Every finding on record at Good Samaritan Society Miller

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 (5) 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). Findings include:1. Observation and interview on 2/17/26 at 3:53 p.m. with resident 5 in his room revealed:*He had a cushion in his wheelchair and an air mattress (a specialized mattress filled with air used for pressure reduction) on his bed.*He did not know why he had the air mattress or cushion in his wheelchair.*He did not know if he had a skin wound.2. Review of resident 5's electronic medical record (EMR) revealed:*He was admitted to the facility on [DATE].*His 12/22/25 Brief Interview for Mental Status (BIMS) assessment score was 8, which indicated he had moderate cognitive impairment.*His diagnoses included stage II pressure ulcer of sacral region (bone directly above the tailbone), diabetes (a condition involving disruptions in how the body regulates blood sugar), weakness, and dementia (a group of symptoms affecting memory, thinking, and social abilities).*Resident 5's 12/16/25 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 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 next level of risk.*His 2/18/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) had a focus area that indicated The resident has potential impairment to skin integrity initiated on 12/17/26 with interventions of High risk for skin injury - use caution during transfers and bed mobility and Keep skin clean and dry. Apply protective barrier cream to peri/rectal [skin between the anus and genitals] area following incontinent [involuntary urine or bowel leakage] episodes and prn [as needed].*His 2/18/26 care plan had a focus area that indicated The resident has hx [history] of Stage 2 pressure ulcer that was initiated on 12/23/26 and revised on 2/18/26 with interventions that indicated Educate resident/family as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, Inform resident/family of any new are of skin breakdown, and Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care.-It did not include his wheelchair cushion or an air mattress.*His 12/22/25 wound assessment documentation indicated that resident 5 had a stage II pressure ulcer to his coccyx that measured 1 cm (centimeter) in length by 0.5 cm in width by 0 cm in depth. The evaluation of the ulcer was documented as a Pink open area. First layer of skin gone.-Resident 5's physician was notified.--There was no documentation on the wound assessment that indicated when resident 5's physician was notified.-The wound was cleansed and a Duoderm dressing was applied.*His 12/23/25 wound assessment documentation indicated resident 5's pressure ulcer on his coccyx measured 1 cm by 0.5 cm by 0.1 cm.*Resident 5's 12/24/25 Braden Scale for Predicting Pressure Sore Risk (a tool used to assess the risk of developing pressure ulcers) assessment score was 17, which indicated he had a mild risk for the development of a pressure ulcer.-12/24/25 was after the stage II pressure ulcer had been identified on resident 5's coccyx on 12/22/25.*Hia 12/26/25 wound assessment documentation indicated resident 5's pressure ulcer on his coccyx measured 2.2 cm by 2 cm by 0 cm.-There was no documentation that resident 5's physician was notified of the increased wound size or if the treatments or interventions changed.*His 12/27/25 wound assessment documentation indicated resident 5's pressure ulcer on his coccyx measured 2 cm by 1.5 cm by 0.1 cm.*His 12/30/25 wound assessment documentation indicated resident 5's pressure ulcer on his coccyx measured 0.5 cm by 0.5 cm by 0.1 cm.*His 1/05/26 wound assessment documentation indicated resident 5's pressure ulcer on his coccyx measured 2.5 cm by 1.5 cm by 0.1 cm.-There was no documentation that resident 5's physician was notified of the increased wound size or if the treatments or interventions changed.*His 1/12/26 wound assessment documentation indicated resident 5's pressure ulcer on his coccyx measured 0.5 cm by 0.5 cm by 0.1 cm.*His 1/15/26 wound assessment documentation indicated resident 5's pressure ulcer on his coccyx measured 0.7 cm by 0.4 cm.-There was no documentation of the depth of the pressure ulcer.*His 1/16/26 wound assessment documentation indicated resident 5's pressure ulcer on his coccyx measured 0.5 cm by 0.2 cm by 0.2 cm and was documented has having improved as evidence by the wound measurements were smaller.*His 1/17/26 wound assessment documentation indicated resident 5's pressure ulcer on his coccyx measured 0.5 cm by 0.5 cm by 0.1 cm.*The 1/24/26 wound assessment documented resident 5's pressure ulcer on his coccyx measured 0.5 cm by 0.5 cm by 0.7 cm.-There was no documentation that resident 5's physician was notified of the increased wound depth or that the treatments or interventions had changed.*On 1/30/26 resident 5's pressure ulcer on his coccyx was documented as healed.3. Interview on 2/19/26 at 10:32 a.m. with certified nursing assistant (CNA) H revealed:*She did not know when the cushion was placed in resident 5's wheelchair.*She stated that his wheelchair cushion was missing, but it was replaced about two weeks ago.-CNA H did not know how long it was missing.4. Interview on 2/19/26 at 12:28 with administrator A revealed:*He stated the Minimum Data Set (MDS) nurse had entered barrier cream to be applied following incontinent episodes in resident 4's care plan on 12/17/25 but did not trigger the task in the point of care (POC), a portion of a resident's EMR that includes the types and frequency of care needed, there was no documentation to support that the CNAs had applied barrier cream to resident 5 after his incontinent episodes.*The MDS nurse had not triggered the daily skin inspection task in resident 5's POC so there was no documentation that the CNAs completed daily skin inspections.*There was no documentation to support that resident 5's physician was notified that his pressure ulcer had increased in size.*There was no documentation when the cushion was placed in resident 5's wheelchair.5. Interview on 2/20/26 at 9:20 a.m. with CNA/unlicensed assistive personnel (UAP) I revealed:*She was aware resident 5 previously had a pressure ulcer on his coccyx.*She stated that prior to him developing the pressure ulcer, the staff helped him transfer between his bed and wheelchair to offload the pressure on his buttocks.*She stated he was able to reposition himself in his wheelchair.*She stated if barrier cream was being applied on resident 5 it would have been documented in his POC tasks in his EMR.*She did not know when the cushion was placed in his wheelchair.6. Interview on 2/20/26 at 10:28 a.m. with registered nurse (RN) K revealed she would expect a resident's physician to be notified if the size of the resident's pressure ulcer increased from the previous assessment.7. Interview on 2/20/26 at 12:53 with director of nursing (DON) B revealed:*The provider did not have a designated wound nurse.*All licensed nursing staff were responsible for completing the resdients' wound documentation and treatments.*She expected every resident to have a skin assessment completed upon admission to the facility by a licensed nurse.*If a resident was incontinent barrier cream was to be added to the CNA POC tasks in the resident's EMR.*DON B stated the barrier cream task and the daily skin check task were not added into resident 5's POC tasks when he was admitted . She stated she added it to the CNAs POC tasks on 2/20/26.*She acknowledged there was no documentation to support when resident 5's cushion was placed in his wheelchair.*She stated the air mattress was put on resident 5's bed after he had developed the pressure ulcer on his coccyx.*She acknowledged resident 1's air mattress, wheelchair cushion, and repositioning that were indicated as interventions for his pressure ulcer on the wound assessments were not on his care plan.*She expected the physician to be notified when a pressure ulcer was identified, if there was no improvement in the pressure ulcer from week to week, and if the pressure ulcer worsened in size or characteristics to determine if there needed to be a change in the treatment of the resident's pressure ulcer.*DON B acknowledged that resident 5's physician had not been notified when his pressure ulcer increased in size and there was no change in treatment to the pressure ulcer.*She was not aware that the size of resident 5's pressure ulcer had increased in size between his weekly skin assessments.*She acknowledged that ensuring the barrier cream was applied after his incontinent episodes, the CNAs were made aware through his care plan to assist resident 5 with repositioning, and the cushion was placed in his wheelchair upon his admission to the facility could have potentially prevented resident 5 from developing the pressure ulcer.8. 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.9. 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 observation, interview, record review, and policy review, the provider failed to maintain a system to account for all controlled (medications with risk for abuse, addiction, and potential theft) medications for one of two observed medication carts and for one of one treatment cart in the East hall, and to document medications related to their receipt, counts, administration details, and destruction process. Findings include:1. Review of the February 2026 Controlled Drugs Count Record on the treatment cart revealed: *There were three headings labeled 7-3 Shift, 3-11 Shift, and 11-7 Shift. *Below heading were columns labeled Nurse Off, Nurse On, and Card or prescription count. *The controlled drug count was signed off by one nurse as the on-coming nurse under the 7-3 heading and the off-going nurse under the 11-7 heading on 2/1/26, 2/2/26, 2/4/26, 2/6/26, 2/10/26, 2/11/26, and 2/14/26. *The controlled drug count was not completed the entire day on 2/3/26, 2/12/26, 2/13/26, 2/18/26, and 2/19/26. *The controlled drug count was signed off by one nurse as the 7-3 on-coming nurse and the 3-11 off-going nurse on 2/5/26 with no documentation under the 11-7 heading. *On 2/7/26 the controlled drug count was signed off by one nurse as the on-coming nurse under the 7-3 heading and no other signatures were documented that day. 2. Review of resident 3's Individual Resident Narcotic Record forms from 12/21/25 through 2/19/26 revealed: *From 12/21/25 to 1/18/26 there were three pages labeled as resident 3's alprazolam (a medication used to treat anxiety) Individual Resident's Narcotic Records, one labeled a.m., one labeled noon, and one labeled 8:00 p.m. These forms did not have documented on them the medication form, the method of administration, the medication dosage, the prescription number, or the pharmacy name. -There were no times documented when the alprazolam was removed from locked storage to be administered to resident 3 for any of the dates on the a.m. or noon record. -There was no time documented when the alprazolam was removed from locked storage to be administered to resident 3 on 12/22/25 on the 8:00 p.m. record. -On 12/28/26 there was no documentation of an alprazolam having been removed from locked storage to be administered at 8:00 p.m. *From 1/19/25-2/15/26 there were three pages labeled as resident 3's alprazolam Individual Resident's Narcotic Records, one labeled a.m., one labeled noon, and one labeled p.m. These forms did not have documented on them the medication form, the method of administration, the medication dosage, or the pharmacy name. -There were no times documented when the alprazolam was removed from locked storage to be administered to resident 3 for any of the dates on the a.m. or noon record from 1/19/26 to 2/11/26. - On 1/25/26 and 2/6/26 there was no documentation of an alprazolam having been removed from locked storage to be administered at 8:00 p.m. -On 1/28/26 an alprazolam was documented as having been removed at 7:45 a.m. The a.m. and noon alprazolam Individual Resident's Narcotic Records did not have times documented when the medication was removed from the locked storage for administration to determine if the 8:00 p.m. alprazolam had been removed from the a.m. or noon medication card. -On 1/31/26 on the p.m. alprazolam Individual Resident's Narcotic Record, it was documented that there were 17 remaining. --The next entry was dated 2/2/26 and it was documented that there were 18 on hand, one was administered, and the remaining was documented as 16. --The next entry is dated 2/1/26, there was no number in the amount on hand column, one was administered, and it was documented there were 15 remaining. -On the bottom of Resident 3's p.m. alprazolam Individual Resident's Narcotic Records it was documented that on 2/17/26 three tablets were returned to the retail pharmacy for repackaging. * From 1/19/25-2/15/26 there were three pages labeled as resident 3's alprazolam Individual Resident's Narcotic Records, one labeled a.m., one labeled noon, and one labeled H.S (bedtime). These forms did not have documented on them the medication form, the method of administration, the medication dosage, or the pharmacy name, or resident 3's name or sticker. -There was no time documented when the controlled medication was removed from locked storage to be administered to resident 3 on 2/19/26 on the noon record. 3. Observation and interview on 2/17/26 at 1:09 p.m. with resident 3 in his room revealed: *He had a feeding tube (a tube surgically placed through the abdomen into the stomach to administer liquid nutrition, fluids and medications). *He waved when surveyor entered the room. *He gave a thumbs up when asked how he was doing. *His verbalizations were grunting noises. 4. Review of resident 3's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His diagnoses included depression, anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), diabetes (a condition involving disruptions in how the body regulates blood sugar), traumatic brain injury without return to pre-existing conscious level (damage to the brain resulting from an external force resulting in permanent impairment in cognitive, physical, and emotional function), and post traumatic seizures. *Review of resident 3's January 2026 and February 2026 medication administration record (MAR) revealed: -DuoNeb Solution (a medication used to open the airways and reduce mucous) four times daily by nebulizer (a device that converts liquid medication into an inhalable mist) for aspiration and was not documented as having been administered on 2/4/26, 2/7/26, and 2/18/26 at 4:00 a.m., 2/4/26, and 2/15/26 at 12:00 p.m., 2/8/26 at 4:0 p.m., and 1/14/26, 1/22/26, 2/7/26, 2/9/26, and 2/12/26 at 8:00 p.m. -Reglan (a medication used to treat heartburn) 10 mg (milligrams) before meals and at bedtime was not documented as having been administered on 2/15/26 at 11:00 a.m., 2/8/26 at 4:00 p.m., and 1/22/26 and 2/9/26 at 9:00 p.m. -Tylenol 1000 mg three times daily for pain was not documented as having been administered on 2/15/26 at 12:00 p.m. and 1/22/26 and 2/9/26 at 8:00 p.m. -Alprazolam 0.25 mg three times daily was not documented as having been administered on 2/15/26 at 12:00 p.m., and 1/22/26, 1/26/26, 2/6/26, and 2/9/26 at 8:00 p.m. --On 1/22/26, 1/26/26, and 2/9/26 resident 3's 8:00 p.m. dose of alprazolam and on 2/15/26 resident 3's 12:00 p.m. dose of alprazolam was documented as having been removed from the locked storage for controlled medication but not documented as having been administered on resident 3's MAR. --On 1/25/26 at 8:00 p.m. resident 3's alprazolam was documented as having been administered on his MAR but was not documented as having been removed from the locked storage for controlled medications. --On 2/6/26 at 8:00 p.m. resident 3's alprazolam was not documented as having been removed from the locked storage for controlled medications to be administered and was not documented as having been administered to him in his MAR. -Simethicone (a medication used to treat gas and bloating) 80 mg three times daily was not documented as having been administered on 2/15/26 at 12:00 p.m. and 1/22/29 and 2/9/26 at 8:00 p.m. -Topamax (a medication to treat seizures and headaches) 50 mg two times daily was not documented as having been administered on 1/22/26 and 2/9/26 at 8:00 p.m. -Valproic acid (a medication for seizure prevention) 250 mg/ml (milligrams per milliliter) give 25 ml two times per day was not documented as having been administer on 1/22/26 and 2/9/26 at 8:00 p.m. -Lispro insulin (a fast-acting insulin used to lower blood sugars) sliding scale (the dose depends on the person's blood sugar level) two times daily was not documented as having been administered on 2/4/26, 2/7/26, 2/10/26, and 2/18/26 at 4:00 a.m. and on 1/27/26, 2/8/26, and 2/12/26 at 4:00 p.m. --Resident 1's blood sugar was not documented as having been taken on 1/27/26 at 4:00 p.m., 2/4/26 at 4:00 a.m. or 4:00 p.m., 2/7/26 at 4:00 a.m., 2/8/26 at 4:00 a.m. or 4:00 p.m., 2/10/26 at 4:00 a.m., 2/12/26 at 4:00 p.m., and on 2/18/26 at 4:00 a.m. -Levetiracetam (a medication for seizure prevention) 100 mg/ml give 15 ml two times daily was not documented as having been administered on 1/22/26 and 2/9/26 at 8:00 p.m. -Guaifenesin (a medication for cough and congestion) 200 mg/5ml give 10 ml two times daily was not documented as having been administered on 1/22/26 and 2/9/26 at 8:00 p.m. -Augmentin (an antibiotic) 400-57 mg/ml give 10 ml two times daily for 10 days was not documented as having been administered on 1/28/26 during the PM medication pass. -Melatonin (a medication used to aid sleep) 6mg one time daily was not documented as having been administered on 1/22/26 and 2/9/26 at 8:00 p.m. -Mirtazapine (a medication used to treat depression) 20 mg one time daily was not documented as having been administered on 1/22/26 and 2/9/26 at 8:00 p.m. -Basaglar insulin (a long-acting insulin used to lower blood sugars) 20 units one time daily was not documented as having been administered on 1/22/26, 1/26/26, 2/6/26, and 2/9/26 during the HS [bedtime] medication pass. -On 1/8/26 at 11:56 a.m. Morphine sulfate (a narcotic used to treat severe pain) 20 mg/ml give 0.25 ml was documented as having been removed from the locked storage for controlled medications but it was not documented as having been administered in resident 3's MAR. 5. Observation and interview on 2/19/26 at 2:33 p.m. with certified nurse aide(CNA)/unlicensed assistive personnel (UAP) I of a binder labeled Narcotic Binder on the east medication cart revealed: *CNA/UAP I stated that the residents' controlled medications were sent from the pharmacy in bubble pack medication cards and stored in a locked box in a locked drawer in each medication cart. *She said the nurse and UAPs were to count the residents' controlled medications at each shift change, and both were to sign as complete with no discrepancies on the narcotic inventory records. *The controlled medication count for each medication cart was to be completed at every shift change by the on-coming and off-going nurses and UAPs. *When the nurses and UAPs signed the residents' narcotic inventory records, it would indicate that the controlled medications were counted, and the medication counts were accurate. *The residents' controlled medications were stored in the east medication cart within the locked drawer and in a locked compartment. *She said that if a controlled medication count was off, she was to notify the nurse and the director of nursing (DON) B, and they would investigate what could have happened. *Review of the East medication carts Controlled Drug - Count Record inventory sheet for February 2026 revealed 48 out of 116 missing signatures. *She acknowledged that there were missing signatures on the February 2026 inventory sheet for the East medication cart. 6. Review of the East medication carts Controlled Drug – Count Record inventory sheets for November 2025, December 2025, and January 2026 for the East medication cart revealed: -November 2025 had 17 missing signatures out of 180 opportunities. -December 2025 had 28 missing signatures out of 186 opportunities. -January 2026 had 62 missing signatures out of 186 opportunities. 7. Observation on 2/19/26 at 2:37 p.m. with CNA/UAP I with the count of the controlled medications locked in the East medication cart revealed that resident 1 had: *A bubble pack medication card dated 2/3/26 that had a pharmacy label reading Pregabalin 150 mg (milligram) capsules, and to take 1 capsule by mouth two times a day. [a.m. and p.m.]. *The Controlled Drug – Count Record inventory sheet identified that the facility received 12 Pregabalin 150 mg capsules from the pharmacy on 2/3/26 that were to be given to him in the mornings. *It was documented on 2/10/26 at 8:32 a.m. that resident 1 received 1 Pregabalin 150 mg capsule, leaving 5 Pregabalin 150 mg capsules remaining. *Resident 1 was transferred to a local hospital on 2/10/26 at 12:54 p.m. and did not receive another dose of that controlled medication as he had not returned to the facility. *It was observed during the controlled medication count that resident 1's a.m. bubble pack medication card, which contained his Pregabalin 150 mg capsules, recorded a remaining count of 4 capsules. *CNA/UAP I acknowledged that resident 1's a.m. bubble pack medication card count for his Pregabalin 150 mg capsules was short by 1 capsule. *CNA/UAP I said she did not know anything about the discrepancy and would need to report the information to DON B immediately. *CNA/UAP I acknowledged that she and the nurse going off shift counted all the residents' controlled medications in the East cart and said all the counts were accurate that morning. 8. Observation and interview on 2/19/26 at 2:42 p.m. with DON B and CNA/UAP I revealed: *The residents' controlled medications were stored in the east medication cart within the locked drawer and in a locked compartment. *DON B acknowledged that resident 1's a.m. bubble pack medication card count for his Pregabalin 150 mg capsules was short by 1 capsule *DON B and CNA/UAP I searched the East medication cart and surrounding areas for resident 1's missing capsule of Pregabalin and were unable to locate it. *She said the nurse and UAPs were to count the residents' controlled medications at each shift change, and both were to sign off on the narcotic inventory records. *The controlled medication count for each medication cart was completed at every change of shift by the nurses and UAPs. *When the nurses and UAPs signed the residents' narcotic inventory records, it would indicate that the controlled medications had been counted, and the medication count was accurate. *DON B stated that if there was an incorrect count, the nurse or UAP would notify her immediately, and she would investigate. *DON B stated that usually the counts were off due to a nurse or UAP adding and/or subtracting incorrectly after administering a dose. *DON B said she was going to review the camera footage and notify the pharmacist. 9. Interview on 2/19/26 at 3:00 p.m. with DON B revealed: *DON B expected that each nurse and UAP would check their own charting for completion before they left their shifts. *She acknowledged that there were multiple missing signatures on the Controlled Drug – Count Record inventory sheet from November 2025 through February 2026 for the East medication cart, which could indicate that the counts had not been completed. *She acknowledged that with the staff not counting the controlled medications at every change of shift by the on-coming and out-going nurse or UAP could increase the risk of drug diversion, and it would make it difficult to determine when the controlled medication went missing. 10. Interview on 2/19/26 at 3:20 p.m. with administrator A revealed: *He was notified by DON B that they were unable to locate resident 1's missing medication capsule and that he was reporting the incident to the SD DOH as it was a reportable incident per their facility policy. 11. Interview on 2/19/26 at 4:07 p.m. with RN K revealed: *She stated resident 3 had a few medications that were in pill form, that were to be crushed and administer through his feeding tube, but most of his medications were liquid. *The pills were sent out through a scheduled monthly refill and the pills are administered from the bubble pack number that corresponds with the date, so those would be more obvious if a medication was not punched out of the medication card. *RN K stated the liquid medications and insulin would be more difficult to determine if a scheduled medication administration had been missed. *If she identified a medication was not administered, she would fill out a medication error form and notify that resident's provider. Review of the provider's medication error reports from September 2025 through 2/19/26 revealed there were no medication error reports completed for resident 3. 12. Phone interview on 2/20/26 at 8:15 a.m. with retail pharmacist S revealed: *He said that he was at the facility monthly and that the pharmacy delivered resident medications on a daily basis with provider orders and provided the scheduled monthly medication bubble pack cards for all the residents. *He said that he contracted a pharmacist to provide the facility with a consultant pharmacist to review resident charts every month and said that they shared responsibilities. *He said they checked the emergency medication kit, medication carts, and medication storage room for expired medications when they were at the facility. *He said that he had not reviewed medication error or incident reports involving missing medications for the provider, but that DON B would notify him of incidents and discrepancies. *He would not be able to determine if resident 3's liquid medications and insulin were being used at an expected rate because those medications are on a routine refill schedule to avoid resident 3 running out of those medications. 13. Interview on 2/20/26 at 9:20 a.m. with CNA/UAP I revealed: *All of resident 3's medications were administered by nurses because they were administered through his feeding tube. *If a resident's medication was not documented as having been administered in that resident's MAR, she would assume that medication had not been administered because the medications should be signed off as administered in the resident's MAR immediately after they were administered to that resident. 14. Interview on 2/20/26 at 9:30 a.m. with DON B revealed: *DON B said that the camera footage confirmed that licensed practical nurse (LPN) T and CNA/UAP I completed the controlled medications count of the East cart the morning of 2/19/26 at 6:30 a.m. *The camera footage confirmed that CNA/UAP I counted the medications and LPN T acknowledged the count from the Controlled Drug – Count Record inventory sheets. *DON B said that she called LPN T during her investigation, and she stated that LPN T did not recall the exact remaining amount of resident 1's Pregabalin medication on the morning of 2/19/26. *DON B said she educated LPN T and CNA/UAP I on 2/19/26 and that during the count, they both were to look at the medication cards and narcotic inventory sheets together for accuracy and confirmation of correct counts. *DON B said she did not know when resident 1's medication went missing or what had happened with it. 15. Interview on 2/20/26 at 10:28 a.m. with RN K revealed: *This was her fifth shift at that facility. *She had not checked in medications from the pharmacy. *The controlled medication count was to be completed at every change of shift by the nurses and UAPs. *The nurse worked 12-hour shifts so the controlled medication count on the treatment cart would be twice daily. *When the nurses and UAPs signed the Controlled Drugs Count Record it would indicate the controlled medications had been counted and the medication count was accurate. *If the controlled medication count was not accurate, she would not let any staff member leave and would search for the missing medication. *She acknowledged that resident 3's alprazolam Individual Resident's Narcotic Record did not have his name on them, and she would not be able to identify whose forms those forms were if they were not on the treatment cart, because he was the only resident whose medications were stored in that cart. *If a resident's medication was not administered at its designated time the medication would display red on the MAR to alert the nurse or UAP that the medication was not administered or if it was it was not documented. *If she noticed that there were medications that had not been documented as administered, she would notify her supervisor. 16. Interview on 2/20/26 at 11:02 a.m. with CNA/UAP L revealed: *She had received medications from the pharmacy delivery person and compared the medication list against the medications that were received from the pharmacy with the pharmacy delivery person. *When a controlled medication was received she would put the resident's name or a resident sticker on a Individual Resident's Narcotic Record and complete the documentation related to the medication such as the name of the medication, dose of the medication, the administration instructions, the prescription number, the amount of the medication that was received, and the date the medication was received. 17. Interview on 2/20/26 at 12:53 p.m. with director of nursing (DON) B revealed: *The pharmacy brings the medications to the facility. *The pharmacy delivery person and the nurse or UAP review the list of medications sent to the facility and compare it to the medications that were received. *If the list and the medications received match the pharmacy delivery person and the nurse or UAP sign that the medications sent were received and each keep a copy of the receipt. *The nurse or the UAP filled out the information related to the medication and the resident on the Individual Resident's Narcotic Record for each controlled medication that was received. *DON B expected the nurse or UAP to complete the medication name, medications strength, medication form, method of administration, medication dosage, the prescription number, the pharmacy name, the date the medication was received, and the amount received, as well as the resident's name or a resident sticker on the Individual Resident's Narcotic Record. *DON B acknowledged there was missing information related to the medication information and resident's name on the Individual Resident's Narcotic Records. *The controlled medications were to be counted by the on-coming and off-going nurse or UAP at every shift change. *After the controlled medications were counted both nurses or UAPs were to sign the Controlled Drugs Count Record, which indicated the controlled medication count had been completed and the count was accurate. *If the count was not accurate the nurse was to notify DON B immediately and search for the missing controlled medication. *She acknowledged there were multiple shifts where the controlled medication count was not documented as having been completed and accurate. *She acknowledged that staff not counting the controlled medications at every change of shift by the on-coming and out-going nurse or UAP could increase the risk of drug diversion, and it would make it difficult to determine when the controlled medication went missing. *She acknowledged there were controlled substances removed from the medication cart, checked out on the Individual Resident's Narcotic Record and not documented as having been administered to the resident. *She acknowledged there were multiple doses of medications that were not documented as having been administered to resident 3. *She had not been aware of the undocumented medications. *She expected the nurses and UAP staff to review each resident's MAR to be sure all the medications for that shift had been administered and documented that they were administered. *She acknowledged that resident 3's sliding scale insulin dose would not be able to determine if his blood sugar had not been checked. *She acknowledged resident 3's medications that had not been documented as having been administered to him, such as his insulin and seizure medications, could significantly affect his physical wellbeing. 18. Review of the provider's revised 7/30/25 Pharmaceutical Services – R/S, LTC policy revealed: *A licensed pharmacist will be employed to provide consultation on all aspects of pharmacy services. Establish a system of records of receipt and disposition of all controlled medications in sufficient detail to enable accurate reconciliation. *Determine that medication records are in order and that an account of all controlled medications is maintained and periodically reconciled. Report any irregularities to the attending physician or the director of nursing services or both. (These reports must be acted upon, and follow-up documentation maintained). 19. 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. 20. 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 record review, interview, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was reviewed with, and a copy was provided to the resident and the resident's representative according to the provider's policy within 48 hours of the resident's admission to the facility for four of five newly admitted sampled residents (2, 5, 19, and 24). Findings include: 1. Review of resident 19's electronic medical record (EMR) revealed: *She admitted to the facility on [DATE] and the development of her baseline care plan was initiated. *Her baseline care plan was reviewed with her on 1/13/25, four days after she admitted to the facility. *There was no documentation that a copy of resident 19's baseline care plan was provided to her and her representative. 2. Review of resident 2's EMR revealed: *He admitted to the facility on [DATE], and the development of his baseline care plan was initiated. *His baseline care plan was not reviewed and acknowledged by resident 2 or his representative until his 11/5/25 care conference meeting, 20 days after he was admitted to the facility. 3. Review of resident 5's EMR revealed: *He admitted to the facility on [DATE]. *His baseline care plan was initiated on 12/17/25. *His baseline care plan was emailed to his representative on 12/31/25, 15 days after he admitted to the facility. *There was no documentation that resident 5 BCP was provided a copy of his baseline care plan. 4. Interview on 2/17/26 at 4:00 p.m. with resident 24 revealed: *She admitted to the facility about a month ago. *She did not remember anyone talking to her about her personal care needs or her individual goals when she admitted to the facility. *She did not remember being offered a copy of her baseline care plan when she admitted to the facility. 5. Review of resident 24's EMR revealed: *She admitted to the facility on [DATE]. *Her 1/26/26 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated she had moderate cognitive impairment. *Her baseline care plan was initiated on 1/21/26. *Her baseline care plan was provided to her representatives on 1/27/26, seven days after she admitted to the facility. *There was no documentation that resident 24 was provided a copy of her baseline care plan. 6. Interview and review of the residents' baseline care plans on 2/20/26 at 12:53 p.m. with administrator A and director of nursing (DON) B revealed: *The nurse who admitted the resident would initiate the resident's baseline care plan. *The admitting nurse or the interdisciplinary team (nursing, activities, social services, and dietary staff) was responsible for editing the resident's baseline care plan to reflect that resident's individual care needs and goals. *DON B stated the baseline care plan was to be completed within 48 hours of the resident's admission to the facility. *Neither administrator A or DON B were aware that the resident's baseline care plan was required to be reviewed with, and a copy offered to the resident or the resident's representative within 48 hours of admission to the facility. *They acknowledged the baseline care plans for residents 2,5,19, and 24 were not reviewed with, and a copy offered to the resident or resident's representative within 48 hours of admission to the facility. 7. Review of the provider's 12/1/25 Care Plan policy revealed: *Baseline care plan – Includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. *Person-centered care – A focus on the resident as the locus of control and supporting the resident in making his or her own choices and having control over their daily life. *A baseline care plan will be developed upon admission according to federal and state regulations. The location must provide the resident and resident representative with a written summary of the baseline care plan.

Based on observation, record review, interview, and policy review, the provider failed to ensure the staff followed professional standards of practice related to respiratory care for:*Cleaning and storing nebulizer equipment (a device used when using a nebulizer machine that converts liquid medication into an inhalable mist) for three of three sampled residents (13, 19, and 28) who used nebulizer machines.*Cleaning the Continuous Positive Airway Pressure (CPAP) machine (a device that uses air pressure to keep breathing airways open) for one of one sampled resident (13) who used a CPAP machine.*Cleaning and storing oxygen equipment for four of four sampled residents (13, 19, 28, and 29) who used oxygen.Findings included:1. Observation on 2/17/26 at 12:38 p.m. of resident 29's room revealed: *She had an oxygen concentrator (a device that filters room air into purified oxygen) beside her bed. *Her nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) was draped over that concentrator. *That nasal cannula was not dated with the date it had been replaced. *The oxygen concentrator filters and the covers that hold the filters in place were missing on both sides of the concentrator. Observation on 2/18/26 at 3:17 p.m. of resident 29's room revealed: *Resident 29 was lying in her bed. *She was wearing an undated nasal cannula that was attached to the concentrator beside her bed. *There was an undated nasal cannula hanging on the handle of her wheelchair that was attached to a portable oxygen tank. Review of resident 29's electronic medical record (EMR) revealed: *She admitted to the facility on [DATE]. *Her 1/22/26 Brief Interview for Mental Status (BIMS) assessment score was 7, which indicated she had severe cognitive impairment. *She had a 12/29/25 physician's order for Oxygen at 3 LPM [liters per minute] continuously per nasal cannula. *There was no order for her nasal cannula to be replaced and dated, which would indicate to the nursing staff when to change the nasal cannula. *There was no documentation that supported when her nasal cannula was replaced in her EMR. 2. Observation and interview on 2/17/26 at 1:52 p.m. with resident 13 in his room revealed: *Resident 13 was sitting in his wheelchair and independently wheeling himself to his door. *Resident 13 had an oxygen concentrator beside his bed. *Resident 13's CPAP and nebulizer machines were stored on top of his three-drawer wood dresser beside his bed. *A black mesh bag was taped to the top drawer of the wood dresser, dated 1/26. *His oxygen tubing, CPAP hose, and mask attached to the concentrator machine were dated 12/1/25. -The CPAP mask was stored in the black mesh bag. *His nebulizer mask was dated 2/9/26. *The nebulizer mask and tubing were stored in the black mesh bag. Observation on 2/18/2026 at 4:57 p.m. in resident 13's room revealed: *His CPAP mask, dated 12/1/25, was hanging over the top drawer of the wood dresser next to his bed. *Resident 13's CPAP mask and connection hose were secured with clear medical tape at their connection point and the tape was wrapped down the hose approximately six inches. -The tape was coming loose in areas and was visibly soiled with small fibers, debris, and dust that adhered to its sticky side. -The non-sticky side of the tape was discolored and light brown in color. *The filter on his concentrator machine contained dust fibers and lint. *Resident 13's assembled nebulizer mask was lying on his bed with clear liquid in the medicine chamber of the nebulizer mask. Review of resident 13's EMR revealed: *He admitted to the facility on [DATE]. *His 12/23/25 BIMS assessment score was 11, which indicated he had moderate cognitive impairment. *Resident 13 had a 7/2/25 physician's order to Change O2 [oxygen] and neb mask weekly on Monday one time a day. *Resident 13 had a 7/2/25 physician's order to Clean CPAP every morning one time a day. *There was no order for his nebulizer mask to be cleaned daily. *There was no order for his concentrator filter to be cleaned or replaced. *There was no documentation of the nebulizer mask being cleaned in his EMR. *There was no documentation of the concentrator filter being cleaned or replaced in his EMR. Observation and interview on 2/18/26 at 5:21 p.m. with director of nursing (DON) B in resident 13's room revealed: *She stated, It does not appear that his c-pap mask is getting removed and cleaned daily. *She acknowledged that clear medical tape had been used to secure the hose and mask together and that the tape was visibly soiled. *She acknowledged that resident 13's oxygen tubing and CPAP mask had a date of 12/1/25, had no staff initials written on it, and was not stored in the black mesh bag. *She acknowledged that resident 13's concentrator filter was visibly soiled with dust fibers and lint. *She acknowledged that resident 13's CPAP mask was hanging over the top drawer of the wood dresser and contained a clear liquid in the cup of the nebulizer mask. *She acknowledged that the staff had not cleaned the nebulizer mask after his scheduled nebulizer treatment at 4:00 p.m. and that the nebulizer mask was not stored in the black mesh bag. 3. Observation on 2/17/26 at 1:53 p.m. of resident 19's room revealed: *Resident 19 was lying in her bed. *She was wearing a nasal cannula attached to an oxygen concentrator beside her bed. *There was a nebulizer machine on her bedside table with an assembled nebulizer mask lying on top of the machine. *There were drops of clear liquid in the cup of the nebulizer mask. Observation on 2/17/26 at 2:37 p.m. of resident 19's room revealed an undated nasal cannula lying on the floor beside resident 19's bed. Observation on 2/18/26 at 3:22 p.m. of resident 19's room revealed an undated nasal cannula hanging on the side rail of her bed. Observation and interview on 2/20/26 at 9:15 a.m. with resident 19 in her room revealed: *Her nasal cannula and nebulizer mask were stored in a black bag attached to her bedside table. *Resident 19 stated she did not have a bag to store her nasal cannula in until yesterday (2/19/26). Review of resident 19's EMR revealed: *She admitted to the facility on [DATE]. *Her 12/29/25 BIMS assessment score was 13, which indicated her cognition was intact. *She had a 1/9/25 physician's order to Change label date oxygen tubing and neb tubing weekly every evening shift every Mon [Monday]. 4. Observation on 2/17/26 at 1:58 p.m. of resident 28's room revealed: *Resident 28 had a nebulizer machine with an assembled nebulizer mouthpiece and tubing lying on his bedside table. *His nebulizer tubing was not dated, and the mouthpiece was dated 1/3/26. *The nebulizer machine was visibly dusty. Observation and interview on 2/18/26 at 10:32 a.m. in resident 28's room revealed: *Resident 28 was sitting on the edge of his bed. *The nebulizer machine with the same assembled nebulizer tubing and mouthpiece remained on his bedside table. *Resident 28 did not know how often the nebulizer tubing and mouthpiece should be replaced. *Resident 28 said he did not use the nebulizer with the mouthpiece for a few weeks and only used it when needed. *Resident 28 said he did not have a storage bag for the nebulizer tubing and mouthpiece to store it in when it was not in use. Review of resident 28's EMR revealed: *He admitted to the facility on [DATE]. *His 12/20/25 BIMS assessment score was 15, which indicated his cognition was intact. *Resident 28 had a 12/30/25 physician's order to administer Albuterol Sulfate Inhalation Nebulization Solution - one inhalation orally every four hours as needed for cough/congestion. *There was no order for his nebulizer tubing and mouthpiece to be cleaned or replaced. *There was no documentation of the replacement of his nebulizer tubing and mouthpiece in his EMR. Interview on 2/18/26 at 5:13 p.m. with DON B in resident 28's room revealed: *She stated that resident 28's nebulizer tubing and mouthpiece were packaged together as one unit. *She said that the nebulizer tubing and mouthpiece unit was supposed to have one date and staff initials written on it when it was replaced. *She acknowledged that resident 28's nebulizer tubing and mouthpiece unit was dated 1/3/26 and had no staff initials written on it. *She acknowledged that resident 28's nebulizer machine was visibly dusty, and his nebulizer tubing and mouthpiece unit were not stored in a storage bag. 5. Interview on 2/19/26 at 10:29 a.m. with certified nursing assistant (CNA) H revealed: *Resident 29 required staff assistance to put on, remove, and store her nasal cannulas. *Nasal cannulas that were not being used were to be stored in a bag in the resident's room. *Resident 19 was able to apply, remove, and store her nasal cannula and nebulizer equipment independently. *CNA H acknowledged that resident 19 would not be able to store her nasal cannula or nebulizer equipment in a bag if there was not a bag provided for her in her room. 6. Interview on 2/19/26 at 2:17 p.m. with CNA/UAP I revealed: *She said UAP's were responsible for cleaning the resident's nebulizer mask after each use. *She stated that the mask or mouthpiece was to be rinsed with water and then placed on a clean paper towel to air dry after each use. *She said nebulizer tubing and masks were to be replaced every week on Mondays and dated. 7. Interview on 2/20/26 at 9:20 a.m. with CNA/unlicensed assistive personnel (UAP) I revealed: *The UAPs were responsible for replacing the residents' nasal cannulas and nebulizer masks weekly on Mondays. *After replacing the nasal cannulas and nebulizer masks she would document those replacements on the resident's TAR. *If the replacement of the resident's nasal cannulas and nebulizer masks were not on the TAR she would replace them but the replacement would not be documented. *She stated the staff know who received oxygen and nebulizer treatments, so they knew who had nasal cannulas and nebulizer masks that needed to be replaced weekly even if it was not on a resident's TAR. 8. Interview on 2/20/26 at 12:53 p.m. with DON B revealed: *The CPAP masks and tubing were to be washed out daily and replaced according to the manufacturer's instructions. *Nasal cannulas and nebulizer masks were to be replaced weekly. *The replacement of the nasal cannulas and nebulizer masks was to be documented in that resident's MAR or TAR. *When the residents' nasal cannulas and nebulizer masks were not in use they were to be stored in the black bags in the resident's room. *DON B acknowledged that nasal cannulas were at risk of being contaminated when they were hung on wheelchairs, oxygen concentrators, or bed rails. *Oxygen concentrator filters were to be cleaned at least monthly and placed back on the concentrator. 9. Review of the provider's 7/30/25 Oxygen Administration policy revealed: *All oxygen therapy equipment will be clean, safe and functional. *When oxygen is not in use, store cannula, face mask or face tent and tubing in zip-lock bag/plastic bag secured to the oxygen cylinder or concentrator. *Disposable equipment should be changed weekly or according to manufacturer's instructions and marked with date and initials. *Change filters between resident uses. *Clean filters according to manufacturer's instructions. 10. Review of the 2022 DeVilbiss 5-Liter Oxygen Concentrator Instruction Guide revealed: *A mask or any nasal cannula can be used with continuous flow delivery and may be sized according to our prescription as recommended by your homecare provider who should also give you advice on the proper usage, maintenance and cleaning. *Individual maintenance requirements may vary based upon local operating conditions, regulations, or other circumstances. *Clean and replace the cannula/mask, tubing, and humidifier bottle according to the manufacturer's instructions. *Check to be sure the cabinet air filter (if applicable) and the intake filter are in place. *Inspect the vents periodically, and wipe with a dry cloth as needed to remove dust. *Cleaning: -Outer Cabinet – 7 days -Water, use only a damp cloth. -Filter Door Vents – 7 days – Wipe with dry cloth, or a cloth dampened with water to remove dust. 11. Review of the provider's 12/10/25 Nebulizer policy revealed: *Following medication administration clean nebulizer after each use: . 4. Separate the nebulizer parts (mask/mouthpiece, cup) and wash in warm soapy water and rinse thoroughly. 6. Place mask or mouthpiece and cup on a paper towel and air-dry until the next use. Cover with clean cloth or towel. 12. Review of the undated Power Neb Ultra Compressor Nebulizer Instruction Guide revealed: *Clean After Every Use: -Disassemble mouthpiece or mask from cap. -Wash all items, except tubing, in a hot water/dishwashing detergent solution. Rinse under hot tap water for 30 seconds to remove detergent residue. Allow to air dry. *Disinfect Daily: -Using a clean container or bowl, soak items in three parts hot water to one part white vinegar for 30 minutes OR use a medical bacterial-germicidal disinfectant available through your provider. Be sure to follow manufacturer's instructions carefully. -With clean hands, remove items from disinfectant solution, rinse under hot tap water, and air dry on a clean paper towel. Store in a zip-lock bag. *Do not towel dry nebulizer parts; this could cause contamination. 13. Review of the undated ResMed AirCurve 10 CPAP User Guide revealed: *You should clean the device weekly as described. *Wash the water tub and air tubing in warm water using only mild detergent. *Rinse the water tub and air tubing thoroughly and allow to dry out of direct sunlight and/or heat. *Wipe the exterior of the device with a dry cloth. *Check the air tubing and replace it if there are any holes, tears or cracks. *Check the air filter and replace it at least every six months. Replace it more often if there are any holes or blockages by dirt or dust. -The air filter is not washable or reusable. *Clean the mask daily by soaking the cushion and frame in warm, soapy water (mild detergent) for 5-10 minutes, then rinse thoroughly and air dry out of direct sunlight. *Hand wash the headgear and any soft sleeves in warm, soapy water, then air dry weekly. *Clean the air tubing in warm soapy water, rinse thoroughly, and hang to dry weekly. *Check the air tubing and mask for cracks, tears, or hardening components weekly and replace as needed.

Based on record review, interview, and policy review, the provider failed to ensure one of two sampled resident (4) who received an antipsychotic medications (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) and a psychotropic medication (drugs that affect brain activities associated with mental processes and behavior) had an attempted gradual dose reduction (systemic dose reduction over time to determine if the condition could be managed with a lower dose or discontinuation of the medication) (GDR) or a physician's documented rationale to support that a GDR was clinically contraindicated (not appropriate based on the resident's condition, potential risks, or adverse effects) for the use of those medications. Findings include:1. Review of resident 4's electronic medical records (EMR) revealed:*He was admitted on [DATE].*His diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with psychotic disturbance (a state of losing touch with reality) and residual schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a distorted sense of reality).*A 12/21/23 physician's order to be given two 50 milligram (mg) tablets of thioridazine hydrochloride (an antipsychotic) by mouth daily for schizophrenia and one 50 mg tablet of trazodone hydrochloride (an antidepressant) by mouth daily for insomnia (inability to sleep).*His 2/19/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) had a focus area that indicated The resident uses psychopharmacological medications [the use of medications to treat mental health disorders by altering brain chemistry] R/T [related to] schizophrenia, and insomnia. Takes antipsychotic and anti-depressant medication with an intervention to Consult with pharmacy, health care provider, etc. to consider dosage reduction when clinically appropriate.*Resident 4's consultant pharmacist recommendations from 12/30/23 through 1/29/26 did not include a GDR for resident 4's trazodone or thioridazine or documentation that a GDR reduction was clinically contraindicated by resident 4's physician since his admission to the facility.2. Interview on 2/20/26 at 8:52 a.m. with consultant pharmacist R revealed:*She reviewed all of the residents progress notes, labs, and medications monthly.*She spoke with staff to determine if there were any areas of concern related to medication use for that resident.*If she had any recommendations based on her record review and interviews with staff, she would document that in her consultant pharmacist progress note.*She stated the physicians were receptive to her recommendations and replied promptly to them.*She stated director of nursing (DON B) asked her about resident 4's GDR recommendation and she was unable to find that she had made that recommendation in his EMR.*The notes she made during her monthly medication review (MMR) stated in April 2025 that resident 4 needed to have a GDR recommended but she could not find where that recommendation was made and addressed by his physician.*If a resident was due for a GDR recommendation she would document that in her consultant pharmacist note for staff to address it with the resident's physician.3. Interview on 2/20/26 at 12:53 p.m. with DON B revealed:*Each month, consultant pharmacist R completed an MMR, for each resident.*During those MMRs, consultant pharmacist R reviewed when each resident was due for a GDR recommendation and documented that recommendation in her progress note.*DON B would then print consultant pharmacist R's progress note and give it to that resident's physician to document why or why not a GDR was clinically contraindicated.*DON B stated GDRs were to be recommended by the consultant pharmacist and addressed by the resident's physician quarterly for the first year after the resident's admission to the facility or after the medication was started, and annually after that.*She stated she was unable to find documentation that a GDR had been recommended for resident 4 or documentation from resident 4's physician that indicated a GDR was clinically contraindicated.4. Review of the provider's 12/9/25 Psychotropic Medications policy revealed:*Definition Graudal Dose Reduction The stepwise tapering of a dose to determine whether symptoms, conditions or risks can be managed by a lower dose or whether the dose or medication can be discontinued.*Based on a comprehensive assessment of a resident, the location must ensure that:- Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.*The reduction committee will review the need for psychotropic medications at least every three months and document the rationale for continuing the medication.*The purpose of tapering medication is to find an optimal dose or to determine if continued use of the medication benefits the resident. Tapering may be indicated when the resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved and/or non-pharmacological interventions have been effective in reducing the symptoms.- Within the first year a resident is admitted on an antipsychotic medication or after the location has initiated an antipsychotic medication, the location must attempt a gradual dose reduction (GDR) in two separate quarters with at least one month between attempts, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated.- The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the location and the physician has documented the clinical rationale for why any additional attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.

Based on record review, interview, and policy review the provider failed to ensure one of four sampled resident (3) who was recently admitted to hospice (specialized care for individuals with a terminal illness that focuses on comfort and quality of life rather than curative treatments) services had a significant change Minimum Data Set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) completed within 14 days after the resident admitted to hospice.Findings include:1. Review of resident 3's electronic medical record (EMR) revealed:*He was admitted to the facility on [DATE].*He had a 10/15/25 physician's order for Hospice referral and admit if appropriate.*He was admitted to hospice services on 10/20/25.*His significant change MDS assessment was completed on 11/21/25, 32 days after he was admitted to hospice.2. Interview on 2/20/26 at 12:53 p.m. with administrator A revealed:*He expected the MDS coordinator to initiate significant change assessments.*The clinical team would discuss a resident who may qualify for a significant change MDS assessment during their daily meetings.*He was aware that a significant change MDS assessment needed to be completed when a resident was admitted to hospice, but he did not know how soon it needed to be completed after the resident's admission to hospice services.*He acknowledged that resident 3's significant change MDS assessment was not completed within 14 days after he admitted to hospice.*The provider's MDS coordinator was from the provider's corporate office and was not at the facility.*He felt resident 3's significant change MDS assessment had was missed during the transition from having an on-site MDS coordinator to an off-site corporate MDS coordinator.3. Review of the provider's 11/12/25 Hospice Provided Services policy revealed review of documentation for residents receiving Hospice Service.A significant change MDS was completed when the resident enrolled in a hospice program.m.

Based on observation, record review, interview, and policy review, the provider failed to ensure the care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was reviewed and revised to reflect the current care needs for two of seventeen sampled residents (2 and 16).Findings include: 1. Interview on 2/20/26 at 9:25 a.m. with certified nursing assistant (CNA) H regarding residents' care needs revealed she would reference the residents' care plans or Kardex (a report of the resident's care needs and interventions) to know how to care for each resident. 2. Review of resident 2's electronic medical record (EMR) revealed:*His admission date was 10/16/25.*His 12/9/25 Brief Interview of Mental Status assessment score was a 7, which indicated his cognition was severely impaired.*His diagnoses included: dementia (a group of symptoms affecting memory, thinking, and social abilities), fracture of the right hip, insomnia, and heart failure.*His weight record included the following weights:*On 10/16/25, his weight was 147.0 lbs.*On 11/6/25, his weight was 157.0 lbs.*On 12/11/25, his weight was 149.0 lbs.*On 1/8/26, his weight was 169.0 lbs.*On 1/26/26, his weight was 151.5 lbs.*On 2/6/26, his weight was 139.5 lbs. 3. Review of resident 2's care plan revealed:*A 1/26/25 focus area that indicated The resident has unplanned/unexpected weight loss R/T [related to] (SPECIFY) E/B [evidenced by] (SPECIFY).-The goal for that focus area was the Resident will maintain weight between (SPECIFY: ____ and ____ lbs. [pounds]) by review date.-The intervention for that focus area was Weigh (SPECIFY FREQ. [frequency]). 4. Interview on 2/20/26 at 2:00 p.m. with director of nursing (DON) B and interim DON C regarding residents' care plans revealed:*When a resident had weight loss, it was to be addressed on that resident's care plan. She expected care plan prompts such as SPECIFY to be replaced with the resident's individualized status and needs. She acknowledged that resident 2's care plan regarding his weight loss was not individualized.*DON B stated she did not feel resident 2's weight loss was a true weight loss. She indicated he had edema (excess fluid) and took a diuretic to reduce fluid build-up, which would cause fluctuations in his weight. 5. Review of resident 16's EMR revealed:*She was admitted on [DATE].*Her 12/22/25 BIMS score was a 2, which indicated her cognition was severely impaired.*Her diagnoses included: anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), and chronic pain.*She had a physician's order for Haldol (brain-calming medicine that improves thinking, mood, and behavior and calms severe agitation) to be given before her bath. 6. Interview on 2/20/26 at 9:33 a.m. with CNA H regarding resident 16 revealed:*Resident 16 does not like her baths, and she received medicine to help her stay calm.-Resident 16 required two staff members to assist her with bathing, one to wash her and the other to keep her calm.-She was to receive a bath on Mondays and Thursdays and the medicine unless she is having a good day. 7. Review of resident 16's care plan revealed bathing interventions that included BATHING: Resident requires assist [assistance] of 1-2 [one to two] staff with bathing. Prefers 1 w/p [whirlpool] bath a week. No preference to time of day.-There was no indication on the care plan that resident 16 had behaviors with her bathing activity. 8. Interview on 2/20/26 at 10:43 with registered nurse (RN) K, regarding developing and updating a residents' care plan, revealed that she thought DON B completed a residents' admission and then developed the residents' care plan. 9. Interview on 2/20/26 at 1:53 p.m. with DON B and interim DON C regarding residents' care plans revealed:*Each department was to develop and edit the residents' care plan based on their assigned areas.*The Minimum Data Set (MDS) nurse would make changes to the resident's care plan after completing the 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), and as the residents' care needs changed, and quarterly.-The MDS nurse worked remotely.-All of the nurses had access to update the residents' care plans, as the residents' care needs changed, and quarterly.*DON B expected resident 16's care plan to include interventions for her behaviors that occurred with bathing. 10. Review of the provider's 12/1/25 Care Plan policy revealed:*Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders.*This 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. It will address the relationship of items or services required and facility responsibility for providing these services.*The interdisciplinary team will review care plans at least quarterly. Care plans also will be reviewed, evaluated and updated when there is a significant change in the resident's condition.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff members followed professional standards of care for:*The assessment, care, and accurate documentation regarding one of one sampled resident (4) with a newly placed suprapubic catheter (flexible tubing surgically placed in the bladder through the abdominal wall to drain urine).*Accurately entering physician's orders into the electronic medical record to ensure one of one sampled resident's (16) Haldol (medication for reducing symptoms of mental health conditions) was transcribed and administered as ordered. Findings include: 1. Observation and interview on 2/18/26 at 3:21 p.m. with resident 4 in his room revealed he: *Had a suprapubic catheter. *Did not know how long he had the suprapubic catheter but stated it had not been too long. 2. Review of resident 4's EMR revealed: *He was admitted on [DATE]. *His 12/22/25 Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated his cognition was moderately impaired. *He had a 3/6/25 physician's order for an indwelling foley catheter [flexible tubing placed in the bladder to drain urine] to straight drainage. 18 FR [French: a standardized sizing system for urinary catheters] Coude tip [a specialized catheter with a curved tip]. *There was a 12/12/25 physician's order to Keep appointment with Urology on 12/16/25. They are to further discuss with Dr. [redacted name] possible placement of a suprapubic catheter. *His treatment administration record (TAR) had a 1/18/26 nursing order to, Cleanse supra pubic [suprapubic] catheter site with soap and water. Apply slit sponge [a gauze dressing with a cut through half of the gauze] and tape daily. The TAR indicated that was to be documented as completed daily at bedtime. -That treatment was not documented as completed on his TAR from 1/18/26 through 1/31/26 from 2/1/26 through 2/9/26, on 2/11/26, and on 2/12/26. *There was no documentation that resident 4 had a suprapubic catheter inserted and when that occurred. 3. Interview and record review regarding resident 4's suprapubic catheter on 2/20/26 at 8:02 a.m. with director of nursing (DON) B revealed: *On 2/18/26 she requested documentation related to resident 4's suprapubic catheter from the hospital where it was surgically placed. *On 2/20/26 administrator A received resident 4's history and physical examination documentation and a procedure note from the hospital regarding his suprapubic catheter placement. -That procedure note indicated resident 4 had his suprapubic catheter surgically placed on 1/15/26. -It did not include any instructions related to the care of the suprapubic catheter site or follow-up after the procedure. *DON B verified there were no discharge instructions provided by the hospital, as she requested on 2/18/26. 4. Interview and record review regarding resident 4's TAR on 2/20/26 at 10:28 a.m. with registered nurse (RN) K revealed: *Resident 4's suprapubic catheter site was scheduled on his TAR to be cleaned and a gauze sponge applied to that site daily at bedtime. *She looked at his suprapubic catheter site that morning (2/20/26), after resident 4's bath, and felt the site looked normal for a newly inserted suprapubic catheter. *She expected the nurse who completed a treatment on a resident would document that treatment as completed in the resident's TAR. -If there was no documentation that the treatment had been completed in the resident's TAR, she would assume that the treatment had not been completed. 5. Interview and record review regarding resident 4 on 2/20/26 at 12:53 p.m. with DON B and administrator A revealed: *Administrator A and DON B did not know what was used as the provider's reference for professional standards. *DON B expected that when a resident left the facility for an appointment or procedure and returned to the facility, a progress note would be entered into that resident's EMR. *DON B acknowledged that there was no documentation in his EMR that indicated resident 4 left the facility to have a suprapubic catheter surgically placed or when he returned to the facility. *DON B acknowledged that there was no documentation that resident 4 and his newly placed suprapubic catheter were assessed when he returned from the surgical procedure. *DON B expected the staff would have assessed resident 4 and his suprapubic catheter insertion site upon his return to the facility and documented their findings. *DON B acknowledged that there were no discharge instructions provided to the facility on how to care for resident 4's newly placed suprapubic catheter when he returned to the facility. *DON B stated the nurse should have called the medical facility where resident 4's suprapubic catheter placed and requested discharge instructions. *DON B acknowledged the treatment order to clean and apply a gauze sponge to resident 4's suprapubic site was entered on 1/18/26, three days after his suprapubic catheter placement. *DON B acknowledged there was no documentation that the cleaning and gauze sponge treatment was completed until 2/10/26, 23 days after the suprapubic catheter placement. *DON B stated the treatment order was not entered into resident 4's EMR correctly so it did not show up on the TAR as a treatment to be completed by the nurse. *DON B stated the nurses told her they had been cleaning the site and applying the gauze sponge around resident 4's suprapubic catheter but there was no documentation to support that. *DON B expected the nurse who identified that the treatment order was not on resident 4's TAR to have corrected the entry error to ensure accurate documentation of completion. *DON B acknowledged that not cleaning and dressing a new suprapubic catheter insertion site could increase the resident's risk of infection. 6. Review of the provider's 4/6/25 Catheter: Care, Insertion and Removal policy revealed: *It is important to keep the dressing dry and cleanse the suprapubic skin insertions site using clean technique every day and as necessary. 7. Review of the provider's 4/6/25 Physician/Practitioner Orders policy revealed: *Order must be obtained for wound care including products to be used, when to change and when to reassess. *Nursing orders are not crested as physician/practitioner orders. Nursing orders must be documented as care plan approaches. Based on record review, interview, and policy review, the provider failed to ensure: *One of one sampled resident's (16) physician order for scheduled Haldol was entered into the resident's electronic medical record (EMR) as ordered. 8. Review of resident 16's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her medication administration record (MAR) included a 10/7/25 physician order for Haloperidol [an antipsychotic medication that alters neurotransmitter activity to reduce symptoms of mental health conditions] Oral Tablet 1 MG (Haloperidol) Give 1 tablet by mouth as needed for prn [as needed] 1 hour prior to bath. *The 10/7/25 original physician order stated Give Haldol [haloperidol] 1 mg 1 hr [hour] prior to shower scheduled. 9. Interview on 2/20/26 at 1:49 p.m. with DON B and interim DON C regarding resident 16's physician order for Haldol revealed: *DON B acknowledged the 10/7/25 written physician's order for Haldol was to be scheduled to be administered one hour before resident 16 received a bath. -She acknowledged the 10/7/25 written physician's order for Haldol was entered into resident 16's EMR as a PRN (as needed) order and that resident 16 had not received the medication as ordered, as she had not received it before each bath, as the order had been entered as a PRN order. *DON B expected the physician's orders entered into a resident's MAR to be verified by two nurses, to ensure they are accurate and followed as ordered, and this order had been. -She was unable to determine how that transcription error had occurred. 10. Review of the provider's 4/6/25 Physician/Practitioner Orders policy revealed: *Physician/Practitioner orders are a critical component to providing quality care to residents. Accurate processing of physician/practitioner orders is important. The nursing services and health information management (HIM) departments each have responsibilities for processing physician/practitioner orders in a timely and accurate manner. *Orders are processed and transcribed into [electronic medical records system] – Clinical – Orders immediately upon receipt of an order. All orders must be noted by the licensed nurse who has processed the order. -Prescriber Entered Orders must be confirmed by a licensed nurse.

Based on observation, interview, and policy review, the provider failed to ensure the medication labels and the resident's medication administration record (MAR) matched during two of two observed medication administrations for two of eleven sampled residents (7 and 29) by certified nurse aides (CNAs)/unlicensed assistive personnel (UAPs) L and I. Findings include:1. Observation and interview on 2/19/26 at 11:00 a.m. with certified nurse aide (CNA)/unlicensed assistive personnel (UAP) L during medication administration revealed:*The medication cart contained resident 7's medications.*The resident's Blink Tears Solution 0.25% (polyethylene glycol 400) (a medication to treat dry eye symptoms) eye drop pharmacy label on the medication container read: Instill 1 drop in both eyes every morning and at bedtime.*Her February 2026 medication administration record (MAR) read: Instill 1 drop in both eyes four times a day for macular degeneration.*CNA/UAP L agreed that resident 7's medication label for that medication did not match the 4/7/22 physician order on her MAR.*She did not know why they did not match and stated that the medication container came from the pharmacy with the label.*She said she was to report the discrepancy to the floor nurse or the director of nursing (DON) B for clarification and notified the floor nurse.*She waited to administer resident 7's eye drops until she had clarification from the nurse. 2. Interview on 2/19/26 at 11:10 a.m. with registered nurse (RN) K revealed:*She acknowledged that the medication label for resident 7's Blink tears solution eye drops did not match the 4/7/22 physician's order on her MAR.*She said she was calling the pharmacy to clarify the physician's order they had recorded for resident 7's Blink tears solution eye drops from the physician.*RN K said that the pharmacy received an order from the physician in February 2025 to change resident 7's Blink tears solution eye drops from four times daily to twice daily.-RN K could not recall the date the physician's order was received by the pharmacy.*She acknowledged that the facility had not received the February 2025 physician order for resident 7. 3. Observation and interview on 2/19/26 at 2:20 p.m. with CNA/UAP I during medication administration revealed:*The medication cart contained resident 29's medications.*The resident's Genteal Tears Solution Moderate(a medication to treat dry eye symptoms) eye drop pharmacy label on the medication container read: Instill 1-2 drops 2-3 times a day into affected eye as directed.*Her February 2026 MAR read: Artificial Tears Solution 1.4% (Polyvinyl Alcohol) Instill 1 drop in both eyes three times a day for dry eyes, irritation.*CNA/UAP I agreed that resident 29's medication label for that medication did not match the 10/23/24 physician order on her MAR.*She did not know why they did not match and stated that the medication container came from the pharmacy with the label.*She said she was to report the discrepancy to DON B for clarification and notified her.*She waited to administer resident 29's eye drops until she had clarification from DON B. 4. Interview on 2/19/26 2:30 p.m. with DON B revealed:*She acknowledged that the medication label for resident 7's Blink tears solution eye drops did not match the 4/7/22 physician's order on her MAR.*DON B said she was calling the pharmacy to clarify the physician's order they had on file for resident 29's Genteal tears solution eye drops from the physician.*DON B stated that resident medication containers or cards requiring a new medication label were to be removed from the medication carts and sent to the pharmacy for new packaging and labeling.*She said the nurse or UAP's working on the floor were responsible for removing any medication containers or cards that needed new labels and notifying the pharmacy promptly to avoid missed medication doses for residents.*She expected the nurses and UAPs to promptly identify discrepancies between the medication label and the physician's order in the MAR when they completed their safety checks with medication administration.*She acknowledged that a discrepancy between pharmacy labels and resident MARs increases the risk of medication errors with UAPs, who may not recognize medications and cannot calculate dosages.*She acknowledged that the pharmacy had received a physician's order on 4/9/25 to substitute resident 29's previous eye drop medication with Genteal Tears eye drop medication.*She acknowledged that the pharmacy had not received a physician's order for resident 29's dose change. 5. Phone interview on 2/20/26 at 8:15 a.m. with retail pharmacist S revealed:*The pharmacy provides daily and monthly medications for the residents.*He said that he or consultant pharmacist R would review and check resident medications in the medication storage room and carts for expiration dates, correct labels, narcotic logs, and perform chart audits monthly.*He said if there was a physician's order change, the resident's medications would be sent back to the pharmacy to be re-packaged with a new pharmacy label.*He stated that he had specialty physicians send new orders to the pharmacy, and those specialty physicians did not forward that new order information on to the resident's primary physician at the facility, which created discrepancies between the pharmacy labels and the resident's MARS.*He stated that the nurses usually caught the discrepancies in a timely manner and called to notify the pharmacy of the updated information. 6. Review of the provider's revised 3/4/25 Medications: Acquisition, Receiving, Dispensing, and Storage-R/S, LTC policy revealed:*The medication orders/changes are communicated to the pharmacy.*The order will include the date of the change, the location name, resident's name, medication name, dosage, route, quantity or duration and strength, diagnosis or indication for use and the physician's name.*All medications (including medication samples or other medications dispensed by the physician) are packaged in accordance with the location dispensing system and state pharmacy rules. These medications must be labeled according to state pharmacy regulations. Cautionary and accessory instructions, as well as the expiration date, will be included. New labels will be applied by the pharmacist or the pharmacist's agent as needed. 7. Review of the provider's revised 4/8/25 Medication: Administration Including Scheduling and Medication Aides- R/S, LTC revealed:*Because medication aides may only dispense medications, they are not allowed to make a determination if one or two tabs [tablets] are needed; therefore, orders with ranges are not accepted from prescribers. For example: 1-2 tablets every 3-4 hours should not be accepted.*Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication.

Based on observation, interview, record review, and policy review, the provider failed to ensure that staff were able to verify the chemical sanitation level required to sanitize the dishes used for preparation and serving residents' food. Failure of that increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the kitchen and served to the residents. Findings include: 1. IMMEDIATE JEOPARDY Interviews with dietary staff throughout the survey indicated that the dishwasher's chemical sanitation was not functioning. Staff were not aware of any process to follow when the dishwasher's chemical sanitation was not functioning. Staff could not accurately verify the chemical sanitation level of the dishwasher to ensure proper sanitation due to the expired test strips. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on [DATE] at 4:25 p.m. to administrator A and business office manager (BOM)/dietary manager (DM) C. An immediate removal plan was requested. IMMEDIATE JEOPARDY REMOVAL PLAN On [DATE] at 7:43 a.m., administrator A provided the survey team with a final written immediate jeopardy removal plan. The removal plan had been approved by the survey team on [DATE] at 8:32 a.m. with guidance from the assistant administrator and long-term care advisor for the South Dakota Department of Health. The provider gave the following acceptable immediate jeopardy removal plan on [DATE] at 7:43 a.m.: 1. Provided to surveyors the requested dishwasher manufacturer manual and disinfectant information to support the instructions are being followed and appropriate sanitation is occurring and documentation from Ecolab's [DATE] visit. 2. Use disposable paper plates, cups, and silverware until dishwasher is up and running appropriately. 3. Placed new non expired strips in, for the 3 comp sink. 4. Removed all expired strips in kitchen. 5. All dishes to be washed in the 3-comp sink until dishwasher is fixed to verify levels. 6. On [DATE] implemented the use of a Monitoring Use of Ecolab disinfectant Test Strips form for staff to sign off on what the expiration date is of a cartridge when they replace it and the label in the cartridge holder on the wall. 7. On [DATE] completed immediate education with all dietary staff. Food service assistant M and [NAME] V were trained onsite at 6:30 p.m. At 10:12 p.m. all dietary staff were texted education and informed prior to their next shift they will receive in person training on proper procedure for non-working dishwasher and education on non-expired test strips with return demonstration. 8. On [DATE] at 7:06 p.m. all staff were educated via PCC Communications with the following message Kitchen staff must ensure all chemical test strips are NOT EXPIRED. This goes for the dishwasher and the 3 comp sink. See BOM/DM C for education before start of your next shift. 9. By [DATE] will add to the TELS Service Provider a task for Director of Environmental Services to monitor weekly if a cartridge is near expiration and needs to be replaced. 10. On [DATE] left messages for EcoLab to come fix dishwasher ASAP. In the meantime BOM/DM C, who holds the dietary manager license, tried a new bucket of Ultra San Ecolab 5 gallon liquid sanitizer in the dishwasher. Retested and the low-temp dishwasher disinfectant tested properly at 50 ppm. Unsure why the initial bucket tested at 0 ppm. It was promptly disposed of. The immediate jeopardy was removed on [DATE] at 12:25 p.m. after verification that the provider had implemented their removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was lowered to an F. 2. Observation on [DATE] at 10:05 a.m. of the kitchen revealed the sanitizing testing strips located by the three compartment sink had an expiration date of [DATE]. 3. Interview on [DATE] at 10:06 a.m. with food service assistant (FSA) M revealed: *She used those same sanitizing testing strips located by the three-compartment sink to test the red bucket of water and sanitizing solution to ensure the parts per million (PPM) was correct for effective sanitization. *That red bucket would be dumped out and new water and sanitizing solution would be put into it and tested . -That process was done in the morning, at noon, supper time, and whenever it was terrible. *The sanitizing solution used was Oasis 146 Multi-Quat Sanitizer. 4. Observation on [DATE] at 10:07 a.m. of the testing documentation of the red sanitizing bucket revealed it was completed at 10:00 a.m. that day. 5. Observation and interview on [DATE] at 10:10 a.m. with cook L revealed: *She tested the sanitizing bucket at the 3-compartment sink and it tested at 10 ppm with the expired testing strips. -She confirmed the test strips were expired. -She emptied the bucket of sanitizing solution. -She then ran new water and sanitizer into the bucket, while priming the sanitizer to add more. -The bucket of sanitizing solution then tested and read at 400 ppm using the outdated testing strips. 6. Interview and observation on [DATE] at 10:12 a.m. with Nutrition and Food Services Supervisor (NFSS) F regarding testing the sanitizing solutions revealed: *She stated the red bucket of sanitizing solution should test at 400 ppm. -That solution should be changed first thing in the morning, at 9:00 a.m., 1:00 p.m., 3:00 p.m., 4:30 p.m., 6:00 p.m., and as needed. -She confirmed the test strips used to test the red bucket of sanitizer were outdated. -She opened a drawer and pulled out a different box of test strips. -She confirmed those expired on [DATE]. -There were no other test strips available for use. *She stated the dishwasher temperature for washing and rinsing of dishes should be at 120 degrees Fahrenheit. -It tested at 120 degrees. -The disinfectant should be at 50 ppm. -She then tested the dishwasher sanitizer and it tested at 10 ppm. -She confirmed that was not a sufficient sanitizing solution to prevent food-borne illness. -The chemical used for sanitation in the dishwasher was Ulta San. *The dishwasher had been leaking water when used and repairs were completed on [DATE]. 7. Observation on [DATE] at 12:05 p.m. revealed the noon meal was served with Styrofoam plates, the drinks and desserts were served in multi-use dishware. 8. Interview and observation on [DATE] at 1:35 p.m. with ancillary services supervisor E revealed: *He was attempting to repair the dishwasher. *There was a rack of trays on the clean side of the dishwasher that appeared to have been run through the dishwasher. *There was a rack of used pitchers on the dirty side of the dishwasher. *Numerous dirty cups and bowls from the noon meal were sitting on the counter. 9. Interview and observation on [DATE] at 1:45 p.m. with cook L revealed: *The dishwasher was being tested for correct sanitizing chemical amount after each dishwashing cycle. -The sanitizer was correct for two cycles of dishwashing. *She then tested the dishwasher sanitizer and it tested at 0 ppm. *She stated it was not working and they would have to rewash or hand wash the dishes. 10. Interview on [DATE] at 1:51 p.m. with NFSS F revealed testing of the dishwasher had been done all day and has not changed (the chemical sanitizing remained at 0 ppm). 11. Observation on [DATE] at 1:52 p.m. of cook L revealed she filled the third compartment of the three compartment sink with water and sanitizer. Interview on [DATE] at 2:00 p.m. with cook L revealed: *The dishwasher sanitizer normally needed to be changed about every three weeks. -She was usually the person to change it. *She had recently been on vacation and was not sure the last time it was changed. 12. Interview on [DATE] at 2:50 p.m. with NFSS F revealed: *Anyone was able to change the sanitizer bucket. *She had placed an order for more sanitizer and it would be delivered on [DATE]. *She had changed the test strips by the three compartment sink. -She was not aware they had an expiration date. -She stated she thought if the test strips expired, they should have turned a different color. 13. Review of the provider's [DATE], [DATE], and [DATE] monthly cleaning log revealed:-*There was an area labeled Chemical Dispensers. *That area was left blank. Review of the provider's documented Ultra San five-gallon bucket supply revealed: *On [DATE] the local school district had donated five buckets to the nursing home. *One bucket of Ultra San was delivered from the provider's chemical supplier on [DATE], [DATE], [DATE], and on [DATE]. *The Safety Data Sheet for Ultra San revealed the ingredients were sodium hypochlorite and chlorine. Review of the provider's [DATE] Consultant Dietitian's Report revealed: *On the Sanitation and Safety area there was a hand written note that indicated, Reviewed audit (business office manager/dietary manager) Conducted. See her report. Many issues identified that need correction. *Attached to that report was a document that included: -Sanitizing strips were expired and given to NFSS F. -The Summarize potential cause. And Summarize action taken areas were left blank. Review of the provider's dishwasher operation manual revealed: *A handwritten note that indicated the dishwasher was installed on [DATE]. *Sanitizer in original concentration is caustic and may cause damage to wash tank and or sump without dilution. *The manual did not indicate the appropriate concentration to be used. Review of the contractor's service record on [DATE] revealed the dishwasher sanitizing solution was to be between ,d+[DATE] ppm, it was at 75 ppm. Review of the Oasis 146 Multi-Quat Sanitizer guidelines revealed: *The solution's broad efficacy range of ,d+[DATE] ppm stays within proper longer. *It was EPA-registered (Environmental Protection Agency) for third sink sanitizing and on hard non-porous food-contact surfaces and ware. *It prevented cross-contamination of food contact surfaces. Review of the provider's Supervisor, Nutrition and Food Services job description revealed: *Assists in the training of new staff members and the development of existing staff members. *Ensure department meets all regulatory requirements. *Advises on the . and sanitation of food. Review of the provider's Manager, Nutrition and Food Services job description revealed: *Assists in the training of new staff members and the development of existing staff members. *Trains others on main considerations and issues related to laws and regulations in the implementation of healthcare and nutritional practices. Review of the provider's [DATE] General Sanitation - Food and Nutrition policy revealed: *Appropriate sanitizers and test strips can be ordered through (provider's supplier name). *Director of food and nutrition services (DFN) or senior living dining director maintains a supply of appropriate test strips and thermometers to monitor sanitizing products in use. *Cleaning and sanitizing equipment surfaces is a two-step process. Surfaces are cleaned and rinsed before being sanitized. All food contact surfaces will be washed, rinsed and sanitized: Review of the provider's [DATE] Sanitizing Food Contact Services - Food and Nutrition Services policy revealed: *Food-contact surfaces - The surface of equipment, worktables, dining tables dishware or utensils were food normally comes into contact, or from which food may drain, drip, or splash onto food or a surface that may come in contact with food. *Employees are trained during orientation on proper handling of all cleaning, disinfecting and sanitizing agents in use as well as the difference between disinfecting and sanitizing. *Monitor to ensure all products are correctly labeled and dated when opened. *Sanitizing solution: Mix sanitizing chemicals I the recommended concentration levels for proper concentrations measure in parts per million (ppm). High concentrations can be unsafe and may leave an odor or bad taste on the objects and corrode metals. *Check solution concentrations frequently with an appropriate test kit since they may become depleted when they kill microorganisms and bind with food. *Change the sanitizing solution when it becomes depleted or when the water is visibly dirty. Review of the provider's [DATE] Warewashing-Mechanical and Manual policy revealed: *To promote good practice during ware washing regarding prevention of foodborne illness. *Food and nutrition employees ensure that food preparation equipment, dishes and utensils are effectively cleaned, sanitized to destroy potential disease carrying organisms and stored in a protective manner., *Temperature information found below refers to temperatures listed in the FDA (Food and Drug Administration) Food Code and can be used for additional guidance as needed. -Low Temp [temperature] - 120 degrees Fahrenheit + [plus] 50 parts per million (ppm) of sodium hypochlorite (or according to manufacturer's guidelines). If temperature/chemicals are outside acceptable parameters, employees notify the DFN, . before proceeding with ware washing., *Manual Ware Washing *Sanitize -c. Chemical Treatment --1) The third compartment of the three compartment sink will be filled with hot water (75 degrees Fahrenheit or per manufacturer's instructions.) Sanitizing solution will be measured and dispensed according to manufacturer's instructions. --2) A high concentration of sanitation solution may be potentially hazardous and can contaminate food. --3) Use proper test strips to ensure accurate results for the chemical use. -7. Temperature and chemical concentration --a. Proper test strips and thermometers are available. 43844

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 one of one sampled resident (15) who was blind had his food and drink free from flies in and on it, received timely care for his incontinence needs, and received a bath as scheduled prior to attending a funeral. Findings include: 1.Review of the provider's 9/11/24 SD DOH FRI revealed: *Interim director of nursing (IDON) B received an allegation of abuse from resident 15 on 9/11/24. *Allegations included he: -Had made requests for his care needs and had to wait up to three hours for staff to come back and perform them. -Had urinary incontinence and had not been provided no incontinent products. -Had visitors during a mealtime who told him flies were on his food and in his cup of hot chocolate. --Stated the visitors had told him they killed a total of 12 flies while seated at the table with him. Observation and interview on 9/17/24 at 9:30 a.m. with resident 15 revealed: *He was lying in bed with a book reading device next to him on the bed. -He was unshaven, with whiskers approximately one-fourth inch in length on his face. *His fingernails appeared dirty, with black residue underneath of them. *He stated he wished he was dead as this was the worst place he had been in all my life. *He said he had two [NAME] friends stop in and have dinner with him. -A problem arose with flies. -While eating dinner with his friends they told him that flies were on his food and in his hot chocolate. *The interview was then ended as his son arrived to him to a take to a funeral. Interview on 9/19/24 at 1:45 p.m. with interim director of nursing (IDON) B regarding resident 15 revealed she: *Submitted a facility-reported incident (FRI) for resident 15 on 9/11/24 regarding suspected neglect. *Completed an interview with the resident but had not completed her final investigation. *Generally started an investigation when an issue was brought to her attention. *Interviewed the resident and included the interview in the FRI. -At the time of his interview, he expressed he was not provided incontinence care and had not used incontinence products. *Talked with and provided education to staff assigned to care for resident 15 regarding incontinence products, continued options, and incontinence care. *Stated staff were to have provided him incontinence care every two hours and as needed. -Was unsure if that had been added to his care plan. *Stated flies were horrible this time of year with the doors opened throughout the day. -Fly swatters were handed out, and the exterminator would came frequently to spray inside and outside the building. -Was not sure what else they could have done about the flies. Interview on 9/19/24 at 2:05 p.m. with resident 15 regarding his care revealed: *The day of his bath had recently been changed from Fridays to Mondays. -He was satisfied with bathing one time a week and had not minded the bath schedule change. *He did not get bathed on 9/16/24 before a funeral he planned to attend on 9/17/24. -He had specifically requested a bath from staff twice on 9/16/24, as he had wanted to be clean for the funeral. -The staff had not communicated with him that they had no hot water in the tub room where he bathed until late the evening of 9/16/24 and he was not offered a bath the morning of 9/17/24 before the funeral. -He was not offered a sponge bath or to have a bath in the other facility bathing room and was not offered assistance with shaving. -He attended the funeral without being bathed or shaved. *He had a bladder condition with incontinence and was told by his physician that he needed to be kept clean and dry and was to be checked for incontinence related needs) every two hours, but the staff did not consistently do that. *He would go to bed at 8:00 p.m. and staff would not check on him until 5:00 a.m. *He was not able to depend on his call light being answered and had waited for over an hour at times for staff to help him. -Had an episode of bowel incontinence within the past month and called his daughter with his talk telephone to get help. She called the main office number and told the person who answered the phone to have staff check on him, and that he had bowel incontinence when he waited for his light to be answered and needed help to get cleaned up. -Had another episode within two weeks, when he waited for over thirty minutes, and he couldn't hold it, so his roommate had helped him to the bathroom. Interview on 9/19/24 at 6:10 p.m. with resident 15's daughter regarding her father revealed: *She confirmed he called her within the last month asking for help and she called the office to have staff check on him. -He told her he waited for over an hour, couldn't hold it, and had a bowel incontinent episode, and had needed help to get cleaned up. *She visited later that day and he had not appeared to have been bathed or clean, his bedding was visibly dirty, and he had not appeared to have been changed. -Whenever she or her sisters visited, he asked them to change his bedding, and the staff had not changed his bedding unless he had an episode of bowel or bladder incontinence in the bed. *She and her siblings felt they couldn't say anything, or it would have made things worse for her father. Interview on 9/19/24 at 6:45 p.m. with business office manager C regarding resident 15 revealed: *She confirmed his daughter called the facility's main number within the past month during the mid-morning and she answered the phone. -His daughter reported her father called her for help and verbalized no one had answered his call light for an extended time. -His daughter requested staff go to his room to help him to the bathroom and clean him up, and that he reported to her he had a bowel incontinence episode while waiting for his call light to be answered. *She went to his room, saw the call light on in the hallway, but there was already a staff person in his room. *She had not asked staff if he had been incontinent. *She had not reported the call or episode to anyone. Review of the provider's 7/22/24 Abuse and Neglect policy revealed: *Purpose -To ensure that all identified incidents of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated. *The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Refer to F553 Finding 3, F657 Finding 5, and F925 Findings 5, 8, 9, and 10.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, and record review the provider failed to ensure one of one resident (17) who required staff assistance with care had not developed facility acquired pressure injuries when left on a bedpan for an extended time. Findings include: 1. Observation and interview on 9/17/24 at 9:02 a.m. with resident 17 revealed: *He was bedridden and dependent on staff for care due to a back injury and a history of a broken arm that did not heal correctly. *He had a mesh sling under him staff used for repositioning and for the lift. *he felt staff did a good job but this shift, but this shift, they don't want to help me. *He stated he pushed the call light button and, she just answered while you are in here, sometimes I am ornery and turn on the call light and wait for them and I have the door wide open so I can yell at them, you should see them run! They should check on me, what if I am on my last breath. 2. Interview on 9/18/24 at 9:49 a.m. with registered nurse (RN) H revealed: *Resident 17 is dependent on staff for all of his cares. *He would forget to use his call light at times, yell, call on his phone or he would call the police. *He has some dementia. *He used the bedpan because the lift was hard on him due to a history of back fractures. *He would use the toilet on his bath days. *He had a mesh sling under him they used to reposition him or to lift him up in the mechanical lift. 3. Interview and observation on 9/18/24 at 10:08 a.m. with RN H regarding resident 17 pressure ulcers revealed: *He had some wounds that were worse on admission but had improved. *She prepared for his wound care and stated it took three staff to reposition him. *She planned to be in his room for about one hour to complete his care. *CMA J and CMA T were in resident 17's room to assist RN H. *CMA J moved to the right side of his bed with CMA T and explained the care they would complete. *RN H placed a barrier down on a chair located on the left side of his bed for supplies. *She explained to resident 17 and the CM's they would clean him with wash cloths and then do his wound care. *She started at his face then his arms, and applied deodorant. *The CMAs rolled him to his right side with the mesh sling. *RN H removed his bandage from his coccyx (tailbone) wound. -That wound was open with pink and peeling skin on both of his outer buttocks. -RN H cleaned and irrigated the wound, applied collagen particles inside the wound and wound packing, she then covered the wound with a foam absorbent bandage. *The three staff repositioned him to his back for a break from wound care and continued to bathe him, then changed his gown. *The staff repositioned him back to his right side with the mesh sling. *RN H elevated his left heel on a pillow and his wound care was completed. *She put new elastic tubular bandage wraps on both of his lower legs. *Staff used the EZ way smart total body mechanical lift, attached his mesh sling to lift while CMA T stabilized his neck and head per RN H's direction. -He was lifted and suspended off the bed. -RN and H and CMA J changed his bedding placed a clean sling and an absorbent pad under, lowered him onto the bed, staff rolled him to his right and removed the dirty sling and replaced it with a clean one. -The three staff positioned him on his back with the head of the bed elevated. -The two CMAs then lifted and rolled resident 17 to his left as RN H pulled him toward her and the CMAs placed a wedge under his right side. -Resident 17 stated he did not want the wedge but RN H explained it was for pressure relief for his right buttock for a while and he stated he knew what it was for and agreed to use it for a while. *RN H placed pillows under each of his arms and under his left heel and a heel protector boot on his right foot. 4. Interview on 9/18/24 at 4:00 p.m. with CMA J regarding resident 17 revealed: *She had heard resident 17 had been left on his bedpan from around 7:45 p.m. to 8:00 a.m. the next morning two weeks ago. *He had been on the bedpan when the day shift came on shift. * There was communication on the computer that stated when you put someone on the bedpan you are to take them off the bedpan. *There had been no education about bedpans since this incident that happened two weeks ago. 5. Interview on 9/18/24 at 4:32 p.m. with interim director of nursing (DON) B revealed: *Resident 17 was left on the bedpan from 9/4/24 at 8:00 p.m. until 9/5/24 at 8:00 a.m. *She stated she had been working and saw him still on the bedpan on 9/5/24 when he was repositioned. -She had seen areas on his buttocks that were red where he had sat on the bedpan all night. *She stated skin issues on his buttocks would have been noted on the Minimum Data Set (MDS). *She stated she had done education about bed pan use. *She did not have documentation of the education she provided. *She did not have an attendance sheet of staff that had attended the education. *She stated she had done the education when the incident occurred for those involved and had left resident 17 on the bedpan, and did not educate everyone. 6. Interview on 9/19/24 at 11:39 am with CNA K revealed: *She was not trained on how to work with challenging residents, but she would leave the room and return later if a resident was being difficult. *She was not involved in the incident when resident 17 was left on the bedpan but found out about it the next morning. *She had no training about bedpans since that incident had happened. *She had heard from other people that administrator A had said if it happened again people would be written up. 7. Interview on 9/19/24 at 12:48 p.m. with certified medication aid (CMA) Q revealed: *She was aware resident 17 had been left on the bed pan from 7:00 p.m. or 8:00 p.m. to 7:00 a.m. or 8:00 a.m. but she could not remember the date. *She had been called by RN R and DON B to his room to help get him off the bedpan. *Resident 17 needed three people to move him for cares and repositioning. *She saw a red mark on his right buttock she thought the red mark on his left upper buttock was a bruise from the bedpan. *She stated there was a mass text that went to her personal phone and was put in computer communication system whoever put a resident on a bedpan were to take them off. *She was not aware of any other education or meeting about bedpan use. 8. Interview on 9/19/24 at 1:15 p.m. with RN R regarding resident 17 being left on the bedpan revealed: *She had gotten report the morning of 9/5/24, walked down the hallway and looked in on resident 17 from the hall and he was asleep. -She was not aware he was still on the bedpan at this time. *She had been providing care on the other hall and the business office manager C had come out of her office and stated resident 17 had called 911. -They both went to resident 17's room and he was crying and stated he had been left on the bedpan all night. *She stated they lifted the cover and could not see the bedpan and they lifted him with the sling and rolled him to his side and could then see the bedpan was still under him. *She stated they had not done this in front of the police officer due resident 17's privacy. *He is very difficult to move due to his size. *He had had his medications the night before and had fallen asleep on the bed pan and didn't feel it. *Staff should have known to get him off the bedpan. *He had a red ring on his buttocks from being on the bedpan all night but the ring was gone now. *She was not aware of any education provided to staff in reference to him being left on the bedpan. 9. Review of resident 17's Minimum data set (MDS) quarterly assessment dated [DATE] for skin conditions revealed: *He was at risk of developing pressure ulcers/injuries. *He did not have any stage 2 pressure ulcers. *He did have a Stage 4 pressure ulcer that was present on admission. *He was not on a turning/repositioning program. 10. Review of resident 17's wound assessments revealed: *On 8/29/24 signed by RN H, Left heel 1. Progress toward healing 1. Wound name -left heel deep tissue injury (DTI), 2. Type of wound a. Pressure ulcer, 2a. No, was this pressure ulcer present on admission/re-admission? 2b. Staging e) Unstageable 3. Healing process-evidenced by: Area is 60% dark pink, pink beefy granulated tissue with 40 percent white slough at the center. 4. Deterioration of wound - evidenced by: [NAME] purulent drainage. Peri-wound border now has dark purple non-blanching tissue. *On 8/29/24 signed by RN H, Left lower leg 1. Progress toward healing 1. Wound name, DTI with epidermal avulsion at center to posterior aspect of left lower leg. 2. Type of wound a. pressure ulcer 2a. No, was this pressure ulcer present on admission/re-admission? 2b. Staging k) Not staged 3. Healing process- evidenced by: Superficial, scant serosanguineous drainage, no erythema. 4. Deterioration of wound - evidenced by: Non-blanching dark purple intact tissue. *On 9/11/24 signed by RN R, Left buttock 1. Progress toward healing 1. Wound name, none 2. Type of wound a. Pressure ulcer, 2a. No, was this pressure ulcer present on admission/re-admission? 2b. Staging b)Stage 2, 3. Healing process- evidenced by: none, 4. Deterioration of wound - evidence by: Skin is sloughing off. *On 9/11/24 signed by RN R, Right buttock 1. Progress toward healing 1. Wound name, none 2. Type of wound a. Pressure ulcer 2b Staging b) Stage 2 3. Healing process- evidence by, none 4. Deterioration of wound - evidenced by: Maceration. 11. Review of resident 17's skin observations revealed: On 8/20/24 signed by RN R, 1. Skin check b. All other skin observations noted (e.g., bruising, abrasion, skin tears, rash, location of closed pressure injury) 2. Location -identify the site of the skin observation. In the description field, include the following: Type of skin condition, size/measurements, other information that further identifies the skin condition. Site 23) coccyx Description stage 4, site 44) Left lower leg (rear) Description stage 2, site 50) Left heel, description unstageable wound. *On 9/10/24 signed by Interim DON B, 1. Skin check 1. B. a1. Skin check b. All other skin observations noted (e.g., bruising, abrasion, skin tears, rash, location of closed pressure injury) 2. Location -identify the site of the skin observation. In the description field, include the following: Type of skin condition, size/measurements, other information that further identifies the skin condition. Site 31) Right buttock, Description Redness noted with skin hardening noted. Continue to monitor. Site 32) Left buttock Description Redness with skin hardening noted. Provider aware. 12. Review of resident 17's diagnosis revealed: *Pressure ulcer of sacral regional, stage 4, Dementia, Pressure ulcer of left heel, unstageable, Spinal stenosis, lumbar region without neurogenic claudication, Morbid obesity, Muscle weakness, Abnormalities of gait and mobility.

Based on observation, interview, and policy review the provider failed to ensure pest control for flies was effective. Findings include: 1. Observation on 9/17/24 at 8:15 a.m. in the conference room revealed a live beetle crawling on the floor. 2. Observation on 9/18/24 at 8:40 a.m. in the dining room revealed a live fly on a clean clothing protector. 3. Observation on 9/18/24 from 8:41 a.m. through 8:45 a.m. revealed: *Ten dead crickets in the hallway by rooms 24 through 38. *Five dead crickets in the side entrance by the nurses station. 4. Observation on 9/17/24 at 9:15 a.m. of resident 22 revealed: *He was in his room, seated in a recliner, and had a blanket covering him. -There were five live flies on the blanket that was covering him. 5. Observation and interview on 9/17/24 at 9:30 a.m. with resident 15 revealed: *He stated he had two [NAME] friends stop and have dinner with him. -A problem arose with flies. --While eating dinner with his friends they told him that there were flies on his food and in his hot chocolate. -He stated he would not have known there were flies in his food if his friends had not told him as he was blind. 6. Observation on 9/17/24 at 2:08 p.m. of resident 37 revealed: *An unknown number of dead flies on the floor. *A live fly was flying around a surveyor's head. 7. Observation on 9/18/24 at 10:27 a.m. of resident 1 in her room revealed three live flies, one had been flying around her head, one on her shirt, and one on her shoe. 8. Interview on 9/19/24 at 12:30 p.m. with ancillary services supervisor E regarding pest control revealed: *A professional pest control company came once a month to the facility. *The North and South hallways had an automatic spray system for killing flies. *The kitchen had a device that looked like a light but had sticky tape in it for catching flies. *The dining room did not have any fly control. -He was not aware there had been a concern with flies in the dining room. *He had knowledge of quite a few crickets. *He stated the facility is close to a bird seed plant and the city sewer lagoon. -He thought these might contribute to the flies in the facility. 9. Interview on 9/19/24 at 1:45 p.m. with interim director of nursing B regarding resident 15 and his concern of flies in his food revealed: *She stated flies were horrible this time of year with the doors opened throughout the day. -Fly swatters were handed out, and the exterminator came frequently to spray inside and outside the building. -She was not sure what else they could have done about the flies. 10. Review of the provider's 8/2/24 Pest Control policy revealed: *All . locations will comply with any federal, state, or local laws concerning pest infestations. *Applicable pest threats will be identified in the plan along with mitigation steps. *Sanitary conditions will be maintained on the grounds and all common areas. The location will have properly fitting exterior doors and will dispose of garbage in a manner so as not to promote insect or rodent infestations. Resident and patient rooms and units should be monitored by staff members performing assigned tasks in the rooms and units for signs of insect or rodent infestations.

Based on interview the provider failed to ensure they had not established and maintained an infection prevention and control program. Findings include: 1. Interview on 9/19/24 at 3:16 p.m. with interim director of nursing B revealed: *She stated she had not done anything with the infection control program in the month she had been there except make two binders. *She did not have updated policies and procedures for the program. *She was not doing any infection surveillance. *She stated she did not have a process in place for antibiotic stewardship and she did not have someone monitoring antibiotic use or orders. 2. Interview on 9/19/24 at 4:30 p.m. with administrator A revealed she agreed they did not did not have an active infection prevention and control program. 3. Interview on 9/19/24 at 5:28 p.m. with quality assurance specialist/certified medication assistant I revealed: *The former director of nursing had been the provider's infection preventionist but she had resigned from her position effective at the beginning of August 2024. *The provider had no current qualified infection preventionist.

Based on interview, record review, quality assurance and performance improvement (QAPI) program review, and job description review, the provider failed to ensure an effective, ongoing, and comprehensive QAPI program was in place to track and measure performance; systematically analyze underlying causes of systemic quality deficiencies; develop and implement corrective action or performance improvement activities; and monitor or evaluate the effectiveness of the corrective action/performance improvement activities, and revise the actions, as needed. Findings include: 1. Interview on 9/19/24 at 5:28 p.m. with quality assurance (QA) specialist/certified medication assistant (CMA) I regarding the QAPI Program revealed: *She had been the QAPI coordinator for the past three years. *The committee met monthly. *The provider's medical director attended monthly. *They had developed and completed a performance improvement plan (PIP) for pressure ulcer prevention and treatment from 12/18/23 through 6/11/24. *There was not a current PIP in place. Continued interview with QA specialist/CMA I regarding areas of non-compliance identified by the survey team and recent facility-reported incidents (FRI) were reviewed and QA specialist/CMA I revealed: *She was aware that there were problems with resident baths not being completed as scheduled and honoring resident preferences and was going to propose a bathing PIP at next week's QAPI meeting on 9/26/24. *She was not aware of any facility-reported incidents through the SD DOH's online reporting system and only tracked adverse events through the provider's electronic medical record (EMR) system. -She was aware of the adverse event regarding a resident (17) who had been left on a bedpan for an extended period of time as administrator A had sent a message to the nursing staff through their online scheduling system and EMR communication system regarding the incident. -She was aware of abuse concerns, both verbal and sexually inappropriate behavior from specific male residents (27 and 37) towards staff members as they had been brought up at the staff stand-up meetings, but those abuse concerns had not been addressed through their QAPI committee. *The dietary department's outdated chemical sanitation test strips had not been identified through the QAPI process. -She had become aware of the problem that morning, 9/19/24. -She was not aware the report from the consultant dietitian for January 2024 had identified the outdated test strips. *She was aware of the problems with communication within the facility including concerns with communication from the facility leadership to the front-line staff. -The last all-staff meeting was on 3/6/24 and the previous all-staff meeting was on 8/31/24. -She agreed that staff meetings were held twice a year but was not aware of expectations regarding how often the all-staff meetings should be held. -Observation on 9/19/24 at 6:11 p.m. was made of the facility's SAFE board, which stood for [provider's parent corporation] Accountability for Excellence, and was located in the facility's beauty salon, where the daily stand-up meeting was held. -The board had 22 sections which included census activity, residents' clinical needs, and staff information. -The board's current date was September 16, 2024 and QA specialist/CMA I agreed that was three days ago. *She was aware of staff complaints regarding the grievance process which included concerns not being taken care of or appropriately responded to. -The concern forms were given to social services coordinator (SSC) G, who was the provider's grievance official and SSC G routed the concern form to the specific department responsible for addressing the concern. -She stated some concern forms went missing or were not addressed. -The QAPI committee had not collected or monitored data reflecting the performance of the grievance process. *Customer satisfaction surveys were conducted last year by an outside company, but the resulting feedback was not reviewed through the QAPI committee. *She was aware of environmental issues with flies that she stated happened every year in the fall. -She stated the pest control company sprays in an effort to control the flies. -The QAPI committee had not addressed the issue. 2. Review of the provider's 11/14/23 Grievances, Suggestions or Concerns-Rehab/Skilled policy revealed: *Grievances, suggestions and concerns are to be deemed high priority customer satisfaction issues and thus will be followed up on in the quickest time frame possible. *The grievance official will route the [grievance form] to the appropriate department manager as soon as reasonably possible. *An investigation must be completed for all grievances . *The grievance official will issue a written grievance decision to the individuals filing the concerns and to the administrator. Review of the provider's 2/1/24 Quality Assurance and Performance Improvement (QAPI) Plan revealed: *QAPI Plan Purpose: -The Quality Assurance Performance Improvement (QAPI) Plan is designed to outline a comprehensive and data driven QAPI program that focuses on improving the outcomes and experiences of those we serve. -The QAPI Plan provides a description of the strategic approach to prevention, identification, reporting, investigation, analysis, and development of performance improvement activities. *Guidelines for Governance and Leadership: -Quality, safety, rights, choice, and respect are priorities for everyone within [provider's name]. -Executive leadership supports improvement work by ensuring the location has a well-defined, adequately resourced QAPI program to address facility specific issues that arise. *Location QAPI Committee: -The location administrator is the leader of the QAPI Committee, with assistance from the QAPI Coordinator, and is responsible for its effective operation. - The location QAPI Committee ensures an effective QAPI program is in place and the program is adequately resourced with time, personnel, training (including contract staff), equipment, and financial resources. *QAPI Program: -The QAPI program addresses the complexity and uniqueness of the care and services provided at [provider's name]. -The location QAPI Committee is responsible to track and trend performance, systematically analyze and prioritize quality deficiencies, develop action plans, and monitor for effectiveness. -Quality of care and safety concerns can be identified through the review of multiple sources including but not limited to safety event reports, grievances, feedback from staff, annual facility or program assessments, and department-specific initiatives. *The committee should have implemented appropriate plans of action to correct identified quality deficiencies. Review of the provider's 11/20/23 Administrator, Long Term Care - 1 job description revealed the administrator: *Was responsible for ensuring a Quality Assurance Performance Improvement (QAPI) Program is in place. *Assigned responsibility to an individual(s) for the daily management of QAPI. *Ensured the leadership of monthly QAPI committee meetings. *Sponsored performance improvement projects and reviews, approved or rejected performance improvement team findings and recommendations. *Provided access to information needed to support quality assurance performance improvement. *Provided equipment and supplies to support QAPI efforts. Refer to F553, F600, F657, F686, F812, and F925.

Based on interview the provider failed to ensure that they had an infection preventionist (IP). 1. Interview on [DATE] at 3:16 p.m. with interim director of nursing (DON) B revealed: *She was told she would be the IP. *She stated she did not have her certificate for infection preventionist as it had expired. *She was not currently enrolled to regain her certification and was not going to enroll since she was an interim DON. 2. Interview on [DATE] at 4:30 p.m. with administrator A revealed she agreed they did not did not have an infection preventionist. 3. Interview on [DATE] at 5:28 p.m. with quality assurance specialist/certified medication assistant I revealed: *The former director of nursing had been the provider's infection preventionist but she had resigned from her position effective at the beginning of [DATE]. *The provider had no qualified infection preventionist.

Based on resident council meeting, observation, interview, record review, and policy review, the provider failed to ensure three of fifteen residents (1, 15, and 18) bathing preferences were followed. Findings include: 1. Resident council meeting held on 9/17/24 at 11:20 a.m. revealed: *The bathing schedule had changed recently. *Residents who wished to remain anonymous voiced their concerns they were not getting bathed on their scheduled bath days. *The lack of baths had been discussed during care plan meetings. 2. Observation and interview on 9/18/24 at 10:35 a.m. with resident 1 regarding her bathing schedule revealed: *She had been getting one bath a week after she was admitted . *The last two weeks her bath had not been completed on her scheduled day. *Her preference was three baths a week like she had received while she was an assisted living resident before she was admitted to the nursing home. Review of resident 1's electronic medical record (EMR) regarding her bathing preferences revealed: *Her 6/27/24 initial care plan was revised on 8/6/24 to include Resident requires whirlpool bath with 1 staff, preference is 2 weekly. *A progress note dated 7/30/24 from social services coordinator G: -Resident talked to this writer about wanting more baths due to her room being warm. -She was getting 3 baths a week at the AL where she was. *Her care plan had not been revised to indicate her preference of three baths a week. *Her bathing record documentation from 8/19/24 through 9/17/24 indicated she had a bath on 8/22/24, 8/28/24, and on 9/5/24. *There was no documentation that she had received a bath for 12 days. 3. Interview on 9/18/24 at 2:05 p.m. with resident 15 regarding his care revealed: *The day of his bath had recently been changed from Fridays to Mondays. -He was satisfied with bathing one time a week and had not minded the bath schedule change. *He did not get bathed on 9/16/24 before a funeral he planned to attend on 9/17/24. -He had specifically requested a bath from staff twice on 9/16/24, as he had wanted to be clean for the funeral. -The staff had not communicated with him that there was no hot water in the tub room where he bathed until late the evening of 9/16/24. -He was not offered a bath on the morning of 9/17/24 before the funeral. -He was not offered a sponge bath or to have a bath in the other facility bathing room and was not offered assistance with shaving. -He attended the funeral without having been bathed or shaved. Review of resident 15's medical record revealed: *His 7/10/24 Sit-Stand-Walk Data Collection Tool indicated he: -Preferred a Whirlpool bath during the day, two or more times per week. *His 9/18/23 care plan regarding bathing revealed: -There was an 8/6/24 focus area for bathing that included: -He required assistance of one staff person with bathing. -He preferred to have one whirlpool bath a week. *His bathing record from 8/19/24 through 9/18/24 indicated he had a bath on 8/23/24, 8/30/24, and 9/9/24. *There was no bathing documentation that he received a bath as he requested on 9/16/24. 4. Interview on 9/19/24 at 6:40 p.m. with resident 18 regarding bathing revealed: *Staff helped her with bathing, and she was not able to bathe herself. *She thought her bath was scheduled for one time a week. *She missed her bath recently, and the staff told her something had broken down. *She did not know if she had not received bathing more often and stated her brain can't compute. Review of resident 18's medical record revealed: *Her 7/30/24 Sit-Stand-Walk Data Collection Tool indicated she preferred a tub bath, during the day, two or more times per week. *Her 9/18/24 care plan regarding bathing revealed: -There was a revised 8/6/24 focus area for bathing that included: --She required two staff members and a mechanical lift sling to transfer into a whirlpool chair. --She preferred one or two whirlpool baths a week. -Her bathing record from 8/19/24 through 9/18/24 indicated she had a bath on 8/23/24, 8/30/24, and on 9/15/24. --On 9/13/24 her bath was documented as not applicable. *There was no bathing documentation that she had received a bath for at least 15 days. 5. Interview on 9/19/24 at 11:07 a.m. with certified nursing assistant (CNA) K regarding resident bathing revealed: *The regular bath aide had changed to working part-time. *The administrative assistant had been scheduling the bath aides. *Different staff were scheduled to give baths when available. *Interview on 9/19/24 at 11:19 a.m. with interim director of nursing (IDON) B regarding resident bathing revealed: *She knew bathing was an issue. *There were recent changes in the bathing schedule due to staffing. *She had started tracking the residents' bathing to ensure they were being completed. *Her expectation was each resident would get two baths a week or according to the resident's preference documented on their care plan. Interview on 9/19/24 at 4:00 p.m. with administrative assistant O regarding resident bathing revealed:*She was in charge of the nursing schedule. *The the full-time bath aide had recently quit working. *She scheduled whomever she could get to cover the bath schedule. *She agreed bathing was not being completed according to resident preferences. 6. Review of the provider's 11/1/23 Care Plan policy revealed: *Comprehensive care plan - Includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. *Person-centered care - A focus on the resident as the locus of control and supporting the resident in making his or her own choices and having control over their daily life. *Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables. *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. *The resident/family or legal representative will have the opportunity to participate in the planning of his or her care to the extent practicable. Review of the provider's 2022 Resident's Rights for Skilled Nursing Facilities booklet revealed: *The resident has the right to be informed of, and participate in, his or her treatment, including: .(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency and duration of care and any other factors related to the effectiveness of the plan of care. 43844

Based on observation, interview, review of the provider's facility reported incident (FRI) to the South Dakota Department of Health (SD DOH), and policy review the provider failed to ensure 4 of 5 sampled residents (1, 15, 18, and 27) had their care plans were followed, updated, and revised promptly to reflect their current status and care needs. Findings include: 1. Interview and observation on 9/17/24 at 4:01 p.m. with resident 27 revealed: *He had an electronic neuropathy machine [device] that he used daily for neuropathy pain on his feet. Review of resident 27's medical record revealed: *His nurse progress notes included: -On 7/17/24 he came in with a long piece of plastic with a rusty pointy end on it. When she asked what he was doing with it he told her since they took his scissors he was going to kill himself. Nurse told him that was not funny and we take those comments quite seriously. He told the nurse he was just kidding. The Social Services Coordinator asked him what he was doing with it and he told her the same thing. Administrator went to his room. [He] said he was not going to hurt himself or anyone else with it. -On 8/1/24 He stated that he was about in a wreck [with his car]. -On 8/2/24 Resident was insistent upon going for a drive in his car. Resident then got in his car, shut the door and drove off at a very fast speed, almost side-swiping the pick-up that was parked in front of his car. -On 9/15/24 He tightly squeezed a female staff's buttock and stated, That's nice. *His care plan had not included his use of the infra-red device, his suicidal ideations, use his inappropriate sexual touching of staff, or that he had a car and drove it. Interview on 9/19/24 at 1:49 p.m. with interim director of nursing (IDON) B and registered nurse H regarding resident 27 revealed: *He had a car that was parked at the facility, and he drove that car at times. *They did not think that he was safe to drive. -They had notified the police; the police had told them they were not able to take his driver's license away from him. *There was no assessment completed for his cognitive abilities in relation to his driving a vehicle. Follow-up interview on 9/19/24 at 2:40 p.m. with IDON B regarding resident 27's driving and his car revealed: *She had found out that he was recently picked up by police a couple of times while driving. -The police had taken his driver's license away from him. -He had sold the car to an employee. 2. Interview on 9/18/24 at 10:35 a.m. with resident 1 regarding her bathing schedule revealed: *She had been getting one bath a week after she was admitted . *Her preference was three baths a week like she had received while she was an assisted living (AL) resident before her admission to the nursing home. Review of resident 1's electronic medical record (EMR) regarding her bathing preferences revealed: *A progress note dated 7/30/24 from social services coordinator G: -Resident talked to this writer about wanting more baths due to her room being warm. -She was getting 3 baths a week at the AL where she was. *Her 6/27/24 initial care plan was revised on 8/6/24 to include Resident requires whirlpool bath with 1 staff, preference is 2 weekly. 3. Interview on 9/19/24 at 6:40 p.m. with resident 18 regarding bathing revealed: *Staff helped her with bathing, and she was not able to bathe herself. *She thought her bath was scheduled for one time a week. *She missed her bath recently, and the staff told her something had broken down. *She did not know if she had not received bathing more often and stated her brain can't compute. Review of resident 18's medical record revealed: *Her 7/30/24 Sit-Stand-Walk Data Collection Tool indicated she preferred a tub bath, during the day, two or more times per week. *Her 9/18/24 care plan indicated she preferred one or two whirlpool baths a week. 4. Observations of resident 18 revealed she was lying in her bed that was raised to its highest position: *On 9/17/24 at 2:39 p.m. *On 9.19.24 at 11:10 a.m. *On 9/19/24 at 2:12 p.m. Observation on 9/19/24 at 2:12 p.m. of resident 18 in her room revealed: *She was in her bed, eyes closed, bedside table positioned across the bed at waist area. *The bed was in the highest position. Interview on 9/19/24 at 2:08 p.m. with certified nursing assistant (CNA) K regarding resident 18's height of her bed: *Her bed should be in the lowest position possible to prevent her from falling. *She required the assistance of staff and a full body mechanical lift to get into bed. *CNA K had not assisted resident 18 on this day. Review of resident 18's medical record revealed: *Her admitted was 10/19/22 *Her Brief Interview of Mental Status score was a 10, indicating she had mild cognitive deficits. *Her care plan did not include the height her bed should be at when she was lying in it. *She required assistance of two staff members and a full-body mechanical lift for bed mobility. 5. Review of the provider's 9/11/24 SD DOH FRI revealed: *Interim director of nursing (IDON) B received an allegation of abuse from resident 15 on 9/11/24. *Allegations included he had urinary incontinence and no incontinent products were in place. Interview on 9/19/24 at 1:45 p.m. with IDON regarding resident 15 revealed: *She interviewed the resident and included the interview in the FRI. -At the time of that interview he expressed he was not provided incontinence care and had not used incontinence products. *She stated staff were to have provided incontinence care every two hours and as needed. -She was unsure if his incontinence care needs had been added to his care plan. Interview on 9/19/24 at 2:05 with resident 15 regarding his care revealed he had a bladder condition with incontinence and was told by his physician that he needed to be kept clean and dry and was to be be provided incontinence care every two hours, but the staff had not consistently done this. Review of resident 15's medical record revealed: *His admitted was 10/12/23. *His diagnoses included: malignant neoplasm of bladder, legal blindness, macular degeneration, and unspecified dementia. *His care plan indicated: -On 2/28/24 Needs to be checked and changed approx. [approximately] q [every] 2-3 hours for incontinence. Uses an incontinent product. Voices that the urinal no longer works for him and he only uses the toilet for BM [bowel movement] purposes. -On 2/28/24 and revised on 5/18/24 ambulates with cane at times, otherwise hangs on to a staff members arm for guidance to get to destinations. May use wheelchair when feeling week. 6. Interview on 9/19/24 at 3:05 p.m. with minimum data set nurse D regarding resident care plans revealed: *The interdisciplinary team, including nursing, dietary, activity, and social services were involved in the development of the care plan. -The resident's physician would review and sign the care plan. -Each member of the interdisciplinary team was responsible for completing their area of the care plan. *The care plan was updated whenever a resident had a change in the care they required and on a quarterly basis. -CNAs would provide her with information on each resident and she would then update their care plan with that information. --There had been lots of turnover with CNAs. *Regarding resident bathing: -Each resident's preference for bathing was obtained through interviews and documented on a Sit-Stand-Walk Data Collection Tool. --Their preference was then documented on their care plan. *Regarding resident 27's care plan: -She had no knowledge of his suicidal ideation. --His physician should have been notified of this. --Social service designee G should have updated his care plan with this focus. -Was not certain if his driving a vehicle was on his care plan. -She was aware he had given a staff member an inappropriate written note asking her to meet him somewhere. *Regarding resident 18's bed positioning and care plan: -The head of the bed was to be elevated 30 degrees when she was in bed. -Resident 18 preferred the bed height to be maintained at a normal height. -Her bed was not to be in a low position as she was not a high fall risk. *Regarding resident 15's care plan and the use of incontinent products. -She was not aware he had not been using incontinent products. 7. Social service designee G was not available for an interview. 8. Review of the provider's 11/1/23 Care Plan policy revealed: *Comprehensive care plan - Includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. *Person-centered care - A focus on the resident as the locus of control and supporting the resident in making his or her own choices and having control over their daily life. *Policy -Residents will receive and be provided 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 towards achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through the use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders. *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, and other employees as determined by the resident needs. *The resident/family or legal representative will have the opportunity to participate in the planning of his or her care to the extent practicable. *The interdisciplinary team will review care plans at least quarterly.

Based on record review, interview, and policy review the provider failed to ensure one of one sampled resident's (27) physician was notified of the resident's suicidal ideation statements and safety concerns related to his staff-observed vehicle driving practices. Findings include: 1. Interview on 9/19/24 at 1:49 p.m. with interim director of nursing (IDON) B and registered nurse H regarding resident 27 revealed: *He had a car that was parked at the facility, and he drove that car at times. *They did not think that he was safe to drive. -They had notified the police; the police had told them they were not able to take his driver's license away from him. *There was no assessment completed for his cognitive abilities in relation to his driving a vehicle. *They had not notified his physician of their concerns about his driving. Review of resident 27's medical record revealed: *His nurse progress notes included: -On 7/17/24 he came in with a long piece of plastic with a rusty pointy end on it. When she asked what he was doing with it he told her since they took his scissors he was going to kill himself. Nurse told him that was not funny and we take those comments quite seriously. He told the nurse he was just kidding. The Social Services Coordinator asked him what he was doing with it and he told her the same thing. Administrator went to his room. [He] said he was not going to hurt himself or anyone else with it. -On 8/1/24 He stated that he was about in a wreck [with his car]. -On 8/2/24 Resident was insistent upon going for a drive in his car. Resident then got in his car, shut the door and drove off at a very fast speed, almost side-swiping the pick-up that was parked in front of his car. -On 9/15/24 He tightly squeezed a females buttock and stated, That's nice. *There was no documentation to support his physician had been notified of his statements of suicidal ideation or regarding his observed unsafe driving. Review of the provider's 12/4/23 Notification of Change policy revealed: *A facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there is: -A significant change in the resident's physical, mental or psychosocial status.

Based on interview, record review, and policy review, the provider failed to provide a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for one of one sampled residents (21) reviewed for facility-initiated transfer to the hospital. Findings include: 1. Interview on 9/17/24 at 9:00 a.m. with resident 21 revealed she did not think she had gone to the hospital recently. 2. Review of resident 21's electronic medical record (EMR) revealed: *She was transferred to the hospital on 5/15/24. -Her power of attorney (POA) was notified of her transfer. -There was no documentation the bed hold information was given to the resident or her POA. *She was transferred to the hospital on 6/18/24. -Her POA was notified. -There was no documentation the bed hold information was given to the resident or her POA. 3. Interview with the facility's local ombudsman on 9/18/24 at 2:51 p.m. regarding resident 21's transfers to the hospital revealed: *She said the facility normally filled out a report online about hospitalization s. *The facility has one month to notify them of the hospital transfer. *She stated that she had not received notifications for either of resident 21's hospital transfers above. 4. Interview on 9/19/24 at 11:12 a.m. with administrator A revealed: *The social services coordinator G was responsible for submitting hospital transfer reports to the ombudsman. *She was not aware that they had to report every hospital transfer to the ombudsman. *No documentation was provided to verify the ombudsman was notified of resident 21's hospital transfers. 5. Review of the provider's 12/6/23 Ombudsman policy revealed: *A website for more information regarding state-specific regulations. *The state-specific regulations on the website stated, Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Fall and safety interventions had been modified, implemented, and monitored for one of five sampled residents (3) who had falls. *Fall and safety interventions had been modified and monitored for one of five sampled residents (6) that had a fall. Findings include: 1. Observation on 1/4/17 of resident 3 revealed: *At 12:50 p.m. she was sitting unattended in her wheelchair in front of the nurses station near the main entrance. -There were no staff at the nurses station. *At 1:00 p.m. she was sitting in her wheelchair unattended in her room facing the television. Review of resident 3's complete medical record revealed: *She was admitted on [DATE]. *She had eight falls since 7/1/16: -July 2016 she had three falls. -September 2016 she had two falls. -November 2016 she had one fall. -December 2016 she had two falls out of her wheelchair on 12/1/16 and on 12/22/16. *Her current care plan revised 11/30/16 had not been updated for her current fall interventions. Review of resident 3's 12/1/16 nursing progress note revealed: *She was found on the floor laying on her back in front of her wheelchair. *She said she had leaned too far forward in her wheelchair. Review of resident 3's 12/1/16 incident report revealed an immediate action taken was Added note to care plan, instructed staff not to leave resident in room alone while in wheelchair because she will stand up and she will not use a call light. Review of resident 3's 12/1/16 fall investigation report revealed: *Contributing factors: -History of falls. -Cognitive impairment. -She did not recognize her limitations. -Sitting and leaning too far forward. -Recent UTI. *Corrective action taken: -Employee education. -Care plan amended. -Staff instructed not to leave resident in room alone in wheelchair. Review of resident 3's 12/22/16 nursing progress note revealed Resident found lying on left side on floor, earlier she was reaching down to the floor says for a piece of candy, this writer sat her up and looked for anything on the floor, which there was not. Sat her back up in her w/chair (wheelchair), gave her hs (nighttime) meds, visited with her and left the room, approx. 10 min. later was summoned to her room, she was on the floor with large goose egg to It forehead, small cut with mod. amt. bright red blood. Neuros (neurological assessment) done. WNR (within normal range), says her head hurts just a little bit. VS (vital signs) T 98.1, P 69, R 18 B/P 139/68. ROM (range of motion) WNR, Assist up to her bed with assist of 3 staff with Total body lift. _____(name) daughter notified, Administrator and Ecare called. Ok to ice area to her head. Review of resident 3's care plan revised on 11/30/16 revealed: *She was at risk of falls related to dementia, weakness, balance problems, history of falls, and incontinence. *A goal she would be free from falls. *No mention of an intervention for the resident not to be left alone in her wheelchair. *The care plan had not been updated after her 12/1/16 fall. *The care plan had non been updated after her 12/22/16 fall. Interview on 1/4/17 at 3:50 p.m. with the administrator and director of nursing (DON) regarding resident 3 revealed: *The intervention identified to not leave the resident unattended in her wheelchair after her 12/1/16 fall had not been added to her care plan. *The intervention that was identified for the resident not to be left in her wheelchair unattended should have been added to the care plan immediately after her 12/1/16 fall. *They had implemented a performance improvement plan (PIP) team for falls. -The PIP team had not identified individualized fall interventions for residents with falls. -The PIP team had not monitored individualized fall interventions for residents with falls. *There quality assurance program had not monitored individual fall interventions for residents with falls. 2. Review of resident 6's complete medical record revealed: *He was admitted on [DATE]. *His conditions included but were not limited to [DIAGNOSES REDACTED], a paralyti[DIAGNOSES REDACTED], seizure disorder, impaired balance, limited mobility, incontinence, weakness, and a history of falls. *He had a fall on 12/23/16. *His current care plan had not been updated to include fall interventions from the identified causes. Review of resident 6's 12/23/16 fall incident report revealed he was found laying on the floor beside his bed. Review of resident 6's 12/23/16 fall investigation report revealed: *The potential causes of his fall were: -The air mattress. -The bed was not in the lowest position. -The resident was positioned too close to the edge of his bed. Review of the resident 6's current care plan revised on 12/12/16 revealed: *His care plan had not been revised after his fall on 12/23/16. *There was no mention of any identified fall cause interventions on the care plan. Interview on 1/4/17 at 5:40 p.m. with the administrator and DON regarding resident 6 revealed they would have expected fall interventions to have been added to his care plan after his 12/23/16 fall. 3. Review of the provider's revised May 2016 Fall Prevention and Management policy revealed: *The purpose was: -To develop a fall prevention and management program -To implement a proactive approach to fall prevention and management -To identify risk factors and implement interventions before a fall occurs -To prevent further injury -To provide guidance for documentation *An Avoidable accident - means that an accident occurred because the location failed to: -Identify environmental hazards and individual resident risk of an accident, including the need for supervision; and -Evaluate/analyze the hazards and risks; and -Implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident; and/or -Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with the current standards of practice.

Based on record review, interview, and policy review, the provider failed to conduct a thorough investigation to rule out neglect or mistreatment for one of one sampled resident (1) who had extensive bruising and a fracture of unknown origin. Findings include: 1. Review of resident 1's medical record revealed: *A [DATE] admitted . *[DIAGNOSES REDACTED]. *She was hospitalized [DATE] with a left femur (long bone in upper part of leg). *She returned to the facility on [DATE]. *She expired (died ) on [DATE]. Review of resident 1's [DATE] and [DATE] Brief Interview for Mental Score (BIMs, memory test) revealed: *[DATE], A score of 2 out of 15. *[DATE], A score of 5 out of 15. *BIMS scoring: -Memory intact (okay) 13 to 15. -Moderately impaired memory 8 to 12. -Severely impaired memory 0 to 7. Review of resident 1's [DATE] through [DATE] nursing progress notes revealed: *[DATE] at 2:47 p.m., Daily skin check. [MEDICATION NAME] boot (treatment of stasis (caused by poor circulation) ulcers) intact to left leg. Right leg is pink with 3+ [MEDICAL CONDITION] (swelling). Has dry scaly patches to left thigh and lower right leg. Cream applied. Under breasts and abdominal fold are intact. *[DATE] at 3:30 a.m., Tylenol give for voicing of pain all over. Rates pain at a 9 (0 is no pain and 10 being severe pain). *[DATE] at 10:41 a.m., Tylenol given for left leg discomfort. *[DATE] at 11:27 a.m., Noted a dark bruise in the inner part of resident's right ear. Bruise is dime sized. Unsure how bruise occurred. *[DATE] at 1:04 p.m., Resident still complaining of severe left knee pain. *[DATE] at 2:37 p.m., Facsimile (fax) to physician. Resident is complaining of severe left knee pain. When leg is lifted up or moved she yells out. Leg is not warm to touch or reddened. Resident does have a rashy area on her left inner thigh (upper leg) that goes from her knee up to her perineal (groin) area. Tylenol was given this morning with no relief. Resident does not have anything stronger to give. *[DATE] at 6:27 p.m., Tylenol given for complaints of left knee pain at a 4 to 5 pain rating. *[DATE] at 9:43 p.m., The system has identified a possible drug allergy for the following order: [MEDICATION NAME]. Communication sent to physician via facsimile (fax). *[DATE] at 5:30 a.m., Tylenol given for pain in left knee/leg. *[DATE] at 7:50 a.m., Tylenol given for left leg pain of 8. *[DATE] at 2:28 p.m., Daily skin check. [MEDICATION NAME] boot remains intact to left lower leg. Circulation, motion, and sensation (CMS) remains unchanged to toes. Dull pink rash to inner thighs. Treatment as ordered. *[DATE] at 5:40 p.m., Tylenol given for complaints of left knee pain. *[DATE] at 9:50 p.m., Resident transferred to bed via (by) stand-up lift (mechanical lift that required resident to be able to bear some weight on their legs). Certified nursing assistant (CNA) called charge nurse in room. Voiced to charge nurse concerning large purplish bruising (no size documented) to left outer breast and under left arm. Bruising very likely occurred while resident being transferred via stand-up lift, area pinched or rubbing against area while being lifted. Skin intact. Resident denies any discomfort, voiced she did not even know it was there. *[DATE] at 1:42 a.m., At 9:50 p.m. last evening [DATE], CNA called charge nurse in regarding a large bruise (no size documented) on resident's left outer breast and under left axillary (armpit). Note large purplish bruise, non-tender to touch. Resident voiced she did not even know it was there. Type of bruising likely to occur during transferring with stand-up lift. Area pinched by lift harness if not appropriately place in the right position while lifting. *[DATE] at 7:11 a.m., Family has been notified of bruise. Voiced understanding. *[DATE] at 8:30 a.m.,Tylenol given for left knee pain. *[DATE] at 3:48 p.m., Resident has been more lethargic (sleepy). Requires more cueing (verbal reminders) and at times physical assist with meal. Sleeps through the meal if left alone. Resident more confused, wanting her parents. If not sleeping she is wandering in her wheelchair. Does not go far but has no idea where she is headed. Temperature 97. 2 degrees (normal 98.6). *[DATE] at 5:50 p.m., Tylenol given for left knee pain. *[DATE] at 10:40 a.m., Tylenol given for complaints of pain/aches all over. *[DATE] at 9:30 p.m., Tylenol given for left knee pain. *[DATE] at 10:30 p.m., Able to sleep when left alone, but still screams when she is moved. Tried repositioning her leg with pillows, helps for awhile. *[DATE] at 4:44 a.m., Tylenol given for pain in her left leg. *[DATE] at 10:42 a.m., [MEDICATION NAME] (narcotic-like pain medication) given per request for left knee pain. *[DATE] at 11:29 a.m., Seen by physician for increased pain to left knee. Left knee more swollen, red, and warm to touch. Resident to be seen at clinic at 1:10 p.m. today for x-ray and labs (laboratory tests) and to be seen via physician. *[DATE] at 12:10 p.m., [MEDICATION NAME] given for discomfort to left knee. *[DATE] at 4:16 p.m., Returned to facility with new [DIAGNOSES REDACTED]. *[DATE] at 5:22 p.m., Noted left knee continues to be swollen/warm to touch, very painful to touch. *[DATE] at 8:51 p.m., [MEDICATION NAME] [MEDICATION]) not available from pharmacy. *[DATE] at 9:55 p.m., Still remains with a lot of soreness in left knee. Left knee remains very swollen, red, warm to touch and has a large bruise type area on inner part of knee. *[DATE] at 12:36 a.m., Resting in bed continues to have a lot of pain in left leg, especially knee area. Left knee remains very swollen, red, and has a large bruise noted on inner side of left knee. Screams out at times with movement. Majority of left breast and under left arms remains with dark bruised area. *[DATE] at 10:03 a.m., [MEDICATION NAME] not available. Will come up from pharmacy tonight. *[DATE] at 3:00 p.m., Tylenol given for leg pain. Continues to be tender to the touch with some relief obtained at this time. *[DATE] at 5:10 p.m., [MEDICATION NAME] given for severe pain to left knee. *[DATE] at 8:25 p.m., Left knee is swollen, bruised and red, and warm to touch. Extremely tender to the touch. Resident yells out ouch, ouch, ouch the entire time during transfers or movement or touch to the left leg. [MEDICATION NAME] (antibiotic injection) scheduled. Had a small emesis (vomiting) after lunch. Resident given [MEDICATION NAME] with some relief at rest. Will monitor. Physician was notified of bruising over the phone and stated to monitor pain at this time. There is no need for an x-ray at this time as she was seen in the clinic yesterday. Stated it will take time for the gout and inflammation to settle down and for the pain to go down. Need to notify the clinic if resident runs a fever or if pain becomes unmanageable. *[DATE] at 10:25 p.m., [MEDICATION NAME] given for knee pain with some relief. *[DATE] at 12:50 a.m., [MEDICATION NAME] given for pain in knee. *[DATE] at 1:59 p.m., Resident having severe pain in left leg. Resident screams with any movement in any area of her body. Called clinic and requested she be seen. *[DATE] at 3:44 p.m., Transferred to hospital for uncontrolled pain in front of left knee and front of left thigh. She was hospitalized for [REDACTED]. Review of resident 1's [DATE] 9:50 p.m. investigation form revealed: *Name of witnesses: None. *If no witnesses, list names of caregivers/staff for past seventy-two hours: -Registered nurse (RN) F. -CNA G. -There were no other caregivers documented. *CNA (not identified) found large bruise (no size documented) purple to outer left breast and into left axillary area. Area non-tender. Type of bruising likely occurs during use of stand-up lift, area gets pinched or rubbed via lift harness if not appropriately placed under resident's arms while lifting. *Corrective action: -Make sure harness placed in right position to prevent further injury. -Facility staff will complete the corrective action. *The form was signed by the administrator and director of nursing (DON) on [DATE]. *The form was not signed by the social worker. *Resident oriented (alert) to name. She was not documented as oriented to time and place. *Predisposing (before) environmental factors was equipment/assistive devices. *Report was prepared by RN F. *Son notified on [DATE] at 10:00 p.m. *Physician notified on [DATE] at 1:40 p.m. *Administrator notified on [DATE] at 1:40 p.m. Review of resident 1's [DATE] through [DATE] CNA documentation revealed: *[DATE], CNAs C, I, and J documented assistance with bed mobility, personal hygiene, transfers, and toilet use. *[DATE], CNAs G and J documented assistance with bed mobility (moving and changing position), personal hygiene, transfers, and toilet use. CNA K documented assistance with bathing. *[DATE], CNAs C, H, and I documented assistance with bed mobility, personal hygiene, transfers, and toileting. *[DATE], CNAs G and H documented assistance with bed mobility, personal hygiene, transfers, and toileting. Review of resident 1's [DATE] physician's orders [REDACTED]. Monitor rash, if worse, needs to be seen. Review of resident 1's [DATE] through [DATE] Medication Administration Record [REDACTED]. That was the day she was sent to the clinic and was diagnosed with [REDACTED]. Review of resident 1's [DATE] physician's clinic ambulatory progress notes revealed: *Staff report over the weekend, today being Tuesday, that she had a very painful left knee. She would holler whenever it was moved. *Today there has been some [DIAGNOSES REDACTED] (redness) and some warmth to the knee. No fever. She is still complaining of pain. *She complains of pain with just minimal movement of that leg. *Unable to rate pain. *She does have some history of [MEDICAL CONDITION] joint disease (DJD) with chronic knee pain and is taking [MEDICATION NAME] for that at this time (was ordered on [DATE] and was not administered until this morning on [DATE]). *No recent fall. *Impression DJD and gouty arthritis. *We will given her [MEDICATION NAME] (anti-[MEDICAL CONDITION] injection). We will also do [MEDICATION NAME] for three days. We will start her on [MEDICATION NAME] three times a day for one week. She should recheck in the clinic in one week. Review of resident 1's [DATE] physician's hospital progress notes revealed: *[AGE] year old lady with significant pain with movement of the left hip and knee. *She denies any falls and no falls noted on the face sheet from the nursing home. *She was seen two days ago for knee pain as well. She was started on antibiotics and given intramuscular steroid. *She does have severe dementia (memory loss) and does not remember things very well and denies falling. *Staff reports she screams out in pain with minimal movement. *Pain in left leg. Unable to rate. *Left knee is swollen with bruising on the left medial (middle) side. She has pain with any movement. Tender to palpitation (touch). *Closed fracture of distal (far) end of left femur. Review of resident 1's [DATE] hospital physician's consultation report revealed: *She does not recall how she injured the leg. She does have bruising along her left side, but no documented falls. *X-rays reviewed and demonstrate an acute displaced oblique (neither parallel or at a right angle) [MEDICAL CONDITION] femur with significant posterior (back) angulations (position) and [MEDICAL CONDITION]. There is severe DJD noted as well with bone-on-bone changes in the medial compartment. *Left lateral hemithorax (one side of chest) and breast ecchymoses (bruising) likely related to lift usage. Review of resident 1's [DATE] physician's surgical report revealed Open reduction, internal fixation (surgical procedure to fix a severe bone fracture or break) left distal femur fracture. Interview on [DATE] at 9:50 a.m. with RN L regarding resident 1 revealed she: *Sent a facsimile to the physician on [DATE] as the resident was having pain with any movement. *Did not work after [DATE] with the resident, so she was unaware the nurses were not administering the [MEDICATION NAME] to her. *Agreed the [MEDICATION NAME] should have been given for greater pain control instead of the Tylenol. At least they gave her something. Interview on [DATE] at 10:30 a.m. with the DON regarding resident 1 revealed she: *Never talked to CNA G regarding the resident's bruising from [DATE]. *Confirmed CNA G had worked with the resident from 7:00 a.m. until the bruising was reported on [DATE]. *Had thought RN F would have spoken to him, but she had failed to document that. *Did not know about the resident's bruising until [DATE]. *Only talked to the nurses on duty, and I told them we had to be more careful with the straps on the lift to prevent further reoccurrences. *Had looked at her bruising and also agreed it was likely due to the harness on the stand-up lift not being appropriately placed. *Nor any of the other nurses watched a transfer with the resident after the incident on [DATE]. *Nor any of the other nurses had completed a lift assessment on the resident after [DATE] to see if that was the appropriate way she should have been transferred. *Had not re-educated any of the staff, including the agency temporary staff after the incident on [DATE]. *Felt it was not necessary to review the different mechanical lifts with all the agency temporary CNAs, as that would have been included in their CNA training. *Had not investigated the resident's bruising, because they were sure it had been caused by the stand-up lift. *Knew the potential allergy to [MEDICATION NAME] had been reported to the physician and did not know why it had not been followed-up on. Interview on [DATE] with the administrator regarding resident 1 revealed she: *Had not investigated the resident's bruising. *Had not reported the bruising or fracture of unknown origin to the South Dakota Department of Health. *Stated it was the social worker's responsibility to initially investigate and report injuries of unknown origin. *Stated when the social worker was done with her investigation she gave the report to her and the DON. *Should have investigated and reported the bruising and fracture when she had signed the investigation report on [DATE] and saw that it had not been done. *Stated the social worker was on vacation during the survey and was unable to be interviewed. Phone interview on [DATE] with the consultant pharmacist regarding resident 1 revealed he: *Had sent a note along with the [MEDICATION NAME] on [DATE] to watch for any sensitivities to the medication as she had sensitivities to other medications. *Would have called the physician or had the nursing staff if he had noted a red flag alerting him to an allergy to [MEDICATION NAME]. *Had sent fifteen tablets of [MEDICATION NAME] to the facility on [DATE] about 5:30 p.m. *Was unsure why they had not administered the [MEDICATION NAME] to the resident for pain control until [DATE]. Review of the agency temporary staff list provided revealed: *CNAs C and H had received safe patient (resident) handling in [DATE]. *CNAs G, T, U, and V had no documentation of receiving the safe patient handling. *Nurses V, W, and X had no documentation of receiving the safe patient handling. Refer to F226 B, finding 1 regarding abuse and neglect training. Review of the provider's February 2013 Abuse and Neglect policy revealed: *The center will provide education and training to staff and volunteers in regards to abuse, neglect, mistreatment and misappropriation of property. *Alleged or suspected violations involving any mistreatment, neglect or abuse including injuries of unknown origin will be reported immediately to the center administrator and to other officials in accordance with state law, including the state survey and certification agency. In the absence of the administrator from the center, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the DON or the director of social services. *The center will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in progress. *Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency within five working days of the incident, or sooner as designated by state law. *The abuse/neglect policies and procedures cannot and do not guarantee that abuse will never occur. To prevent such occurrences, all reasonable measures within our control will be taken. Review of the provider's [DATE] Pain Management policy revealed: *All residents will receive interdisciplinary consultations in managing pain. *When a resident is identified as being in pain, the social worker, as part of the interdisciplinary team, will assess the psychosocial well-being of the resident. *Individualized approaches will be developed to address the resident's pain management needs in a holistic manner. *The RN will assess current pain levels and develop with the physician and interdisciplinary team interventions that may be non-pharmacological as well as pharmacological. *The RN will review response to medication intervention and work closely with the physician to assist in the individualized pain measurement plan.

A. Based on observation, record review, interview, and policy review, the provider failed to follow professional standards of not moving a resident with acute pain and a suspected fracture for one of two sampled resident's (2) condition following a fall resulting in a fracture. Findings include: 1. Observation on 11/10/15 at 10:00 a.m. of resident 2 revealed she: *Was dependent on a wheelchair for mobility (movement). *Was transferred from the wheelchair into bed by certified nursing assistants (CNA) AA and BB. *Put toe-touch weight bearing on her right leg during the transfer. *Showed no discomfort during the transfer. Review of resident 2's 10/28/15 through 10/29/15 nursing progress notes revealed: *10/28/15 at 11:37 p.m., At 8:00 p.m. tonight resident was found laying on her right side on the floor beside her bed. Wheelchair was beside her. Range of motion (movement of arms and legs) within normal limits. Denies pain. Assisted up per two staff and total lift (mechanical lift that requires no weight bearing on legs from the resident). No injury noted. Daughter came to facility and was informed of fall at 8:15 p.m. Will notify physician by facsimile (fax). *10/29/15 at 7:30 a.m., Transferred to hospital. [MEDICAL CONDITION]. *There was no documentation of her condition from 10/28/15 at 11:37 p.m. until her transfer to the hospital on [DATE]. Review of resident 2's 10/29/15 ambulance report revealed patient (resident): *Transferred from clinic to hospital with fractured right hip. *Complains of right leg and back hurting. *Was confused as to surroundings and reason for transport. Review of resident 2's 10/28/15 investigation report revealed: *Resident continues to self transfer. *Oriented (alert) to person. Disoriented (poor memory) to time and place. *Personal alarm system (body alarm that sounds when resident attempts to self-transfer). *Alarm did not sound. Interview on 11/10/15 at 9:00 a.m. with registered nurse (RN) L regarding resident 2 revealed: *She came to work at 6:45 a.m. on 10/29/15 and had sent the resident to the clinic by 7:30 a.m. The clinic then sent the resident to the hospital for a right [MEDICAL CONDITION]. *The CNAs had called her into the resident's room when she had gotten there. She was in a lot of pain and could not move her right leg and was pulling at her right knee. *The resident rarely complained of pain so I knew her well enough to know there was something wrong. *RN CC had worked the night shift and said she was okay in report. *RN CC came into the room with me and Thought her pain was caused from her lying in bed all night. *She assessed the resident in bed for pain. The CNAs told her they were going to try and get her up in her wheelchair and see how she did. *She did not tell the CNAs not to get her up in her wheelchair since she was in so much pain, nor did she stay in the room and watch them transfer her. *She had no comment when asked why she had allowed the CNAs to transfer her into her wheelchair when she was having so much pain. *She had not documented her assessment of the resident in the medical record and should have. *The resident was unable to rate her pain, but she thought it was maybe a 5 or 6 out of 10 (0 being no pain and 10 being severe pain). Phone interview on 11/10/15 at 10:30 a.m. with RN CC and the director of nursing (DON) regarding resident 2 revealed: *The resident was put to bed at 10:30 p.m. on 10/28/15 and was having no pain yet. *Her daughter had come into the facility after the fall and pushed her around in her wheelchair for awhile. *She had not documented anything in her medical record, because she was okay and not having any pain. *She was not sure but she should have been up to the bathroom a couple of times or the CNAs had provided incontinent care in bed. *The CNAs would have let her know if the resident was experiencing any pain. *She probably should have made some documentation in her medical record at least that she had been okay during the night shift. Review of the provider's September 2012 Documentation policy revealed: *Documentation of all nursing care and observations, assessments and treatments, and effects will be written by an authorized professional using the PointClickCare system and Resident Services System of Forms. *All documentation is expected to be legible, accurate, understandable, timely, and pertinent. *Frequency of documentation will be determined depending on the condition of the resident. *All of the following will be clearly documented according to the respective policies and procedures: -Physical health observations. -Reassessments (checking for change in resident status or condition). Review of the provider's July 2015 Fall Prevention and Management policy revealed: *For fallen resident: -Do not move the resident. *For a fall with injury do the following: -Cover the resident and have him or her lay quiet until help arrives. -Do not move the resident if suspected spinal or [MEDICAL CONDITION]. *A licensed nurse must observe the resident and perform a full-body examination to determine if there may be a suspected injury and direct whether to move the resident. Do not attempt to move the resident if spinal or [MEDICAL CONDITION] is suspected. B. Based on observation, record review, interview, and policy review, the provider failed to follow physician's orders [REDACTED]. Findings include: 1. Review of resident 4's medical record revealed she: *Had [DIAGNOSES REDACTED]. *Had a Brief Interview for Mental Status (BIMS) score of 9. *BIMS scoring: -Memory intact (okay): 13 to 15. -Moderately impaired memory: 8 to 12. -Severely impaired memory: 0 to 7. *Had fallen on 10/6/15 at 1:20 p.m. and was noted to: -Have an elevated temperature of 99.5 degrees. -Have a strong urine odor. -Complained of feeling weak and just doesn't feel good. *Had a physician's orders [REDACTED]. *Became unsteady on 10/7/15 at 7:08 p.m. while walking by herself and had an elevated temperature of 99.8 degrees. -There was documentation unable to get urine specimen today. Will continue to try to get specimen. -Did not have the UA completed until 10/8/15. *Was ordered an antibiotic (medication to treat infection) by her physician to treat her urinary tract infection [MEDICAL CONDITION] on 10/9/15. -The first dose of the antibiotic was held that evening due to resident was vomiting. -At 2:39 a.m. the charge nurse documented Resident has UTI, antibiotic to start in the morning, Temperature 99.8 (degrees). No complaints during the night. -That antibiotic did not get started until 10/10/15. Continued review of her medical record revealed she: *Still had low grade elevated temperatures (99.2 and 99.1 degrees) and complained of weakness on 10/11/15 and 10/12/15. *Was seen by the certified nurse practitioner in the nursing home on 10/13/15, and the antibiotic was changed to a different antibiotic medication. *Took the first dose of the new antibiotic on 10/13/15 at 8:00 p.m. *Had fallen again on 10/14/15 at 5:30 a.m. and was sent to the hospital for complaint of hip pain. *Was admitted to the hospital for a right [MEDICAL CONDITION] following her fall on 10/14/15. *Had been re-admitted to the facility on [DATE] following a surgical repair of that right [MEDICAL CONDITION]. *Required supervision and set-up help only with activities of daily living (ADL; dressing, bathing, moving, toileting, hygiene, and eating) prior to her 10/14/15 fall. *Required extensive staff assistance with her ADLs after she returned from the hospital on [DATE]. Random observations from 11/9/15 through 11/10/15 of resident 4 revealed she: *Utilized a wheelchair assisted by staff to move around the facility. *Required staff assistance with a mechanical lift (equipment to move resident) to transfer to and from her wheelchair. *Was pleasant and interacted with staff. *Wore a disposable brief for urinary incontinence and was assisted with toileting and personal hygiene. Review of resident 4's 11/9/15 care plan revealed: *She had impaired cognitive function, impaired decision making, and short term memory loss. *She had bladder incontinence (unable to control urine). -Interventions for incontinence included: Monitor/document for s/s (signs and symptoms) of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. *She had a history of [REDACTED]. *She required staff assistance with ADLs since she had been readmitted . Interview on 11/10/15 at 8:30 a.m. with registered nurse L regarding resident 4 revealed she: *Agreed: -The resident had symptoms of an infection on 10/6/15. -The physician's orders [REDACTED]. *Was unsure why it took two days to obtain the UA for resident 3. -If they were having difficulty getting a UA they should have contacted the doctor and gotten an order for [REDACTED]. *Confirmed she had not received her first dose of antibiotic to treat her UTI until 10/10/15, four days after the symptoms had started. *Held the dose of antibiotic on the evening of 10/9/15 due to the resident vomiting. *Did not know why the night nurse had not given the first dose of the antibiotic on 10/10/15 when the resident was feeling better. *Agreed the UA and antibiotics were not completed in a timely manner. Interview on 11/10/15 at 10:15 a.m. with the administrator regarding resident 4's orders for a UA and the start of antibiotics confirmed they were not completed in a timely manner. Interview on 11/10/15 at 11:00 a.m. with the director of nursing regarding resident 4 revealed: *When a physician ordered a UA for a resident it should have been completed as soon as possible. *If staff had difficulty obtaining a UA for a resident they should have contacted the doctor and gotten an order for [REDACTED].>*She agreed the resident had shown symptoms of a UTI on 10/6/15. *She confirmed the UA was not done timely, and the antibiotics did not start until 10/10/15. Review of the provider's September 2012 Physician/Practitioner Orders policy revealed the purpose was to: *Provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. *Provide a procedure that facilitates (helps) the timely and accurate processing of physician/practitioner orders. Review of Patricia A. Potter and Anne Griffin Perry et al, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., 2013, p. 236-237, revealed: *Patients (residents) benefit most when their care represents a collaborative effort from the expertise of all health care team members. A plan of care is dynamic and changes as the patient's needs change. *Priority setting is the ordering of nursing [DIAGNOSES REDACTED].