/upper bilateral buttocks measured 2.2 cm in length by 2.4 cm in width.*His 8/19/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 6.0 cm in length by 5.3 cm in width and was described as slit in coccyx with shearing [deeper skin layers slide beneath the surface of the skin causing internal damage] off to both sides of [the] buttocks.*His 8/26/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 7 cm in length by 5.6 cm in width by 0.1 cm in depth and described as, large 'butterflies' over coccyx and bilateral buttocks. It did not indicate that resident 7's physician was notified of the increased size of that pressure ulcer.*His 9/02/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 0.9 cm in length by 0.3 cm in width by 0.3 cm in depth.*Resident 7's 9/8/25 Braden Scale for Predicting Pressure Sore Risk assessment score was 19, which indicated he had no risk/low risk for the development of a pressure ulcer.-Resident 7 had a pressure ulcer on his coccyx at the time of this assessment and had two other pressure ulcers since his admission to the facility on 1/10/25.*His 9/9/25 wound assessment indicated resident 7's pressure ulcer on his coccyx was described as 'butterflies' to bilateral buttocks. Lt [left] buttocks: 0.3x0.2; rt [right] buttocks 0.2x0.1. coccyx wound closed. skin pink.*His 9/16/25 wound assessment documentation indicated resident 7's pressure ulcer on his coccyx described as, Open area measuring 1.1x0.7 [1.1 cm in length by 0.7 cm in width] with two tiny openings below. The measurements were documented as 2.0 cm in length by 0.7 cm in width by 0.1 cm in depth.*His 9/19/25 wound assessment indicated resident 7's pressure ulcer on his coccyx was described as, open slit with redness surrounding.*His 9/23/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 0.9 cm in length by 0.3 cm in depth.*His 9/30/25 wound assessment indicated resident 7's pressure ulcer on his coccyx/upper bilat [bilateral] buttocks measured 0.4 cm in length by 0.3 cm in width.*His 10/06/25 wound assessment indicated resident 7's pressure ulcer on his coccyx was skin intact/closed, pink.*His 10/13/25 wound assessment indicated resident 7's pressure ulcer on his coccyx described as reddened and skin starting to break down.*His 10/14/25 wound assessment indicated resident 7's pressure ulcer on his coccyx measured 1.1 cm in length by 0.2 cm in width and was described as re-opened, slit.*His 10/28/25 wound assessment documentation indicated resident 7's pressure ulcer on his coccyx was described as skin intact; no open area noted.*A 12/14/25 physician's order for the staff to apply a Mepilex (a soft foam) dressing to resident 7's coccyx, and to change it every three days, related to a stage I pressure ulcer.*A 12/14/25 physician's order for staff to apply a zinc oxide cream, to resident 7's coccyx and red areas twice daily as needed related to a stage I pressure ulcer.*His 3/4/26 care plan did not indicate when the trapeze bar was attached to resident 7's bed.*A care plan focus area initiated on 3/2/26 indicated he had a potential for impairment to skin integrity R/T [related to] weakness, decreased functional ambulation with an 2/5/25 intervention of Provide pressure relieving mattress on bed and/or cushion in wheelchair and a 2/25/25 interventions of, Monitor location, size and treatment of skin injury. Report abnormalities, failure to heal s/s [signs and symptoms] of infection, maceration, etc. to [the] health care provider.-It did not indicate if or when the pressure reduction cushion was placed in his wheelchair or recliner.3. Observation and interview on 3/3/26 at 11:09 a.m. with resident 83 and his wife in his room revealed:*Resident 83 was sitting in his wheelchair.*There was no pressure reduction cushion in his wheelchair.*There was a pressure reduction cushion in his recliner.*Resident 83 stated that he had a wound on his buttocks before he was admitted to the facility.*Resident 83's wife stated that resident 83 was admitted to the facility with a pressure reduction cushion but it had gone flat, and the staff removed it from his room.*After resident 83 developed a wound on his buttocks, resident 83's wife demanded that he get another pressure reduction cushion.*A pressure reduction cushion was then provided to him at that time.*Resident 83's wife stated resident 83 spent most of his time in his recliner or in his bed.*The pressure reduction cushion in resident 83's recliner was flat.4. Review of resident 83' EMR revealed:*He was admitted to the facility on [DATE].*His 1/2/26 BIMS assessment score was 12, which indicated his cognition was moderately impaired.*His diagnoses included: Adult failure to thrive, pain, malnutrition, dementia, and muscle spasms.*A care plan focus area initiated on 6/4/25 indicated he had a potential for impairment to skin integrity R/T physical conditioning and decreased mobility, and history of pressure injury to buttock with an 11/5/25 intervention of Monitor location, size and treatment of skin injury. Report abnormalities, failure to heal s/s of infection, maceration, etc. to [the] health care provider and Provide pressure relieving mattress on bed and/or cushion in wheelchair.-It did not indicate if or when the pressure reduction cushion was placed in his wheelchair or recliner.*His 11/05/25 wound assessment indicated that resident 83's facility acquired stage II pressure ulcer to his right buttocks was not measured.-The physician was notified of the newly developed pressure ulcer.*There was no further documented pressure ulcer measurements until 11/25/25 and it was documented as 0 cm in length by 0 cm in width by 0 cm in depth.*The right buttocks wound continued to be documented as a pressure injury until 12/7/25 when it was documented as a scab.*The pressure ulcer was documented as a facility acquired wound from 11/5/25 through 12/7/25 without measurements or documentation of characteristics.5. Interview and EMR review on 3/5/26 at 11:55 a.m. with Minimum Data Set (MDS)/wound nurse F revealed:*She confirmed resident 7 and 83's pressure ulcers were facility-acquired.*Resident 7's PRN [as needed] Mepilex was not documented as applied for prevention before the development of his pressure ulcer. The Triad cream was ordered by his physician the day after his coccyx pressure ulcer was discovered and documented by the staff.6. Interview on 3/5/26 at 1:57 p.m. with CNA L revealed:*Pressure ulcer prevention interventions included repositioning the residents every two hours, using pressure reducing cushions to offload pressure, and some residents used specialized mattresses.*She documented in the residents' EMR when she repositioned residents, who were on a repositioning schedule.-The repositioning documentation section would not be available in the residents' EMR if it was not scheduled.*She documented the residents' barrier cream application if the residents' EMR prompted the staff to document it.*She confirmed that residents 7 and 83 did not have repositioning schedules or barrier cream documentation sections in their EMRs.7. Interview on 3/5/26 at 2:30 p.m. with RN C revealed:*She was aware that resident 83 had a pressure ulcer.*Resident 83 had a pressure reduction cushion in his chair, and he had the standard pressure reduction mattress.*She expected the staff to move the cushion from the wheelchair to the recliner if they were transferring the resident.*The residents' EMR should reflect pressure ulcer interventions and prevention measures. 8. Interview on 3/5/26 at 5:43 p.m. with DON B revealed:*She designed a pressure ulcer prevention sheet that was supposed to be referenced by the nurses to determine what interventions needed to be implemented for the residents.-That sheet was used for about a month but was no longer being used.*If a resident was hospitalized , the interventions from the hospital should have been continued upon the resident's readmission to the facility.*She expected either the care plan or the physician's orders to indicate any pressure ulcer interventions and prevention measures.*She confirmed she was aware that the pressure reducing cushion that resident 83 had when he arrived was flat.-Another pressure-reducing cushion was acquired for him, but she was not aware if the new cushion was provided before or after he developed the pressure ulcer.*She acknowledged there was no documentation of the pressure ulcer preventative measures for both residents 7 and 83 before they developed the pressure ulcers.*She was not aware that the staff could document barrier cream applications and each time they repositioned residents in the electronic medical record. She was not aware that those tasks had to be triggered in the resident's medical record for the staff to be able to document each time those tasks were completed.9. Continued interview on 3/5/26 at 3:02 p.m. with MDS/wound nurse F revealed she confirmed there was no documentation to support any pressure ulcer prevention measures were implemented before residents 7 and 83 developed their pressure ulcers.10. Review of the provider's 2/17/25 Pressure Ulcers policy revealed Based on the resident's comprehensive assessment, the location will use prevention and assessment interventions to assure that a resident entering the location without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable.11. Review of the provider's 12/8/25 Skin Assessment Pressure Ulcer Prevention and Documentation policy revealed:* Any resident at risk [for developing a pressure ulcer] will be placed on a pressure redistribution surface as determined appropriate.* When a pressure ulcer is present, complete the Wound Data Collection UDA [user defined assessment] daily, documentation should include the following:-An evaluation of the ulcer, if no dressing is present .-The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection.* If the pressure ulcer is not determined to be clinically unavoidable, the ulcer should show signs of improvement within two to four weeks. Signs of improvement might include decrease in size of the wound (length times width), decrease in the amount of exudate [drainage] and improvement in the tissue type.* Observations of the ulcer's characteristics may be documented by a licensed nurse and should include at least the following:-Measurements - length, width, depth-Characteristics of the ulcer - including wound bed, undermining, and tunneling, exudate, surrounding skin, etc.-Presence of pain-Current treatments.

Based on interview, record review, policy review, South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, and staffs' training records review, the provider failed to ensure the residents were protected from risk of injury or harm by staff members failing to safely use lift devices and to provide supervision for:*One of one sampled resident (100) who sustained a skin injury to his buttocks after a total body lift (a mechanical lift and sling used to lift a person's full body) was pulled out from under him by registered nurse (RN)/former director of nursing (DON) DD.*One of one sampled resident (36) identified as unable to safely operate a lift recliner chair and sustained a skin laceration to his head when he fell from that chair onto the floor after being left unsupervised.*One of one sampled resident (10) identified as needing to be transferred by two members with the use of a sit-to-stand lift (a mechanical device used to assist from a seated to a standing position) and fell after certified nursing assistant (CNA) (N) transferred the resident with that lift, without the assistance of another staff member.*One of one sampled resident (93) identified at risk for elopement (leaving the facility without staff knowledge) who eloped and remained outside unsupervised for about five minutes on 9/12/25. Findings include:1. Interview on 3/4/26 at 1:59 p.m. with certified nurse assistant (CNA) X revealed: *Resident 100 had a wound on his right buttocks area that had healed, then it opened back up. *He thought he was repositioned every 2 hours (hrs) and his incontinence brief was changed every hour. 2. Interview on 3/4/26 at 2:06 p.m. with CNA W regarding resident 100's wound revealed: *He stated he had wound on his buttock that had a wound vac (a device that uses negative pressure to remove excess fluid and debris from a wound to promote wound healing). *He stated that resident 100 developed the wound while he was on the rehab unit. *He stated that resident 100 had a mechanical lift sling placed underneath him for a transfer, and it scraped him when they removed it. CNA W stated the sling caused a rash, then it opened. *He thought that the wound was avoidable. 3. Interview on 3/5/26 at 9:17 a.m. with RN J regarding resident 100 revealed: *She had finished checking his wound, which involved making sure the wound vac was working, monitoring for redness, swelling, warmth, and that the dressing was secure. *She stated wound care was completed by the wound care clinic on Mondays, Wednesdays, and Fridays, and the floor nurses checked it daily. *She stated that he had the wound when he was admitted , and he had no other wounds. 4. Interview on 3/5/26 at 11:58 with assistant director of nursing (ADON) G regarding resident 100's wound revealed: *Resident 100 had an abscess (confined pocket of pus, bacteria, and dead tissue) while he was in the hospital, which had opened. *He stated that the wound was not from a sling while he was in the rehab unit. 5. Interview on 3/5/26 at 2:00 p.m. with minimum data set (MDS)/wound nurse RN F regarding resident 100's wound revealed: *She was the wound nurse. *She was present in the residents room when he acquired the wound to his right buttock. *She stated registered nurse (RN)/former director of nursing (DON) DD attempted to pull a mechanical lift sling from under the resident and caused that wound. *She stated the wound was not from pressure, it was from shearing, and the wound was avoidable. *She stated he was sent to the hospital for an unrelated issue and the staff discovered the resident was septic. She stated that after further investigation and scans they discovered the wound was deeper than they thought and was tunneling (wound that extends from the skin surface into deeper tissue layers, forming narrow channels or passageways). *She stated the resident returned from the hospital with a wound vac. 6. Review of resident 100's electronic medical record (EMAR) revealed: *He was readmitted to the facility on [DATE]. *He did not have a Brief Interview of Mental Status (BIMS) assessment score completed and he was nonverbal. *His diagnoses included: -Quadriplegia (paralysis of all four limbs and he torso), Unspecified open wound of right Buttock sequela. *His care plan revealed he had a focus area of impairment to skin integrity related to a shearing injury to the right buttock that was initiated on 8/12/25. *His care plan interventions regarding his right buttock were identify potential causative factors and eliminate/resolve where possible, turn and reposition him in bed every two to three hours, weekly skin observations by a licensed nurse, provide a pressure-relieving/reducing mattress on his bed and/or cushion in his wheelchair. *His 8/8/25 wound assessment indicated that the wound was caused by friction/shearing. It was an open area that measured 0.9 cm (centimeters) in length by 0.2 cm in width by 0.1 cm in depth, and it was not present on admission/readmission to the facility. The physician was notified, and the wound was cleansed, and a barrier cream was applied to it. The assessment was signed as completed on 8/10/25 by RN Z. 7. Interview on 3/5/26 at 2:00 p.m. with DON B regarding resident 100's wound revealed: *She was not aware that the wound was caused by shearing related to the removal of the mechanical lift sling from under the resident. *She was not sure what policy would address accident hazards regarding that incident. 8. Interview on 3/5/26 at 4:15 p.m. with administrator A regarding resident 100's wound revealed: *He did not have an accident hazards policy regarding mechanical lift slings. *He was not aware that resident 100 had a facility acquired wound from a mechanical lift sling. 9. Review of the provider's 12/12/25 Safe Resident Handling Program (SRHP) Overview revealed: *Good Samaritan's goal is to maintain a safe living and working environment for residents and employees. The Safe Resident Handling Program (SRHP) supports this goal. Each location will follow SRHP practices when performing mobilization and other care tasks that require employee assistance. 10. Interview on 3/4/26 at 3:14p.m. with resident 36's family member revealed: *He was informed resident 36 was transferred to his lift chair (recliner) by the staff after they completed his personal cares. After the staff left the room the chair control somehow activated and lifted him all the way up, and he fell on the floor, and had hit his head. 11. Interview on 3/5/26 at 10:32 a.m. with occupational therapist registered and licensed (OTR-L) AA, revealed: *She would have completed resident 36's lift chair safety assessment, but she did not work for the provider at that time. She stated that the nursing staff also completed lift chair assessments. *She was not aware of a resident's fall that involved a lift chair. 12. Interview on 3/5/26 at 9:17 a.m. with RN J revealed: *Resident 36 had one fall in the last two months. *She thought that he may have slipped out of his wheelchair, but he had no injuries. 13. Interview on 3/5/26 at 2:30 p.m. with DON B revealed: *She stated that resident 36 did not have any falls regarding the requested fall information. *She stated that she would look further when this surveyor verbalized that he had fallen, and one fall involved a lift chair. *She stated that resident 36 had one lift chair safety assessment completed 12/27/25. 14. Review of resident 36's (EMR) revealed: *He was admitted to the facility on [DATE]. *His diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) and Parkinson's Disease without Dyskinesia (a movement disorder characterized by erratic and uncontrollable muscle movements). *He had a BIMS assessment score of 3, which indicated his cognition was severely impaired. *His care plan indicated on 9/27/24 that he had an activities of daily living (ADL) self-care performance deficit related to Parkinson's Disease, pain, shortness of breath, and dementia. His interventions indicated that a lift chair assessment was completed on 10/1/25 and 12/27/25, which indicated he was unable to demonstrate the safe use of the lift chair/remote, and that the remote was to be placed out of his reach. *His 12/27/25 lift chair assessment revealed he was unable to demonstrate safe use of the lift chair and needed his wife or son to operate it for him. 15. His 9/22/25 progress indicated: Resident 36 was found lying on his right side on the floor. He had a cut on his skin above his right eyebrow that measured 2 cm in length by 0.2 cm in width, and was bleeding. He was conscious, alert, able to move all four limbs, denied having pain, and answered the staff's questions. The staff checked his vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate), which were not documented, and his neurological evaluation (assessment of nerve function, reflexes, coordination, motor skills, sensation, and mental status) was completed. RN Y placed a bandage on his cut above his right eyebrow and notified the resident's family and physician of his fall. Before his fall, resident 36 was sitting in his recliner and had the remote tucked over the recliner. 16. Review of the providers 9/22/25 Fall Scene Huddle Worksheet regarding resident 36 revealed: *Resident 36 was found on the floor. *A CNA had transferred him to his recliner five minutes before his fall. *He had diarrhea that day, and last went to the bathroom at 9:00 a.m. *Resident 36 seemed alert and oriented before and after his fall. *His range of motion (measurement of movement around a joint or body part) was within normal limits, and he had a skin tear above his right eyebrow. 17. Review of the provider's 9/23/25 fall interdisciplinary review for resident 36 revealed: *He had a skin laceration to his right eyebrow. *His fall was not reported to the South Dakota Department of Health. *They were unsure of his last fall occurred. *The staff were to complete a lift chair assessment for resident 36. 18. Review of the provider's 9/12/25 submitted FRI regarding resident 93 revealed: *On 9/12/25 at 2:00 p.m. resident 93 had eloped from the front door entrance of the facility. *Resident 93 was not observed leaving the facility and was missing approximately five minutes before staff intervened according to the video footage that was reviewed by the facility leadership. *When approached by the staff, resident 93 stated she wanted to go home and refused to come back into the facility. *The resident eventually agreed to go to the hospital for an examination after much encouragement and a phone conversation from her brother. *Resident 93 was examined at the hospital emergency department and discovered to have a urinary tract infection. -She was hospitalized and returned to the facility with her family transporting her back on 9/17/25. *The resident had no prior elopements from the facility. *Resident 93's family planned to move her to a facility in another state to be near her family members by 10/1/25. *Following the incident, the provider immediately provided re-education to the staff who were on duty of the provider's elopement policy and procedure, and planned to re-educate all other staff by 10/2/25. *Weekly elopement drills were to be conducted for one month, bi-weekly for one month, then monthly for four months. *All residents with a WanderGuard (a wearable door alarming device) would be checked for proper function each shift by nursing staff and recorded on the resident's treatment administration record. *DON or designee would audit one resident WanderGuard per week for one month, bi-weekly for one month, then monthly for four months. 19. Review of resident 93's EMR revealed: *She was admitted to the facility on [DATE]. *Her BIMS score was 7, which indicated her cognition was severely impaired. *Her diagnoses included dementia (cognitive communication deficit), anxiety, depression, and a history of a femur and cervical spine level two fractures. *She required the assistance of one staff member for bathing, bed mobility, dressing, and personal hygiene, but was independent with ambulation (walking) around the facility. *She wore a C-collar (a type of brace used to stabilize the neck). *Resident 93's revised 8/28/25 care plan revealed: -A focus area: The resident has impaired thought processes R/T [related to] cognitive communication deficit/dementia. --Goal: Resident will be safe in their own environment as evidenced by: not eloping, not wandering into other resident rooms, etc. --Identified interventions for that goal included that staff were to ask yes/no questions to determine her needs, cue, reorient, and supervise as needed. A WanderGuard was to be used to alert the staff to her movements and help monitor her, and the staff was to offer her assistance by calling her brothers, helping her shower, or offering her a Diet Coke or candy. 20. Interview on 3/4/25 at 8:40 a.m. with RN C revealed: *She was working in the facility the day of resident 93's elopement. *RN C observed staff sitting, interacting, and attempting to keep resident 93 occupied on 9/12/25 because she made statements that she wanted to leave and to go home. *When resident 93 eloped, the staff stayed with her to ensure that she remained safe. *Education was provided to the staff following the elopement incident on 9/12/25 of the provider's elopement process to follow. *A code yellow is called over the intercom system in the event a door alarm goes off. *The door alarms are loud and easily heard by the staff. *A list of current residents with a WanderGuard was kept at the nurse station in the event a door alarm sounded, which indicated a possible resident elopement. *Nursing would take the lead with giving out resident assignments to the staff. *Each staff completed a head count for the residents on their list, and they reported back to nursing. *All residents needed to be accounted for before the nurse in charge would give an all clear to resume normal activities. *Education was initiated by leadership and provided to all staff members following that elopement incident. -Elopement drills were held to ensure the staff knew the process to follow in the event a door alarmed. -Nurses were to check every shift for the resident's WanderGuards and document them on the resident's treatment administration record (TAR) to ensure each resident's WanderGuard functions properly. The device used to check the WanderGuard functions was kept in the locked medication cabinet. 21. Interview on 3/4/26 at 1:40 p.m. with RN Nurse Manager R revealed: *She was the nurse manager in charge of the rehabilitation unit. *Resident 93 was admitted to the facility on [DATE] for rehabilitation services. *Her room was located on the long-term care side of the facility and not in the regular rehabilitation services hallway which was not unusual. *An elopement assessment was completed with her admission, and resident 93 was not identified as an elopement risk at that time. *The family had let the facility staff know they were interested in a permanent placement for resident 93, but the resident stated she did not want to stay at the facility long term and wanted to return to her apartment. *After resident 93 became aware of the family plan for her to stay long term, she started to make statements about not wanting to be there and that she wanted to go home. *An updated elopement risk assessment was completed after those statements began and a WanderGuard was added on 8/27/25 as an intervention and added to her care plan. -The family agreed with the proposed WanderGuard intervention, and a physician's order for it was obtained on 8/27/25. *On days resident 93 had made statements about wanting to go home or to leave the facility, the staff were usually able to distract her from those thoughts by offering to call her family or to talk about her dog. *The day that she eloped from the facility she was near the front entrance area and making statements that she did not want to be there. *The staff were keeping a close eye on her due to those statements and interacted with her to help distract her thought process from wanting to leave. *RN nurse manager R was aware that resident 93 eloped that day but was not involved with the incident. *No other resident elopements occurred since resident 93's incident on 9/12/25. 22. Interview on 3/4/26 at 2:02 p.m. with administrator A revealed: *He was working inside his office on 9/12/25 at the time resident 93 eloped from the facility. *Resident 93 was making statements earlier in the day that she wanted to go home. *Administrator A believed he was the first staff member to find resident 93 when he saw her outside of his office, which was located next to the front door entrance. *Resident 93 was seated on a bench outside of the building which was next to his office window, and he recognized that she was to have staff supervision. *He thought only a few minutes had passed before her discovery and he had approached her. *While resident 93 was seated on the bench, he attempted to reason with her to come back inside, but she refused. *She then got up and walked away toward a nearby car because she believed it was her personal car and stated she was going to use it to leave and go home. *Resident 93 became angry and suspicious of administrator A at this time because he had tried to talk her out of entering the car. *She refused to go back into the building, but she walked back and sat on the same bench again. *Several other staff members attempted to intervene with resident 93 but were unsuccessful in bringing her back inside. *Resident 93's brother and power of attorney (someone designated on a legal document to act on behalf of a resident) was contacted by telephone and had a conversation with resident 93, but he was also unable to talk her into going back inside the building. *Eventually she agreed with the staff to be evaluated at the emergency department and was transported by a facility vehicle with two staff members. *She was hospitalized with a urinary tract infection and remained at the hospital for treatment and then returned to the facility. *The family decided to discharge resident 93 to another facility near them in Illinois and she was discharged on 10/1/25. *As a result of resident 93's elopement, the provider had implemented door audits to ensure alarms functioned correctly, nursing checked all residents with a WanderGuard for proper function each shift, elopement drills were conducted, and all the staff were re-educated on the provider's elopement policy and procedure. 23. Interview on 3/5/26 at 8:00 a.m. with clinical learning and development specialist S and DON B revealed: *Clinical learning and development specialist S was responsible for training new staff members and ensuring that all the staff were up to date with the required ongoing training. *The majority of the facility training was assigned and provided online. *He could run reports for all the staff to see what training they had to complete. *Each staff member was assigned the required training, and he checked to ensure that their training was completed on time. *If a staff member did not complete the training as assigned and it was near the required completion date, he was alerted and would then contact that staff member by email to remind them to do the training before the completion date passed. *If there were continued issues, DON B received alerts and would also contact the staff member with reminders. *The elopement training that was conducted after the 9/12/25 incident was completed in person by the staff with DON B and administrator A. *The staff who were educated had signatures on a sign in sheet to indicate they completed the elopement training. *He was not aware that there were staff who did not attend that training. *He stated administrator A and DON B did not communicate to him that he was to ensure all the staff had completed that training, but he would have if he was informed. 24. Interview and audit review on 3/5/26 at 9:15 a.m. with maintenance supervisor T revealed: *The maintenance department was responsible for conducting the audits for the door alarm function when a resident's WanderGuard was triggered. *The audits were completed weekly after resident 93's 9/12/25 elopement and were currently being done once a month. *The audits included the use of a WanderGuard to ensure that the door alarm triggered appropriately when the WanderGuard was near an exit door. *The surveyor verified that these audits were completed. *No resident had eloped from the facility since the 9/12/25 incident. *He believed he was working the day of the 9/12/25 elopement but was not directly involved. *He stated a staff member stationed at the front desk was assisting the family of a resident who had a WanderGuard on to leave the building for an outing. *When the door alarmed, the staff thought it was due to the resident who was leaving who also had a WanderGuard. -The same staff member did not notice resident 93 near the front door entrance when the family and other resident were leaving the facility. -She turned to reset the alarm and did not notice resident 93 follow the family and resident outside of the building. *Resident 93 was out of the building for a few minutes before she was discovered and the staff had intervened. 25. Interview on 3/5/26 at 9:20 a.m. with CNA U revealed: *The staff were provided with re-education on the procedure to follow when a resident eloped from the facility. *She had heard about resident 93's elopement but was not involved with the incident. *Elopement drills were being conducted regularly so the staff would be familiar with what to do in the event a door alarmed. *In the event of a suspected resident elopement, a code yellow would be called over the intercom system to alert the staff. *The staff would report to their unit nurse station for instructions and resident assignments. *Once the resident assignments were given, the staff would conduct room-to-room searches ensure every resident was accounted for. *When the resident assignments were completed, the staff would check in at the nurse station. *After all the residents were accounted for, the designated person in charge would give an all clear on the overhead intercom system to resume regular facility activities. *She was not aware of any other resident elopements taking place after the 9/12/25 incident with resident 93. 26. Review of the staff re-education completion sheets regarding the provider's elopement policy and procedure revealed: *The elopement training was completed over several days according to the dates listed next to the staffs' signatures on the completion sheets. *There were ten staff members on the re-education completion sheets who did not receive the required elopement training. 27. Interview on 3/5/26 at 10:30 a.m. with administrator A revealed: *Administrator A and DON B had conducted the elopement policy and procedure re-training for their staff. *The elopement policy and procedure did not change. *He was not aware there were ten staff members who had missed the elopement re-education training but expected all staff to receive the training. *He expected the clinical learning and development specialist to have checked to ensure all staff had received the elopement training, but that did not happen. *He agreed he was responsible for ensuring all staff were trained. *No further documentation was provided to indicate that those ten employees had received the elopement re-education training. 28. Interview on 3/5/26 at 2:00 p.m. with DON B and administrator A revealed: *The resident WanderGuard audits of the TAR that were to be conducted by the DON or designee as reported in the 12/1/25 FRI submitted for resident 93 were not completed and should have been. *They both agreed the elopement re-education training was not completed for all staff and should have been. *DON A stated administrator A and she had been working on their follow-up of facility incidents. *They did not complete all interventions for resident 93's elopement as they had planned and recognized they had issues with the completion of documentation to ensure that future incidents did not occur. 29. Review of the provider's revised 4/7/25 Elopement policy and procedure revealed: *The SNF [skilled nursing facility] location and each Adult Day Program will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring residents/clients at risk for elopement. These include identifying, evaluating and analyzing environmental hazards and risks; and implementing, monitoring and modifying interventions as needed. All SNF residents will be assessed for risk of elopement through the pre-admission and/or admission process and as needed. All Adult Day clients will be screened for risk of elopement through the intake process and as needed. Each SNF location and Adult Day Program will put measures in place to minimize the risk of elopement that are individualized to resident/client needs and identified on the care plan. When an elopement occurs, immediate efforts to locate the resident/client will be taken. All occurrences will be documented, and follow-up will be completed as required by state and federal regulations. 30. Review of the provider's 12/1/25 FRI regarding resident 10 revealed: *On 12/1/25, a post-fall huddle [when the staff gathered to discuss information available related to a resident's fall] form review was completed by the provider leadership, and it was determined that a report would be submitted to the SD DOH regarding resident 10's fall. -The fall report was not reported to the SD DOH within the required 24-hour reporting window. *On 11/28/25 at 11:30 a.m. CNA N was transferring resident 10 with a sit-to-stand mechanical lift (a mechanical lift used to assist from a seated to a standing position) from the toilet to his wheelchair. *Before the resident was able to be positioned and lowered into the wheelchair, he slipped and slid out of the sling and onto the floor on his bottom, then rolled onto his right side. *The nursing staff came to the room immediately and completed a physical assessment of resident 10. *The resident indicated he bumped his head and Neurological evaluation (assessment of nerve function, reflexes, coordination, motor skills, sensation, and mental status) (neuros) and vitals were completed and within normal limits. *Notifications were made to the family and resident 10's medical provider. *CNA N was educated regarding the need for a second staff member when completing transfers with the sit-to-stand with resident 10. *The provider's investigation of the fall revealed that the sit-to-stand lift was functioning properly, the correct sling size was used, but CNA N had failed to follow resident 10's care plan, which indicated he was to be transferred using the sit-to-stand mechanical lift with the assistance of two staff members. *The provider planned to implement education to all CNAs regarding resident transfer status and to follow the residents' care plans. *Safe resident handling audits were to be completed by DON B or designee including: -The review of five random residents' care plan per week observing the resident transfers, weekly for eight weeks, biweekly for two months, and monthly for two months. -All resident care plans were to be reviewed by 12/9/25 to ensure their resident transfer status was correct. 31. Review of resident 10's EMR revealed: *He was admitted to the facility on [DATE]. *His Brief Interview of Mental Status (BIMS) assessment score was 00, which indicated he could not be interviewed. -Resident 10 was able to make his needs known by gesturing with his hands and with a head shake or nod. *His diagnoses included aphasia (a language disorder commonly caused by stroke or injury that impairs the ability to speak, understand, read, and write), and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke) affecting the right side. *He required the assistance of one staff member for bed mobility, dressing, oral care and personal hygiene. *He required the use of a sit-to-stand mechanical lift with the assistance of two staff members for transfers. *He was dependent upon the staff to ensure his care plan was implemented and followed. Resident 10's care plan revised on 12/17/25 revealed an identified problem of, The resident has an ADL [activities of daily living] self-care performance deficit R/T [related to] obesity, pain/osteoarthritis, stroke with hemiparesis, expressive and receptive aphasia, OA [osteoarthritis], RUE/RLE [right upper extremity/right lower extremity] paralysis, LICA [left internal carotid artery] and [NAME] [right internal carotid artery] stenosis, low back pain and arthritis, and vitamin D deficiency E/B [evidenced by] assist needed with ADLs. -Identified interventions for that problem area included: Transfer between surfaces: mechanical sit to stand assist of 2 [staff members]. Sling size XL [extra-large], staff to assist right arm on bar. Initiated: 9/15/25. 32. Interview on 3/3/26 at 11:55 a.m. with CNA I revealed: *CNA I had worked at the facility for 13 years and was a CNA for 30 years. *Usually, she was scheduled to work in restorative, but also worked as a CNA when needed. *When the staff were working with the residents, the expectation was that they would consult the Kardex (a report of the resident's care needs and interventions), the whiteboard (a dry erase board used for communication) within the resident room, or use their computer tablets to ensure the residents care plan was followed. There were several resources that were available to the CNAs in each hallway of the facility. *The gait belts and slings for mechanical lift transfers were hung on the backside of the entrance door in each resident room. -Each resident's sling size was indicated in their individual care plan. *There were to be two staff members to assist with all full body lift (a mechanical lift and sling used to lift a person's full body) transfers. *If a sit-to-stand mechanical lift was used, it could either be one or two staff members involved, depending on the resident's needs. *The facility expectation was that CNAs would check the resident's care plan before assisting a resident to ensure their care plan was being followed correctly. *Resident 10 was known to need two staff to assist him with sit-to-stand mechanical lift transfers. 33. Interview on 3/4/25 at 8:40 a.m. with RN C revealed: *She had worked at the facility for 27 years. *Care plans were initiated by the MDS coordinators or the admissions nurse. *When there were care plan updates, the nursing leadership usually made those changes. *She expected the CNAs to ask nursing if there were any questions or concerns about the residents. *The CNAs should check the resident care plans for the correct way to care for and assist the resident. 34. Interview on 3/4/26 at 11:35 a.m. with CNA N regarding resident 10 revealed: *She was a CNA for a year but was hired by the facility on 11/4/25. *During her orientation training at the facility she thought she remembered ot

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the staff completed and documented controlled medications (medications at risk for abuse and addiction) supply counts for five of five medication carts (Mystic Ranch, Park View, Focus, East, and [NAME] Lane), failed to prevent the theft of one of one sampled resident's (94) controlled pain medication (oxycodone) by registered nurse (RN) FF, and failed to ensure insulin was administered according to the physician's order for one of one sampled resident (10) who was evaluated at an emergency room after being administered the wrong insulin by licensed practical nurse (LPN) CC.Findings include:1. Review of the provider's 12/18/25 FRI involving resident 10's medication error revealed: *On 12/17/25 at 8:45 p.m. LPN CC administered the incorrect insulin to resident 10. *His insulin medication orders were to inject Novolog) a fast-acting insulin according to the sliding scale: *Novolog sliding scale order indicated if his blood sugar was: -between 60 and 150, to inject zero units. -between 201 and 250, to inject two units. -between 251 and 300, to inject four units. -between 301 and 350, to inject six units. -between 351 and 400, to inject eight units. *The physician was to be notified if his blood sugar level was less than 70. *He was to be given 18 units of Novolog with his breakfast meal and 15 units daily with his noon and evening meals. *He was to receive 38 units of Tresiba (a long -acting insulin) one time a day. *LPN CC noticed she injected the resident with Novolog and not the Tresiba. *The resident's primary provider was called immediately and requested that the resident be sent to the emergency room (ER) for overnight observation. *The resident was alert, non-verbal, and easy to arouse. *The resident's wife was notified of the insulin error. *His blood sugar was 234, and no other vital signs were obtained. *Resident 10's blood sugar levels remained stable in the ER, with the lowest level of 100. *Resident 10 returned to the facility on [DATE] at 4:16 a.m., and he had no adverse effects from that incident. *There were no new physician's orders or orders to hold any of his medications. *The facility's investigation revealed that the resident's insulin pens were stored in one bulk container on the medication cart. *LPN CC stated she did not realize which insulin she had until she was administering the units to the resident. *The insulin medications were now stored in the medication drawer in the medication cart, and every resident had their own container of their insulin medications. *Insulin education was provided to LPN CC and for all nurses by 1/1/26. 2. Observation and Interview on 3/3/26 at 11:24 a.m. with resident 10 revealed: *He was in a wheelchair with headphones on and was watching television (TV). *He took his headphones off, indicated he was non-verbal and shook his head to respond yes or no to questions asked. *He acknowledged that he received good care from the staff, and that he did not have problems with his insulin. *He indicated that he received good care from the staff, and that he did not have problems with his insulin. 3. Review of resident 10's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *Diagnoses included: hyperglycemia (high blood sugar) and Type 2 Diabetes Mellitus with Diabetic Neuropathy. 4. Interview and observation of the medication care on 3/4/26 at 4:20 p.m. with LPN CC regarding resident 10's incident above and insulin storage revealed: *When she went to administer resident 10 his Tresiba , she took his Tresiba and Novolog insulin pens to his room. *She dialed the insulin dose and while she was injecting him with that insulin, she realized it was the Novolog pen, which was the wrong insulin. *She stated she stopped the injection, but she had already administered the resident a significant amount of the incorrect medication. *She called director of nursing ( DON) B to discuss the error and was directed to call 911. *She explained to resident 10 that she had given him too much insulin and she would send him to the ER. She contacted his wife regarding the medication error. *She stated that resident 10 had done well and returned to the facility within a few hours, but not during her shift. *Before that incident, all residents' insulin pens were stored together in one container in the medication cart. *The insulin pens were stored in the medication cart in separate containers for each resident and were labelled with their names. *She did not remember being educated regarding storing the insulin pens in individual containers, but noticed the resident-specific insulin containers during the next shift she worked. 5. Observation of the medication carts and interview on 3/5/26 at 10:08 a.m. with registered nurse (RN) C revealed: *The medication carts had separate containers in them that were labelled with each resident's name and contained their individual insulin pens. *She stated the new insulin storage containers process was started two to four months ago. She received education to keep the residents' insulin pens stored separately. 6. Interview on 3/5/26 at 2:00 p.m. with DON B regarding the 12/17/25 incident with resident 10 and insulin storage revealed: *She was called right away regarding the insulin error involving resident 10 by LPN CC. *She stated the resident did not have a negative outcome from receiving the wrong insulin and had been monitored in the ER. *She stated LPN CC had been educated regarding medication errors but DON B did not have documentation to support that had occurred. *She stated each resident had a container in the medication cart that was labelled and contained their insulin pens. 7. Review of the provider's 3/3/26 Medication Error policy revealed that medication errors were defined as: *The observed or identified preparation or administration of medications or biologicals which are not in accordance with prescriber's order, manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological or accepted professional standards and principles which apply to professionals providing services. 8. Review of the provider's 9/18/25 FRI regarding resident 94 revealed: *On 9/17/25 at approximately 6:10 a.m. DON B was notified that the Mystic Ranch hall medication cart had a discrepancy in its controlled drug (medications with risk for abuse and addiction) count. *Resident 94's bottle of oxycodone (a controlled pain medication) 5 milligram (mg) tablets were counted by the on-coming and off-going nurses and was found to have 84 halved tablets, but the Controlled Drug Count Record sheet indicated there was supposed to be 90 halved tablets in the bottle. *DON B removed the bottle of oxycodone from the Mystic Ranch medication cart and initiated an investigation into the oxycodone that could not be accounted for. *The bottle of oxycodone had arrived at the facility from the pharmacy on 9/11/25. *The Individual Resident's Narcotic Record for resident 94 did not have a signature of the nurse who received that bottle of oxycodone and verified the bottle contained the correct amount of oxycodone in it. *DON B identified through her investigation that RN FF had cut the oxycodone 5 mg tablets in half to equal the 2.5 mg dose that was ordered to be given to resident 94 on 9/11/25. *Resident 94's oxycodone tablets were not counted after they were cut by RN FF and put into the locked medication drawer in the medication cart. *The 9/11/26 evening nurse placed a piece of tape over the top of the bottle of oxycodone without counting the pills in that bottle to prevent staff from using that bottle of oxycodone. *That bottle of oxycodone was not counted until 9/17/25, when the discrepancy was found. *On 9/17/25 at 2:33 p.m. DON B and administrator A spoke with RN FF on the telephone. -RN FF denied that she had cut resident 94's oxycodone tablets in half, stating she was allergic to oxycodone. *DON B reviewed the facility's video footage from 9/11/25 at the west nurses' station where she identified RN FF putting a pill in her hand, placing the pill in her mouth, and then she took several drinks of water. *On 9/23/25 at 8:51 a.m. administrator A, DON B, and human resources lead GG called RN FF on the telephone to discuss the events on 9/11/25 when RN FF was on video surveillance cutting resident 94's oxycodone tablet in half. -RN FF stated she had a problem and human resources lead GG ended the phone conversation by telling RN FF she was terminated for theft related to consuming medications that did not belong to her. *DON B determined there were six halved tablets of oxycodone 5 mg that could not be accounted for. *All medication carts were audited for controlled medications and it was determined that there were no other controlled medications that were not accounted for. *DON B started audits on the controlled drugs in the medication carts and the Controlled Drug Count Record sheets and began educating staff on controlled medication counts and the cutting of medications. 9. Observation on 3/4/26 at 1:32 p.m. of the three-ring binder on the Park View medication cart revealed that on 3/3/26 at 11:00 p.m. the on-coming nurse did not sign the Controlled Drugs Count Record sheet to indicate a count of the controlled medications were completed with no discrepancies. 10. Interview on 3/5/26 at 2:30 p.m. with RN C revealed: *The controlled drugs were to be counted by the on-coming and off-going nurses at the change of each shift, or if the keys to the medication cart are exchanged between nursing staff members and then documented on the Controlled Drugs Count Record. *The off-going nurse was to review the Individual Resident's Narcotic Record while the on-coming nurse counted the medications. *She did not recall being educated on the controlled drug count process. She stated process was the same for years. *The nursing staff was educated during a nurses' meeting to remember to count the controlled medications between each shift and sign the Controlled Drugs Record to indicate the drug count was completed and accurate. 11. Review of the December 2025 Controlled Drugs Count Record sheets on the Mystic Ranch medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 12/4/25. *The controlled drug count was not signed as completed with no discrepancies by the 7-3 shift off-going nurse and the 3-11 shift on-coming nurse on 12/14/25 and 12/22/25. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 12/1/25, 12/3/25, and 12/28/25. 12. Review of the December 2025 Controlled Drugs Count Record sheets on the Focus medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 12/3/25 and 12/31/25. *The controlled drug count was not signed as completed with no discrepancies by the 7-3 shift off-going nurse and the 3-11 shift on-coming nurse on 12/12/25. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 12/30/25 and 12/31/25. 13. Review of the December 2025 Controlled Drugs Count Record sheets on the East medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 12/3/25 and 12/27/25. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 12/2/25 and 12/29/25. 14. Review of the December 2025 Controlled Drugs Count Record sheets on the Park View medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 12/4/25, 12/6/25, 12/15/25, and 12/27/25. *The controlled drug count was not signed as completed with no discrepancies by the 7-3 shift off-going nurse and the 3-11 shift on-coming nurse on 12/14/25, 12/22/25, 12/26/25 and 12/27/25. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 12/5/15, 12/14/25, 12/18/25, 12/23/25, 12/24/25, and 12/31/25. 15. Review of the December 2025 Controlled Drugs Count Record sheets on the [NAME] Lane medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 12/4/25 and 12/27/25. *The controlled drug count was not signed as completed with no discrepancies by the 7-3 shift off-going nurse and the 3-11 shift on-coming nurse on 12/9/25, 12/17/25, and 12/31/25. 16. Review of the January 2026 Controlled Drugs Count Record sheets on the East medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 1/6/26 and 1/22/26. 17. Review of the January 2026 Controlled Drugs Count Record sheets on the [NAME] Lane medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 1/30/26. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 1/2/26. 18. Review of the January 2026 Controlled Drugs Count Record sheets on the Park View medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 1/2/26, 1/14/26, and 1/21/26. *The controlled drug count was not signed as completed with no discrepancies by the 7-3 shift off-going nurse and the 3-11 shift on-coming nurse on 1/14/26 and 1/15/26. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 1/1/26 and 1/6/26. 19. Review of the January 2026 Controlled Drugs Count Record sheets on the Mystic Ranch medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 1/25/26. *The controlled drug count was not signed as completed with no discrepancies by the 7-3 shift off-going nurse and the 3-11 shift on-coming nurse on 1/23/26 and 1/25/26. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 1/1/26, 1/2/26, 1/3/26, 1/5/26, 1/21/26, 1/24/26, and 1/28/26. 20. Review of the February 2026 Controlled Drugs Count Record sheets on the Mystic Ranch medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 2/5/26, 2/7/26, 2/10/26, and 2/19/26. *The controlled drug count was not signed as completed with no discrepancies by the 7-3 shift off-going nurse and the 3-11 shift on-coming nurse on 2/6/26, 2/10/25, 2/20/26, 2/21/26, and 2/22/26. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 2/2/26, 2/4/26, 2/18/26, and 2/21/26. 21. Review of the February 2026 Controlled Drugs Count Record sheets on the [NAME] Lane medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the 7-3 shift off-going nurse and the 3-11 shift on-coming nurse on 2/25/26, and 2/27/26. 22. Review of the February 2026 Controlled Drugs Count Record sheets on the Park View medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 2/5/26. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 2/3/26. 23. Review of the February 2026 Controlled Drugs Count Record sheets on the Mystic Ranch medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the on-coming nurse under the 7-3 shift heading and the off-going nurse under the 11-7 shift heading on 2/5/26, 2/7/26, 2/10/26, and 2/19/26. *The controlled drug count was not signed as completed with no discrepancies by the 7-3 shift off-going nurse and the 3-11 shift on-coming nurse on 2/6/26, 2/10/25, 2/20/26, 2/21/26, and 2/22/26. *The controlled drug count was not signed as completed with no discrepancies by the 3-11 shift off-going nurse and the 11-7 shift on-coming nurse on 2/2/26, 2/4/26, 2/18/26, and 2/21/26. 24. Review of the February 2026 Controlled Drugs Count Record sheets on the East medication cart revealed: *There were three headings labeled 7-3 Shift (7:00 a.m. to 3:00 p.m.), 3-11 Shift (3:00 p.m. to 11:00 p.m.), and 11-7 Shift (11:00 p.m. to 7:00 a.m.). *Below those headings were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was not signed as completed with no discrepancies by the 7-3 shift off-going nurse and the 3-11 shift on-coming nurse on 2/27/26. 25. Interview and review of the Controlled Drugs Count Records on 3/5/26 at 5:43 p.m. with DON B revealed: *Education was provided to the nursing staff related to controlled medication counts to ensure all controlled medications were accounted for after resident 94's oxycodone could not be accounted for on 9/17/25. *Resident 94's oxycodone was changed to be supplied by a local pharmacy so it would arrive in half tablets and in a bubble pack to prevent the need to cut the pills and to be easier to count to ensure they were accounted for. *DON B reviewed the Controlled Drugs Count Record sheets intermittently, but she was not auditing them routinely. *She expected the controlled drugs were counted by the on-coming and off-going nurse at each shift change and any time the keys to a medication cart were exchanged. *The signatures on the controlled drug count record indicated that the count was completed and accurate. *She acknowledged there were missing signatures on the Controlled Drug Count Records. 26. Review of the provider's revised 10/20/25 Medication: Missing/Diversion of Medication – R/S, LTC, AL policy revealed: *Upon discovery of a medication that may be missing or diverted, notify the Director of Nursing/AL Nurse. Document the incident in SAFE Event Reporting application. *If controlled medication is discovered missing during perpetual count, consider: Recount, Checking addition and subtraction from previous activity, check the outdated medications. *Nursing employees with access to the medication cart are asked to search the cart, their pockets and surrounding areas for the missing medications. *An investigation of the situation is performed by the investigation team. *Notify the administrator, the state survey and certification agency, law enforcement, and other designated agencies in accordance with state law of a medication diversion. 27. Review of the provider's revised 3/4/25 Medications: Acquisition, Receiving, Dispensing, and Storage – R/S, LTC policy revealed: *It Is preferred that a licensed nurse receive and verify the medications. Once the medications are received, they will be secured in the appropriate storage area (i.e., medication cart or medication room). Licensed nurses and medication aides (when allowed by state law) are responsible for reconciling medications received. *Disposal will be done in accordance with state/pharmacy regulations. *Controlled drugs (Schedule II) and other drugs subject to possible abuse will be stored in separate, locked, permanently fixed compartments, except when a single unit package drug distribution is used. These drugs will be reconciled daily through an appropriate system of records of receipt and disposition established by the licensed pharmacist.

Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans (personalized plan to address a resident's care needs, goals, and interventions) were revised to reflect their current care needs for three of twenty-five sampled residents (6, 7, and 29). Findings include:1.Observation and interview on 3/3/26 at 9:24 a.m. with resident 6 revealed: *She was currently on a liquid diet. *Her nasogastric (NG) tube (a flexible tube passed through the nose, down the esophagus, and into the stomach to provide nutrition and medication) was removed at the end of February. *She used a NG tube for receiving nutritional formula and medications, but that was removed. 2. Observation on 3/3/26 at 11:57 a.m. of resident 6 in the dining room revealed she was drinking broth and eating Jello for lunch. 3. Interview on 3/5/26 at 7:51 a.m. with certified nursing assistant (CNA) I revealed: *The residents' diet orders were on their dietary meal tickets, and Kardex (a report of the resident's care needs and interventions). *The Kardex for resident 6 indicated she was NPO (nothing by mouth) and used an NG tube. 4. Observation and interview on 3/5/26 at 7:58 a.m. with licensed practical nurse (LPN) H revealed: *She had worked for the provider for seven and a half years. *The residents' diet orders were in their care plan and physician's orders. *Resident 6 takes her medications crushed with applesauce. *She agreed that her nursing cheat sheet (a compact report of resident needs and interventions for nurse's) indicated to administer resident 6's medications through her NG tube. *She agreed that resident 6's care plan stated that she was using an NG tube for eating. *She was able to update resident care plans. *If a resident received new diet orders, she would update the resident's care plan. 5. Observation and interview on 3/5/26 at 8:09 a.m. with resident 6 in the dining room revealed: *She was drinking broth, juice, water, and a Boost Breeze supplement drink for breakfast. *She thought her breakfast was good. *She was going to advance her diet to full liquids (foods that are liquid or melt at room temperature, plus strained cream soups, milkshakes, and pudding) in a couple of days. *She was tolerating the clear liquid diet well. 6. Review of resident 6's electronic medical record (EMR) revealed: *Her 11/25/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. *She had a 2/26/26 physician's diet order for clear liquids, with a thin consistency, which ended on 3/5/26. *She had a 3/6/26 physician's diet order for a full liquid diet, with a thin consistency, which would end on 3/13/26. *She had a 3/12/26 physician's diet order for a regular diet, with a minced moist texture with thin liquids. *She had diagnoses of: -dysphagia (difficulty swallowing). -gastro-esophageal reflux disease (GERD). *On 2/25/26 her NG tube was removed at her gastrointestinal (GI) appointment. *Her care plan indicated a focus area of activities of daily living (ADL) self-care performance deficit due to weakness, physical deconditioning, decreased balance, decreased activity tolerance. Decreased functional ambulation and mobility evidence by decreased independence with ADLs initiated on 7/23/25 and revised on 7/24/25. -Goal of she will improve current level of function in bed mobility, transfers, eating, dressing, toileting use and personal hygiene by the review date initiated on 11/24/25, revised on 11/24/25 with a target date of 4/30/26. -she had interventions of NPO, and received tube feedings. Those were initiated on 7/23/25 and revised on 7/24/25. *The 3/4/26 Kardex for resident 6 under eating/nutrition/hydration indicated she was NPO, and received tube feedings. 7. Interview on 3/5/26 with assistant director of nursing (ADON)/infection preventionist (IP) G revealed: *All the nurses were to update care plans for the residents. *On 2/26/26 after resident 6's diet order changed the interdisciplinary team (IDT) reviewed her care plan, and they missed changing her diet and removing the NG tube on her care plan. *The residents' care plans are reviewed on admission, as needed, quarterly, when there are significant changes in their care, and when a resident is discharged from the facility. *The nurses try to be timely with resident care plan updates, to ensure they are accurate. *The CNAs refer to the resident's Kardex which generates its information from the resident's care plan. *He was responsible for updating the nursing cheat sheets. 8. Interview on 3/3/26 at 10:58 a.m. with resident 7 in his room revealed: *He had experienced a lot of trauma in his life. *He had spoken to a counselor about his trauma, but not for quite a while. *He thought his post-traumatic stress disorder (PTSD) was under control, but he knew he could not turn on the television and see the conflict and bombing in the Middle East, or it might trigger his PTSD symptoms. 9. Review of resident 7's EMR revealed: *He was admitted to the facility on [DATE]. *His 1/30/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated his cognition was intact. *His diagnoses included PTSD, depression, insomnia (the inability to sleep), and mood disorder (a mental health condition characterized by long term extreme emotional states). *His 3/4/26 care plan did not include that he had PTSD, interventions to help him cope with his trauma history, or what the staff could do to prevent triggering a traumatic response. 10. Interview on 3/4/26 at 4:04 p.m. with resident 7 revealed he: *Had only spoken with his VA counselor about his past traumatic experiences. *Would have spoken with a facility staff member about those experiences if they had asked him. 11. Review of resident 29's EMR revealed: *She was admitted to the facility on [DATE]. *Her diagnoses included depression, dementia (a group of symptoms affecting memory, thinking, and social abilities), and anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). *She had a 3/27/25 physician's order for olanzapine (an antipsychotic medication) 5 mg (milligrams) at bedtime. *Her 3/5/26 care plan did not have a focus area related to her taking antipsychotic medications, monitoring identified behaviors that the antipsychotic medication was prescribed for, or non-pharmacological interventions for those behaviors. 12. Interview and record review on 3/5/26 at 11:55 a.m. with Minimum Data Set (MDS)/wound nurse F revealed: *She was responsible for updating the residents' care plans. *Care plans were to be updated anytime there was a change in that resident's care needs or a new class of medication prescribed. *She reviewed each resident's care plan quarterly, annually, as needed, and when a resident had a significant change MDS assessment completed. *She acknowledged resident 29's care plan did not indicate she was prescribed an antipsychotic medication, what her behaviors were or non-pharmacological interventions for those behaviors. *She stated that resident 29's use of antipsychotic medications, the potential side effects of that medication, her behaviors, and non-pharmacological interventions should have been included in the resident's care plan. *A resident with a diagnosis of PTSD was to have PTSD identified on the resident's care plan, along with potential triggers of the resident's PTSD, pharmacological, and non-pharmacological interventions to prevent re-traumatization and to provide interventions that were identified as potentially effective to cope with the resident's trauma. *She acknowledged that resident 7's care plan did not indicate he had PTSD, what his potential triggers may be, or the interventions for those triggers. *She expected a resident with a PTSD diagnosis to have the PTSD addressed in the resident's care plan, even if the resident's past trauma was not shared during the resident's trauma assessment, so staff would be aware that the resident may have unidentified trauma triggers and what the interventions may be tried. 13. Interview on 3/5/26 at 1:57 p.m. with CNA L revealed she would reference a resident's Kardex to identify that resident's potential behaviors and the interventions for those behaviors. 14. Interview on 3/5/26 at 2:30 p.m. with registered nurse (RN) C revealed she: *Was aware of resident 7's PTSD diagnosis because he had talked to her about some of his experiences. *Did not know if resident 7 had any potential triggers for his PTSD, but stated he was able to express his needs and concerns. *Expected a resident's PTSD triggers and interventions to be identified on that resident's care plan. *Expected the behaviors and interventions for those behaviors for a resident on an antipsychotic medication to be addressed in that resident's care plan. 15. Interview on 3/5/26 at 5:43 p.m. with director of nursing (DON) B revealed: *Care plans were to be updated by the unit managers, or the MDS nurse quarterly, annually, with a significant change in a resident's heath status and care needs, and anytime a resident's care needs changed. *She was aware that resident 7 was a military veteran and had a diagnosis of PTSD. *She stated resident 7 talked about the military and shared some of his experiences with the staff. *She was not aware that resident 7 had identified the conflict and bombing in the Middle East as a trigger for his PTSD and felt he could not watch about it on television. *She acknowledged that the failure to identify a resident's past exposures to traumatic events and identify those triggers in that resident's care plan for the staff to reference posed a risk for the resident to be exposed to potential triggers and be re-traumatized. *She expected the use of antipsychotic medications to be a focus area on a resident's care plan, with the behaviors the antipsychotic was being used for, the non-pharmacological interventions for that resident's behaviors, and any side effects of the antipsychotic medication that the nursing staff should monitor for. 16. Review of the provider's 12/1/25 Care Plan policy revealed: *To develop a comprehensive care plan using an interdisciplinary team approach. *To provide guidance to the interdisciplinary team in developing the initial care plan. *Residents will receive and be provided with the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the residents' optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders. 17. Review of the provider's 12/9/25 Psychotropic Medications policy revealed: *Individualized, non-pharmacolgical approach that are provided as part of a supportive physical and psychosocial environment and are directed toward understanding, preventing, relieving and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical or psychosocial well-being. *Non-pharmacological interventions are recommended before medication interventions. Attempts should be documented in the resident medical record.

Based on interview, record review, and policy review, the provider failed to identify and implement specific care approaches that addressed the mental and psychosocial needs of one of two sampled residents (7) with diagnosed post-traumatic stress disorder, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event (PTSD) to mitigate trauma triggers and prevent re-traumatization.Findings include:1. Interview on 3/3/26 at 10:58 a.m. with resident 7 in his room revealed:*He had experienced a lot of trauma in his life.*He had spoken to a counselor about his trauma, but not for quite a while.*He thought his post-traumatic stress disorder (PTSD) was under control, but he knew he could not turn on the television and see the conflict and bombing in the Middle East, or it might trigger his PTSD symptoms.2. Review of resident 7's EMR revealed:*He was admitted to the facility on [DATE].*His 1/30/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated his cognition was intact.*His diagnoses included PTSD, depression, insomnia (the inability to sleep), and mood disorder (a mental health condition characterized by long term extreme emotional states).*The focus area related to depression on his 3/4/26 care plan had interventions of, Resident talks with VA Mental Health Counselor every 6 months or more often if needed by phone and Resident states he has had this counselor many, many years and likes this set up.*His last documented visit with his VA counselor was on 12/3/24.*He had a 1/10/25 physician's order for Psych [psychological] services as needed, duloxetine (an antidepressant) 60 mg (milligrams) daily for depression, and mirtazapine (an antidepressant) 7.5 mg daily for insomnia.*His 1/10/25, 4/17/25, and 7/30/25 trauma assessments indicated resident 7 answered No to Have you ever experienced some form of trauma or stressful event, (i.e., serious accident or fire, a natural disaster, a physical or sexual assault or abuse, torture, a war, seeing someone be killed or seriously injured or loss of a loved one)?*There were no trauma assessments documented since 7/30/25 in resident 7's EMR.3. Interview on 3/4/26 at 4:04 p.m. with resident 7 revealed he:*Had only spoken with his VA counselor about his past traumatic experiences.*Would have spoken with a facility staff member about those experiences if they had asked him.4. Interview and record review on 3/5/26 at 11:55 a.m. with Minimum Data Set (MDS)/wound nurse F revealed:*All residents were to be assessed on admission, quarterly, and with a significant change in condition to determine if they had experienced a traumatic event.*A resident with a diagnosis of PTSD was to have PTSD identified on the resident's care plan, along with potential triggers of the resident's PTSD, pharmacological, and non-pharmacological interventions to prevent re-traumatization and to provide interventions that were identified as potentially effective to cope with the resident's trauma.*She stated she knew resident 7 had a diagnosis of PTSD but was not aware his trauma assessments indicated he did not experience trauma.*She stated resident 7 had experienced trauma during his time in the military.*A resident with a diagnosis of PTSD was to have PTSD identified on the resident's care plan, along with potential triggers of the resident's PTSD, pharmacological, and non-pharmacological interventions to prevent re-traumatization and to provide interventions that were identified as potentially effective to cope with the resident's trauma.*She acknowledged that resident 7's care plan did not indicate he had PTSD, what his potential triggers may be, or the interventions for those triggers.*She expected a resident with a PTSD diagnosis to have the PTSD addressed in the resident's care plan, even if the resident's past trauma was not shared during the resident's trauma assessment, so staff would be aware that the resident may have unidentified trauma triggers and what the interventions may be tried.5. Interview on 3/5/26 at 2:30 p.m. with registered nurse (RN) C revealed:*Was aware of resident 7's PTSD diagnosis because he had talked to her about some of his experiences.*Did not know if resident 7 had any potential triggers for his PTSD, but stated he was able to express his needs and concerns.*Expected a resident's PTSD triggers and interventions to be identified on that resident's care plan.6. Interview on 3/5/26 at 5:43 p.m. with director of nursing (DON) B revealed:*All residents were to be assessed to determine if they had experienced trauma on admission, quarterly, and with a significant change in condition.*Trauma assessments used to be completed by social services, but with the new updates within the EMR system, nursing also assessed residents for trauma during the completion of a resident's admission assessment.**She was aware that resident 7 was a military veteran and had a diagnosis of PTSD.*She stated resident 7 talked about the military and shared some of his experiences with the staff.*She was not aware that resident 7 had identified the conflict and bombing in the Middle East as a trigger for his PTSD and felt he could not watch about it on television.*She was not aware that resident 7's 3/4/26 care plan indicated he was seeing a VA counselor.*She stated he did not see a VA counselor since she had been in the facility (3/18/25).*She was not aware that his trauma assessments indicated he did not experience trauma.-She acknowledged that those assessments did not accurately reflect resident 7's past exposure to traumatic events.*She acknowledged that the failure to identify a resident's past exposures to traumatic events and identify those triggers in that resident's care plan for the staff to reference posed a risk for the resident to be exposed to potential triggers and be re-traumatized.7. Social worker BB was not in the facility or available for interview during the survey.8. Review of the provider's 12/31/25 Trauma Informed Care policy revealed:* Moving from the community into a long-term care facility, for an individual with a history of trauma or PTSD, can be a very difficult transition and cause worsening or reemergence of symptoms. Additionally, the structured environment of the rehab [rehabilitation] /skilled care facility can trigger memories of traumatic events. Trauma-informed care means being intentional by anticipating and avoiding institutional processes and practices that are likely to re-traumatize a resident who has a history of trauma.* Trauma-informed care- an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma to avoid re-traumatization.* Staff will ensure that residents who experience trauma receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization.* 1. The Trauma Assessment is required:a. Within five days of admission for all new residents;b. PRN [as needed].2. The Trauma Assessment is completed by Social Services while interviewing the resident/representative.

Based on observation, interview, record review, and Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure one of one sampled resident's (11) Minimum Data Set (MDS) assessments, a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs, were accurately coded in the areas for an invasive mechanical ventilator (a device that delivers air into the lungs through a hole in the neck into the windpipe or a flexible tube inserted in the mouth or nose through the windpipe) and a non-invasive mechanical ventilator (positive air pressure delivered through a mask into the lungs to treat severe breathing difficulties).Findings include:1. Observation and interview on 3/3/26 at 10:22 a.m. with resident 11 in her room revealed:*She was sitting in her recliner with oxygen administered through a nasal cannula (flexible tubing with prongs that delivers oxygen through the nose).*There was no invasive or non-invasive ventilator in the room.*Resident 11 denied that she was on a ventilator.2. Review of resident 11's electronic medical record (EMR) revealed:*She was admitted to the facility on [DATE].*Her 12/16/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact.*Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), shortness of breath, mild intermittent asthma (a lung disease characterized by inflamed, narrow airways that produce excess mucous and cause wheezing and shortness of breath), and chronic respiratory failure with hypoxia (a long-term progressive condition where the lungs cannot adequately transfer oxygen into the blood).*There was no physician's order for an invasive mechanical ventilator or non-invasive mechanical ventilator such as a Continuous Positive Airway Pressure (continuous air pressure administered through a mask to keep the airway open) (CPAP) machine or a Bilevel Positive Airway Pressure (delivers pressurized air through a mask at two different pressures) (BiPAP) machine.*Her 3/5/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) did not indicate she used an invasive or a non-invasive mechanical ventilator.*Item O0110 F1 of resident 11's 12/16/25 quarterly MDS assessment was coded to reflect that she was on an invasive mechanical ventilator within the last 14 days before the completion of that MDS assessment.*Item O0110 G1 of resident 11's 12/16/25 quarterly MDS assessment was coded to reflect that she was on a non-invasive mechanical ventilator within the last 14 days before the completion of that MDS assessment.-It did not identify if resident 11 had used CPAP or BiPAP machine as the non-invasive mechanical ventilator.3. Interview on 3/5/26 at 7:58 a.m. with registered nurse (RN) J revealed:*She had worked as a nurse at the facility for eight years.*No resident had used an invasive mechanical ventilator in the facility during those eight years.4. Interview and review of resident 11's 12/16/25 MDS assessment on 3/5/26 at 11:55 a.m. with MDS/wound nurse F revealed:*The provider did not admit residents to the facility who needed invasive mechanical ventilators.*She completed resident 11's 12/16/25 quarterly MDS assessment.*She verified that item O0110 F1 of resident 11's 12/16/25 quarterly MDS assessment was coded that she was on an invasive mechanical ventilator within the last 14 days before the completion of that MDS assessment.-She acknowledged that section O0110 F1 was coded incorrectly.*She verified that item O0110 G1 of resident 11's 12/16/25 quarterly MDS assessment was coded that she was on a non-invasive mechanical ventilator within the last 14 days before the completion of that MDS assessment and did not indicate if resident 11 had used a CPAP or BiPAP machine.-She acknowledged that section O0110 G1 was coded incorrectly.*MDS/wound nurse F felt that the incorrect MDS coding was due to human error.5. Interview on 3/5/26 at 5:43 p.m. with director of nursing (DON) B revealed:*She expected the MDS assessments to be coded accurately.*The provider did not have the ability to care for residents on invasive mechanical ventilators.*Resident 11 did not use an invasive or a non-invasive mechanical ventilator.*She acknowledged that resident 11's 12/16/25 quarterly MDS assessment was coded inaccurately in the areas related to the use of an invasive mechanical ventilator and a non-invasive mechanical ventilator.6. Review of section O in the Centers for Medicare and Medicaid Services Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed:* The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods.* Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic procedure such as IV [intravenous] medications or ventilators.* O0110F1, Invasive Mechanical Ventilator (ventilator or respirator)Code any type of electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the resident who is or who may become (such as during weaning attempts) unable to support their own respirations on this item. During invasive mechanical ventilation the resident's breathing is controlled by the ventilator.* O0110G1, Non-invasive Mechanical VentilatorCode any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to report incidents to the SD DOH within the required time frame, for one of one sampled resident (10) who fell on the floor while being transferred with a sit-to-stand mechanical lift (a mechanical lift used to assist from a seated to a standing position) by certified nursing assistant (CNA) N without the assistance of another staff member, one of one sampled resident (49) related to allegations of having been verbally abused by CNA K, and one of one sampled resident (44) related to allegations of having been verbally abused by CNA E. Findings include:1.Review of the provider's 12/1/25 submitted FRI regarding resident 10 revealed: *On 12/1/25, the provider completed a review of a fall incident for resident 10 that had occurred on 11/28/25 at 11:30 a.m. *Resident 10 was assisted to the restroom and back to his wheelchair by CNA N with the use of a sit-to-stand mechanical lift. *During the transfer, resident 10 slipped and slid from the sling to the floor onto his bottom and then rolled onto his right side. *CNA N called for assistance and licensed practical nurse (LPN) HH immediately came to the room. *Resident 10 was assessed by the nurse and was not injured as a result of the fall. *The investigation revealed CNA N failed to follow resident 10's care plan, which stated he was to be transferred with the use of a sit-to-stand mechanical lift and the assistance of two staff members. *CNA N was immediately re-educated by director of nursing (DON) B after the incident to ensure she checked a resident's care plan before she provided resident care. *The incident was not reported to the SD DOH until 12/1/25, which was past the 24-hour required timeline. 2. Review of the provider's 2/26/26 submitted FRI regarding resident 49 revealed: *On 2/20/26 at 8:15 p.m. DON B was notified that CNA D left her scheduled 2/20/26 shift 30 minutes after reporting to work. *CNA D stated she did not feel comfortable working until she spoke with the scheduler and DON B on Monday (2/21/26). *CNA D called DON B and texted the scheduler, which prompted administrator A and DON B to investigate CNA D's report of quality of care concerns. *On 2/20/26 administrator A and DON B went to the facility and interviewed residents and staff. *Resident 49 reported that CNA K told her not to sing and to shut up and Sit Up or I am not going to help you. -Resident 49 could not provide a date or time when CNA K had said that to her. *During resident interviews there were two other residents who stated CNA K made rude and inappropriate comments such as, You would not have these issues if you went out to the dining room and Don't be Cocky. *No resident had reported feeling unsafe or having received poor care from the staff during those resident interviews. *CNA K denied having made rude or inappropriate comments to residents. *The FRI was reported to the SD DOH on 2/26/26 at 1:06 p.m., six days after DON B was notified of the allegations of verbal abuse. *DON B indicated in the report, This report is late as the Administrator felt that with all residents stating they do not feel abused, no care issues of abuse were raised, and all residents interviewed stated they felt safe we did not feel [it] would require reporting. After speaking with [the] Regional Nurse consultant and explaining the details of the investigation she stated that both [investigations involving residents 44 and 49] needed to be reported.We have learned that any and all allegations of verbal, psychological, physical, or emotional abuse will be reported first and investigated second. 3. Review of the provider's FRI on 2/27/26 at 12:46 p.m. regarding resident 44 revealed: *On 2/20/26 at 8:15 p.m. director of nursing (DON) B was notified that CNA D left her scheduled 2/20/26 shift 30 minutes after reporting to work. *CNA D stated she did not feel comfortable working until she spoke with the scheduler and DON B on Monday (2/21/26). *CNA D called DON B and texted the scheduler, which prompted administrator A and DON B to investigate CNA D's report of quality of care concerns. *CNA E reported that resident 44 had used her call light several times during the night on 2/19/26 regarding leg pain and needed to be repositioned. *CNA E reported to the charge nurse that resident 44 could not get comfortable. The nurse assessed resident 44 and provided care and medications ordered by her doctor. *CNA E stated she did not use profanity toward residents or while providing them care, but she did use profanity at times when talking with other staff members about a resident, as an expression of how she felt, not towards the resident. *CNA E was assigned the following training: Abuse and Neglect of Vulnerable Adult Abuse, Neglect and Exploitation, and Creating a Restraint – Free Environment, which was to be completed by 3/4/26. 4. Interview on 3/5/26 at 5:43 p.m. with DON B revealed: *The reports of resident abuse and neglect were to be reported to the SD DOH within two hours of being reported to herself or another staff member. *All other reportable events were to be reported to the SD DOH within 24 hours. *DON B acknowledged she did not report the allegations of verbal abuse, related to residents 44 and 49, within the required two-hour time frame to the SD DOH. *DON B stated she did not recall the 12/1/25 FRI regarding the 11/28/25 incident that involved resident 10's fall from a mechanical lift or that it was not reported within the required 24-hour time frame. 5. Review of the provider's 4/7/25 Abuse and Neglect policy revealed: *If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident/client property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made. *If there is an allegation that does not involve abuse and there is no serious bodily injury, then it will be reported no later than 24 hours after the allegation is made.

Based on observation, interview, and policy review, the provider failed to ensure one of one sampled resident (100) who [NAME] left alone in his room with his nebulizer (a device that converts liquid medication into an inhalable mist) machine administered by certified medication aide(CMA) (EE), was assessed for the resident's ability to safely sefl-adminster that medicaiton. Findings include: 1. Observation on 3/5/26 at 7:56 a.m. revealed resident 100 was alone in his room, lying on his back in his bed. He had a nebulizer mask positioned on the right side of his face without covering his nose and mouth while the nebulizer machine was on and administering the breathing treatment(nebulized medication). 2. Observation, interview, and electronic medication administration record (EMAR) review on 3/5/26 at 8:00 a.m. with CMA EE revealed she was standing at the medication cart and stated she put the nebulizer mask on resident 100. When she entered his room she stated, Oh, you knocked the cup (container that held the medication) off.-She removed the nebulizer mask and turned off the nebulizer machine.-She stated she was not sure if the resident could have that nebulizer treatment without supervision.-She looked at the resident's (EMAR) but could not find a physician's order for him to self-administer that medication. 3. Interview on 3/5/26 at 9:17 a.m. with registered nurse (RN) J revealed she thought that resident 100 could self-administer his nebulizer treatments in his room by himself. 4. Interview on 3/5/26 at 4:00 p.m. with director of nursing (DON) B revealed:*Resident 100 did not have a doctor's order to self-administer his medication. *He did not have an assessment for his ability to safely self-administer medication completed. *She expected a resident's self-administration assessment to be completed and to have a physician's order before a resident was left in their room unattended. 5. Review of resident 100's electronic medical record (EMR) revealed:*He had a physician's order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter) (Ipratropium-Albuterol 1 vial inhale orally via nebulizer four times a day related to Quadriplegia (the paralysis in all four limbs and the torso).*He was readmitted to the facility on [DATE].*He did not have a brief Interview of Mental Status (BIMS) assessment score completed and he was nonverbal.*His diagnoses included:-Traumatic subdural hemorrhage with loss of consciousness (a type of bleeding near the brain), unspecified intracranial injury with loss of consciousness, cognitive communication deficit, facial weakness, psychomotor deficit, and convulsions.*His care plan indicated that he had limited physical mobility and interventions were initiated on 7/10/25 that included a private room to accommodate for his specialized larger wheelchair, the use of a Total body lift (a mechanical lift and sling used to lift a person's full body), and two staff members to assist him with all his cares. *His care plan indicated he had an altered respiratory status related to his obstructive sleep apnea. The intervention that was initiated on 7/10/2 was to monitor for signs and symptoms of respiratory distress and to report to a health care provider as needed. 6. Review of the provider's 10/31/58 resident self-administration of medication policy revealed:*Purpose: To determine if the resident can safely self-administer medications.*To identify which mediations may be safely self-administered.*To assist the resident who is self-administering medications to manage his or her prescribed medications in a safe manner*To provide residents who can do so safely with the opportunity to self-administer medications

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to administer a physician-ordered BiPAP (a device that delivers pressurized air through a specialized mask to assist with breathing) for one of one sampled resident who was lethargic and unresponsive the following morning and was transferred to the hospital. Findings include: 1.Review of the providers [DATE] SD DOH FRI revealed:*Resident 1 was a full code and found not responsive to verbal commands and sent to the hospital on [DATE]. * Resident 1's diagnoses upon admission to long term care on [DATE] were:*Included acute respiratory failure (problems with breathing) with hypercapnia (too much carbon dioxide in the bloodstream) and hypoxia (low levels of oxygen), chronic fatigue (low energy), and hypertension (high blood pressure). *She had a full code status (wishes to receive life-sustaining measures) with CPR (cardiopulmonary resuscitation) to be administered.*She had gone to the hospital on [DATE] and again on [DATE] for similar symptoms.*Resident 1's [DATE] hospitalization admitting diagnoses were, CIPD (chronic inflammatory demyelinating polyneuropathy) (disorder affecting the peripheral nerves that may cause loss of strength and sensation), hypertension, Acute respiratory failure with hypoxia and hypercapnia and paroxysmal atrial fibrillation (irregular heart rate). *The BiPAP machine was not put on resident 1 the night [DATE] prior to that incident.*She had a Brief Interview for Mental Status) (BIMS) of 15 (which indicated her cognition was intact and she had the ability to ask for her BiPAP. *Resident 1's baseline oxygen was delivered at 2 lpm (oxygen flow rate two liters per minute) via NC (nasal canula, tubing with nasal prongs).*Resident 1's oxygen saturation (oxygen level in the blood) was 98 percent. *Resident 1 had a doctor's order for oxygen (O2) to be delivered at a rate of 2L (liters) to titrate (measure and adjust) to keep her O2 saturation (sat) greater or equal to 90 percent. *Resident 1's family was present at the hospital with her and she had been alert and oriented with some lethargy. They family had decided to stop all treatments and changed her code status to do not resuscitate and do not intubate with palliative and comfort cares started.*Resident 1 passed away in the hospital. 2.Review of resident 1's electronic medical record (EMR) revealed:*A [DATE] physicians order for BiPAP by mask at bedtime related to acute respiratory failure with hypercapnia.*A [DATE] physician's order or O2 at 2L to titrate for O2 sat greater or equal 90 percent every shift related to acute respiratory failure with hypoxia.* She had a BIMS assessment score of 15.*Her treatment administration record (TAR) for the BiPAP treatment did not have a nurse's initials to have indicated the treatment was completed as ordered in the boxes dated [DATE], [DATE], or [DATE]. 3.Interview on [DATE] at 1:40 p.m. registered nurse (RN) G regarding resident 1 revealed:*She was familiar with that resident 1 and stated that resident 1 had moved from a different wing [DATE] and had an order for O2, and an autoimmune disorder that was making her muscles weaker. *RN G had worked the day shift on [DATE] when resident 1's episode occurred. *On [DATE] at approximately 7:00 a.m. certified nursing assistant (CNA) H had asked her to look in on resident 1 because she was not responding to her like she normally would have.*She stated resident 1 was in bed with the head of the bed elevated at about 30 degrees, she did not answer to her name, she opened her eyes, but did not visually track (follow an object one's eyes as it moves) anything. *RN G asked resident 1 to squeeze her hands and move her toes, but she did not follow that command. *She stated east clinical care leader (ECCL) C had come to the facility and agreed that resident 1 should go to the emergency room.*RN G obtained her vital signs (measurement of the body's basic functions, such as temperature, blood pressure, pulse and respirations). Resident 1's heart rate was elevated, but her other vitals signs were normal at that time. *She stated she had received a physicians order for resident 1 to transfer to the the emergency room.*She had not received verbal report from the night shift nurse regarding resident 1 not using her BIPAP the night before [DATE]. *She was not aware if resident 1 had refused her BiPAP at any time.*She stated that resident 1 like the nurse to put the BiPAP on her.*She stated resident 1's BiPAP order in the TAR would have turned red, indicating that treatment had not been completed during that shift when it was due, but did not indicate she had checked that at that time.*Resident 1's family were notified. 4. Interview on [DATE] at 3:25 p.m. with RN D regarding resident 1 revealed:*Resident 1's BiPAP order was a new from her last hospitalization on [DATE] for confused, altered mental status and respiratory distress. *Resident 1 had been very compliant with the BiPAP, and it was important to her.*She stated that when she worked, resident 1 had not refused to wear the BiPAP, had always worn the BiPAP and had needed physical help to put it on.*She stated she would have documented on the TAR either yes or no in the TAR to have indicated if the BIPAP had been put on resident 1 or not.*She stated that when she documented yes in the TAR resident 1's name would have turned green on the computer screen, if she had documented no it would have turned red, to indicate the BiPAP was late or not done. *She stated she used those colors to ensure she had not missed any of her assigned residents' treatments when she worked, and that was how she double checked that she had completed and documented the residents' ordered treatments. 5. Interview on [DATE] at 9:36 a.m. with licensed practical nurse (LPN) E regarding resident 1's BiPAP the night of [DATE] revealed:*She did not put resident 1's BiPAP on her the night of [DATE].*She had a very busy shift that night and had been in another hall with a resident with a low blood sugar.*The CNA I had told her that resident 1 would call for her when she wanted the BiPAP put on.*She had not been called in to resident 1's room by the CNA the night of [DATE].*LPN E agreed she was responsible for 1's treatments and should have made she had her BiPAP on that night but she didn't.*She stated she could not remember exactly what resident 1's BIPAP order said; she just put it on her at night.*She stated she thought the CNAs could put a BiPAP on the residents but had not put it on resident 1 that night.*She stated she had not received training regarding how to use a BIPAP but had her own personal experience with her own.*She had not gone in resident 1's room that night but she had walked by her room and had visually seen her from the doorway.*She stated the blank on the TAR for resident 1's BIPAP treatment for the night of [DATE] indicated she had not put resident 1' BiPAP on her.*She stated she had not reported to the nurse working the next day shift [DATE] that she had not put resident 1's BIPAP on her. 6. Interview on [DATE] at 10:03 a.m. with ECCL C revealed:*CNAs could apply BiPAP devices and turn them on, but the nurse check that the resident had it on. The facility staff did not change any BiPAP settings which were done by the company who had originally set up that machine. *She was not sure if it was in their policy that a CNA could apply a BiPAP to a resident.*She thought BiPAP training had been part of the CNA onboarding training.*The day of resident 1's episode [DATE] episode, she had been asked to go int to her room because she was lethargic but responding.*She stated the doctor and ambulance had been called and resident 1 had been sent out to the emergency room within 20 minutes of her assessment. *She had gone into resident 1's room after she had left for the emergency room to clean it up.*She stated when she was cleaning resident 1's room, the BIPAP mask was on top of he BiPAP machine and the cannister was dry, which indicated it had not been used the night before.*She stated if resident 1 had refused her BiPAP the nurse would have documented no in the RAR documentation system, and a progress note would have automatically opened for that nurse to document a reason why the resident refused their BiPAP treatment.*She stated that she was not sure if resident 1 not wearing her BiPAP caused that episode,as she had gone to the hospital before with the same symptoms. *She stated resident 1 had a new diagnosis of autoimmune disorder of CIPD that weakened her muscles, and she had declined quickly. *She stated resident 1 had been started on an immunoglobulin (antibodies that boost the immune system), but resident 1 had stated she felt the medicine was not working.*She stated the facility did not have a process in place for the next shifts nurse to check if things were not done but the nurse should have verbally reported to the oncoming nurse that resident 1 had not had on her BIPAP.7. Interview on [DATE] at 10:34 a.m. with director of nursing B revealed:*She expected the nurse to go into each resident room during their shift and check on each resident. *She expected each nurse to have completed and documented the care and treatments ordered for each resident and to have documented before leaving at the end of their shift.*The CNA had been in resident 1's room the night [DATE] to turn and reposition her that night. She felt a CNA could put on a residents BiPAP but no they were not trained to and it was not part of their policy. *She did not think that resident 1 going without her BiPAP the night of [DATE] had caused her episode on [DATE] because she had gone without out it on [DATE] and [DATE] and did not have a episode. 8. Interview on [DATE] at 3:05 p.m. with certified nursing assistant (CNA) F regarding resident 1 revealed:*She stated she had worked on the focus rehab unit when resident 1 had resided on that unit.*She stated resident 1 would be in her recliner during her shift with her oxygen, on not her BiPAP because she did not go to bed until after 10:00 p.m.*She stated the nurse would have put the BiPAP on resident 1 because she did do that. 9. Review of the provider's LPN Long Term Care (LTC) Job Description dated [DATE] revealed:*Essential Functions *.Observe patients, document and report changes in patient condition, such as adverse reactions to medication or treatment, and take any necessary action.*.Promote a safe and therapeutic environment by providing appropriate monitoring and surveillance of the care environment. 10. Review of the provider's policy for Non-Invasive Respiratory Support-R/S, LTC dated [DATE] revealed:*.Provide the most effective treatment option for reducing CO2 in hypercapnic COPD patients and those suffering with respiratory insufficiency.*Policy*[BiPAP] - -A term used to refer to a bi-level positive airway pressure. A BiPAP machine is a breathing apparatus that helps its user get more air into the lungs. BiPAP uses variable levels of air pressure instead of continuous pressure. 11. Review of the provider's Legal Documentation Standards-Rehab/Skilled and Assisted Living policy dated [DATE] revealed:*Completeness*Document all facts and pertinent information related to occurrences, course of treatment, resident condition, response to care and deviation from standard treatment (including reason for it). Each entry will be complete and contain all significant information.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to implement fall prevention interventions as described in the care plan for one of one (1) resident who fell and sustained injuries that required treatment at an emergency department. Findings include: 1. Review of the SD DOH FRI submitted on 2/2/25 at 10:34 a.m. revealed: *On 2/1/25 at 10:20 p.m., resident 1 was found lying face down on the floor next to his bed. -There was noticeable blood on the floor. -Resident 1 had a laceration near his right eye. -He was transported to the emergency department for further evaluation. -He received six sutures and was transported back to the facility. *The provider's investigation of the fall determined that resident 1's silent TABs alarm (a device that flashes at the nurses station to alert staff when resident stands up) was in his recliner at the time of the fall and the resident was in his bed. *The certified nursing assistant (CNA) that assisted resident 1 to bed had forgotten to move the TABs alarm when she assisted the resident to bed. *As a result of the fall, the provider updated resident 1's care plan and Kardex to have a TABs alarm in both his recliner and his bed at all times. *Director of nursing services (DNS) O placed a STOP, Wait for assistance sign in the resident's room as a reminder for resident to not get up without staff assistance. 2. Review of resident 1's electronic medical record revealed: *He was admitted to the facility on [DATE]. *His diagnoses included: repeated falls, generalized muscle weakness, Dementia (a group of symptoms affecting memory, thinking, and social abilities), use of anticoagulants (blood thinning medications). *His 6/3/25 Brief Interview for Mental status (BIMS) assessment score was 12, which indicated he was moderately cognitively impaired. *A progress note on 3/16/25 at 11:54 p.m. regarding his TABs alarm stated Alarm not placed under resident at bedtime, alarm pad found in recliner chair and resident is sleeping in bed. Resident [was] not woke [woken] up at this time to place under him d/t [due to] [the resident] sleeping soundly. Will monitor closely, night CNAs aware of this. *A progress note on 3/19/25 at 11:35 p.m. regarding his TABs alarm stated Not under resident in bed, alarm found in recliner chair and not connected. *Resident 1's 6/18/25 Kardex stated in the Monitoring section Personal Alarm: Silent TABs alarm used to alert staff of resident's movement and to assist staff in monitoring movement. Place TABs alarm in both bed and recliner at all times. Ensure this is used, plugged in, and functioning when [the resident is] in bed or [the] recliner. *Resident 1's 6/4/25 Care Plan Report indicated: *A Focus are of The resident has had an actual fall R/T [related to] epilepsy, dementia, muscle weakness, decreased balance as E/B [evidenced by] history of falls. *Goals for that area included Resident will be free of falls through the review date. Resident will be free of minor injury through the review date. Resident will not sustain serious injury through the review date. *Interventions included PERSONAL ALARM: Silent TABs alarm used to alert staff to resident's movement and to assist staff in monitoring movement. Place TABs alarm in both [his] bed and recliner at all times. Ensure this is used, plugged in, and functioning when [resident is] in bed or [the] recliner. 3. Observation and interview on 6/17/25 at 10:45 a.m. with resident 1 in his room revealed: *Resident stated he had lived there for the past couple years. *He had no obvious observed signs of bruising or injury. *His room was free of clutter. *He was sitting on his TABs alarm and his call light was within his reach. *There was no TABs alarm on his mattress. *There was no STOP, Wait for assistance sign on his wall. 4. Observation and interview on 6/17/25 at 1:20 p.m. with resident 1 revealed he was still sitting up in his chair, with the TABs alarm under him. 5. Interview on 6/17/25 at 2:20 p.m. with certified medication aide (CMA) M revealed: *Resident 1 should have had a TABs alarm in both his chair and on his bed. *That was to be documented in the resident's TAR (treatment administration record) by a nurse. 6. Interview on 6/17/25 at 2:30 p.m. with CMA L revealed: *There should be an alarm in the resident's chair and in his bed. *She was not aware why there was not two alarms because she was not usually assigned to that unit. 7. Interview on 6/17/25 at 3:45 with registered nurse (RN) N revealed she was the nurse assigned to work in resident 1's unit but was not aware if resident 1 should have one or two TABs alarms. 8. Interview on 6/17/25 at 3:50 p.m. with CNA E revealed: *There should have been two TABs alarms in resident 1's room. *She was aware there was only one alarm that was being transferred back and forth from his chair to his bed. *She reported that there had not been two alarms in resident 1's room recently due to a malfunction when using two alarms. *She explained that when there were two alarms, one would malfunction and alarm when the resident was not using it. *She stated that maintenance personnel had tried to repair the system but were unable to. -The solution to that was to remove the second TABs alarm from resident 1's room. *She was not aware of any other fall prevention interventions that had been put into place for resident 1. 9. Interview on 6/17/25 at 4:00 p.m. with resident 1's spouse revealed: *She felt resident 1 received good care at the facility. *She stated, I wish sometimes there were more staff, but they work very hard. *She reported that resident 1 had fallen and that required him to go to the hospital and receive sutures. 10. Interview on 6/17/25 at 4:15 p.m. with RN/clinical care leader (CCL) F revealed: *Resident 1's cognition varied (sometimes he was confused, sometimes he was not), which could make it difficult to provide his care at times. *She was aware he was care planned to have two TABs alarms in his room. *She was aware there was only one TABs alarm in his room. *She reported that the staff were performing more frequent rounding (visually checking on resident's status) to ensure their safety. 11. Observation on 6/18/25 at 9:05 a.m. revealed: *Resident 1 was not in his room. *There was one TABs alarm in his chair, and none on his bed. *There was no STOP, Wait for Assistance sign visible in his room. 12. Interview on 6/18/25 at 1:50 p.m. with DON B revealed: *She was familiar with resident 1's fall but was not employed by the facility when the fall occurred in February 2025. *She was not aware of the fall prevention interventions that were to have been put in place as a result of the February 2025 fall (additional TABs alarm and STOP, Wait for assistance sign) for resident 1. *She was not aware that only one alarm was being used for resident 1. *She agreed resident 1 could fall again. 13. Interview on 6/18/25 at 2:30 p.m. with administrator A revealed: *His goal was to eliminate the use of TABs alarms for residents in the facility. *He preferred to focus on completing more frequent rounding on the residents instead of relying on alarms. *He stated Frequent checks should have been added to resident 1's care plan after his fall. *He agreed resident 1 could fall again. 14. Review of the provider's 4/8/25 Fall Prevention and Management policy revealed: *Purpose, To promote resident well-being by developing and implementing a fall prevention and management program. To identify risk factors and implement interventions before a fall occurs. *Proactive Approach before a Fall Occurs (e.g., New Admit) procedure. -3. Care Plan the appropriate interventions, including personalizing all (SPECIFY) areas. -4. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-Hour Report, care plan and Kardex, daily stand-up meeting, and/or Fall Committee meetings.

Based on observation, interview, record review, and policy review, the provider failed to ensure staff followed the care plan regarding the hydration needs for one of two sampled residents (2). Findings include: 1. Observation and interview on 6/18/25 at 8:50 a.m. in resident 2's room with certified medication aide (CMA) G revealed: *Resident 2 was sitting in his wheelchair. *CMA G brought resident 2 his morning pills in a medicine cup with chocolate pudding in it. *He agreed to take his pills. *CMA G administered him the pills with a spoon. *She gave him a drink of water from his water mug through a straw. *She stated this was the first time she had passed medications in that hallway. 2. Review of resident 2's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had diagnosis of: -Essential (primary) hypertension (high blood pressure). -Cerebral infarction, unspecified. -Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. -Dysphagia following cerebral infarction. *The care plan dated 4/9/25 stated: -Resident has order for mildly thickened liquids with meals. -OK for thin liquids in room, NO straws per speech therapy. 3. Interview on 6/18/25 at 1:00 p.m. with dietitian H and dietary manager I regarding resident 2's dietary needs revealed: *He was admitted with an ordered minced and moist therapeutic diet. *The speech therapist upgraded his diet to soft and small bites of food in January 2025. *He was also on the Frazier Free Water Protocol (he needed thickened liquids with food at meals, and thin liquids in his room after oral care was provided). *He was not to use straws to drink liquids. *His care plan stated no straws. *The no straw information had not transferred over to the Kardex (electronic report of residents' care needs) for the front-line caregiver staff to see. *They expected that information to have been on the Kardex. 4. Observation on 6/18/25 at 1:20 p.m. in resident 2's room revealed his water mug still had a straw in it. 5. Interview on 6/18/25 at 1:35 p.m. with certified nursing assistant (CNA) J regarding resident water mugs revealed: *The CNAs were responsible for replacing water mugs. *The mugs usually got straws put in them. *She would rely on the Kardex or the dietary staff to know which residents were not allowed to have straws. 6. Interview and record review on 6/18/25 at 2:00 p.m. with registered nurse (RN) K regarding resident 2's hydration status needs revealed: *Resident 2 had a history of a stroke. *He could have thin liquids in his room with no food. *He confirmed resident 2 should not have had a straw in his water mug. *That hydration information was documented in resident 2's care plan. *The information had not been selected in the care plan to be transferred to the Kardex for the front-line caregiver staff to know. 7. Interview on 6/18/25 at 3:05 p.m. with director of nursing (DON) B regarding resident 2's care plan and hydration needs revealed: *She was not aware that he should not have used a straw. *She expected that the information the front-line caregiver staff needed to know to provide the resident's care needs should have been on the Kardex. *She agreed staff should have marked it in the care plan so it would pull over to the Kardex. 8. Review of the provider's 12/2/24 revised Care Plan policy revealed: *Residents will receive and be provided with the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. *The plan of care will be modified to reflect the care currently required/provided for the resident. *The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, observation, interview, and policy review the provider failed to ensure Buprenorphine (pain medication) transdermal (TD) (delivered through the skin) patch was removed before a second Buprenorphine patch was applied to one of one sampled resident (1) whose altered mental state required evaluation at a hospital. Findings include: 1. Review of the SD DOH FRI dated 1/17/25 revealed: *There was concern regarding nursing services and the quality of care provided to resident (1) who had two Buprenorphine patches on his skin when he was evaluated at a hospital for his altered mental state. *He had an order to apply one Buprenorphine patch every 7 days. *He had a patch applied to his skin on 1/3/25 and a second patch applied on 1/11/25 because it was not available when it was due on 1/10/25. *The patch was delivered on 1/11/25. The nurse applied the patch and was not aware the previously applied patch had not been removed from the resident's skin. *The doctor at the hospital suspected the cause of resident 1's altered mental status was from having two Buprenorphine patches on his skin. *Further investigation was pending. 2. Review of resident 1's electronic medical record (EMR) revealed: *Diagnosis of a neurogenic bladder, history of urinary tract infections (UTI) and he had a super pubic catheter. *Pain level from 1/3/25-1/15/25 revealed it was between 2-5/10. 3. Observation and interview on 1/22/25 at 7:38 a.m. with licensed practical nurse (LPN) C revealed: *TD patches were to be signed out on the medication administration record (MAR) and the narcotic book was to be signed. *She would have removed the old patch and applied the new patch. -She would have kept the patch she removed and had another nurse destroy it with her. *She would have signed the time and date on the patch placement form . *If a medication wasn't available, she would notify clinical care leader (CCL) D. -She would have called the pharmacy if a medication was not availabl to check if it was waiting on a doctor's order or for a doctor's signature. *She would let the nurse manager know what was going on while she checked on the missing medication. 4. Interview on 1/22/25 at 7:50 AM with CCL D revealed:. *If there wasn't a medication available, they would have checked to determine if it was waiting for pharmacy delivery, if the order had changed, or if it had not been faxed to the pharmacy. *Their pharmacy delivered at 10:00 am., and had tow to four hours to deliver their orders for newly admitted residents. *Pharmacy would deliver for a stat (as soon as possible) order within one hour. 5. Interview on 1/22/25 at 10:52 a.m. with LPN C regarding the narcotic patch placement form revealed resident 1's form for his Buprenorphine TD patch had areas the placement had not been signed off as verified. 6. Interview on 1/22/25 at 2:30 PM with LPN C regarding resident 1's TD patch revealed: *Before she left her shift on 1/10/25 resident 1's TD patch had not been delivered from the pharmacy. - Pharmacy had said the TD patch was ordered Wednesday and should be delivered 1/10/25. -She reported to oncoming LPN E and instructed him to put the TD patch on resident 1 when it came in. -It was reported to her when she came to work 1/12/25 that the patch had been delivered on 1/11/25. -Resident 1's TD patch was signed out on 1/11/25 Saturday night at 3:00 p.m. as placed on the residents skin. *LPN C stated medications were ordered from the label they pulled from the medication label on the narcotic count sheet. That label was faxed to the pharmacy. *The pharmacy would send a response back as complete if they received it. If the fax return sheet indicated no response that meant the pharmacy had not received the reorder request for the medication. 7. Interview on 1/22/25 at 2:35 p.m. CCL D regarding resident 1's TD patches revealed: *She stated transdermal patches had four refills and would automatically go to the doctor for renewal and doctor signature. -Pharmacy would receive those orders, fill the order and send the medications to the facility *Resident 1's order needed to be signed by the doctor on Friday 1/10/25 the day the patch was due. *The order did not get filled until Saturday 1/11/25 in the morning and delivered in the afternoon. *When the order came in the nurse put the patch on resident 1. 8. Interview on 1/22/25 at 1:33 p.m. with administrator A regarding resident 1's TD patch and hospital visit revealed: *He had been positive for kidney stones and bacteria in his urine. *There had been communication on 1/10/25 questioning that resident 1 had a UTI and were waiting for more results. *Resident 1 had white blood cells in his urine, and he was ordered Keflex at the hospital. *Resident 1's daughter stated the signs and symptoms of altered mental status were the same symptoms that he had in the past with his urinary tract infections that often had required hospitalization . 9. Interview on 1/22/25 at 2:30 p.m. with licensed practical nurse (LPN) E regarding the incident of two Buprenorphine TD patches found on resident 1 at the hospital revealed: *He remembered hearing that a patch had not come in and when it did come in it was to be put it on the resident right away. *He normally worked the 2-10 p.m. shift. *If a patch was not available, he would fax the pharmacy or call the pharmacy. -Pharmacy delivered between 7:00 p.m. and 7:30 p.m. Monday through Friday. *He stated pharmacy would deliver on Saturdays but not on Sundays. - He would get the medications he needed from the pharmacy deliverd medications and check- in the rest later when he had time. *If a medication not available, he would sign not available on the MAR. *He stated that on 1/11/25 when the patch was delivered he put the patch on resident 1. *He thought it was a new order and there was none available per the report he had received. *He stated there was no form in the book to see where the last patch would have been placed on resident 1. *He applied the Buprenorphine patch on resident 1 but did not check if he had an old patch on his skin. *He stated a couple of days later resident 1 went to the hospital. *LPN E stated he had applied TD patches on residents but not for resident 1 generally. - He said he liked to try to get them done before residents went to bed and were asleep so he didn't have to wake them up or bother them. *He had been educated on the safeguards for patches, to sign on the MAR for the placement and removal of the old patch which was new process. 10. Interview on 1/23/25 at. 8:20 a.m. with registered nurse (RN) F revealed: *Had worked at the facility since 1/9/25. *Stated the clinical nurse manager advised RN F to call the daughter. *Stated TD patches were to be changed per the doctor's order. -Remove the old patch and destroyed it with a 2nd nurse, applied the new patch on a different site. *Thought the resident had signs and symptoms of a UTI when he was sent out to the hospital. *Buprenorphine TD patches came in their own box and each box had their own count and placement forms . -Stated the old forms would be pulled out of the book and replaced with the new ones. *Stated there had not been any new education since that incident and was not aware of a different process. 11. Observation and Interview on 1/23/25 at 8:14 a.m. with LPN C regarding resident 1's Buprenorphine patch placement revealed: * He was to receive 15 micrograms per hour (mcg/hour) every week on Thursdays on the a.m. shift. *The hospital had a 10 and 5 mcg/hour patches, so they put one on each of resident 1's arms *At 8:22 AM she went to resident 1's room to apply a new patch for resident 1 for the surveyor to observe. -Resident 1 was in his wheelchair in his room, he appeared sleepy but would open his eyes occasionally when spoken to. -She stated those were the same symptoms he had the day he went out to the hospital. *His vital signs were taken and were within normal limits, his blood sugar was 129. *She removed the patches that the hospital had placed on him: - The patch removed from his left arm was 5 micrograms and the patch removed from the right arm was a 10 micrograms. -She stated that was the doses the hospital had versus one patch of 15 micrograms. *These patches were destroyed with CCL D. *She did not place the new one patch on resident 1 because she was going to call to the doctor. -She stated resident 1's nurse practitioner was coming in to see him for normal rounds that morning and would see the resident in person and labs had been ordered. -This did not occur before the end of survey. 12. Interview on 1/23/25 5 at 8:47 a.m. with director of nursing service (DNS) B revealed: *She sent the report into the SD DOH concerning the patch incident that involved resident 1. *They had not been concerned because he had a history of UTI'S and he had the symptoms his daughter had explained that he would have when he had a UTI. *She stated she talked to the nurse at the hospital about the 2 patches and that the doctor had suspected they had cause his altered mental status. *She stated his labs were pending but the urine drug analysis screen came back negative, and she was to call back the next day. *She called back the next day but he was being discharged back to the facility. *She stated she had wanted to explain to the hospitalist to have the doctor further investigate because the first patch went on 1/3/25 and the dose on 1/10/25 was a missed dose. -The second patch was applied on 1/11/25 and the duration of the medication was five days. *The resident was sent back with a Keflex antibiotic order for UTI. *She stated the symptoms that resident 1 had during this survey were the same symptoms that he would have with UTIs. *She had spoken with LPN E about the patches. *She stated there was now an apply and a remove area to sign off on for the nurses in the MAR. *She reiterated that the drug screen was negative, but they did not run the specific drug screen for that particular synthetic Buprenorphine at the hospital. *She stated that they were considering revising the forms and the new patch process for removal and applying patches with signatures by the nurses. *She expected the forms the nurse signed out for placement of the TD patches would not be removeed from the book until new ones had been placed in the book for new orders. *She stated that she had educated the LPN who placed the 2nd patch but not for all staff regarding the new process of the forms for removal and applying TD patches. -She had contacted their education specialist to get the education set up for all staff but did not have the date when this would occur. 13. Interview on 1/32/25 at 9:30 a.m. with LPN G regarding transdermal medication patches for resident revealed: *She knew she had to take a patch off before putting another patch on and to check if they had a patch on. *She did not remember any new education or of a new process for the signing removal or application of transdermal medication patches. 14. Interview on 1/23/25 at 9:58 a.m. with administrator A regarding the transdermal patch policy and education revealed: *She did not have a more updated transdermal patch policy since 11/25/24. *She did not think a change in policy was needed because it was the ordering process that was updated. -Her nurses knew of the new process and should have known the process because the orders had the removal and apply information on them. *She stated more education was not needed because it was just adding the signature for the removal but again reiterated that the removal was part of the doctor's orders for the transdermal patches. 15. Review of the provider6's medication transdermal patch application and disposal policy dated 11/25/24 revealed: *Purpose, to administer medication as ordered. *Procedure 13. b. Fentanyl and other controlled medication patches - Disposal should be documented on the Individual Resident's Narcotic Record .

A. Based on interview, observation, record review, and policy review the provider failed to ensure the safety of one of one sampled resident (14 ) who required the assistance of two staff during transfers with a sit-to-stand mechanical lift. Findings include: 1. Interview and observation on 10/15/24 at 3:45 p.m. with resident 14 revealed: *He had gone to the hospital because he had been dropped from a lift in the shower room and hit his head. *He pointed to his head and said, that's what this bump is from. *He had a raised area on his left forehead and a brace on his left foot. 2. Review of resident 14's electronic medical record (EMR) revealed a progress noted dated 9/9/24: *CNA [certified nursing assistant] called nurse to tub room res laying on the floor, skin tear to left arm above elbow, measures 5x5x5 triangle shaped area, also has a bump on left forehead with abrasion resident right leg is turned inward resident c/o [complaints of] pain when tried to move right leg. Resident stated I was standing up to get on bath chair and I fell . VS [vital signs] and Neuro check done, d/t [due to] pain and leg turning inward PCP [primary care provider] call and sending res to ER [emergency room ] via ambulance, will wait to transfer res from floor when EMS [emergency medical service] arrives, EMS arrived approximately 0815. 3. Interview on 10/16/24 at 1:40 p.m. with resident 14 revealed, he had stopped this surveyor in hall and asked what was found out about the lift and stated, That thing [the lift] is going to kill me. 4. Interview on 10/16/24 at 1:44 p.m. CNA O regarding resident 14's transfers revealed: *She would check his Kardex for changes in how they were to help him transfer, but he used the sit- to-stand mechanical lift with the assistance of two staff. *She stated he didn't like to use the lift and could be ornery or stubborn about using it. *She stated she would report to the nurse if he had trouble with the lift and maybe they would maybe get therapy to reevaluate him. 5. Interview on 10/16/24 at 1:50 p.m. with licensed practical nurse (LPN) F regarding resident 14 revealed: *She was aware resident 14 did not like to use the sit-to-stand lift. *She thought it was safer than a pivot transfer (spinning to move while bearing weight on one or both legs) and resident 14 thought he could still pivot. *She was not aware of him being dropped from a mechanical lift but resident 14 had told her he thought staff were going to drop him. *She stated she could put in a request for therapy to reevaluate him and the mechanical lift, but she had not placed one yet. *She later returned and informed this surveyor she had checked, and he was currently working with physical therapy and the use of the mechanical lift. 6. Interview on 10/16/24 at 1:56 p.m. with resident 14 revealed he stated: *His left leg and arm were weak from a stroke. *Only one staff would come in when they used the mechanical lift. *When staff used the lift it would pull his toes right into the stopper on the footrest toward the person that operated the machine. *He reported to staff he didn't like the mechanical lift and did not feel safe in it, but they still used it. 7. Interview on 10/16/24 at 2:10 p.m. with physical therapist assistant (PTA) Q regarding resident 14 revealed he stated: *Resident 14 had not been dropped from a lift by staff. *Resident 14 would lean back in the lift and not work well with staff about the lift being used. *He stated he would hate to go back to using a Hoyer full body mechanical lift (total body mechanical lift) when resident 14 could stand up. *Resident 14 was currently working with therapy and he would get their notes for the last few weeks. 8. Interview and observation on 10/17/24 at 7:32 with CNA I during resident 14's transfer revealed: *Resident 14 was laying in bed with his legs hanging off the edge of bed. *CNA I stated that she would know how to care for residents because their information was on a Kardex which contained information on how to care for a resident. -The Kardex was updated timely. *While resident 14 was seated on the edge of the bed, CNA I placed the lift sling behind him and explained she would get him up with a stand lift by herself. *This surveyor stopped CNA I before she hooked the sling up to the mechanical lift and asked her if he needed two staff to assist with the lift for safety. *CNA I said she thought he was one assist but she would check his care plan and left the room. -CNA I then re-entered resident 14's room at 7:44 a.m. with CNA P and stated resident 14 was to have two staff to assist with the mechanical sit-to-stand lift and stated his care plan must have recently changed. *She agreed she had been transferring resident 14 by herself with the sit-to-stand mechanical lift. 9. Observation on 10/17/24 at 8:06 a.m. in the nurse's station revealed a whiteboard hanging on the wall near the entrance dated 10/16/24 at the top and had instructions written on it in orange to check Kardex daily. 10. Interview on 10/17/24 on 8:09 a.m. with LPN L regarding resident 14 when transferred with the mechanical lift revealed: *He was a fall risk and staff should use two people when using the mechanical lift. *He thought the Kardex was updated timely to include that information. 11. Interview on 10/17/24 at 8:12 a.m. with director of nursing (DON) B regarding resident 14's fall and transfers with a mechanical lift revealed: *Resident 14 had fallen in the tub room while one staff was assisting, but he did not fall from the mechanical lift. *CNA I was not involved with that transfer and fall but CNA R was. *She was disappointed CNA I used the mechanical sit-to-stand mechanical lift without the assistance of an additional staff person for resident 14. *She stated, That is a big deal we had recently done training on 9/19/24 because he had fallen. *CNA I was trained on 10/4/24 regarding transfers and Kardex's updated for transfers. *She stated, CNA R was not available for interview because she had called off work for the last two days. 12. Review of resident 14's 9/9/24 fall investigation revealed: *CNA R indicated resident 14, Was going to get a w/p [whirlpool] bath. He stood up at the bars and turned to sit and his good leg gave out on him and down he went. -The root cause of resident 14's fall was indicated as, Lost balance and fell , resident did not have a gait belt on when nurse entered room. -Summary of meeting: Resident found to not have fracture after being sent to the emergency department for evaluation. Investigation revealed resident was being transferred via one assist versus care planned sit-stand lift, this was how all consistent care givers were transferring resident. -Conclusion: Use sit-to-stand for all transfers, ensure appropriate room arrangement to accommodate lift use. -Additional Care Plan/Nurse aide assignment updates, CNA received coaching by the DON on 9/12/24, education provided to CNAs and nurse re: use of Kardex and how to request that transfer status be updated, Resident noted to have concerns about sit-to-stand lift and request part B therapy to work with resident on safe transfers in the lift. 13. Interview on 10/17/24 at 10:20 a.m. with DON B revealed: *DON B verified at the time of resident 14's fall incident on 9/9/24 resident 14 was transferred with the assistance of one staff and did not use a gait belt and she did not use the sit-to-stand mechanical lift. -She stated CNA R admitted to all of that. 14. Review of resident 14's care plan regarding transfers between surfaces revealed it was updated on 9/16/24 and instructed staff to use a mechanical sit-to-stand for transfers with assistance of two staff. Resident 14's transfer information on his Kardex matched those instructions. 15. Review of resident 14's 9/23/24 - 10/21/24 physical therapy evaluation and treatment plan revealed he would work with therapy to imporve his strength his left hip and knee and upper extremities needed to assist with transfers. 16. Review of the provider's 7/29/24 Fall Prevention and Management policy revealed: *Purpose: -To promote resident well-being by developing and implementing a fall prevention and management program. -to identify risk factors and implement interventions before a fall occurs. -To give prompt treatment after a fall occurs. -To provide guidance for documentation. *Falls - refers to unintentionally coming to rest on the ground floor or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen if not for employee intervention, is considered a fall. A fall without injury is still a fall. *Proactive Approach before a Fall Occurs procedure: -3. Care Plan the appropriate interventions, including personalizing all (SPECIFY) areas. -4. Communicate fall risks and interventions to prevent a fall before it occurs per Fall Committee meetings. -12. If appropriate, contact the physician for a referral to therapy and communicate this to resident an family.' -14. Communicate that a fall has occurred during shift change and daily stand-up meetings in the preferred method of communication. The PCC Shift and 24 Hour report are available options. -16. Review and update the Care Plan with any changes/new interventions. 50916 B. Based on observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (39) who received a bodily injury from an undocumented fall. Licensed practical nurse (LPN) K failed to identify and accurately document and report timely to facility leadership an incident when one of one sampled resident (39) was lowered to the floor after her legs had buckled. A fibula fracture was determined later. Findings include: 1. Observation and interview on 10/15/24 at 5:15 p.m. with resident 39 in her room revealed: *The room was free from clutter and potential injury hazards. *She was sitting in her recliner watching TV with her legs not elevated and her call light was within reach. *She could not remember if she had fallen recently. 2. Review of resident 39's electronic medical record (EMR) revealed: *Her diagnoses included hypothyroidism, other amnesia, history of falling, and type 2 diabetes. *Physician progress notes on 5/17/24 at 10:30 a.m. indicated: -She complained of increased right knee pain. -She reported she had a previous fall and was concerned for injury to her knee. -Her knee appeared swollen and had tenderness. -A nurse reported she was having difficulty with ambulation. *Her nursing progress notes indicated: -On 5/17/24 at 3:19 a.m. administration of, acetaminophen oral tablet for pain related to her legs. -On 5/17/24 at 5:36 p.m. new orders from physician for, ice pack/cold pack to right knee 15 min on and then 2 hours off as needed for pain. -On 5/17/24 at 5:37 p.m. new orders from physican for, Biofreeze External Gel 4% (Menthol (Topical Analgesic)) Apply to knees topically four times a day for pain. -On 5/18/24 the X-ray results of her right knee shown, osteoarthritis, and unremarkable examination of tibia and fibula. -On 5/20/24 the X-ray results of her right knee shown, she has arthritis. -On 5/22/24 at 11:15 a.m. the resident was sent to hospital for, right lower extremity (RLE) concerns of cellulitis. -On 5/22/21 at 7:17 p.m. the hospital called, resident is going to be admitted for broken fibula [calf bone]. *There was no documentation found in her EMR of a fall that occurred from 5/9/24 through 5/22/24. *Her careplan indicated her fibula fracture was a result of a fall that occured on 5/11/24. *Interventions for falls in her care plan initiated on 11/29/23 included staff were to: -Educate resident/family/IDT as to causes of fall. -Remind resident not to bend over to pick up dropped items. Encourage the use of a grabber or to ask for assistance. *Interventions for falls in her care plan updated on 5/28/24 included she was to work with physical therapy/occupational therapy for strengthening, endurance, and safety awareness. *Kardex as of 10/17/24 indicated: -She needed one staff assist with a walker and gait belt for ambulation. -She needed the assistance of two staff with a full body lift and an extra-large sling for transfers between surfaces. -Staff were to elevate feet when sitting up in chair to help prevent dependent edema. 3. Review of resident 39's 3/4/24 Sit-Stand-Walk Data Collection Tool assessment revealed: *She could bear weight on at least one leg. *She could extend at least one leg at the knee, flex her ankle and point her toes. *There was no indication of how she could pull herself to a standing position and maintain her position. *Interventions for ambulation and transfers between surfaces indicated the assistance of one staff member, walker, and gait belt. 4. Review of resident 39's 5/28/24 Sit-Stand-Walk Data Collection tool assessment revealed: *She could bear weight on at least one leg. *She could extend at least one leg at the knee, flex her ankle, and point her toes. *She could not pull herself to a standing position and maintain the position. *She would need the sit-to-stand equipment for transfers. *She was unsafe to ambulate. *Interventions for ambulating and transfers between surfaces indicated assistance of one staff member, walker, and gait belt. 5. Interview on 10/16/24 at 4:21 p.m. with certified nursing assistant (CNA) J regarding resident 39 revealed: *She needed the assistance of a sit-to-stand lift for transfers between surfaces prior to her fracture. *She always had ace wraps on her legs during the day for edema. *She was non-weight bearing when she had returned from the hospital. *She was in a boot that went up to her kneecap. 6. Interview on 10/17/24 at 7:32 a.m. with CNA G regarding resident 39 revealed: *She needed the assistance of a sit-to-stand lift between surfaces prior to going to the hospital because she had difficulty transferring because of pain. *She was sent out for X-rays after a potential injury was discussed. *She was in a boot and non-weight bearing status when she came back from the hospital. *Physical therapy had worked with her for a while, but she was not getting any better. *She was changed to use a full body lift for transfers. 7. Interview on 10/17/24 at 8:01 a.m. with administrator A regarding resident 39 revealed: *She was aware that there was no documentation of a fall that occurred. *She was on maternity leave when the fibula fracture was found. *She stated that agency LPN K had been with her when the fall occurred on 5/12/24. *LPN K had told her that she lowered resident 39 to the floor in the bathroom when her legs buckled. *When administrator A had asked LPN K why she had not documented the fall, LPN K stated she was not aware it was considered a fall. *Administrator A stated her expectation would be if she was there, she would have looked into the fibula fracture of unknown origin and started an investigation. *She was aware that a final report was not submitted to the Department of Health. 8. Interview on 10/17/24 at 8:21 a.m. with LPN K regarding resident 39's fall revealed: *She was not aware that the facility considered lowering a resident to the ground as a fall. *She had thought the resident needed the assistance of one staff with transfers. *Once the resident had been lowered to the ground, she needed multiple people to get her back up. *She did not believe the resident was hurt at the time of the incident. *Resident 39 needed a total body lift for transfers after her fracture and she cannot walk anymore. 9. Review of providers 7/29/24 Fall Prevention and Management policy revealed: *Purpose: - To promote resident well-being by developing and implementing a fall prevention and management program. - To identify risk factors and implement interventions before a fall occurs. - To give prompt treatment after a fall occurs. - To provide guidance for documentation. * Fall-refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for employee intervention, is considered a fall. *e. Notify the physician and resident representative of the incident. * f. Complete Fall Scene Huddle Worksheet. * 16. Review and update the Care Plan with any changes/new interventions. * 17. Report to the state regulatory agency when appropriate.

Based on observation, interview, cleaning log review, and policy review, the provider failed to ensure food items were appropriately stored and labeled and to maintain a clean and sanitary food service environment in one of one kitchen and one of one kitchenette. Findings include: 1. Observation of the kitchen on 10/15/24 at 10:23 a.m. revealed: *At least six cardboard boxes were piled on a metal cart with a blue bucket that contained a hardened brown and white substance. *A plastic bin with a blue lid that contained cookies and was not labeled or dated. *The floor, wall, and metal grease trap box under the three-compartment sink was covered with a brown and black substance. -There was unidentifiable debris between the sink and the grease trap. *There was no soap in the dispenser at the hand-washing sink. *The wall above the food preparation sink had areas of white peeling paint. *The base of the Magic Bullet, used to puree small portions of food, contained crumbs and a tan, brown, and pink substance. *A tub contained butter covered in crumbs that was not labeled or dated. *A container of peanut butter that was not labeled or dated. *A corkboard above the toaster contained at least six pieces of paper that were not in protective sleeves that were stained and curled at the edges. -One paper was touching the hot toaster. *A binder labeled What to do when a team member calls in was soiled with a brown substance and touched the toaster. *The areas between the oven and the stove, the stovetop, and the backsplash were splattered with a brown, black, and white substance. *A plate of cookies was in the pantry closet and was not labeled or dated. *The walk-in refrigerator contained: -A bag of celery that was visibly spoiled and was not labeled or dated. -An open bag of salad that was not labeled or dated. -A tub of cottage cheese labeled Discard by 10/07/24. -A box of cottage cheese labeled Best if used by 10/14/24. The walk-in freezer contained: -An open package of breaded chicken strips that were not labeled or dated. -An open package of french fries that was not labeled or dated. -An open package of carrots that was not labeled or dated. 2. Observation of the serving area located outside of the kitchen on 10/15/24 at 10:47 a.m. revealed: *The area between the steam table and the plate storage was soiled with food crumbs and debris. *A tray of cookies above the steam tables that were not labeled or dated. *The refrigerator contained: -A carton of thickened water labeled Best used by 10/8/24. -A dish that contained blueberries that was not labeled or dated. -A salad labeled [resident name] that was visibly spoiled and was not dated. 3. Observation on 10/15/24 at 12:05 p.m. of the 500-wing kitchenette revealed: *A tub of peanut butter with a lid had peanut butter smudged on the outside of the container and it was not labeled or dated. *A tub of butter that was not labeled or dated that contained significant food crumbs. A refrigerator contained: -Thickened cranberry juice labeled Discard by 10/11/24. -Thickened water labeled Discard by 10/8/24. -Three individual prune juice containers labeled Discard by 10/8/24. -Four slices of cheese in plastic wrap that was not labeled or dated. -Open packages of waffles, pancakes, and French Toast that were not labeled or dated. 4. Observation of the main kitchen on 10/17/24 at 9:15 a.m. again revealed: *The cardboard boxes and the blue bucket that contained a hardened brown and white substance remained on the metal cart. *The floor, wall, and metal grease trap box under the three-compartment sink were covered with the same brown and black substance. *There was no soap in the dispenser at the hand-washing sink. *The base of the Magic Bullet contained the same tan, brown, and pink substance. 5. Review of the Weekly Cleaning Assignments Logs revealed: *The September 2024 log was divided into five weeks each with 49 tasks. -Week one had 10 of the 49 tasks marked completed. -Week two had 22 of the 49 tasks marked completed. -Week three had 18 of the 49 tasks marked completed. -Week four had 6 of the 49 tasks marked completed. -Week five had 1 of the 49 tasks marked completed. *The October 2024 log was divided into five weeks each with 49 tasks. -Week one had 35 of the 49 tasks marked completed. -Week two had 21 of the 49 tasks marked completed. -Week three had 16 of the 49 tasks marked completed. 6. Interview on 10/17/24 at 9:47 a.m. with director of dining services M revealed she: *Stated that she had asked staff to dispose of the trash on the metal cart. *Had not been aware that the soap dispenser was empty and replaced the soap. *Confirmed that the area under the sink was dirty and needed to be cleaned. *Indicated the kitchen was to receive new counters and expected the areas around the sinks to be updated with the remodel. *Stated, That's gross, when she looked inside the Magic Bullet base. *Indicated that the butter and peanut butter containers are typically left on the counter and should have been labeled. *Expected items in the refrigerator and freezer to have been labeled and dated with the open date and the discard date when they were first opened. -Items were to have been discarded by the discard date on that sticker. *Confirmed that the Weekly Cleaning Assignments logs were incomplete. 7. Review of the provider's 4/3/24 Date Marking-Food and Nutrition policy revealed: *When TCS [Time/Temperature Control for Safety Foods] has been opened but remain in storage, employees: Ensure that ready-to-eat TCS foods opened at the location are clearly date marked for: 1) The date/time the original container is open. 2) The date or day by which the food shall be consumed on the premises, sold or discarded. *A food item is discarded when: the TCS item is beyond the USE by date. 8. Review of the provider's 11/27/23 Cleaning Schedule-Food and Nutrition Services policy revealed: *To promote a system that identifies cleaning tasks to be completed. *Employees will initial the schedule after completing his or her cleaning duties each day. *The DFN, food and nutrition supervisor, senior living dining director, senior living manager or person in charge is responsible for monitoring employees to ensure that cleaning duties are completed in a satisfactory and timely manner.

Based on observation, interview, and policy review, the provider failed to ensure the care plan for one of two sampled residents (73) was updated after her catheter was removed. Findings include: 1. Observation and interview on 10/16/24 at 8:20 a.m. with resident (73) while in her room revealed: *She confirmed she had no catheter. *Resident 73 denied she had a catheter. 2. Review of resident 73's electronic medical record (EMR) revealed: *Her care plan indicated she required Enhanced Barrier Precautions (EBP, the use of gowns and gloves) for an indwelling medical device - Foley Catheter initiated 05/28/24. *A progress note (PN) dated 5/28/24 indicated the resident will communicate understanding of need for EBP by the review date. *There was no current physician order for a Foley catheter. *Her 6/03/24 Minimum Data Set (MDS) assessment indicated she had a catheter at that time. *Her 8/20/24 MDS indicated she did not have a catheter at that time. *A PN dated 8/12/24 indicated her Foley catheter was discontinued. *Her 8/20/24 Brief Interview for Mental Status (BIMS) assessment score was 10 which indicated she was moderately cognitively impaired. 3. Review of resident 73's paper medical record revealed: *On 6/20/24 the 14 French (FR) catheter was removed. 4. Interview on 10/16/24 at 8:30 a.m. with registered nurse (RN) E revealed: *Resident 73 did not have a catheter. *She stated, She may have had a catheter when she first came in. 5. Interview on 10/16/24 at 2:30 p.m. with certified nurse assistant (CNA) H revealed: *[Resident 73] does not have a catheter. *She indicated she would have looked at the resident's care plan or MDS to know if a catheter was present. *She stated, The nurse is who updates the care plans, and the nurse manager is who overlooks the care plans/MDS. 6. Interview on 10/16/24 at 2:53 p.m. with RN/MDS nurse D revealed: *She stated, I do 75 percent of the care plans. *She reviewed the resident chart and the records provided by the admitting facility. *[RN C's name] should have updated that care plan. *The nurse manager on the unit that the resident lived on, would then have notified her of the changes at their stand-up morning meeting or by email. Review of the provider's Care Plan policy revealed: *The purpose of the care plan is to provide a centralized coordination of the services that will be provided to each resident, based on his or her individual needs, abilities, and preferences.

Based on record review, interview, and policy review, the provider failed to ensure the proper Medicare notices were completed and provided for two of two sampled residents (79 and 84) prior to their discharge from skilled services. Findings include: 1. Review of resident 79's CMS (Centers for Medicare and Medicaid Services) SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form provided by clinical care leader D on 9/7/23 revealed her Medicare Part A Skilled Services Episode start date was 6/14/23 and the last covered day for Part A services was on 7/11/23. Review of resident 79's medical record revealed: *She had been admitted on [DATE]. *Her 6/16/23 Brief Interview for Mental Status (BIMS) was 3 that indicated severe impairment. *She had skilled covered days remaining and continued to reside in the facility. *Her daughter/health care power of attorney signed the Notice of Medicare Non-coverage (NOMNC) on 7/8/23 with the benefit's expiration of 7/11/23. - That standardized notice informs Medicare beneficiaries when their Medicare-covered services were ending and provided an opportunity to request an expedited determination from the Quality Improvement Organization (QIO). *The resident was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) form. -That standardized notice allows Medicare beneficiaries to make informed decisions about whether to receive certain Medicare services and accept financial responsibility for those services if Medicare would not cover the cost of those services. -The resident representative was not given their alternative payment or appeal options located on the SNFABN form. 2. Review of resident 84's CMS SNF Beneficiary Protection Notification Review form provided by clinical care leader D on 9/7/23 revealed her Medicare Part A Skilled Services Episode start date was 8/17/23 and the last covered day for Part A services was on 9/6/23. Review of Resident 84's medical record revealed: *She had been admitted on [DATE]. *Her 8/22/23 BIMS score was 12 that indicated moderate impairment. *She had skilled covered days remaining and continued to reside in the facility. *She signed the NOMNC on 8/31/23 with the benefit's expiration of 9/6/23. *The resident was not given an SNFABN form. -The resident was not given their alternative payment or appeal options located on the SNFABN form. 3. Interview on 9/7/23 at 4:22 p.m. with clinical care leader D regarding Medicare notices revealed: *She was a registered nurse, who identified herself as the Rehab Manager. *She was responsible for providing the notices to residents when they were discharged from skilled services. *The residents were only given the NOMNC forms to sign. *She did not know about providing the SNFABN form to a resident who remained in the facility after all skilled services had ended. *It was her understanding that they did not need to provide the SNFABN forms. *She confirmed the findings above and agreed that residents 79 and 84 were not provided the SNFABN form prior to their skilled services ending. Interview on 9/7/23 at 4:42 p.m. with director of nursing services B revealed: *Her expectation was that the Medicare guidelines would have been followed in providing the Medicare notices to the residents. *She was not sure which Medicare notices were required. *She agreed with the findings above. 4. Review of the provider's 2/13/23 SNF Medicare Part A Advance Beneficiary Notice of Non-Coverage (SNFABN) policy revealed: *The SNFABN is given to SNF beneficiaries enrolled in the Medicare fee-for-service program (Part A). *The SNFABN is to be issued prior to PPS [Prospective Payment System] extended care items or services that are furnished, reduced, or terminated when the SNF believes Medicare may not pay for those extended care services based on the basis of one of the following statutory exclusions: -Not reasonable and necessary (i.e., medical necessity) . or -Custodial care (i.e., not a covered level of care). *The SNFABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items/services furnished to a beneficiary for which Medicare does not pay. *If Medicare is expected to deny payment on the basis of one of the exclusions listed above, a SNFABN must be given to the beneficiary in order to transfer financial liability for the item/service. *Provider Delivery of the SNFABN -The SNF must advise the beneficiary (verbally and in writing) before the extended care items/services are provided that, in the SNF's opinion, the beneficiary will be fully and personally responsible for payment of services furnished. -Failure to provide a valid SNFABN may result in the SNF being held financially (provider) liable.

Based on observation, record review, interview, and policy review, the provider failed to ensure: *One of one sampled resident (32) had been supervised to prevent a burn from a heat register.*Twenty-five of forty-eight random and sampled residents in rooms with a heat register that was parallel to and close to their beds (rooms 101, 103 B, 108 B, 110 B, 301 B, 303 B, 305 B, 309 B, 310 B, 403 B, 404 B, 405 B, 406 B, 411 B, 502, 503 B, 504 B, 505, 513 B, 518 B, 519, 522, 602 B, 604, and 605) had been evaluated and had interventions in place to reduce the risk of [CONDITION(S)]. Findings include: 1. Observation on 5/18/21 at 3:30 p.m. of resident 32 revealed: *She was laying on her bed. *She had not acknowledged this writer when she was approached. *A mat had been placed on the floor beside her bed. Review of resident 32's medical record revealed: *She was admitted on [DATE] after a hospital stay from a fall at an assisted living center. *She was placed on hospice on 3/30/21 due to continued declines and weight loss. *A 4/10/21 progress note indicated, Resident rolled her legs in between the wall and the wall heater. When CNA [certified nursing assistant] and RN [registered nurse] moved her back into bed, a burn was noted to her left knee. Review of resident 32's 4/10/21 incident report revealed: *The report had been completed on 4/10/21 at 11: 40 a.m. *CNA called RN to room where resident was visualized to have her head in bed but torso and legs in between the wall/heater and her bed. Heater was on and residents [resident's] legs were tangled in her blanket and resting on top of wall heater. *Resident and CNA moved her legs and torso back into bed and burn mark from heater visualized to left outer knee. Bed moved to face other wall away from heater. *The injury type was a burn on the left front knee. *Her mental status was described as lethargic and oriented to person only. *Predisposing environmental factors: No apparent unsafe condition. *Predisposing physiological factors: Confused, drowsy, impaired memory. *Predisposing situation factors: No factors had been identified at that time. *There were no witnesses to the incident. Review of resident 32's 4/10/21 Wound Data Collection report revealed: *Left knee burn from wall heater, first layer of skin removed. *The burn measured 9.5 centimeters (cm) by (x) 6 cm. *The area was open and red. Review of resident 32's 4/10/21 Wound RN Assessment identified the above wound as a partial thickness loss. Interview on 5/18/21 at 3:30 p.m. with director of nursing (DON) B revealed: *The resident had been found at 9:30 a.m. on a weekend day. *Staff RN H and CNA I who were interviewed at the time reported they had peeked in on the resident approximately 30 minutes before they found her between the bed and the wall. *The staff reported: -The heater was warm at the time she was found, and the resident had fragile skin. -They estimated her knee and leg had rested against the heater for more than five minutes. *A burn had occurred to the left knee and leg. *An event report had been completed after the burn had been identified. *Her physician and her husband had been notified of the burn. *The provider had not notified the South Dakota Department of Health (SD DOH) of the event that had caused a burn to her leg. *The administration thought that since resident 32 had not required medical attention in the emergency room it was not necessary to notify the SD DOH. *The staff completed a root cause analysis to identify the cause of the injury. Review of resident 32's 4/12/21 root cause analysis form revealed: *The event had occurred at 9:30 a.m. on 4/10/21. *Her diagnosis was senile degeneration of the brain, dementia. *Factors that had contributed to the incident: Resident had legs out of bed, legs were in between bed and heater resulting in burn to (L) [left] knee. *1 time occurrence. *Corrective actions taken to prevent recurrence of this incident: -Modify environment. -Bed moved to another position in room and no longer next to heater. -Nursing education per nursing leadership staff - to keep bed away from heater with resident's fall risk and repositioning self in bed at times. *Results of investigation: Found that heater in room was warm to touch, resident has fragile skin and when knee/leg rested between bed and heater for a period of time burn did occur to knee/leg. Review of resident 32's 5/12/21 left knee Wound Data Collection form revealed: *The burn measured 8 cm x 5 cm. *The wound bed was fully covered 100 percent with black eschar (dead tissue). Review of resident 32's 5/12/21 Wound RN Assessment revealed: *Full thickness tissue loss. *Deterioration of wound - evidenced by red wound edges, black eschar and slough present. On 5/12/21 resident 32's physician changed her wound treatment to help with removing the eschar. Observation on 5/19/21 at 8:44 a.m. of resident 32's dressing change to her left leg with RN J revealed resident 32: *Was living in another room when she rolled onto the heat register, getting the burn on her leg. *Had told staff she did not feel any discomfort at the time her leg was burned. *Had slid off her bed onto the floor on 5/10/21. -After that fall they had placed a mat on the floor to prevent injuries from falls. Review of resident 32's care plan revealed: *A revised 4/10/21 skin impairment focus had identified the burn on her leg. *A revised 5/11/21 fall focus related to a fall on 3/6/21 at the assisted living and another fall on 5/10/21. -There was no indication of the fall against the heat register on 4/10/21. -Interventions for falls had included: --Appropriate footwear. --Monitor for significant changes. --Monitor for medication combinations that could predispose her to falls. --Review her status for any medical conditions that could predispose her to falls. ---The interventions had not included the use of the mat beside her bed. Interview on 5/20/21 at 10:30 a.m. with DON B regarding resident 32 revealed: *After reviewing the 4/10/21 event report and the 4/11/21 root cause analysis she confirmed she had not identified the resident had fallen on 4/10/21. *She confirmed the provider had not implemented interventions to prevent her from being burned. Interview on 5/19/21 at 4:45 p.m. with DON B regarding the resident 32's root cause analysis confirmed: *The nursing department had been educated after the burn was identified by the nursing leadership to keep her bed away from the heater due to the resident's fall risk and history of repositioning herself in bed. *The root cause analysis had focused only on resident 32 and her environment. -No other beds/rooms had been observed for at-risk residents. *Administrator in training A, DON B, and social worker G who had participated in the analysis had not: -Considered the potential safety concerns for all other at-risk residents who had a bed by the window where the heating registers were located. -Implemented interventions for those residents who were at risk of [CONDITION(S)]. Review of the provider's December 2020 Falls Resource Packet policy revealed: *A fall referred to unintentionally coming to rest on the ground, floor, or other lower level, but because of an overwhelming external force, such as being pushed. *A fall committee gathered to analyze the fall data using the root cause analysis and looking for trends and patterns. *After a fall staff were to have checked the resident's care plan to determine if the cause of the fall had been addressed to avoid additional falls. *Fall reduction began with proactively recognizing potential fall risk factors and proceeded with communicating actions to reduce the possibility of falls. Review of the provider's November 2016 Resident's Rights for Skilled Nursing Facilities policy revealed:*The provider must protect and promote the rights of each resident. *The provider must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. *The resident had a right to a safe, clean, comfortable, and homelike environment. *The resident had a right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on record review, interview, and policy review, the provider failed to provide the necessary care and services for one of one sampled resident (1) with a left ventricular assist device (LVAD) with regard to the following: *A facility specific policy and procedure for the device. *Training of staff. *physician's orders [REDACTED]. *Verification the device was hooked up and functioning properly. Findings include: 1. Review of the closed medical record for resident 1 revealed: *He was admitted on [DATE] following a hospitalization for a urinary tract infection and altered mental status. *He passed away on 6/15/18. *He had [DIAGNOSES REDACTED]. *A 5/31/18 physician's orders [REDACTED]. Review of the Minimum Data Set (MDS) assessments for resident 1 revealed he: *Had a 6/7/18 admission assessment: -Had a Brief Interview for Mental Status (BIMS) score of ten indicating moderate cognitive impairment. -Required the extensive assistance of two people to transfer. -Required the extensive assistance of one person to get dressed. -Required the limited assistance of one person for personal hygiene. -Used a walker or a wheelchair to get around the facility. *On 6/14/18 a fourteen day assessment was completed. Review of resident 1's undated care plan revealed: *It was initiated on 5/31/18 and several focus, goal, and intervention areas were revised on 6/12/18. *It did indicate the resident had an LVAD in place. *It did not address how the LVAD was cared for and by whom. Review of the provider's internal investigation and report to the South Dakota Department of Health (SD DOH) revealed: *He was found without heartbeat or respirations at 6:26 a.m. on 6/15/18. *His LVAD machine was not plugged in. -His wife usually plugged the machine in at night. *No staff had heard the low battery alarm sound. Interview on 6/26/18 at 12:55 p.m. with licensed practical nurse (LPN) A regarding resident 1 revealed: *She had worked a twelve-hour overnight shift immediately prior to the resident's death. *The nurse giving her report on 6/14/18 at approximately 6:30 p.m. had passed along he had some confusion during the day. There was an order for [REDACTED]. *She spoke with the resident the evening of 6/14/18 and did not notice any confusion, and the resident was pleasant. -Her last visit with the resident was between 4:00 a.m. and 4:30 a.m., and she had no concerns. *The certified nursing assistants (CNA) working with her had not brought any concerns to her regarding the resident's condition. *She verbalized she had not had any issues with the LVAD, and his wife took care of most of the care with the LVAD. *Had not verified if the LVAD was plugged in when the resident went to bed. -Stated the wife did that activity. -Was not aware if the CNAs checked on the device overnight. -Had not received any training for the LVAD but knew there was a resource number to call with questions or concerns. Interview on 6/26/18 at 1:20 p.m. with registered nurse (RN) B regarding resident 1 revealed: *She started her shift at approximately 6:00 a.m. on 6/15/18. *No concerns had been passed on to her in report by LPN A. *She had entered his room with CNA D and found the resident sitting in his recliner and without a pulse or respirations. -It had been customary for him to sleep in his recliner at night. -His portable battery packs were still on, and the LVAD was not plugged in. -It was her understanding his wife removed the battery packs and usually plugged the device in at night. *In addition to plugging in the LVAD at night his wife completed much of the LVAD related care. *She had received training on the LVAD around the time of the resident's first admission in early (YEAR). -They had been educated by (hospital name) personnel, and it included how to check the readings on the device and complete a mean arterial pressure (MAP). Interview on 6/26/18 at 2:20 p.m. with CNA C regarding resident 1 revealed he had: *Worked the overnight shift with LPN A immediately prior to the resident's death. *Gone into his room twice in the evening to help him get ready for bed and to assist the nurse. *Not heard any alarms sound overnight and did not have any concerns that he had taken to the nurse. *Received any training related to the LVAD. Interview on 6/26/18 at 2:40 p.m. with CNA D regarding resident 1 revealed: *She had started her shift at approximately 6:00 a.m. on 6/15/18. *She had entered his room with RN B, so she could provide cares prior to his therapy. *Acknowledged the wife did complete some of the resident's care each day. *She could not remember receiving training related to the LVAD. -She would ask the nurse if she had any questions or concerns. Interview on 6/27/18 at 9:55 a.m. with the director of nursing revealed: *The facility did not have a policy regarding the LVAD. -They would reference the (MONTH) 2013 (hospital name) Ventricular Assist Device policy. -It did not address caring for the resident in the long-term care facility. *Regarding LVAD training: -On-site training had been provided by (hospital name) in early (YEAR). -Ongoing training to staff had been done by RN E. -It was not her expectation that competency training be completed with staff, since the resident was on a short-term rehabilitation stay. -Competencies would have only been completed if a resident with an LVAD was going to be at the facility long-term. *Oversight of the care and management of the LVAD was minimal since the family was trained to provide that care. *With regard to his wife completing LVAD care: -She was often at the facility several times throughout the day. -She had been trained on care of the LVAD by the hospital that had performed the insertion of the device. -They followed the recommendation of (hospital name) to let the family complete the care as had been done at home and in the hospital. -Confirmation of the competency of a family member to complete care would have been completed by that hospital. *She acknowledged the 5/31/18 physician's orders [REDACTED]. -She was not aware of any additional physician's orders [REDACTED]. -The resident had been at the facility for two short-term rehabilitation stays in the past several years. -Would not have expected the order to be clarified to include additional care until after the fourteen day assessment. *The care plan in place at the time of his death was the baseline care plan. -It was not her expectation the baseline care plan would have included care of the LVAD. -The LVAD care would have been added to the comprehensive care plan. -A comprehensive care plan was due seven days after a comprehensive assessment had been completed. *Acknowledged the facility risk assessment did not include the acceptance of residents with an LVAD. -It was revised in (MONTH) (YEAR). -Stated, We did not have any residents with an LVAD at that time. *Interventions that were not implemented until after the resident's death included: -The nurse practitioner from (hospital name) would complete hands-on training with staff. -They would implement an every four hour battery check. Interview on 6/27/18 at 10:45 a.m. with RN E regarding LVAD training revealed: *She confirmed she was in charge of training new staff regarding the LVAD. *The training for new permanent staff was to include: -What the device was/reason for use. -Location of the three-ring resource binder. -Where the battery packs and their connections went. -How to check the MAP using the blood pressure cuff and doppler. -That training was verbal, unless there was a resident with an LVAD in the facility. *The training was also provided to agency staff. *Any training provided was done verbally and had not been documented. *A resident admitted with an LVAD was infrequent, and she would have tried try and reinforced information to the staff in the day or two leading up to the admission. Interview on 6/27/18 by electronic mail with the hospital that managed resident 1's LVAD heart failure care team revealed: The spouse or significant other is trained at the implanting center such as (hospital name) or (hospital name). The patient (resident) cannot get an LVAD without their spouse or significant other passing a competency test from the implanting center. The patient also takes this test to prove competency. Review of the provider's (MONTH) (YEAR) Care Plan policy revealed: *Each resident will have an individualized, person-centered plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial and educational needs. Through the use of departmental assessments, the Resident Assessment Instrument and review of the physicians's orders, any problems, needs and concerns identified will be addressed. *The comprehensive plan of care will be finalized during an interdisciplinary care team conference no later than seven days after completion of the comprehensive resident assessment.

A. Based on record review, interview, and policy review, the provider failed to ensure: *Emergency services were appropriately contacted for one of one sampled resident (1) who had stopped breathing. *Five of five licensed nurses (A, E, F, G, and H) failed to intervene and perform cardiopulmonary resuscitation (CPR) correctly and in a timely manner for one of one sampled resident (1) who had stopped breathing and was without a pulse. *Five of five licensed nurses (A, E, F, G, and H) failed to use emergency equipment (automated external defibrillator) (AED) for one of one sampled resident (1) who had stopped breathing. Findings include: 1. Review of resident 1's [DATE], 9:15 a.m. through 11:20 a.m. progress notes by registered nurse (RN) A revealed: *9:15 a.m.- "Writer walked by dining room. Resident stated I'm choking. Immediately started [MEDICATION NAME] maneuver and did a throat sweep. Second nurse arrived within 30 seconds. Resident became unresponsive." *9:20 a.m.- "Resident rushed into room where cardiopulmonary resuscitation (CPR) was begun." *9:25 a.m.- "Ambulance was called. Resident unresponsive and no breathing. *9:45 a.m.- "Ambulance personnel arrived and took over CPR." *10:12 a.m.- "Resident pronounced dead." *10:20 a.m.- "Discussed with daughter death of mother. Daughter driving from five hours away. Hold body until resident's son-in-law is present." *11:20 a.m.- "Physician called with time of death of 10:12 a.m." Interview on [DATE] at 10:30 a.m. with RN F regarding resident 1 revealed: *On [DATE] at about 9:15 a.m. she saw two nurses (A and E) standing by the resident in the dining room. *"The resident was unresponsive and ashy (gray colored)." *She heard certified nursing assistant (CNA) D page licensed practical nurse (LPN) E to the dining room, and went to the dining room to see if she could help. *"The two nurses (A and E) were doing the [MEDICATION NAME] maneuver." *She thought the resident had choked on bacon from the looks of her breakfast tray. The bacon was cut up on her plate. *She never heard the resident talk. She was only "unresponsive"when she saw her. *"I made the decision to move her from the dining room to her room. She was taken to her room and placed on her bed." *"Two CNA (D and I) got the mechanical lift and got her into bed." *The oxygen concentrator was obtained, but she did not know by whom. *"The resident was not breathing from the dining room to the bed." *"CPR was started first and the back board was gotten later." *"We felt the prayer room next to the dining room was too small to get the resident on the floor and start CPR." *"As soon as you know the resident is not responding to treatment 911 should be called." *"I stayed in the room and did CPR." *"I did not call 911, but the decision was made to call 911 after they had started CPR." *"The ambulance did not get here very fast." *"CPR was not stopped until the ambulance arrived." Interview on [DATE] at 12:00 noon with the medical director regarding resident 1 revealed: *Emergency 911 services should have been called if she had stopped breathing and was non-responsive. *He could not imagine transferring her to the bed with the Hoyer lift (mechanical lift) if she was not breathing. *The response time for the emergency services seemed to be a long time if they had been informed it was a medical emergency. He stated "They were not as responsive as they should be." Interview on [DATE] at 1:32 p.m. with LPN G regarding resident 1 revealed: *On [DATE] she had been orienting RN H on another wing of the facility. *"I knew there was a problem in the focused rehab dining room on [DATE] I guessed about 8:00 a.m. to 8:15 a.m. A nurse (unsure who) had come down to the oxygen room. That nurse had asked her to watch the focused rehab dining room as they had an emergency with a resident. The nurse told her the ambulance needed to be watched for." *She sent RN H to the resident's room to be the "runner." RN H assisted nurses E and F with CPR. *She had not seen the resident in the dining room. When she did go into the resident's room (unsure time) the resident was not breathing. Nurses E, F, and H were performing CPR on the resident in bed. *"I was taught during orientation to call the non-emergent ambulance services for normal emergencies and with a non-breathing episode or stroke to call 911." Interview on [DATE] at 1:46 p.m. with CNA D regarding resident 1 revealed: *On [DATE] she had assisted her with her care and taken her to the dining room at about 8:30 a.m. to 9:00 a.m. *She had talked with the resident, taken her to the bathroom, and obtained her weight prior to taking her to the dining room. *She had brought her a plate of food that contained scrambled eggs, sausage patty, pancakes, and two slices of bacon. The resident had started to eat while she was still in the dining room. *Another resident wanted to go to her room, and she (CNA D) had left the dining room for about five minutes. *When she returned five minutes later "The resident lipped to her she was choking. There was no verbal response from the resident." *She had paged LPN E to come to the dining room immediately. RN F also came to the dining room. *"RN F told her to take the resident to her room. The resident was in a wheelchair with pedals, and she was wheeled to her room. She was not breathing." *"The nurses A, E, and F were working with the resident." *"She assisted LPN E to put oxygen on the resident." *"She was told to watch for the ambulance by RN F. She waited for the ambulance eight to ten minutes. *She heard the ambulance had been called twice. The emergency medical technicians put the resident on the floor." Phone interview on [DATE] at 2:00 p.m. with RN H regarding resident 1 revealed: *On [DATE] she was in her second week of training at the facility. She was orienting that day on another area of the facility with LPN G. *On the morning of [DATE] (unsure time) RN A came to the oxygen room. LPN G told her to go check on resident 1. *Nurses E and F were performing CPR on the resident in bed. "I knew they needed a back board and obtained one off the crash cart. I then assisted nurses E and F with CPR. RN A had already called the ambulance." *"Myself and nurses E, F, and G took turns at performing CPR until emergency medical technicians arrived. The emergency medical technicians put her on the floor and hooked her up to the monitors." *"The first time I had seen the resident she was in bed and not breathing." *She had received no training in orientation when to call the non-emergency ambulance or 911. *"She would call 911 with a change in resident condition." *It took the ambulance about 10 to 15 minutes to come after they had been called. Interview on [DATE] at 2:15 p.m. with LPN E regarding resident 1 revealed: *On the morning of [DATE] (unsure time) she was helping another resident in the bathroom when she was paged by CNA E to come immediately to the focused rehab dining room. *She finished assisting the other resident and immediately went to the dining room. RN A and CNA D were with the resident. RN A was doing the [MEDICATION NAME] maneuver to the resident. She was told the resident had eaten one bite of food. *RN F grabbed her to get the oxygen for the resident and told her to put the oxygen concentrator on 5 liters with a mask. The oxygen was put on her after she had been assisted into bed with the Hoyer lift by CNAs D and I. *Myself and nurses F, G, and H took turns doing CPR. *The resident was not breathing in the dining room when she first had seen her at about 9:15 a.m. to 9:16 a.m. *"The back board was not in the room the first five minutes of CPR. RN H brought the back board to the room when she came to assist with CPR." *She stayed in the room while RN A called the ambulance. *"You call 911 or the ambulance. It depends on the circumstances." *"RN A told her she called the ambulance first and the call was dropped. RN A then told her she called 911." *"RN A told her it was taking a long time for the ambulance to come. She told her she had called the ambulance, and they told her they were enroute." *The ambulance usually only took about ten minutes to arrive once they were called. *She did not remember if they went over when to call the non-emergency number for the ambulance or 911 during her orientation. Phone interview on [DATE] at 2:35 p.m. and on [DATE] at 10:15 a.m. with RN A regarding resident 1 revealed: *She said she found her at the dining room table on [DATE] about 9:15 a.m., and the resident said she was choking. She became unresponsive and stopped breathing she thought at about 9:16 a.m. "She was getting breathless in 20 to 30 seconds with no breathing." *Certified nursing assistant (CNA) D came into the dining room at the same time, and they attempted the [MEDICATION NAME] maneuver a couple times without success. CNA D immediately paged licensed practical nurse (LPN) E to the dining room to assist them. *By the time LPN E got to the dining room the resident was unresponsive and not breathing. LPN E attempted the [MEDICATION NAME] maneuver once without success. *At about 9:20 a.m. RN F came into the dining room and stated to take the resident to her room, so she could get some oxygen. CNAs D and I assisted to put the resident into bed with the use of a Hoyer lift. A Hoyer lift had been used to transfer her, because she was no weight bearing due to a fractured right ankle. *"I know it took just a few seconds for CNAs D and I to transfer her into bed with the Hoyer lift. We started CPR immediately once the resident was in bed." *She was not sure why the decision was made to transport her to her room first before starting CPR. It had not been her decision. RN F had wanted to get the resident out of the room to give her some oxygen. It had taken them only a few seconds to get her to her room and lifted into bed with the Hoyer lift. *She thought she had called 911 first about 9:30 a.m. and had told them the resident was not breathing, and was not responsive. The emergency service did not respond, so she hung up and thought she just called the ambulance (non-emergency number), and they told her "They were enroute." *It seemed to be taking a long time for the emergency services to arrive, so she called a third time to 911 at about 9:35 a.m. and again they told her they were enroute. She waited five to ten minutes and called the ambulance a fourth time. *The emergency services arrived about 9:45 a.m. and took over CPR. They laid her on the floor and intubated her (tube into throat to clear airway). They told the nurses there was not anything lodged in her throat. *She was unsure who had pronounced her dead at 10:12 a.m. but thought it was the emergency services. *She did not comment when asked what training she had received during orientation when the non-emergency ambulance number should have been called or 911. Interview on [DATE] at 3:40 p.m. with RN B nurse manager regarding resident 1 revealed: *She arrived on [DATE] at 10:30 a.m. and was informed of the resident's death. *She was told RN A had called the ambulance (non-emergency) number about 9:25 a.m. and was disconnected, and then she made a call to 911. She agreed if the ambulance arrived at 9:45 a.m. that was a significant delay if they had been informed the resident had not been breathing since 9:16 a.m. *Emergency 911 services should have been called since the resident was not breathing and unresponsive. Nurses were informed in orientation to call 911 for emergency situations, and the ambulance number if the situation was non-emergent. *The resident should have been transferred to the floor when she had stopped breathing at 9:16 a.m. and CPR started. She was not sure why they had transported her back to her room and took the time to transfer her into bed with a mechanical lift. *There was discrepancy among the nurses with the interviews and the above progress notes for the following: -The actual time the resident's respirations had stopped. -If the emergency service number called was the emergency number 911 or non-emergency number. -The exact time CPR was initiated. -The exact time the emergency services arrived. Interview on [DATE] at 9:45 a.m. with the director of nursing regarding resident 1 revealed: *She was concerned with the ambulance response time. *They did not have a policy regarding when the non-emergent ambulance service or 911 should have been called. They also did not have a CPR policy. *She had been informed by the nurses the resident had stopped breathing at 9:16 a.m., and CPR was initiated at 9:25 a.m. *It had been discussed that oxygen could have been started in the dining room instead of transporting her back to her room. The resident should have been laid on the floor in the dining room or the prayer room next to the dining room, and CPR initiated at 9:16 a.m. when she had stopped breathing. *"I would rather have put her on the floor and not worry about any injuries that would have occurred." *She was not certain why there was a nine minute delay from when she stopped breathing until CPR had started. One of the nurses had looked at the resident's electronic medical record at 9:25 a.m. and determined she was to be resuscitated. *There seemed to be confusion if the 911 emergency services was called or the non-emergency service was called and the actual time they were called and arrived. Emergency 911 services should have been called since the resident was not breathing. RN A had told her the resident was unresponsive when she had called the ambulance. *If the emergency services were called at 9:25 a.m. initially as documented and did not arrive until 9:45 a.m. she would consider 20 minutes too long in an emergency. *The emergency services had informed her that the next time the nurses should call 911 for emergency situations and not the non-emergency number. *"The ambulance and 911 are not the same thing." *"The nurses should have checked her code status at 9:16 a.m. and started CPR. All interviews support the resident stopped breathing at 9:16 a.m. Her code status was not checked until 9:25 a.m. which was nine minutes after she had stopped breathing. Phone interview on [DATE] at 10:50 a.m. with the shift manager at the emergency services regarding resident 1 revealed: *On [DATE] the 911 number was not called. *Two calls came into the business line at the local non-emergency service. The times those calls came in were not known as calls to that number were not recorded. Calls made to that number also did not display the address or phone number the calls were being made from. *Calls made to the business line were dispatched to a city located in another state, and then emergency services were dispatched by them. *The nurse that made the two calls did not wait on the line to give any information to the secretary that answered the phone. The secretary had told the nurse both times to wait on the line. *The nurse made a third call on [DATE] at 9:49 a.m., and the secretary asked her the location she was calling from and would dispatch emergency services herself instead of forwarding her call to the other city and state. The secretary was not trained to dispatch emergency services but had conveyed to her she knew the person on the other line needed help for someone. *The secretary dispatched emergency services at 9:49 a.m., and they arrived at the facility at 9:52 a.m. according to their records *The information the resident was not breathing and was not responsive was not given to the secretary. *Emergency 911 services should always have been called for emergency services. The 911 calls were recorded, and they were able to track the phone number and address even if the caller had hung up. Phone interview on [DATE] at 11:15 a.m. with RN F regarding resident 1 revealed: *"We have an AED in the facility." *"The AED was not used on [DATE] for the resident." *"The ambulance used their AED on the resident when they arrived." *"She was not sure why they had not used their AED on the resident." *"All the nurses at the facility had been trained how to use the AED." *She was not sure if they had a CPR policy. Review of the provider's [DATE] CPR policy faxed to the facility on [DATE] at 11:30 a.m. by RN F revealed: *"CPR is mandatory for all licensed nursing staff. Each shift will have a staff person scheduled who will perform CPR unless: -The resident has a do not resuscitate order. -The resident has obvious signs of clinical death. -The initiation of CPR could cause injury to the rescuer. *Each center will create a center specific procedure with input from their rehabilitation skilled care consultant to quickly access CPR status of all residents in the center." Review of the [DATE] revised American Heart Association CPR guidelines revealed: *"The steps for CPR have not changed since 1954 when it was first introduced." *"The order of the different steps for performing CPR has always been A-B-C (airway, breathing, and compressions). This was accepted practice until recently." *"In 2010, the American Heart Association came out with a report with their recommendations, rearranging the order to C-A-B (compressions, airway, and breathing), placing emphasis on the chest compressions." *"The research concluded that the old approach creates an unnecessary delay in chest compressions." *"By beginning with chest compressions instead of postponing them until after completing the airway and breathing steps, we are able to get the blood flowing immediately." *"Immediate restoration of blood circulation has been determined to be the utmost priority for saving the victim's life." Review of Patricia A. Potter and Anne Griffith Perry, Fundamentals of Nursing, 8th Ed., St. Louis, MO, p. 853, revealed: *"If a patient's [MEDICAL CONDITION] (not breathing) is severe and prolonged, cardiac (heart) arrest (stops) results." *"During [MEDICAL CONDITION] there is an absence of pulse and respirations (breathing)." *"Permanent heart, brain, and other tissue damage occurs within four to six minutes." *"The critical elements found to be essential for survival were chest compressions and early defibrillation (device used to administer an electrical shock through the chest wall to the heart to stop the abnormal rhythm.)" *"The defibrillator is used to strengthen the chain of survival. Every minute of a sudden [MEDICAL CONDITION] without defibrillation decreases the survival rate by 7 percent (%) to 10%." *"Early CPR with defibrillation within the first three to five minutes can result in greater than 50% long-term survival." B. Based on closed record review, interview, and policy review, the provider failed to obtain a physician's order for one of two sampled residents (1) with a change in condition. Findings include: 1. Closed record review on [DATE] of resident 1's medical record revealed: *Resident had been unresponsive and not breathing on [DATE] in the a.m. *On [DATE] at 10:12 a.m. registered nurse (RN) A had documented "Res. (Resident) pronounced death (dead) at 10:12." *On [DATE] at 11:20 a.m. RN A had documented "Called Dr.______with time of death 1012 (10:12 a.m.)." *There had been no physician's order to release the body to the mortician. Interview on [DATE] at 3:40 p.m. with RN B nurse manager regarding resident 1 revealed: *The charge nurse that had documented the death of the resident had done so without proper [DIAGNOSES REDACTED]. *RN A had documented that the resident had been pronounced dead and the "pronouncement of death-can't do this as nurses." *Making a [DIAGNOSES REDACTED]. *The provider had not received a physician's order for the body to have been released to the mortician. Interview on [DATE] at 4:55 p.m. with the director of nursing services regarding resident 1 revealed: *The physician needed to have been called regarding no respiration, no heart beat, and no blood pressure. *The charge nurse that had documented the death of the resident had done so without proper [DIAGNOSES REDACTED]. *There needed to have been a physician's order to release the body to the mortician. Review of the provider's [DATE] Physician's Orders policy regarding a discharge due to death revealed: *The physician was to have been notified regarding the date and time of death. *The nurse was to have obtained a physician's order to discharge the body to the mortuary. Pursuant to SDCL [DATE].1 Determination of death - Any individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the [DIAGNOSES REDACTED], is dead. A determination of death shall be made in accordance with accepted medical standards.