Every finding on record at Good Samaritan Society New Underwood

Based on observation, interview, and policy review, the provider failed to follow food safety standards related to food storage practices of packaged food in the kitchen, dry food storage area, food service station area, and walk-in refrigerator.Findings include:1. Observations on 12/1/25 between 11:00 a.m. and noon and again at 4:40 p.m. revealed: *In the kitchen above a service window, there was a clear, plastic tub. The label affixed to the tub identified the contents in that tub as Food Thickener. There was no date marking on that label to support when it was opened and put in that tub. A hand scoop was inside that tub. -Next to that tub was a clear glass dispenser with a piece of masking tape on it that read thickner. There was no date marking on that dispenser. *Inside the dry food storage room, there were: -Seven boxes of unopened rice with no date markings on them. -One 16-oz opened bag of unopened Instant Mashed Potato flakes with a best by date of 2/10/25. -Twelve bags of unopened gravy mix with no date markings on them. -One undated bulk-sized, opened bag of Cherrios. -One unopened and undated 28-oz bag of cream soup base. -One opened and undated 28-oz bag of cream soup base. -One 28-oz bag of unopened Uncle Ben's cornbread stuffing mix with a best by date of 8/11/25. -One opened and undated bag of rice. -One 11-pound (lb) tub of chocolate fudge icing with an expiration date (product should be consumed on or before the date listed) of 11/12/25. -One box of six, 20-oz unopened squeezable strawberry fruit spread bottles with a best if used by date of 3/28/25, and three unopened and undated 14-oz squeezable ketchup bottles were in that same box. -Four unopened buttermilk biscuit mix boxes dated 8/10/24. *Underneath the counter of the food service station, there were three plastic drawers that each contained different types of dry cereal. Hand scoops were inside each of those drawers on top of the dry cereal. *Inside the walk-in refrigerator, there were: -Two 20-oz strawberry fruit spread squeeze bottles with best if used by dates of 3/28/25. -One 32-oz container of chopped garlic with a best if used by date of 8/30/25. -One undated, unlabeled plastic container of ham slices. -One 16-oz opened and undated bag of whipped topping. A piping tip protruded from one corner of the bag. 2. Observation on 12/3/25 at 10:15 a.m. of the above food storage areas and interview with nutrition and food service supervisor (NFSS) E revealed: *The expired food items and food items that exceeded their best if used by dates should have been discarded. *The above unlabeled food items were expected to have been date-marked for staff to have known when they were expected to have been discarded. *Opened food packages, such as the bag of rice and the bagged whipped topping, should have been stored in air-tight storage containers. *Hand scoops should not have been stored inside food containers due to the risk of cross-contamination. *Applicable bulk food items should have remained in their transport boxes. Those boxes had date-marked labels on them for staff to know if that food item was safe to use. *It was her and all the dietary staff's responsibility to ensure food was safely stored, food packages were properly labeled, and any outdated food was discarded, but there was no formal process to ensure those things occurred. 3. Review of the provider's 3/7/25 revised Food-Supply Storage-Food and Nutrition Services policy revealed:*Procedure: -5.c. Stock items are individually dated with delivery date if removed from the original container.-7. Foods that have been opened or prepared are placed in an enclosed container, dated, labeled, and properly stored.-9. Use By and Freeze By (expiration) dates are checked on a regular basis; foods/fluids that have expired or are otherwise unsafe for use are discarded.-10. Foods that do not have a Use By or Freeze By date are rotated and used within one year of delivery or according to the Best If Used By/Best If Freeze By date.

Based on interview, review of Resident Council minutes, and policy review, the provider failed to ensure that grievances regarding long call light response wait times reported at resident council meetings were addressed and documentation reflected:*The staff's efforts to resolve those grievances.*Efforts to resolve those grievances were approved as effective resolutions by the resident council.Findings include:1. Interview on 12/2/25 at 10:45 a.m. and again on 12/8/25 at 12:15 p.m. with resident 15 revealed she was an active resident council participant. The group had monthly meetings. The council's concern since May 2025 was long call light response times, especially during the late afternoon and early evening hours. That response time ranged between 30 minutes to one hour. Resident 15 was able to move within the facility independently, use her call light, and verbally advocate for herself. She felt the call light response times did not impact her as much as other residents, like her roommate. Her roommate had significant physical and verbal impairments. Sometimes, resident 15 activated her own call light to seek assistance for her roommate when her roommate's call light was unanswered by staff for extended periods of time. Resident 15 said director of nursing (DON) B and administrator A attended past resident council meetings to address the ongoing call light response time concern. Their response to the council was people don't want to work. Resident 15 stated that the council was not updated about changes that were implemented to mitigate or resolve the call light response time concern. Reporting the same call light response time concern month after month during resident council meetings without any known attempts to resolve the issue made her feel like the council's concern was not listened to or addressed by the management team. 2. Review of the provider's June 2025 through November 2025 Suggestion or Concern forms revealed:*On 6/19/25, the resident council expressed concerns lengthy call light wait times in the evening hours.Investigation: Will discuss in All Staff meeting.Resolution: Wait times were identified as occurring during the evening shift change, which coincided with the evening meal. Encourage staff to answer [the call light], reset [the] call light, and give [the resident] approx [approximate] time of return. Will audit call lights if this comes up in Aug [August] 2025.Follow-up: The resident council indicated call light wait times remained a concern, and a new Concern form was completed. The above-written response was declined by the council. *On 7/17/25, Concerns expressed [by the resident council] with long call light wait times during evening and weekend hours, indicating they can wait 30+ [30 or more] minutes at a time.Investigation: [Call light wait time] Continues to be a concern for certain residents regardless of staffing, or improvements made in schedule/evening routine.Resolution: Continue [to have] staff assess and anticipate needs for residents who require assistance and are dependent [on staff]. Answer call lights timely and have positive interactions [with residents].Follow-up: The resident council indicated call light wait times remained a concern, and a new Concern form was completed. The above-written response was declined by the council. *On 8/21/25, Concerns expressed [by the resident council] with long call light wait times during evening hours indicating they can wait for 30+ minutes at a time.Investigation: Residents [in their rooms] want to go to bed or have assistance when [other] residents are still in [the] dining room.Resolution: Continue to encourage staff to anticipate needs and assist residents who request assistance in a timely manner.Follow-up: The resident council indicated call light wait times remained a concern in the evening, and a new Concern form was completed. The above-written response was declined by the council. *On 9/18/25, Concerns expressed [by the resident council] with long call light wait times during evening hours indicating they can wait for 30+ minutes at times, also communicated during evening shift change they are being told someone will be back and no one comes back.Investigation: High traffic times in evening hours-during HS [evening] cares and ADL [activities of daily living] completion.Resolution: Staff were educated about returning to resident room if they are told you will be back. This instills a trusting relationship [between staff and residents].Follow-up: Not completed. *On 10/15/25, the resident council reported lengthy call light wait times in the evening hours.Investigation: Call light audits ongoing. Meal times become lengthy. Will continue to encourage staff to make rounds and assist all residents in rooms and prior to assisting [residents] in [the] dining room.Resolution: Call light wait times have been a continued issue during meal times-no complaints after [the] kitchen is done serving. Educate/encourage staff to assist resident [residents who are] in [their] rooms prior to assisting [residents] in dining room.Follow-up: Dietary will also be encouraged to answer call lights during meal time/room tray delivery. *On 11/20/25, the resident council Expressed concerns with lengthy call light wait times in the evening.Investigation: Call light times reflective of completion of dinner and when residents want to go to bed. Additional staff added [hired] to mitigate during assisting with meals.Resolution: Will continue to encourage collaboration with dietary staff to minimize downtime during dinner.Follow-up: Continue to monitor processes weeks and [during] QAPI [Quality Assessment and Performance Improvement] review. 3. Interview on 12/2/2025 4:13 p.m. and again on 12/8/25 at 9:00 a.m. with social services supervisor (SSS) D revealed it was her responsibility to document resident council concerns on the Suggestion/Concern form. She routed those forms to the appropriate department head for their investigation, resolution, and/or recommendations regarding that grievance. SSS D reviewed the department head's responses with the resident council at their meetings. Administrator A completed the final review and sign-off (review and approve) of those forms. He was the facility's grievance official. Regarding action plans that had been developed and implemented in response to the Council's ongoing concern regarding call light response times, SSS D stated, I don't know that anything other than education and trying to get more staff had occurred. 4. Interview on 12/8/25 at 10:15 a.m. with administrator A revealed that he was the grievance official. It was his responsibility to ensure prompt resolution to grievances occurred. He stated the long call light wait response times occurred around the evening shift change and at the time when residents were being prepared for, taken to, and assisted in the dining room. Some residents chose to eat their evening meal in their rooms. That made it difficult for the staff in the dining room to answer their call lights activated during the meal service. After the meal service, residents wanted assistance with their evening needs so they could go to bed. The 6:00 p.m. to 6:00 a.m. shift usually had three caregivers who were either licensed nurses or certified nurse aides on duty. The facility added a 6:00 p.m. to 10:30 p.m. staff shift to support the evening staff; however, that position was unfilled. Staff were educated regarding the facility's expectation for answering resident call lights. Dietary staff were asked to assist residents with non-care requests when they delivered evening meals to those residents who chose to eat in their rooms. Administrator A confirmed there was no data to support how or if these interventions had been effective in lessening the call light response times in the evening. Administrator A stated that two evenings per week, he was working from noon to 8:00 p.m. to support the evening shift staff. Changing the times of meals, medication administration, treatments, and/or residents' evening cares was not discussed or attempted as a potential resolution to the residents' call light response complaints. Administrator A knew there were a few residents who routinely activated their call lights even if staff had just answered their call lights. The facility attempted to regularly check in with these residents before they activated their call light. There was no data to support whether this intervention was effective. Administrator A agreed that the June 2025 through November 2025 Suggestion/Concern forms did not include detailed resolution efforts, or that efforts were effective to resolve the resident council's evening call light response time grievance. 5. Review of the provider's 12/2/24 Grievances, Suggestions or Concerns policy revealed: *Definition:-The Grievance Official was responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility -Prompt efforts to resolve-facility acknowledgment of a grievance and actively working toward a resolution of the grievance.*Procedure:-7. An investigation must be completed for all grievances. -8. The grievance official was expected to issue a written grievance decision to the individuals filing the concern that included .the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.-10. If the individual is not satisfied with the response and/or resolution to the grievance or concern, the grievance official will notify the administrator.

Based on observation, interview, record review, and policy review, the provider failed to ensure that nursing professional standards were followed by: *One of one observed registered nurse (RN) (F) who did not following the physician's order for one of one sampled resident (3) during a skin wound treatment.*One of one RN (H) who did not document if three doses of an antibiotic were administered to one of one sampled resident (3) as ordered.Findings include:1. Interview on 12/1/25 at 1:30 p.m. with resident 3 revealed she was hospitalized in September 2025 because her suprapubic catheter (flexible tubing surgically placed through the abdomen into the bladder to drain urine) was not working properly. She required intravenous (IV) antibiotics after she was discharged from the hospital and returned to the facility. 2. Review of resident 3's electronic medical record (EMR) revealed that on 9/25/25, she was transferred to the emergency department (ED) for evaluation of a non-functioning catheter. She was admitted to the hospital and treated for septic shock (a severe infection that triggers a life-threatening emergency). Resident 3 was discharged from the hospital and returned to the facility on [DATE]. Her hospital discharge orders included two IV antibiotics. One of those antibiotics, Daptomycin, was scheduled for administration every 48 hours for ten days. The second antibiotic, Zosyn, was scheduled for administration two times a day (at 6:00 a.m. and 6:00 p.m.) for 11 days. That was a total of 22 Zosyn administrations. Resident 3's October 2025 medication administration record (MAR) revealed that the Daptomycin was documented as having been administered as ordered. There was no documentation to support that the resident was administered her morning doses of Zosyn on 10/5/25, 10/9/25, or 10/11/25. 3. Interview on 12/4/25 at 12:45 p.m. with director of nursing (DON) B revealed the facility received 22 doses of Zosyn from the pharmacy, and none of those doses had been returned to the pharmacy. DON B determined registered nurse (RN) M was responsible for administering and documenting the 10/5/25, 10/9/25, and 10/11/25 morning Zosyn doses. The facility no longer employed RN M. DON B stated she had interviewed resident 3 regarding the above post-hospital IV antibiotic administrations. She stated resident 3 had known what her post-hospital IV antibiotic medications and administration schedule were. Resident 3 confirmed that she had not missed any of those IV antibiotic administrations. DON B believed resident 3's morning Zosyn doses were administered on 10/5/25, 10/9/25, and 10/11/25, but RN M failed to document those administrations. Licensed nurses were expected to document medication administrations on the resident's MAR after each medication administration was completed. That had not occurred. Nursing staff who had documented their administrations of resident 3's 6:00 p.m. Zosyn doses on 10/5/25, 10/9/25, and 10/11/25 should have noticed and reported to DON B the missing morning IV medication administration documentation for investigation. 4. Observation on 12/1/25 at 5:15 p.m. of RN F completing resident 3's stoma (a surgically created opening in the abdomen that allows a feeding tube to deliver liquid nutrition) care revealed she removed the medical tape that held two, two-inch by two-inch (2 X 2) sponge dressings from around the resident's stoma site and then removed the two sponge dressings. She discarded the tape and the dressings. She used a wound spray cleanser to moisten the stoma area and wiped that area with gauze pads. RN F then placed two clean 2 X 2 sponge dressings around the stoma site without securing the 2 X 2s to the resident's abdomen. Resident 3 reminded RN F to secure the sponge dressings to her skin before she completed her skin treatment, but RN F did not secure them with tape. 5. Review of resident 3's EMR revealed a 6/25/25 physician's order for her stoma care that read: Change 2 X 2 split sponge and cleanse area, apply zinc [an over-the-counter skin cream protectant that forms a protective barrier on the skin] to 2 X 2 and place over stoma, tape in place . 6. Interview on 12/3/25 at 12:45 p.m. with RN F regarding the above observations revealed she did not follow the physician's order for resident 3's skin treatment. She did not apply zinc to the 2 X 2 sponge dressings, and she did not secure those dressings to the resident's abdomen with tape to ensure the dressings remained in place. 7. Interview on 12/4/25 at 12:45 p.m. with DON B regarding the above observation revealed RN F was expected to have read the physician's orders for resident 3's skin treatment before she completed that treatment and followed that physician's order as it was written. Review of the providers' revised 4/6/25 Physician/Practitioner Orders policy revealed: *Purpose: -To provide individualized care to each resident by obtaining appropriate, accurate, and timely physician/practitioner orders. -To provide a procedure that facilitates the timely and accurate processing of physician/practitioner orders. *Policy: -A physician, physician's assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care, consistent with the resident's present physical and mental status and needs. *Procedure: -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 departments each have responsibilities for processing physician/practitioner orders in a timely and accurate manner. Teamwork and communication between the two departments is essential. *Physician/Practitioner Orders Content: -1. Clarification orders are needed when reviewing any type of physician/practitioner orders that are incomplete or raise questions. -Orders may need to be clarified for the following reasons: --missing diagnosis/medical reason. -If any question arises, nursing services are responsible for obtaining clarification. -3. Medication orders must include: --Diagnosis or medical reason/indication for use. Review of the providers' Nursing Documentation Guidelines,Timelines policy revealed: *Purpose: -To ensure appropriate documentation is completed in a timely manner. Review of the revised 5/12/25 RN Long Term Care job description revealed: *An essential function of that job included Documents current patient medication, medication administered, and reactions/results. *A competency of that job included Knowledge of how to read and interpret patient [resident] charts regarding medication sheets, diets, history and physicals, tests; ability to apply this knowledge appropriately to patient care. *Implements intervention identified and carries out safely, reliably, and in a timely manner. *Documents evaluation results. *Uses resources and collaborates with others to implement plan. *Implements physician and nursing orders. *Awareness of isolation precautions.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed standard infection control practices for:*Not having placed two of two sampled residents (4 and 20) on enhanced barrier precautions (EBP) (glove and gown use when providing contact care).*Posting clear signage indicating the type of precaution for three of three sampled residents (5, 12, and 19). *Appropriate hand hygiene (HH) (handwashing with soap and water or use of a hand sanitizer) and glove use by three of three staff members (registered nurse RN (F), certified nursing assistant CNA (G), and clinical care leader CCL (C) during treatment, care, and transition in care for three of four sampled residents (1,3, and 20). *Appropriate personal protective equipment (PPE) (gown and glove) application and removal by one of one CCL (C) and removal by one of one CNA (G). *Not having placed barriers by two of two staff RN (F) and CCL (C) during medication administration and treatments of two of two sampled residents (1 and 20).*The use and storage of skin treatment supplies by one of one RN (F) during one of one sampled resident's (3) skin treatment. Findings include: 1. Observation and interview on 12/1/25 at 2:11 p.m. with resident 20 in her room revealed: *The resident was in her room, sitting in her wheelchair with her feet resting on the wheelchair foot pedals. *The resident stated she was unable to walk due to a broken left leg and that she had open sores on her heels. *There was no precaution sign posted outside or inside the door of her room related to the open sores on her heels. *There was no personal protective equipment (PPE), such as gloves and gowns, available for use inside resident 20's room or near her door. *She was unsure whether the staff wore gowns and gloves when providing her care or changing her dressing. *CNA G entered the room at approximately 2:20 p.m. to assist resident 20 to the bathroom and did not put on gloves and a gown. Review of resident 20's electronic medical record (EMR) and the pocket care plan/walking care sheet (a document that identifies residents' care needs and interventions) revealed: *She was admitted on [DATE]. *Her 11/4/25 BIMS assessment score was 5, which indicated her cognition was severely impaired. *Her diagnoses included a fracture of the shaft of the left femur (the long tubular part of the thigh bone). *She had a pressure sore (injury to skin and underlying tissue from prolonged pressure) on her left heel that resolved on 9/17/25. *She was receiving wound care treatment twice weekly and as needed for an open traumatic wound on her left heel that occurred on 10/22/25. *The pocket care plan/walking care sheet did not indicate she was on EBP. 2. Review of resident 4's EMR and the pocket care plan/walking care sheet revealed: *She was admitted on [DATE]. *Resident 4 was positive for Methicillin-resistant Staphylococcus aureus (MRSA) in her nares on 7/7/24. *Resident 4 was not being treated for an active infection. *The pocket care plan/walking care sheet did not indicate she was on EBP. 3. Observation and interview on 12/1/25 at 2:34 p.m. with activities supervisor K outside of resident 19's room revealed: *There was a white three-drawer bin in the hall next to resident 19's door, stocked with PPE supplies (gowns, gloves, and red trash bags). *There was a contact precaution sign (measures used to prevent spreading germs requiring gloves and gowns to be worn) posted on the door, and an EBP magnet on the door frame. *Activities supervisor K did not know which resident in that room was on precautions when asked. Review of resident 19's EMR and pocket care plan/walking care sheet revealed: *She was admitted on [DATE]. *She was positive for MRSA in her urine on 11/1/20. *Resident 19 was not being treated for an active infection. *The pocket care plan/walking care sheet did not indicate she was on EBP. 4. Interview on 12/1/25 at 3:13 p.m. with registered nurse (RN) F revealed: *RN F did not know which resident in resident 19's room was on precautions. *RN F stated that the precaution information was not given to her in the morning shift report and that it was not included on the pocket care plan/walking care sheet for the residents who resided in that room. *RN F agreed that she should have been provided with that information to ensure proper infection control processes were followed. 5 Observation and interview on 12/1/25 at 2:42 p.m. in the north hall with business officer coordinator (BOC) J outside resident 12's room revealed: *There was a white three-drawer bin stocked with gowns, gloves, and trash bags, and a large white trash can with a lid in the hall next to resident 12's door. *There was no precaution sign posted outside or inside the door of his room. *BOC J was asked if residents in the room were on precautions. *She stated she wanted to clarify and left the hallway to verify the information. *She returned and stated that social services supervisor (SSS) D verified the information and confirmed that resident 12 was on EBP. 6. Interview on 12/1/25 at 4:44 p.m. with resident 12 in his room revealed: *He stated that staff sometimes wore a gown and gloves when helping him with his care. Review of resident 12's EMR and pocket care plan/walking care sheet revealed: *He was admitted on [DATE]. *He was positive for MRSA in his nares in March 2023. *Resident 12 was not being treated for an active infection. *The pocket care plan/walking care sheet did not indicate he was on EBP. 7. Observation and interview on 12/2/25 at 8:46 a.m. with resident 5 in his room revealed: *There was a white three-drawer bin stocked with gowns, gloves, and red trash bags, and a large white trash can with a lid in the hall next to resident 5's door. *There was no precaution sign posted outside or inside the door of his room. *He stated he had an open sore on the top of his right foot. *He stated that staff had been applying a dressing and that he was going to the VA to see a doctor. *He stated, I think they [the staff] wear a gown, and I know they wear gloves when they do my dressings. Review of resident 5's EMR and pocket care plan/walking care sheet revealed: *He was admitted on [DATE]. *He was receiving wound care treatment every other day and as needed for an open wound on his right lower leg that started on 9/12/25. *The pocket care plan/walking care sheet did not indicate he was on EBP. 8. Observation on 12/3/2025 at 9:32 a.m. of RN F preparing resident 1's feeding tube (a tube placed into the stomach or small intestine that delivers nutrition) treatment revealed: *She entered the supply room, gathered an enteral feeding gravity set bag, a graduated measurements container, a 60 milliliter (ml) syringe, tubing, and an end cap, and returned to the medication cart in the north hall. *Without performing hand hygiene (handwashing), RN F removed the packaging from the gravity set bag, tubing, and end cap. *Without cleaning the top of the medication cart or placing a clean barrier, she placed them on top of the cart and then dated the items. *She performed hand hygiene and prepared resident 1's medications. *An EBP sign was posted on resident 1's door. *A 3-drawer white bin containing PPE supplies was outside her door in the hall. *A trash can with a lid was next to the 3-drawer bin. *She placed resident 1's feeding tube supplies, medication cup, eye drop container, nasal spray bottle, and a mouthwash rinse bottle on top of the PPE supply cart outside the resident's room without first laying a clean barrier down. *Without first performing hand hygiene, RN F put on a gown and gloves and entered the resident's room. *Without placing a clean barrier, she placed resident 1's medications on the counter next to the sink. *RN F administered completed the flush, administered her medications mixed in water via the feeding tube, and administered another flush. *She then began resident 1's scheduled 250ml of water by gravity administration. *Without removing her gloves and performing hand hygiene, she administered resident 1's eye drops, nasal spray, and mouth rinse with those same gloved hands. *RN F clamped the feeding tube and bag set, grabbed the nasal spray bottle and mouthwash rinse bottle with those same gloved hands, and placed those items on top of the PPE supply cart outside the resident's room without a clean barrier under them. *RN F exited the resident's room, removed her gown and gloves in the hall, disposed of them in the trash can that was in the hall next to the resident's 3-drawer bin, and performed hand hygiene. *She returned the nasal spray and mouthwash rinse bottles to the medication cart without sanitizing them and placed them in a drawer that stored other resident medications. 9. Interview on 12/4/2025 at 1:59 p.m. with RN F regarding the above observations with resident 1's feeding tube treatment and medication administration revealed: *She should have performed HH before removing the packaging of the feeding tube supplies. *She should have cleaned the top of the medication cart or placed a clean barrier before placing the supplies on top of the cart. *She should have placed a clean barrier down before she placed the medications and feeding tube supplies on the 3-drawer PPE bin. *She should have performed hand hygiene before putting on her gown and gloves. *She should have placed a clean barrier down before she placed the medications and feeding tube supplies on the counter next to the sink. *She should have removed her gloves and performed hand hygiene before she administered resident 1's eye drops, nasal spray, and mouthwash rinse. *She should have taken off her gown and gloves in the resident's room and put them in the trash can inside resident 1's room. *She should have cleaned resident 1's medication bottles before returning them to the medication cart to prevent cross-contamination. 10. Observation and interview on 12/3/2025 at 2:11 p.m. with clinical care leader (CCL) C during resident 20's wound care revealed: *Without cleaning the top of the treatment cart or placing a clean barrier, she removed wound care supplies (bordered foam dressing, wound cleanser spray, scissors, two packages of sterile gauze, one package of collagen powder, and three to four alcohol wipes) and placed them on top of the treatment cart. *She opened the dressing packages and, without cleaning the scissors, used them to cut the adhesive edges of the bordered foam dressing. She then dated and initialed the dressing and returned it to the package. *Without putting on a gown and gloves, she entered resident 20's room and placed the wound care supplies on a blanket at the foot of resident 20's bed without first placing a barrier down. *She washed her hands with soap and water and put on a pair of gloves. *She got paper towels from the bathroom and put them at the foot of resident 20's bed. *She gathered the wound wash and scissors and placed them on the paper towel barrier, while the other supplies remained on the blanket. *She finished the dressing treatment, took off her gloves, put them in the trash, tied the trash bag shut, and held it in her left hand. *Without performing hand hygiene, she picked up the wound wash, scissors, and a package of gauze with her right hand, opened resident 20's top drawer of the stand next to her bed with her right hand (while holding the items), and placed the gauze package inside. *She then grabbed the wound wash and scissors (which she was holding in her right hand) with her left hand, which was holding the trash bag, and left the room. *Without placing a barrier on the treatment cart, she placed the wound supplies on top of the cart, opened the door to the utility room, and placed the trash into a trash can. *Without performing hand hygiene, she put on a pair of gloves and cleaned the wound wash bottle and scissors with bleach wipes. *CCL C was unsure why a barrier was needed for all the wound care supplies in resident 20's room. *She agreed that she placed the wound cleanser and scissors on the blanket on the resident's bed before putting them on the paper towel barrier. *She agreed that she missed hand hygiene opportunities during resident 20's observed wound care treatment and that she did not follow EBP by putting on a gown and gloves before she entered her room. 11. Interview on 12/3/2025 at 2:53 p.m. with director of nursing (DON) B revealed: *She expected that hand hygiene would be performed before putting on gloves and after removing gloves. *She expected that clean barriers should have been used during the treatments above, before supplies and medications were placed on the PPE bin, the counter by the sink, the medication and treatment carts, and on the resident's blanket. *She expected that hand hygiene should have been performed before and after completing resident treatments, between transitions in resident care, and after discarding trash. 12. Interview on 12/4/2025 at 2:05 p.m. with certified medication aide (CMA) H regarding EBP revealed: *PPE should be worn by the staff when direct care was provided to residents on EBP. *The information for residents on EBP or other types of transmission-based precautions was shared during the morning huddle meetings. *Sometimes the information was recorded in the binder in the staff break room, but at times it could be unclear which residents were on precautions. 13. Interview on12/4/2025 at 2:10 p.m. with CNA G regarding EBP precautions revealed: *Staff should have been informed in the morning report who was on precautions. *The pocket care plan/walking care sheets should indicate who was on precautions. *She was trained to throw her gowns and gloves in the trash can in the hall. *She was unsure why other residents on EBP did not have trash cans outside their rooms in the hall. 14 Interview on 12/4/2025 at 4:06 p.m. with DON B and CCL C regarding EBP revealed: *They both were unsure why some residents' rooms who were on EBP had trash cans outside in the hall, while others did not. 15. Observation on 12/1/25 at 2:20 p.m. of RN F outside of resident 1's room revealed there was contact precaution (a type of transmission-based precaution that requires gown and glove use when providing contact care) signage on that resident's door. Without first performing hand hygiene (HH) (handwashing with soap and water or using a hand sanitizer), RN F put on a gown and a pair of gloves, then entered the resident's room to provide feeding tube (a tube placed into the stomach or small intestine that delivers nutrition) care. 16. Observation on 12/1/25 at 3:30 p.m. of CNA G revealed that without first performing hand hygiene, CNA G put on a gown and a pair of gloves, entered resident 1's room with a mechanical lift, then closed the door. When she exited the room with the mechanical lift, she was carrying a closed garbage sack. CNA G removed her gown and gloves and placed them in a trash receptacle outside of the resident's room. She discarded the garbage sack in a soiled utility room, returned to the hallway by resident 1's room, and performed hand hygiene. She removed a pair of gloves from inside her smock pocket, put them on, and cleaned the mechanical lift with a disinfectant wipe. 17. Observation on 12/1/25 at 5:15 p.m. of RN F outside of resident 3's room revealed there was posted contact precaution signage outside of that room. RN F was preparing and completing resident 3's stoma care (a surgically created opening in the abdomen that allows a feeding tube to deliver liquid nutrition) and medication administration. She gathered two 2-inch by 2 inch (2 X 2) packaged sponge dressings, a wound cleanser spray bottle, several squares of loose gauze, and a medication cup with a powdered protein supplement in it. She placed those supplies directly on top of the PPE supply cart outside of the resident's room without first laying down a clean barrier between the supplies and the top of the cart. Without first performing hand hygiene, RN F put on a gown and a pair of gloves, then entered the resident's room with the supplies. The resident was lying in her bed, covered with a blanket. RN H set the treatment supplies directly on top of the resident's blanket without first laying down a clean barrier between the blanket and the supplies. RN F removed the medical tape that held the 2 X 2 dressings in place around the resident's stoma site, then removed the dressings. The dressings had spots of dark dried blood on them. RN F discarded the tape and the soiled 2 X 2 dressings. She used the wound spray cleanser to moisten the stoma area, and with gloved hands, she used the gauze pads to clean that stoma area. She then placed the two new 2 X 2 sponge dressings around the stoma site. With those same gloved hands, RN F mixed the contents of the medication cup with water for administration through the resident's feeding tube. RN F removed and discarded her gloves and gown inside resident 3's room and performed hand hygiene. She returned the wound care cleanser spray bottle to the treatment cart without first sanitizing it. 18. Interview on 12/3/25 at 12:50 p.m. of RN F regarding the above care observations with residents 1 and 3 revealed that she should have performed hand hygiene before putting on gloves. She should have changed her gloves, performed hand hygiene, and put on clean gloves between transitions in care, such as resident 3's skin treatment and medication administration. She also should have placed a clean barrier under resident 3's treatment supplies to avoid possible cross-contamination. 19. Interview on 12/4/25 at 4:00 p.m. with DON B and CCL C regarding infection control revealed: *Hand hygiene was expected to occur before staff put on gloves. Glove removal, hand hygiene, and then putting on a pair of clean gloves was expected to occur between transitions in resident care. Gloves were expected to be removed from glove dispensers and not from the staff's clothing pocket. *PPE was expected to be removed and discarded inside the room of a resident who required transmission-based precautions. *A clean barrier was expected to be used underneath clean supplies that were used during resident care, such as skin treatments. Review of the provider's revised 11/13/25 Hand Hygiene policy revealed: *Healthcare workers will use alcohol-based hand sanitizer or soap and water to clean their hands: -Before donning sterile gloves. -After contact with patient's non-intact skin, wound dressing, secretions, excretions, mucous membranes, as long as hands are not visibly soiled. -When moving from contaminated body site to a clean body site during patient [resident] care. Review of the provider's revised 7/7/25 Standard, Enhanced Barrier, and Transmission-Based Precautions policy revealed: *Procedure: -Post clear signage indicating the type of precautions and required PPE (i.e., gown and gloves). -Position a trash and laundry receptacle inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room, or before providing care for another resident in the same room, or bag and remove trash and soiled laundry immediately. -Incorporate process surveillance to determine adherence and need for additional training and education. -Provide education to residents and visitors on the importance of hand hygiene, especially when entering and exiting the resident's room and the facility.

Based on record review, interview, and policy review, the provider failed to:*Identify and implement interventions to help prevent elopement for one of one sampled resident (5) who eloped (left the facility without staff knowledge) when he pressed the exit bar on the door long enough to release it. Findings include:1. Review of a nurse progress note dated 11/24/25 at 3:30 p.m. titled 'Safety Event-Incident Report' regarding resident 5 revealed:*Resident 5 left the facility through the southwest door. *He propelled his wheelchair out onto the sidewalk and into the gazebo.*An unidentified dietary staff member arriving at work saw resident 5 outside and helped him back into the building through the southwest door.*He was evaluated after the event, and his condition remained unchanged.*Resident 5 complained that it was cold. Resident 5 refused education when the nurse tried to discuss the risks of leaving the facility unattended.*A 72-hour safety check and charting were started for every shift.*The physician was notified via fax.*A telephone call was made to his spouse regarding the incident. 2. Review of resident 5's electronic medical record (EMR) revealed:*He was admitted on [DATE]. *His 9/11/25 Brief Interview of Mental Status (BIMS) assessment score was 8, which indicated his cognition was moderately impaired.*His diagnoses included vascular dementia (a type of cognitive decline caused by reduced blood flow to the brain from strokes or clogged vessels) with agitation and anxiety disorder.*He had a history of behaviors, including unprovoked verbal expressions of anger, poor listening skills, and resisting care.*He moved around the facility as he desired in his wheelchair independently.*He enjoyed sitting in the hallway or at the nurse's station and watching the staff.*His 6/12/25 and 9/9/25 Elopement Risk Assessments revealed he had no wandering behaviors and was at no risk for elopement.*He was taking quetiapine fumarate (an antipsychotic medication used to treat mental health conditions) 75 milligrams (mg) by mouth three times a day, related to his vascular dementia with agitation.*Resident 5's 6/18/25 and 9/11/25 Minimum Data Set (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) (MDS) had no wandering behavior coded on the assessments. Resident 5's progress notes indicated:On 6/13/25 at 22:35 (10:35 p.m.), He [resident 5] did state that he wanted to call his wife to pick him up. He lived 3 miles from here and is ready to leave.On 6/17/2025 at 14:02 (2:02 p.m.), After finishing breakfast resident sat at DR [dining room] table making several ph [phone] calls. Nurse heard him say I've got to get the hell outta here and proceeded to call his wife. Wife could be heard telling [resident 5] that there was nothing she could do about it. [Resident 5] was not pleased with response and hung up his phone.On 6/27/2025 at 22:30 (10:30 p.m.), Resident is refusing HS care assistance and has not been cooperative or pleasant with staff. He wants to leave and would like his wife to come pick him up. One on one time and attention was provided with this resident. Will continue to monitor and provide comfort and support.On 7/2/2025 at 15:58 (3:58 p.m.), Resident has been loud and demanding today. Demanded to see [physician] and then yelled when he was informed that he wasn't on the physician's schedule until next Friday. [Resident 5] stated he won't be here for another week. On 7/10/2025 at 13:05 (1:05 p.m.), [Resident 5] was very angry this morning, called his wife and told her that nurse said he could leave the facility for three hours and she should come pick him up. Wife, called and said when she told [resident 5] no, he cursed at her and hung up. Advised [wife] this nursed did not tell [resident 5] that he could leave facility and we do not have orders from MD (doctor) for him to leave facility. Resident told dining room staff that he is going to get his shoes on and leave facility.On 8/14/2025 at 17:53 (5:53 p.m.), Resident upset with physician assistant-certificed (PA-C) this shift as she wouldn't allow him to go home on day pass to visit wife. PA-C explained for his safety it would be best for his wife to visit him here. Resident threatened to walk out of facility and walk home. Staff advised him not to. Resident used walker this afternoon instead of w/c.[wheelchair].On 9/4/2025 at 20:10 (8:10 p.m.), Resident had conversation with PA-C today and argued with her about going home on a pass. PA-C explained that it is not safe for him to go home at this time. Resident argued awhile longer and ended up throwing his cane at/toward PA-C. Administrator came and visited with resident along with PA-C.On 9/5/2025 at 20:21 (8:21 p.m.), Resident called his wife after his MD (doctor) visit and told her that he said he could go home after his Xray on 9.10.25 and that the doctor said the only thing keeping him from doing so would be if she didn't want him to come home. Resident has been demanding and impatient with staff all shift, repeating his on demand requests over and over again despite interaction and communication with him on waiting his turn.On 9/9/2025 at 20:38 (8:38 p.m.), Resident states he wants to leave this place. Resident has been verbally aggressive and did not accept redirection well.On 9/11/2025 at 09:14 (9:14 a.m.), Continue to monitor and discuss behaviors in IDT. Resident becomes easily agitated d/t wanting to discharge to home.On 11/15/2025 at 15:42 (3:42 p.m.), After lunch he went to the door at the end of the hallway and pushed on the exit bar, setting off the alarm. When CNA asked resident to move away from the door, resident yelled I'm right where I want to be Goddamn it. CNA was then able to move resident away from exit door and to the dining room for lunch.On 11/24/2025 at 13:26 (1:26 p.m.), Resident continues to ambulate throughout facility as desires. Does like to sit in the hallway and watch staff as well as in the dining room. Continue to monitor for episodes of increased wandering and pacing. 3. Review of resident 5's 11/28/25 care plan revealed:*There were no interventions in place for staff to follow before resident 5's elopement on 11/24/25 to ensure his safety from elopements.*His care plan was updated on 11/24/25 after resident 5 eloped, which included:-The placement of a WanderGuard (a wearable door alarm device) below the seat of his wheelchair.-72-hour monitoring to maintain his safety. -Offering to take him for a walk outside when the weather was appropriate. -Monitoring for signs and symptoms of wandering and exit seeking.-Monitoring closely when resident was near exit doors. 4. Interview and review of resident 5's EMR on 12/8/25 at 1:50 p.m. with director of nursing (DON) B revealed:*Staff would report incidents such as falls with injury, abuse allegations, and elopements to her or administrator A.*DON B or administrator A would begin an investigation and send an initial report to the Department of Health. *All incidents were discussed and reviewed with the interdisciplinary team (IDT) in morning stand-up/huddle meetings and reported to the regional office during their morning calls.*Nursing completed elopement assessments upon resident admissions to the facility and then quarterly.*She stated that resident 5 had never wandered and was not at risk of elopement before he left the faciity on [DATE]. *She reported that resident 5 told a staff member he was leaving the facility, but she did not know which staff member he told.*She confirmed that there was no documentation in resident 5's EMR indicating he told a staff member he was leaving the facility.*She stated that the IDT discussed resident 5's 11/24/25 incident and concluded it was not a system failure, so it was not reported to the South Dakota Department of Health (SD DOH) as an elopement.-The facility's door alarm was triggered, serving as the basis for the decision not to report resident 5's elopement.*She confirmed that resident 5 left the facility without staff knowledge by holding down the exit bar on the southwest door long enough to release it.*She confirmed that resident 5 had propelled himself in his wheelchair out the southwest door, was found in the gazebo, and had not left the facility property.*She confirmed that an unidentified dietary aide, who had parked in the lot and was headed into work, brought resident 5 back through the southwest door of the facility within a few minutes of him leaving.*She was unaware of any previous statements or attempts from resident 5 that indicated his desire to leave the facility. *She agreed that resident 5 had prior statements, threats, and a near elopement attempt documented in his EMR, and that interventions should have been in place before his 11/24/25 incident due to his risk of wandering and actual elopement.*She confirmed that the facility did not have an investigation report available.*She agreed that resident 5's incident of leaving the facility on 11/24/25 at 3:30 p.m. was an elopement and should have been reported to the SD DOH as required. 5. Interview on 12/08/2025 at 2:05 p.m. with administrator A regarding facility-reported incidents and resident 5 revealed:*Administrator A stated that he reviewed the facility camera footage regarding resident 5 exiting the southwest door of the facility on 11/24/25 at 3:30 p.m. *An unidentified certified nursing assistant (CNA) was walking toward the southwest door to respond to the door alarm when an unidentified dietary aide, who was outside reporting to work, assisted resident 5 back into the building through the southwest door. -Resident 5 was outside for a couple of minutes and did not leave the facility property.*He stated, our system worked, and the IDT determined that resident 5 exiting the facility on 11/24/25 was not an elopement. *When asked to explain the facility's system, he stated that as long as the door alarm activated, and staff responded, there was no system failure. This was why the facility did not complete an investigation, an initial report, or report the incident to the SD DOH. He stated whether it was luck or not, it worked. *He confirmed that resident 5 exited the building through the southwest door in his wheelchair after he held the exit bar on the door long enough for it to release.*He confirmed that resident 5 left the facility without the staff's knowledge or supervision. Review of the provider's revised 4/7/2025 Elopements policy revealed:*Purpose:- To assess and identify residents/clients at risk for elopement.- To clearly define the mechanisms and procedures for monitoring residents/clients at risk for elopement.- To provide a system of documentation for the prevention of, and in the event of, elopement.- To minimize risk for elopement through individualized interventions.*Definition:- Elopement-When a resident/client who needs supervision leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.*Policy:- The SNF [skilled nursing facility] location and each Adult Day Program will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring residents/clients at risk for elopement. These include identifying, evaluating and analyzing environmental hazards and risks; and implementing, monitoring and modifying interventions as needed.*Procedure:- Elopement Search:-- 1. In the event of a suspected missing resident/client:--- . f. If the resident/client is found, the lead staff member will notify employees on duty. The resident will be evaluated for injuries and the physician contacted as appropriate.--- .j. Notify other agencies as required by state and/or federal regulation. Review of the provider's revised 8/29/25 Alarms-Bed, Chair, and Door policy revealed:*Policy:- The center will ensure that a system is in place for all bed, chair and door alarms and these alarms are in proper working order.*Procedure:- 1. Alarms are to be checked for proper operation and/or battery charge as follows:-- Wandering alert door alarms- Environmental Services are to check weekly.- 2. Nursing staff will be responsible for visually checking placement of alarms daily.- 3. All staff will be responsible for physically checking on the resident when an alarm goes off.

Based on interview, record review, and policy review, the provider failed to ensure an effective, comprehensive quality assurance and performance improvement (QAPI) program was implemented to track and measure performance; systematically analyze underlying causes of a systemic quality deficiency; develop and implement corrective actions or performance improvement activities; and evaluate the effectiveness of the corrective actions, and to revise those actions as needed.Findings include:1. Interview on 12/2/25 at 10:45 a.m. and on 12/8/25 at 12:15 p.m. with resident 15 revealed she was an active resident council participant. Social Services Supervisor (SSS) D facilitated those monthly council meetings. Since May 2025, the council had been concerned about long call light response times, especially during the late afternoon and early evening hours. That response time ranged between 30 minutes to one hour. 2. Review of the provider's June 2025 through November 2025 resident council minutes confirmed that during each of those monthly meetings, the council had identified a concern regarding long call light response times. 3. Interview on 12/2/2025 4:13 p.m. and again on 12/8/25 at 9:00 a.m. with SSS D revealed it was her responsibility to document resident council concerns on the Suggestion/Concern (Grievance) form. She had completed Suggestion/Concern forms regarding call light response times each month since the June 2025 resident council meeting. Those forms are routed to the appropriate department head for their investigation, resolution, and/or recommendations regarding the grievance. SSS D attended the facility's QAPI committee meetings. The resident council's ongoing concern with call light response times was discussed during those meetings. Regarding what action plans had been implemented in response to the council's concern, SSS D stated, I don't know that anything other than education and getting more staff had occurred. 4. Review of the provider's June 2025 through November 2025 QAPI minutes revealed that each month, the following agenda item was listed: Resident/Family suggestion/concern trends. Beside that line item were the following columns: Discussion Points/Notes, Actions/Outcomes/Follow-up Needed, Responsible Person, and Follow-Up/Report Out Date. *The 7/16/25 QAPI minutes indicated the Resident Council's concern was Trash isn't being taken out timely. Leaving trash for other shifts to remove. There was no mention of the Resident Council's concern regarding excess call light wait times. *The 8/28/25 QAPI minutes reflected the Resident Council's concern regarding call light timeliness.- Actions/outcomes/Follow-up needed: Staff education/All Staff [meeting].-During August 2025, several QAPI Ad Hoc meetings occurred to address the evening snack pass, lab orders, anti-microbial surveillance, and psychiatric services. There was no Ad Hoc meeting related to excess call light wait times. *There were no September 2025 QAPI meeting notes. *The 10/2/25 QAPI minutes indicated Consistent reports of untimely call light response time. QAPI completed d/t [due to] frequency of report.-There was no mention of any data that had been collected or analyzed to support whether the staff education that was referred to in the 8/28/25 QAPI minutes had reduced call light wait times. -Actions/Outcome included Angel Rounds. There was no explanation of what that was, its purpose, or who the target population was. The interdisciplinary members were identified as being the responsible persons for that action. It was to occur daily. *The 10/23/25 QAPI minutes reflected the same information as the 10/2/25 minutes concerning call light response time. There was no follow-up regarding the status of the Angel Rounds that was discussed on 10/2/25. *The 11/25/25 QAPI minutes made no mention of call light response times. There was no indication whether the Angel Rounds were implemented, what the data from that program revealed, if any recommendations related to that program were made, or if any new action plans had been developed regarding call light response times. 5. Interview on 12/8/25 at 12:45 p.m. with director of nursing (DON) B revealed she was responsible for overseeing the facility's QAPI program. She was new to that position and had received little education or training regarding the expectations of that position. The facility's corporate Quality Coordinator had reviewed the facility's QAPI program and scrubbed it, indicating the process was ineffective in its current state and required improvement. *With regards to call light wait times, data collection and analysis, action plan initiation and revision, and the quality improvement process related to the Council's call light wait time concern, DON B stated: -The facility opened a 6:00 p.m. to 10:30 p.m. shift to support the evening shift, but they were unable to fill that position due to a lack of applicants. That was not reflected in the QAPI minutes. -All caregivers had been educated that if a call was answered and the caregiver had to leave and then return to the room to help the resident, the caregiver was expected to let the resident know their approximate return time. There had been no documented follow-up with residents after that education had occurred to know if that expectation was being followed or if it had an effect on the call light wait times. -Every Friday, she was completing call light audits. Her data indicated there were specific residents who regularly had call light response concerns. The purpose of the Angel Rounds was to have management staff proactively check in with those residents to anticipate and meet some of their needs before call light activation was needed. She agreed that the QAPI minutes failed to define Angel Rounds, made no mention of her audits, the analysis of her audit data, or any follow-up action related to that data. -Dietary staff who passed the evening in-room resident meal trays had been educated to offer non-direct care assistance to those residents before leaving the residents' room. QAPI minutes failed to include any information about the implementation of this action plan, any data, or analysis of data that was gathered after the action plan was initiated to determine if it impacted call light response times. Review of the provider's revised 5/20/25 QAPI policy revealed:*Program Design and Scope: -1.a. The QAPI program is ongoing, comprehensive, and data-driven, and addresses the complexity and uniqueness of the care and services provided. -b. Capable of showing measurable improvement and focuses on safety, choice, outcomes, quality of care and quality of life as applicable to each location, -c. The QAPI program will measure, analyze, and track quality indicators, including adverse events, and other aspects of performance that enable the location to assess processes of care, services and operations. Refer to F565, findings 2 and 4.

Based on observation, interview, and policy review, the provider failed to ensure the staff protected the resident's right to personal privacy for:*One of one sampled resident (1) during administration of her medications through an alternative method by one of one registered nurse (RN) (F).*One of one sampled resident (3) during her skin treatment by one of one RN (F).Findings include:1. Observations on 12/1/25 at 2:20 p.m. of registered nurse (RN) F in resident 1's room revealed that resident 1 was seated in her wheelchair facing the television. A window on the left side of the resident faced a parking lot and a road. The door to her semi-private room was open to the hallway on her right side. Resident 1's roommate was lying in bed and could see resident 1. Without closing the room door, drawing the privacy curtain between resident 1 and her roommate, or closing the window curtain, RN F lifted the front of resident 1's shirt, exposed the resident's abdomen to reach her feeding tube (a tube surgically placed in the abdomen for administration of liquid nutritional formula). After RN F flushed the feeding tube with water, she lowered the resident's shirt and exited the room. 2. Observation on 12/1/25 at 5:15 p.m. of RN F with resident 3 and in her room revealed RN F closed the resident's door after she entered the private room. The resident was lying in her bed. There was a window facing a parking lot and a road to the resident's right side. Clinical care leader (CCL C was present in the resident's room. Without first drawing the window curtain closed, RN F lifted the resident's shirt, exposing her abdomen, and began the resident's skin treatment. CCL C asked resident 3 if she wanted the curtain closed while her care was provided, and the resident responded yes. The window curtain was closed, and the skin treatment was completed. 3. Observations on 12/3/25 at 9:32 a.m. of RN F with resident 1 and in her room revealed: *The resident was seated in her wheelchair watching television when RN F knocked and entered the semi-private room. *The resident's roommate was lying in her bed, and the privacy curtain between the residents was open, which allowed her to see resident 1. *The curtains and blinds on the window were open to a view of the outside, and the door to the room was left open to the hallway. *Without closing the room door, drawing the privacy curtain between resident 1 and her roommate, or closing the window curtain, RN F lifted her shirt, exposed her abdomen and feeding tube, and administered the resident's scheduled water flushes and medications through that tube. 4. Observation 12/3/25 at 12:45 p.m. of registered nurse (RN) F in resident 1's room revealed that resident 1 was seated in her wheelchair facing the television. A window on the left side of the resident faced a parking lot and a road. The door to her semi-private room was open to the hallway on her right side. Without closing the room door or closing the window curtain, RN F lifted the front of resident 1's shirt and exposed the resident's abdomen to reach her feeding tube. After RN F flushed the feeding tube with water, she lowered the resident's shirt and exited the room. 5. Interview on 12/2/25 at 10:30 a.m. with CCL C regarding the above observation revealed RN F was expected to have maintained resident 1's privacy by closing the resident's window curtain before she started the resident's skin treatment. 6. Interviews on 12/3/25 at 12:45 p.m. and on 12/4/25 at 1:59 p.m. with RN F regarding the above observations with residents 1 and 3 revealed she agreed she had not protected their privacy during their personal care when she had not closed the room door, drawn the privacy curtain, or closed the window curtains before providing those residents' care. 7. Interview on 12/4/25 at 8:30 a.m. with DON B regarding the above observations revealed she expected the staff to protect all residents' right to privacy and dignity when providing care and treatments. That included closing room doors, window curtains, and privacy curtains. Review of the provider's revised 12/11/2024 Resident Dignity policy revealed: *Purpose: -To maintain the dignity of all residents. -To promote, encourage, support and enhance the residents' self-esteem. -To promote a sense of self-worth. -To assist with respecting and ensuring resident rights. *Policy: -The location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. *Procedure: -.e. Respecting resident's private space and property. Review of the provider's 10/4/16 Resident's Rights For Skilled Nursing Facilities revealed: *Resident Rights: -(a) The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights: -(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. -.(h) The resident has the right to personal privacy and confidentiality regarding his or her personal and medical records. -(1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

Based on record review, interview, and policy review, the provider failed to:*Report an incident to the South Dakota Department of Health (SD DOH) for one of one sampled resident (5) who left the facility without staff knowledge (eloped) on 11/24/25.Findings include:Refer to citation writing at F689.

Based on observation, interview, record review, and policy review, the provider failed to ensure the care plans were reviewed and revised to reflect the current care needs for four of six sampled residents (5, 12, 19, and 20).Findings include:1. Observation and interview on 12/1/25 at 2:11 p.m. in the north hall with resident 20 in her room revealed:*Resident 20 was in her room, sitting in her wheelchair with her feet resting on the wheelchair foot pedals.*Resident 20 stated she was unable to walk due to a broken left leg and that she had open sores on her heels.*There was a pair of black and gray soft padded boots on top of her bed.-She stated she was supposed to wear them throughout the day, but she didn't like them.*There was no precaution sign posted outside or inside the door of her room related to the open sores on her heels.*There was no personal protective equipment (PPE), such as gloves and gowns, available for use inside resident 20's room or near her door. 2. Review of resident 20's electronic medical record (EMR) revealed: *She had a pressure sore (injury to skin and underlying tissue from prolonged pressure) on her left heel that resolved on 9/17/25.*She was receiving wound care treatment twice weekly and as needed for an open traumatic wound on her left heel that occurred on 10/22/25.*A 10/23/25 physician's order for her to wear the heel protector boots as needed for healing and protection. *A 5/7/25 physician's order for her to weight-bear as tolerated, with toe touch (touching toes on the floor to balance without bearing weight) on the left lower leg. 3. Review of resident 20's current care plan (personalized plan that addresses a resident's care needs, goals, and interventions) dated 11/6/25 revealed:*An initial focus area identified on 5/8/25 for activities of daily living and self-care performance deficits related to her history of a left femur fracture. *An intervention initiated on 8/6/25 for her bilateral heel lift boots to be worn at all times, except during transfers for pressure relief.*An intervention for transfers initiated on 8/14/25 for her to use a sit-to-stand lift ( a mechanical lift used to assist from a seated to a standing position) with the assistance of one staff person.*An initiated 9/24/25 focus area on the potential for skin impairment related to dementia, obesity, poor bed mobility, evidenced by need for a sit-to-stand lift for transfers, inability to reposition independently, and protein-calorie malnutrition.*Her care plan was not updated to reflect that she was to weight-bear as tolerated, with toe-touch on the left lower leg. *Her care plan was not updated to reflect that she was to use heel protector boots on both of her heels.*Her care plan was not updated to reflect her treatment needs for her left open heel traumatic wound.*Her care plan did not include a focus area, goal, or interventions for enhanced barrier precautions, which require glove and gown use when providing contact care (EBP) related to her open wound on her left heel. 4. Observation on 12/1/25 at 2:34 p.m. in the north hall outside resident 19's room revealed:*There was a white three-drawer bin in the hall next to resident 19's door.*It was stocked with gowns, gloves, and red trash bags.*There were two precaution signs posted on the door of her room.-A sign for contact precautions (measures used to prevent spreading germs through direct touch or touching contaminated surfaces).-A sign for enhanced barrier precautions. 5. Interview on 12/1/25 at 3:15 p.m. with DON B revealed: *Resident 19 was on EBP as a precaution because of Methicillin-resistant Staphylococcus aureus (MRSA) in her urine from 11/1/20.Resident 19's care plan dated 11/15/25 was not updated to reflect that she was on EBP. 6. Observation on 12/1/25 at 2:42 p.m. in the north hall outside resident 12's room revealed: *There was a white three-drawer bin and a large white trash can with a lid in the hall next to resident 12's door.*It was stocked with gowns, gloves, and red and white trash bags.*There was no precaution sign posted outside or inside the door of his room. 7. Interview on 12/1/25 at 3:15 p.m. with director of nursing (DON) B revealed:*Resident 12 was on EBP as a precaution because he tested positive for MRSA in his nares.in March 2023. Resident 12's care plan dated 10/7/25 was not updated to reflect that he was on EBP. 8. Observation and interview on 12/2/25 at 8:46 a.m. with resident 5 in his room revealed:*An oxygen concentrator (a device that filters room air into purified oxygen) at the foot of his bed with oxygen tubing in a plastic bag secured to it. -The concentrator was shut off.* He stated that he wore his oxygen whenever he wanted and he decided when he would wear it. *He was sitting in his wheelchair, ready to go out for breakfast. * He left his room to attend breakfast and was not wearing oxygen. 9. Review of resident 5's EMR revealed:*He had a physician's order for oxygen to be administered at a rate of two liters per minute via nasal cannula (tubing with prongs that deliver oxygen into the nose), titrated (adjusted) to keep his oxygen saturation level (percent of oxygen in the blood) between 88 and 92% every shift.*He exhibited behavioral and mood changes frequently and would often resist wearing his oxygen. 10. Review of resident 5's care plan dated 11/28/25 revealed: *His care plan had not been updated to reflect his oxygen, his refusal to wear oxygen, and interventions for staff to try when he refused to wear his oxygen. 11. Interview on 12/8/25 at 10:40 a.m. with Minimum Data Set (MDS)/registered nurse (RN) I revealed:*She completed the residents' care plans when they admitted to the facility, and updated the care plans quarterly or when there was a significant change in a resident's status. *She agreed that the residents' care plans should be person-centered.*She would receive residents' changes or updates from staff during huddle or stand up meetings held every morning. *She would update resident care plans with the information she received from the meetings that same day. *She agreed that resident 5's use of oxygen should have been included in his care plan as an intervention for his ADL and fall risk areas, but was not. 12. Interview on 12/1/25 at 3:15 p.m. and again on 12/8/25 at 11:10 a.m. with director of nursing (DON) B revealed:*She confirmed that the care plans for residents 20, 19, 12, and 5 had not been updated to reflect their current needs.*She expected resident's care plans to be reviewed and updated by MDS/RN I to reflect their current care needs. Review of the providers revised 1/31/25 Comprehensive Care Plan and Care Conferences policy revealed:*Purpose: - To develop a person-centered care plan for each resident that includes measurable objectives and timetables to meet his or her physical, mental, spiritual, and psychosocial well-being.- To provide an ongoing method of assessing, implementing, evaluating, and updating the resident's care plan to help maintain the resident's highest practicable level of function, including culturally competent and trauma-informed care. *Definitions:- Responsible Employees:--MDS coordinator (MDS coordinator or designated employee);--Care plan coordinator (social worker or designated employee).

Based on observation, interview, and record review, the provider failed to ensure the posted daily staff information included the total number and the actual hours worked by registered nurses, licensed practical nurses, licensed vocational nurses, and certified nursing assistants per shift.Findings include:1. Observation on 12/2/25 at 9:30 a.m. of the posted nurse staffing information revealed: *It was posted near the front entrance door and on a wall near the nurses' station.*There were three sections for each shift and four categories of staff listed in each section: RN (registered nurse), LPN (licensed practical nurse), LVN (licensed vocational nurse), and CNA (certified nurse aide). *The nurse category sections listed the number of nursing staff scheduled for each shift.*There were no documented actual hours or total number of nurse staffing hours worked on the form. 2. Interview on 12/4/25 at 2:33 p.m. with director of nursing (DON) B revealed:*She was unsure of all the required details for the posted nurse staffing data, such as the total number and actual hours worked per nursing discipline.*A posted daily nurse staffing policy was requested, but they did not have a policy that addressed that.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the facility failed to ensure that an allegation of verbal abuse by a certified nursing assistant (CNA) A to a resident (1) was reported with the required time frame by CNA B. Findings include: 1. Review of the provider's 7/7/25 FRI revealed:*On 6/30/25, CNA B heard CNA A call a resident (1) a (profanity), while providing care to that resident.*CNA B asked CNA A to repeat what she said, CNA A said, Not you, [resident 1], then CNA A walked out of the room.*CNA B had not reported the incident to the provider until 7/7/25 at 10:00 a.m.-Resident 1 was assessed at that time and was unable to explain or report the occurrence.*CNA A was suspended pending investigation. 2. Review of resident 1's electronic medical record revealed:*She was admitted on [DATE].*Her 6/3/25 Minimum Data Set (MDS) assessment indicated she was rarely understood or able to understand others and was severely cognitively impaired.*Her diagnoses included: Alzheimer's Disease, cerebral infarction (stroke), and dementia with other behavioral disturbances. 3. Interview on 7/9/25 at 10:11 a.m. with administrator C regarding reporting of allegations of abuse revealed:*He expected allegations of abuse or neglect to be immediately reported to a supervisor so that an investigation could be initiated.*He was not aware of the alleged verbal abuse until 7/7/25 when director of nursing D reported it to him.4. Interview on 7/9/25 at 11:24 a.m. with licensed practical nurse E regarding the above incident revealed CNA B had reported the alleged verbal abuse toward resident 1 by CNA A to her on 7/6/25, and she had reported it to director of nursing D on 7/6/25.The provider implemented changes to ensure the deficient practice does not recur was confirmed after record review revealed the facility had followed their quality assurance process, including initiating a performance improvement project, education was provided to all staff regarding reporting of potential abuse incidents, and after staff interviews confirmed knowledge of the reporting of incidents policies and process.Based on the above information, non-compliance at F609 was determined on 6/30/25, and based on the provider's 7/7/25 implemented corrective actions for the deficient practice confirmed on 7/9/25, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell as she walked to her room with the assistance of one of one certified nursing assistant (CNA) who had not used a safety device (gait belt) while assisting the resident. That fall resulted in resident 1's development of a hematoma (collection of blood outside blood vessels) to the back of her head and a fractured left femur (thigh bone). CNA C's failure to use a gait belt may have contributed to the accident. Findings include: 1. Review of the provider's 3/28/25 SD DOH FRI regarding resident 1 revealed: *On 3/28/25, CNA C was walking with resident 1 to her room after lunch when resident 1 lost her balance and fell backwards. *CNA C was not using a gait belt (a waist strap gripped as support for safe mobility and transfers) while walking with resident 1, and was not able to intervene when resident 1 started to lose her balance. *Resident 1 fell, hit the back of her head and was sent to the emergency department (ED) for a head scan. *While resident 1 was at the ED, it was determined that she had a left femur fracture, which required pinning (a surgical procedure to repair the fracture). *Resident 1's care plan stated she needed the assistance of one staff member and the use of a gait belt and a walker while walking. *CNA C was suspended on 3/28/25 pending an investigation of the accident. 2. Review of resident 1's electronic record revealed: *She was admitted on [DATE]. *Her 4/3/25 Brief Interview for Mental Status (BIMS) assessment score was 1, which indicated she was severely cognitively impaired. *Her diagnoses included fracture of the left femur, acute kidney failure, altered mental status, osteoporosis (a condition that causes weak and brittle bones), hypertension (high blood pressure), fracture of the right femur, Alzheimer's, anterior dislocation of the right hip, fracture of the shaft of the right humerus (arm), and dementia. *Her care plan indicated she needed the assistance of one staff with the use of a gait belt and her walker when walking. *A progress note on 3/28/25 at 3:04 p.m. indicated: - ambulance here, when we moved resident she is expressing more pain [her] in left hip, added to note [her transfer] to ER [emergency room] and ambulance EMT [emergency medical technician] will bring [that information] to [the] ER [staffs] attention. *A progress note on 3/30/25 at 9:28 a.m. indicated: - Received fax from [surgical doctor] at [local hospital], with [an] assessment plan. 1. Patient is weight-bearing as tolerated in the left lower extremity [leg]. 2. Continue Physical and occupational therapy. 3. Patient will need 30 days of DVT [deep vein thrombosis] prophylaxis [preventative treatment] after surgery. *A progress note on 3/31/25 at 7:37 p.m. indicated: - Reason resident was hospitalized or received services at a hospital: LEFT HIP FX [fracture] ORIF [open reduction [and] internal fixation]. 3. Interview on 6/10/25 at 2:17 p.m. with director of nursing (DON) B regarding the 3/28/25 FRI for resident 1 revealed: *She stated that CNA C was walking with resident 1 without using a gait belt. *Resident 1 had lost her balance, CNA C was not able to prevent the fall, and resident 1 fell and hit her head. *Registered nurse (RN) F assessed resident 1 after the fall and discovered the resident hematoma on the back of her head. *RN F and CNA C assisted resident 1 to her bed by using a Hoyer lift (a mechanical lift and sling used to lift a person's full body). *RN F had obtained a physician's order to send resident 1 to the ED for evaluation. *DON B stated administrator A reviewed the camera footage of that hallway regarding the incident on 3/28/25. *She stated she had discussed safety issues with CNA C prior to the 3/28/25 incident with resident 1. That discussion included CNA C using her phone when she was assisting residents, not following residents' care plans, and not using gait belts with residents who needed them to support safe mobility. *She stated CNA C was suspended pending investigation of the 3/28/25 incident, due to her not using a gait belt with resident 1 while walking. *When she became aware that resident 1 had a fracture, the administration team discussed CNA C's multiple safety issues and decided to terminate her employment with the facility on 4/3/25. *DON B stated all CNAs had completed a gait belt competency when they started their employment and then every year after that. -She stated the online competency was called Safe Resident Handling. *She stated she has not provided a formal all-staff education since the 3/28/25 incident. -During huddles meeting with the CNAs and RN in the mornings at 10:30 a.m. she had discussed using gait belts, but she did not have a sign-in form to acknowledge that all CNAs and RNs had been provided the gait belt use education. -Gait belts use education was posted on a communication clipboard for all staff to see. --There was no sign-in form for staff to sign, acknowledging they had read that sheet. *She stated that when walked around the facility, she observed to ensure the staff were using gait belts appropriately, but did not document those observations to use them as an auditing tool for safe gait belt use to discuss in the QAPI (Quality Assurance and Performance Improvement) meetings. 4. Interview on 6/10/25 at 3:28 p.m. with administrator A revealed: *He had reviewed the camera footage for the incident on 3/28/25 with resident 1 and CNA C but he would have to review his notes to remember everything he had seen. *He stated CNA C was very nice, but had not been following the residents' care plans. *He stated that the administration team determined that CNA C's employment would be terminated after the 3/28/25 incident. *He expected the staff to follow the residents' care plans and the facility's policies to ensure safety. 5. Review of CNA C's personnel file revealed: *She was hired on 1/9/25. *She had completed the following online education classes: -Safe resident handling program on 1/22/25. -Fall prevention: What YOU can do on 1/27/25. *She had completed a Safe Resident Handling session on 2/3/25. *Her employment was terminated on 4/3/25. 6. Interview on 6/10/25 at 4:03 p.m. with CNA E revealed: *She was hired on 9/27/22. *She worked day and evening shift. *She stated that staff were to use a gait belt every time they were walking with a resident. *She stated she remember receiving education from the DON regarding the gait belt use after resident 1 had fallen on 3/28/25. 7. Interview on 6/10/25 at 4:30 p.m. with CNA D revealed: *She was hired on 1/3/24. *She usually worked night shifts. *She thought she had received online training for gait belt use after resident 1 had fallen on 3/28/25. *She stated that staff were to use a gait belt every time they were walking with a resident. 8. RN F was unavailable for an interview at the time the survey was conducted. 9. Review of the provider's 9/23/24 Gait Belt policy revealed: *Purpose: To promote safety with patient ambulation and transfers by providing guidance for gait belt use. Gait belts are used to aid patients during transfers and/or ambulation. The gait belt provides a firm grasping surface for the healthcare provider, protects the patient from accidental trauma.

Based on observation, interview, record review, and policy review, the provider failed to prevent one of one sampled resident (23) from developing a facility-acquired pressure ulcer and to assess and document that facility-acquired pressure ulcer accurately. Findings include: 1. Observation and interview on 1/28/25 at 9:20 a.m. with resident 23 revealed: *She was in bed lying on her back. -She stated, I have a blister on my butt, so they wanted me to lay here a little longer to help it heal, but I hate it. -Resident 23 agreed to the observation of her wound care and stated that her dressing changes were usually done in the morning. 2. Observation and interview on 1/28/25 at 3:43 p.m. with resident 23 revealed: *She was sitting up in her chair. -She stated that the staff uses a sling to move her from her bed to her chair and she eats all of her meals sitting in her chair in her room. 3. Observation of wound care on 1/29/25 at 10:03 a.m. revealed a pressure ulcer on resident 23's left buttock that had already been cleaned and covered with zinc oxide. -The nurse applied a Mepilex dressing (a foam dressing used to treat pressure ulcers) over the sacral area (a bony structure at the base of the lumbar spine). 4. Interview on 1/30/25 at 9:20 a.m. with certified nursing aide (CNA)/unlicensed medication aide (UMA) L about pressure ulcer prevention for residents revealed he would use the following interventions: frequent position changes, offloading (removing pressure from the site), and keeping skin clean and dry. -He stated he would know which interventions to use for each resident by looking at the resident's care plan. -If he had any concerns about a resident's skin or noticed any changes, he would report it to the nurse. -When asked specifically about interventions for resident 23, he stated that she prefers female care providers, so he did not often work with her and was unsure of specific interventions ordered for her. 5. Interview on 1/30/25 at 9:26 a.m. with registered nurse (RN) J about preventing pressure ulcers revealed the interventions she would use included: providing good skin care by keeping skin clean and dry, and using barrier cream, good nutrition, pressure relieving mattresses, and weekly skin assessments. *She stated CNAs should report any changes in skin integrity to the nursing staff immediately, and then the nursing staff would contact the physician for specific wound care orders. 6. Interview on 1/30/25 at 10:45 a.m. with director of nursing (DON) B revealed the interventions she would expect her staff to provide to prevent pressure ulcers would include using cushions in chairs/wheelchairs, pressure relieving mattresses, dietary/nutrition assessment, turning or repositioning every two hours, good skin care and using a barrier cream to protect the skin. *She stated: -Residents' weekly skin assessments were to be completed following each resident's bath. -CNAs would not know which interventions to use if they were not listed on the care plan. -Documentation for pressure ulcers was to include weekly measurements of the pressure ulcer by the infection preventionist/wound care RN, and the treatment orders were to be reviewed every two weeks for efficacy. -When asked specifically about resident 23's pressure ulcer, she stated she would be surprised if no measurements were documented because that was the expectation. -She reviewed the documentation and agreed that the required pressure ulcer measurements were missing. 7. Review of resident 23's medical record revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) assessment score of 13, which indicated she was cognitively intact. *Her diagnoses included hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness that affects one side of the body) following cerebral infarct (a stroke) affecting the left non-dominant side, essential (primary) hypertension, deficiency of other specified B-group vitamins, vitamin D deficiency, neuromuscular dysfunction of the bladder (nerves controlling the bladder are damaged, leading to disrupted communication between the brain and bladder), and polyneuropathy (multiple peripheral nerves are damaged, leading to problems with sensation and coordination). *A 10/12/24 nursing-to-physician communication note indicated resident 23 had a small opening on her left buttock; the area was cleaned, and zinc oxide was applied, encouraging her to offload. *An order received was on 10/15/24 for wound care to left buttock. Cleanse, apply zinc oxide until healed. *On 10/15/24, a family communication note said, Summary of discussion/notification and any education provided: Shearing to resident's left buttock. *A 10/20/24 nursing note indicated she had a Left buttock open sore. *A care plan focus revised on 11/11/24 indicated: The resident has potential for pressure ulcer development R/T [related to] hx [history] of Cerebral Infarction, Polyneuropathy; E/B [evidenced by] Left hemiparesis, Left side neuropathy, Extensive assistance with Bed Mobility, Total Lift for all transfers. -The associated goal revised on 11/11/24 indicated: [Resident 23] will maintain intact skin integrity, free of redness, blisters or discoloration through the review date. *A 12/4/24 nursing note indicated Left buttock with shearing, with 2 open areas on right buttock, zinc and mepilex applied. *A care plan focus area revised on 1/23/25 indicated: The resident has potential for impairment to skin integrity R/T [related to] incontinence, bed/chair bound. *Care plan goals revised on 1/23/25 indicated: -Resident will be free from skin injury through the review date. -Resident will have no complications R/T [related to] skin injury through the review date. *Wound assessments were documented by a licensed practical nurse (LPN) but were incomplete and lacked measurements to document the size of the wound and description of wound bed. *A care plan intervention revised on 1/23/25 indicated she was to be repositioned every two hours. 8. In an interview on 1/30/25 at 12:35 p.m. with infection preventionist/wound care RN E regarding pressure ulcers she stated, Here's our wound care policy. According to our policy, we don't have to measure shearing. 9. Review of the provider's 6/5/24 Pressure Ulcer/Wound Care Resource Packet- Rehab/Skilled policy revealed: *Introduction -Promotion of healing, pain management and prevention of complications is extremely important, as well as accurate assessment and documentation. *Forms: -Wound RN Assessment UDA (user-defined assessment) is required every seven days and as needed when skin integrity is impaired or open area is present. This assessment includes measurement of the wound to document improvement or worsening of the wound. *Best Practices for Wound Management -The Wound Care Education Institute (WCEI) is listed as a resource for comprehensive training and education. --A review of WCEI education indicates a shearing wound damages the skin on a deeper level and shearing can only contribute to and compound the damage created by pressure.

Based on interview and record review, the provider failed to ensure bathing was provided to 13 of 16 sampled residents (2, 7, 10, 11, 12, 17, 23, 27, 29, 30, 32, 34, and 35), in a census of 36 residents while certified nursing aide (CNA)/bath aide N was not at the facility. Findings include: 1. Interview on 1/29/25 at 1:40 p.m. with CNA L revealed: *Residents were to be bathed at least once per week. Some residents preferred two baths. *CNA/bath aide N was in charge of bathing residents and making the bathing schedule. *He stated that all CNAs were trained and capable of bathing residents. *He was able to show this surveyor the bathing schedule and the completed bath sheet. Interview on 1/29/25 at 2:30 p.m. with licensed practical nurse (LPN) F revealed: *Residents were to be bathed at least once per week. *CNA/bath aide N was in charge of bathing residents. *If CNA/bath aide N was ill or unable to work, another CNA would be given the task of bathing residents that day if staffing permitted. *If staffing did not permit, the resident would be offered their bath on a different day that week. Interview on 1/30/25 at 1010 a.m. with CNA/bath aide N revealed: *She is scheduled to work every week from Sunday through Thursday, 8 hours per day. *She recently missed two weeks period work due to a scheduled hand surgery. *It was her expectation residents would still have received their baths during her absence. *She reported that she had trouble keeping up with the bathing schedule by herself. *The other CNAs help as much as they can. *She had asked management for help but has not received it. Interview on 1/30/25 at 10:30 a.m. with director of nursing (DON) B revealed: *She was aware CNA/bath aide N was recently on leave from work. *She expected residents to be bathed at least once per week. *She reported that registered nurse (RN) E made the CNA schedule. *She had assumed RN E would have scheduled other staff to complete the bathing task in CNA/bath aide N's absence, but she did not. Interview on 1/30/25 at 12:35 p.m. with resident 10 revealed: *She preferred to have two baths per week. *She recalled when CNA/bath aide N was not working recently, she was not receiving her baths as scheduled. Interview on 1/30/25 at 12:45 p.m. with resident 29 revealed: *She preferred to have two baths per week. *She recalled she recently was not getting her baths as scheduled. It's because [CNA/bath aide N] was gone. *We really missed her. Review of the provider's Suggestion or Concern form completed by resident 17's daughter on 1/22/25 revealed she had concerns about resident 17 missing his scheduled baths. Review of documentation in Point Click Care (PCC) (documentation system used by the provider) regarding resident baths revealed: *Resident 2 received a bath on 1/15/25, then did not receive a bath until 1/29/25, 13 days in between baths. *Resident 7 received a bath on 1/15/25, then did not receive a bath until 1/28/25, 12 days in between baths. *Resident 10 received a bath on 1/9/25, then did not receive a bath until 1/27/25, 17 days in between baths. *Resident 11 received a bath on 1/8/25, then did not receive a bath until 1/29/25, 20 days in between baths. *Resident 12 received a bath on 1/7/25, then did not receive a bath until 1/23/25, 15 days in between baths. *Resident 17 received a bath on 1/9/25, then did not receive a bath until 1/23/25, 13 days in between baths. *Resident 23 received a bath on 1/9/25, then had not receive a bath through the time of the survey on 1/29/25. *Resident 27 received a bath on 1/7/25, then did not receive a bath until 1/20/25, 12 days in between baths. *Resident 29 received a bath on 1/9/25, then did not receive a bath until 1/26/25, 16 days in between baths. *Resident 20 received a bath on 1/13/25, then did not receive a bath until 1/23/25, 9 days in between baths. *Resident 32 received a bath on 1/13/25, then did not receive a bath until 1/27/25, 13 days in between baths. *Resident 34 received a bath on 1/13/25, then did not receive a bath until 1/27/25, 13 days in between baths. *Resident 35 received a bath on 1/7/25, then had not received a bath through the end of the survey on 1/29/25.

Based on observation, interview, and policy review the provider failed to ensure: *Medications for three of three residents (30, 32, and 35) were properly labeled. *An insulin pen for one of one resident (89) was dated when opened. *Two of two medication carts were locked when left unattended. *An outdated medication for one of one resident (22) was properly disposed of. Findings include: 1. Observation on 1/30/25 at 7:36 a.m. of the medication cart in the 200-hallway revealed: *The medication cart was unlocked. *No staff were present at the medication cart. *Registered nurse (RN) J exited a resident room, returned to the medication cart, and charted medication administration. Observation on 1/30/25 at 11:16 a.m. revealed the medication cart in the 100-hallway was not locked and there was no staff at or within eyesight of the medication cart. 2. Observation on 1/29/25 at 10:58 a.m. of the medication cart in the 100-hallway revealed a Lantus (long-acting) insulin pen that belonged to resident 89 without a date on the pen that would have indicated when the pen was removed from the refrigerator and was opened. Interview on 1/29/25 at 11:08 a.m. with licensed practical nurse (LPN) F regarding resident 89's insulin pen revealed she: *Verified the insulin pen was not dated. *Indicated it should have been dated when it was opened. *Disposed of the insulin pen. *Stated the pen needed to be disposed of because the date it was opened could not be verified. 3. Observation and interview on 1/29/25 at 11:28 a.m. of the medication cart in the 200-hallway revealed: *Two open packages of 4 x 4 Hydrogel Impregnated [for wound healing] Gauze Dressing. -There was a portion removed from each of the gauze dressings. -The dressings did not include an opened date or a resident identification. *A medication card that of hydrocodone-acetaminophen (pain medication) 5/325 milligrams (mg) indicated it had been dispensed on 11/1/23 for resident 22. -The back of that medication card indicated the medication expired on 10/24. *Certified Nursing Assistant (CNA)/unlicensed medication aide (UMA) L indicated that licensed nursing staff completed all dressing changes. *He verified the expiration date of that medication and stated he would alert the charge nurse. 4. Observation and interview on 1/30/25 at 8:25 a.m. with RN J during medication pass on the 200-hallway revealed: *There was no dose indicated on resident 35's Calcium Citrate with vitamin D medication card. *Resident 35's Preservision (eye health supplement) order read 1 unit and the label on the bottle reflected tablets. *Resident 32's had an order for Senna S 8.6/50 mg one tablet daily. *That medication card did not indicate a dose and the name of the medication on the medication card was Stimulant Laxative Plus, which did not match the medication name on the order. *Resident 30's ordered dose of Calcium + Vit D liquid did not match the dose on the label of the medication bottle. *RN J verified all of the above, collected those medications, and brought them to the charge nurse. *The charge nurse then gave the collected medications to the director of nursing (DON). Interview on 1/30/25 at 11:05 a.m. with DON B revealed: *She was notified of and verified the above medication and label issues with the medications and had notified the pharmacy. *It was her expectation that insulin pens be dated when opened. *She would expect that a new dressing be opened with each dressing change and any dressing that was left over was to be disposed. *She witnessed the unlocked medication cart in the 100-hallway and locked it. Review of the provider's 9/5/24 Medication: Insulin Administration policy revealed during the procedure indicated, Verify provider order, the expiration date and the number of days the pen has been open. Review of the provider's 3/29/24 Medications: Acquisition Receiving Dispensing and Storage policy revealed: *Licensed nursing employees are responsible for ordering from the pharmacy and checking all new orders of medications from the physician's orders. *The order will include the date of 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. *Medications will be stored in a locked medication cart, drawer or cupboard. *The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Contact precautions were appropriately implemented and utilized for one of one sampled resident (10) with a feeding tube and a history of MRSA Bacteria [Methicillin-resistant Staphylococcus aureus], VRE [Vancomycin-resistant Enterococci], and MDR [multidrug-resistant organism] infections. *Enhanced barrier precautions (EBP) were appropriately implemented and utilized for one of one sampled resident (23) with an indwelling urinary catheter and daily dressing changes. *One of one resident (27) was separated from other residents while awaiting further tests following a positive QuantiFERON (blood test for tuberculosis) result. Findings include: 1. Observation on 1/28/25 at 5:47 p.m. of resident 10's room and tube feeding placement revealed: *There was a sign on her door that stated to use contact precautions. -Directions on the sign included to put on gloves and a gown before entering the room and to remove the gown and gloves before leaving the room. -There was no available gloves and gown available outside of resident 10's room. *Registered nurse (RN) J entered resident 10's room and washed her hands. -She then placed clean one-time-use gloves on her clean hands. -She did not have on a gown. *RN J then completed the tube feeding. Observation 1/29/25 at 9:55 a.m. of resident 10's room and hallway. *The door to her room was closed. *The contact precaution sign remained posted on her door. *There was a personal protective equipment (PPE) cart located in hallway, next to her room, with gowns and gloves in it. *There was a trashcan with lid located next to PPE cart. Review of resident 10's electronic medical record (EMR) revealed: *Her admitted was 12/5/23. *Her 12/9/24 Brief Interview of Mental Status assessment score was a 14, indicating her cognition was intact. *Her diagnoses included: multiple sclerosis, adult failure to thrive, unspecified severe protein calorie malnutrition, adjustment disorder w/depressed mood, chronic kidney disease, major depressive disorder. *There was a 12/6/23 physician order that indicated to use contact precautions when performing cares or in close contact as per facility policy. -This order included No swab for VRE Clearance at this time. *Her 1/27/25 care plan included a 12/6/23 focus of a history of MRSA Bacteria, VRE and MDR infections requiring Contact Precautions during cares. -The goal for this focus included, The resident's infection will resolve with minimal complications as evidenced by negative culture, vital signs WNL [within normal limits] and no s/s [signs and symptoms] of acute infection through the review date. -The interventions for this focus and goal included, CONTACT PRECAUTIONS: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. Interview on 1/29/25 at 1:25 p.m. with licensed practical nurse (LPN) S regarding resident 10's care revealed: *She had been placed on contact precautions since enhanced barrier precautions [EBP] were initiated for the facility. -She was not certain of that date. *When she provided care to resident 10, she wore a gown, gloves, and a mask just because. Interview on 1/29/25 at 2:40 p.m. with infection preventionist (IP)/registered nurse (RN) E regarding contact precautions for resident 10 revealed: *Contact precautions included a staff member wearing a gown and gloves when providing care. *Resident 10 was admitted on [DATE] with a physician's order to use contact precautions. -When staff members went into resident 10's room they were to complete hand hygiene before entering the room and when exiting the room. -They were to wear a gown and glove when providing her close contact cares. *Her expectation was for a nurse to wear a gown and gloves when assisting resident 10 with her tube feeding. *She was not aware PPE was not outside of resident 10's room on 1/28/25. -She stated the trashcan should be in the resident's room and not in the hallway. *Regarding contact precautions due to no swab for VRE clearance, she thought resident 10 had a couple of drug-resistant organisms in her urine. *Review of resident 10's care plan confirmed contact precautions were to be used. -Those contact precautions listed did not include gloves. -She stated gloves should be a big part of that [contact precautions]. *Her expectations for contact precautions included the use of a gown and gloves and a trashcan should be placed in the resident's room for disposal of PPE before leaving the room. Review of the provider's 4/2/24 Standard and Transmission Based Precautions revealed: *Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used in the care of all residents. These precautions are designed to reduce the risk of microorganisms regardless of diagnosis. They are designed to protect employees and residents from both recognized and unrecognized sources of infection. *Contact precautions will be used in addition to standard precautions for residents/patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact precautions. *Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE. -Gloves and Gowns. 50915 2. Review of resident 27's electronic medical record (EMR) revealed: *A progress note from 1/10/25 at 10:19 a.m. written by RN I stated lab returns showing + quantiferon, order received per physician assistant (PA) X to send resident to urgent care for CXR [chest x-ray] today. *Progress note on 1/10/25 at 12:43 p.m. noted that resident's sister was informed of the positive TB blood test. *Progress note on 1/10/25 at 1:26 p.m. stated resident returned with note to call Radiology for report, per PA X, she will watch for report. *Progress note on 1/11/25 at 5:43 a.m. stated 24 hr [24 hour] check-still awaiting dictation. Interview on 1/29/25 at 2:40 p.m. with resident 27 revealed he was not able to recall if he had ever been exposed to tuberculosis or the events that occurred on 1/10/25. Interview on 1/29/25 at 3:05 p.m. with licensed practical nurse (LPN) F revealed: *She had never cared for a resident who was positive for tuberculosis. *Her expectation was if there were a resident positive for tuberculosis, she would notify the director of nursing (DON) immediately and the resident would be separated from other residents to prevent spreading it. Interview with DON B on 1/30/25 at 10:30 a.m. revealed: *She was not immediately made aware of resident 27's positive tuberculosis test on 1/10/25. *She was surprised RN I did not notify her of the positive tuberculosis result. *RN I did immediately call the physician, but did not separate resident 27 from other residents and staff. *She reported resident 27's roommate was not moved to a different room after the RN I knew of the positive tuberculosis blood test. *It was the DON's expectation to be notified immediately of a positive tuberculosis test and to separate that resident from any other residents or staff. Interview on 1/30/25 at 1:05 p.m. with administrator A regarding tuberculosis revealed: *It was his expectation that RN I would have notified the DON and administrator immediately. *It was his expectation resident 27 would have been isolated from other residents and staff until the results of his chest x-ray were available. *It was his opinion that a positive tuberculosis blood test should have been considered active tuberculosis until determined otherwise by the chest x-ray. Review of the provider's 5/2023 Tuberculosis Control Plan for Residents, R/S, LTC, Home Health policy revealed: *PURPOSE: To provide early identification of residents infected with Mycobacterium tuberculosis (TB) to prevent the spread of TB through appropriate screening, placement, and treatment of residents with exposure to TB. *Residents with Suspected or Confirmed Tuberculosis (SNF and Home Health) -Isolate the resident on Airborne Precautions. The resident may be isolated in their own room if roommates are removed. -Place a warning sign outside the isolation room. The wording must say STOP, HALT, or NO ADMITTANCE and refer persons to the nurses' station or to other staff members for instructions. -Restrict contact with the resident until transfer to an appropriate center. -Notify the transportation company that the resident being transported has suspected or confirmed TB. Respiratory protection is required for the transporting team when the resident is in a closed vehicle. 51816 3. Observation on 1/28/25 at 9:19 a.m. revealed EBP signage was posted outside resident 23's room. Interview and observation on 1/28/25 at 9:20 a.m. with resident 23 revealed she had an indwelling urinary catheter and received daily dressing changes for a pressure ulcer on her buttocks. -She agreed to the observation of her wound care and stated that dressing changes are usually done in the morning. Observation of wound care on 1/29/25 at 10:03 a.m. revealed: *Certified nursing aide (CNA) M had already performed personal hygiene for resident 23 and was holding her on her left side. -CNA M was wearing gloves but no gown. *Licensed practical nurse (LPN) F provided wound care to resident 23's pressure ulcer. -LPN F was wearing gloves but no gown. Interview on 1/29/25 at 2:40 p.m. with infection preventionist/wound care registered nurse (RN) E regarding EBP revealed she expected staff to wear a gown and gloves during close contact care and to perform hand hygiene before and after resident contact. Review of resident 23's medical record revealed: *She was admitted on [DATE] *She had a brief interview for mental status (BIMS) assessment score of 13, which indicated she was cognitively intact. *Her diagnoses included hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness that affects one side of the body) following cerebral infarct (a stroke) affecting the left non-dominant side, neuromuscular dysfunction of the bladder (nerves controlling the bladder are damaged, leading to disrupted communication between the brain and bladder), and polyneuropathy (multiple peripheral nerves are damaged, leading to problems with sensation and coordination). *A care plan focus area initiated on 6/28/24 indicated: -The resident requires Enhanced Barrier Precautions (EBP) R/T [related to] indwelling medical device- Foley catheter. *Her care plan included a 6/28/24 initiated intervention: - [NAME] [put on] gown and gloves when performing high contact care activities including: dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing [related to incontinence needs], device care and/or use, and wound care. Review of the provider's 4/2/24 Standard and Transmission-Based Precautions, All Service Lines policy revealed: *Enhanced Barrier Precautions - Enhanced barrier precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. - Enhanced barrier Precautions are needed for residents with chronic wounds (Pressure Ulcers, Diabetic Foot Ulcers, Unhealed surgical wounds, and venous stasis ulcers) and Residents with Indwelling Medical devices (central line, hemodialysis catheters, indwelling urinary catheters, feeding tubes, and tracheostomies). - High-contact Resident Care Activities include: Transfers, dressing, assisting during bathing, providing hygiene, changing briefs or assisting with toileting, working with resident in therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility, changing linens, device care or use (central line, urinary catheter, feeding tube, tracheostomy), Wound care.

Based on observation, interview, and policy review, the provider failed to ensure: *Kitchenware was stored in a clean and sanitary manner. *Food items in one of one refrigerator designated for resident use and one of one side-by-side refrigerator in the dining room were properly labeled and dated. *One of one refrigerator designated for resident use and one of one side-by-side refrigerator were maintained in a clean manner. *Kitchenware was handled in a manner to mitigate the risk of cross-contamination by one of one lead cook (G) during two of two observed meal services. Findings include: 1. Observation on 1/28/25 at 10:40 a.m. during the initial kitchen tour revealed: *Multiple plastic water pitchers and pitcher lids were stored inside one of the slide-out drawers of the six-drawer kitchenware storage unit. -The pitchers sat upside down inside of that drawer. Two pitchers and one of the lids sat on top of an area that was damp with water. *A four-drawer Tool Shop cabinet held kitchen utensils. -A piece of black foam sat on the bottom of the inside of those drawers. Food crumbs were scattered on top of that foam where the kitchen utensils sat on top of. -Some of the drawers had plastic organizers inside of them that held kitchen utensils. Food crumbs were scattered on the bottom of those organizers that the kitchen utensils sat on top of. *The wall-mounted plastic knife holder had scattered food crumbs on the bottom of it. *There was a [NAME] Cleaning List taped onto a wall. One of the weekly tasks included Clean utensil drawers inside and out. and was initialed as having been completed on 1/24/25. 2. Observation on 1/28/25 at 11:25 a.m. of the refrigerator designated for resident use revealed: *A white carton of peach and vanilla ice cream. It had no open or expiration date on it. *A jar of Buffalo Berry jam without an open date. *About 75% of the refrigerator's back wall was covered in a layer of thin, lumpy white ice build-up. 3. Continued observation of the side-by-side refrigerator next to the resident refrigerator revealed the bottom of the inside of that refrigerator had a dried red-colored substance on it. That same substance had run down one side of the inside of that refrigerator. Interview on 1/29/25 at 1:30 p.m. with food service assistant (FSA) H regarding the above refrigerators revealed: *All staff were responsible for cleaning both refrigerators on a regular and an as needed basis. *Residents' families or kitchen staff were expected to have labeled and dated all food placed inside the resident designated refrigerator. -All staff were responsible for ensuring the refrigerator's contents were regularly checked for outdated or unlabeled food and to have removed those food items. 4. Observations on 1/28/25 from 11:35 a.m. through 12:10 p.m. and on 1/29/25 at 5:00 p.m. of lead cook G preparing food in the kitchen and serving food at the steam table revealed he: *Removed a metal container of pureed vegetable from the steam oven using his bare thumb to hold the inside rim of that container as he removed it. -Shook then wiped off his thumb after it had touched the contents of the pureed food mixture when it was removed. *Used the countertop blender to puree a mixture of boneless pork chop, gravy, and vegetable stock. -Took the blender lid off then placed his bare thumb on the inside rim of the blender cup, removed it from its base, and poured the contents into a metal container for serving. *Removed mashed potatoes from the steam oven and inserted a digital food thermometer far enough into the potatoes to cover both the temperature probe and the bottom surface of the plastic base attached to the probe. *Used his bare thumb to hold the inner lip of each plated dish that was served to a resident. -Handled paper menus, touched the metal top of the steam table and other items in and around that food service area in between touching each plate and without having performed any hand hygiene. *Placed two re-usable squeeze bottles of salad dressing inside the same container of lettuce salad mix causing those bottles to touch the salad mix. -Removed and returned the squeeze bottles from that container throughout the meal service to dispense salad dressing. At the end of the meal service the bottles were placed back into a refrigerator. Interview on 1/30/25 at 11:30 a.m. with dietary manager D regarding the above observations revealed: *Since November 2024 he had been splitting his time as dietary manager between this facility and a sister facility until a full-time dietary manager was hired for this facility. *He had educated kitchen staff about safe kitchenware storage practices. He knew kitchenware that was stored on moist surfaces had the potential to attract bacteria. *He had assigned a FSA to examine the contents of both the above refrigerators to ensure all food items had been properly labeled/dated or discarded if that was appropriate. Examining the refrigerators would have also included ensuring they had been clean. He had not checked to ensure the assigned FSA had completed the task as he requested. *He expected hot food vessels to be handled using hot pads preventing the need for contact with the inside of that vessel. Bare fingers should not have been used to handle the inside of a blender cup or to hold the inner rim of serving plates. Only the probe of the digital food thermometer was expected to have touched food including the potatoes. Re-usable plastic squeeze bottles should not have been placed in the same container with a consumable food item. -Failure to perform the practices above in an appropriate manner had increased the risk of cross-contamination. Review of the provider's revised 5/12/23 Safe Handling of Personal Food, Outside Food-Food and Nutrition policy revealed: *Procedure: 6.b. Food and beverages without manufacturer expiration date should be dated upon arrival in the facility and discarded 7 days after date marked. *Personal Food Stored in Common Areas: -3. The resident/family: a. Labels, dates and covers all opened foods that are brought in for the resident. All food must have the resident name and room number clearly visible on the container/package. lb. Removes personal food when no longer considered safe for consumption. 4. Employees monitor common food storage areas, clean the equipment and remove unsafe foods without replacing the items. Review of the provider's revised 6/13/24 Dining Service Standards-Food and Nutrition Services policy revealed employees will follow procedures for prevention of foodborne illness when serving meals.

Based on record review, interview, and policy review, the provider failed to ensure: *Two of two sampled residents' (12 and 2) PRN (as needed) psychotropic medications had been discontinued after fourteen days. *An appropriate diagnosis for the use of a psychotropic medication administered to two of two sampled residents (2 and 28). Findings include: 1. Review of resident 12's electronic medical record (EMR) revealed: *A 12/20/24 physician's order for .25 milligrams lorazepam (anti-anxiety/psychotropic medication) to have been administered every 24 hours PRN for combativeness with personal cares. -The physician's order note regarding that same medication indicated: If PRN, order stop date=14 days. Review of resident 12's December 2024 and January 2025 medication administration records (MAR) revealed. *She was administered PRN lorazepam on 12/23/24 and 1/7/25. -The PRN lorazepam order had not been discontinued after 14 days. Interview on 1/30/25 at 12:15 p.m. with director of nursing (DON) B regarding resident 12's PRN lorazepam order revealed it was the responsibility of a licensed nurse to have entered a stop date for that medication for it to have been discontinued according to the physician's order notes. That had not occurred. 51472 2. Review of resident 2's EMR revealed: *She was admitted on [DATE]. *Her 11/13/24 Brief Interview of Mental Status (BIMS) assessment score was 5, which indicated she had severe cognitive impairment. *Her diagnoses included Alzheimer's disease and other specified depressive episodes. *A 1/15/25 physician's order for lorazepam injection solution 2 mg/ml(milliliters) with instructions to inject 2 mg intramuscularly every 24 hours as needed. -The order did not have an end date. -The targeted behavior was indicated to be anxiety aggressive behavior. -There was no diagnosis associated with the lorazepam order. *She did not have a diagnosis of anxiety or behavioral disturbances. 3. Review of resident 28's EMR revealed: *She was admitted on [DATE]. *Her 1/10/25 BIMS assessment score was 3, which indicated she had severe cognitive impairment. *Her diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. *A 11/11/24 physician's order for Ativan (lorazepam) every two hours as needed. *The targeted behavior for the Ativan was anxiety. *There was not a diagnosis associated with the Ativan order. *She did not have an anxiety diagnosis. Interview on 1/30/25 at 11:26 a.m. with DON B regarding the Ativan (lorazepam) orders revealed: *She agreed there was no end date on the Ativan order for resident 2. *It was her expectation that the nurse that received the order would enter and date at 14 days unless there was another date specified by the provider. *She verified there was not a diagnosis associated with the Ativan orders for resident 2 and 28, only an indication for use. *Neither resident had a diagnosis of anxiety in their EMR. Review of the provider's 12/30/24 Psychotropic Medications policy revealed: *Residents do not receive psychotropic drugs pursuant to a PRN [as needed] order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. *The order must contain an appropriate medication, in an appropriate dose and corresponding diagnosis, as well as medical symptoms from the physician. *PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the prn order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the prn order.

Based on record review, interview, and policy review, the provider failed to follow their policy for: *Maintaining a physical inventory count of controlled substances at each shift change by two qualified staff for two of two medication carts. *Maintaining a system of receipt for controlled medications (medications that risk abuse or addiction)received from the pharmacy to ensure accurate medication reconciliation of those medications for four of four (2, 6, 17, and 25) residents. Findings include: 1. Review on 1/29/25 of the January 2025 Narcotic Control Sheet (sheet used to document the count of controlled medications between shifts) and the Controlled Drug Records located in the 100-hall medication cart revealed: *The form indicated: -When signed at each change of shift by off-going and on-coming nurse of medication aide, verifies the correct number of schedule 2 narcotics in lock box. -Both nurses and/or medication aides must sign. -Sign-off times on the form were 0630 (6:30 a.m.), 1430 (2:30 p.m.), and 1830/2230 (6:30 p.m./10:30 p.m.). *There were areas where signatures were not present, which included: -One signature on 1/7/25 at 1430 and one at 1830/2230. -One signature on 1/18/25 at 0630 and two at 1430. -Two signatures on 1/21/25 at 1430 and one at 1830/2230. -One signature on 1/22/25 at 0630 and one at 1430. -One signature on 1/23/25 at 1430 and one at 1830/2230. *One Controlled Drug Record did not contain the quantity, date, or nurses signature to verify the receipt of 60 Tramadol, for resident 25. 2. Review on 1/29/25 of the January 2025 Narcotic Control Sheet and Controlled Drug Records located in the 200-hall medication cart revealed: *There were areas where signatures were not present, which included: -Two signatures on 1/4/25 at 1430. -One signature on 1/5/25 at 1430. -One signature on 1/8/25 at 1830/2230. -Two signatures on 1/11/25 at 1430. *Resident 2's controlled drug record did not contain the quantity, date, or nurse's signature to verify the receipt of 10 tablets of lorazepam (anxiety medication). *Resident 17's controlled drug record did not contain the quantity, date, or nurse's signature to verify the receipt of 30 tablets of oxycodone (pain medication). *Resident 6's controlled drug record did not contain the quantity, date, or nurse's signature to verify the receipt of 60 tablets of Tramadol. Resident 6's controlled drug record did not contain the quantity, date, or nurse's signature to verify the receipt of 30 half tablets of Tramadol. Interview on 1/29/25 at 11:08 a.m. with licensed practical nurse (LPN) F revealed: *When controlled medications would arrive from the pharmacy the licensed nurse on duty was to count the medications and compare that count to the amount documented on the controlled drug record. *If the controlled medication count matched the amount documented on the controlled drug form the licensed nurse would document the quantity, the date, and sign the form to verify that the information on the form was accurate. *There were missing nurse signatures on the controlled drug records. *The controlled drug form was then placed in the binder with the Narcotic Control Sheet to be used for the medication reconciliation counts between each shift. *Controlled medication counts were to be done on both carts between each shift. *The nurses'/ UMA's signatures indicated that the narcotic count had been completed. *There were missing signatures on the Narcotic Control Sheets. Interview on 1/30/25 at 10:59 a.m. with director of nursing (DON) B revealed: *It was her expectation that the narcotics were to be counted anytime there was an exchange of medication cart keys. *She expected the nurse who received the controlled medications from the pharmacy to verify the medication count being received, document the quantity and date received and then sign the controlled drug record. Review of the providers 6/27/24 Medications: Controlled policy revealed: *The provider along with the consultant pharmacist will establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation that determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. *Each time the keys that secure controlled medications change from one nurse/medication aide to another, the oncoming and off-going nurse/medication aide will work together to reconcile controlled medications, including all discontinued controlled medications and document the same. *When a new controlled medication is delivered, the nurse in the skilled nursing facility will be responsible for counting the medication.

Based on observation, interview, record review and policy review the provider failed to ensure the care plans were reviewed and revised to reflect the current care needs for two of fourteen sampled residents (2 and 35). Findings include: 1. Observation on 1/28/25 at 10:40 a.m. of resident 2 revealed: *She was sitting in the hallway on a bench. *She had a four-wheel walker in front of her. *She loudly requested staff to remove another resident that was talking to her, stating, She is bothering me. *She got up from the bench and walked to an exit door. *She pushed on the door but did not exit. Observation on 1/28/25 at 3:38 p.m. of resident 2 revealed she had a Wander guard (wearable door alarming device) on her left ankle. Interview on 1/29/25 at 4:34 p.m. with certified nursing assistant (CNA) T regarding resident 2 revealed: *Interventions for behaviors and falls were included in her care plan. *When she exhibited behaviors staff were to offer her picture books, assist her to call her daughter, and turn on old country music. *Interventions in place for her falls included a pressure call light under hip to alert staff when she was getting up. *She recently was on a one-to-one staff monitoring because when she was left alone, she tried to get up and she was unsteady. *She had been working with physical therapy. Review of resident 2's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 11/13/24 Brief Interview of Mental Status (BIMS) assessment score was 5, which indicated she had severe cognitive impairment. *Her diagnoses included Alzheimer's disease and other specified depressive episodes. *A 1/15/25 physician's order for lorazepam injection solution 2 mg(milligrams)/ml(milliliters) with instructions to inject 2 mg intramuscularly every 24 hours as needed for anxiety, aggressive behavior. Review of resident 2's 1/29/25 care plan revealed: *An intervention, initiated on 11/18/24, within the cognitive function focus area indicated, Wander Guard applied to walker due to wandering and difficulty with direction. *A focus area initiated on 11/1/24 of at risk for altered mood/psychosocial well-being r/t [related to] SNF [skilled nursing facility] placement, change in environment, loss of independence, depression and anxiety. *On 12/10/24 it was revised to include Deer Oaks [a psychological service utilized by the provider] for psychological services in place. *A focus area of The resident has potential for elopement R/T [related to] Hx. [history] leaving building during night hours R/T [related to] Alzheimer's, Dementia *Interventions for this focus included: -Attempt non-pharmacological interventions. -Wander guard used to alert staff to resident's movements. -Minimize potential of resident behavior problems by modifying environmental factors and daily routine. --The modifications were not specified. *A focus area for falls r/t [related to] Alzheimer's Disease, Dementia, Wandering behavior's, E/B [evidence by] Confusion, Wander Guard in place, Exit seeking, hx [history] of falls prior to admission. *The interventions for falls did not include a pressure call light under hip to alert staff when she was getting up. *Interventions that staff identified were not addressed in the care plan. 2. Observation on 1/28/25 at 9:39 a.m. of resident 35 in her room revealed: *The door on her room was closed. *After being invited to enter, resident 35 was crouched behind her lift chair. *Her walker was not near her. *She was pulling cords out of the back of the partially lifted lift chair. *She walked to the bathroom without her walker. *There was a sign on the wall above her bed that said, CALL DON'T FALL. *Resident 35 then stood beside the lift chair, lowered the chair to a reclined position and turned on the heat and massage function of the chair. *Her call light was attached to the lift chair. *She returned to the back of the lift chair and pulled on the cords. *When she was asked if she could turn her call light on for assistance, she moved from behind the lift chair and pressed the call light to turn it on. *She then walked to her room door, without her walker. *Multiple unidentified staff walked past resident 35 standing at the door of her room without her walker. *When CNA U answered the call light she removed the remote for the heat/massage from the lift chair. *Resident 35 continued to walk in her room without the use of her walker. CNA U did not give the walker to resident 35 or encourage her to use it. Observation on 1/28/25 at 3:38 p.m. of resident 35 in her room revealed: *The door to her room was open. *She was walking in her room without her walker. *There was a gold gait belt hanging on the bathroom door. Observation on 1/29/25 at 10:49 a.m. of resident 35 revealed: *She was walking in the hall with her walker. *Staff were not assisting. *She was not wearing a gait belt. Interview on 1/29/25 at 4:36 p.m. with CNA T regarding intervention for resident 35's falls revealed: *Staff visualized her frequently. *Staff were to ensure she had her walker when she was ambulating, and she used it correctly. *Staff were to ensure her call light was near her when she is in her room. *A gait belt was not used because she walked independently with her walker. Review of resident 35's EMR revealed: *She was admitted on [DATE]. *Her 1/6/25 BIMS assessment score was 8, which indicated she had moderate cognitive impairment. *Her diagnoses included dementia, depressive episodes, and anxiety. *There was no assessment completed for resident 35's safe use of the lift chair. Review of resident 35's 1/29/25 care plan revealed: *Her care plan did not address the use of a lift-chair with heat and massage features. *Within the activities of daily living focus area the ambulation intervention indicated, Resident 1 assist to ambulate with walker or at least supervised with ambulation, gait belt on if resident allows, as safety measure. Resident will not remember to use call light or wait for assist [assistance] to walk. Respect residents right to self ambulate. *The focus falls area indicated, The resident is at risk for falls R/T [related to] reported by resident and [family member] that [resident 35] has fallen frequently in the past few months E/B [evidence by] Bruises present to buttocks and right elbow/forearm when admitted . *One of her fall interventions indicated, Obtain gold gait belt for increased compliance and use. *The interventions for frequent visualizations and ensuring resident 35 had her walker and was using it properly were not included in her care plan. Interview on 1/30/25 at 9:19 a.m. with Minimum Data Set (MDS) registered nurse (RN) K revealed: *Care plans gave direction for staff to care for the residents and should be person-centered. *Each morning there was a stand up meeting, where the falls were reviewed, and interventions were determined. *After the meeting the interventions were to be entered in the resident's care plan. *The updates were to be in the care plan, at the nurse's station, and in the breakroom. *CNAs could also refer to the resident's Kardex (a report of residents' care needs and interventions) to view the interventions. *New residents had a baseline care plan for falls, pressure ulcers, and pain. *Sometimes specific falls were put included in the care plan. *She stated if she was not aware of a specific fall it would not be entered into the care plan. *She indicated multiple staff would enter information into the residents' care plans. *MDS RN K indicated the injuries identified in resident 35's care plan were no longer present. *When asked to clarify if resident 35 was to use a gait belt with the assistance of one staff or was to walk independently she replied, the staff should know if someone was walking independently and a gait belt did not need to be used. *When asked about the gold gait belt for resident 35, MDS RN K indicated she was not aware of that intervention. *She stated staff should know how to care for the residents and their interventions, because the facility is small. *She agreed that resident 35's improper use of her walker and the interventions should be included under her risk for falls in her care plan. Review of the provider's 12/2/24 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. *The plan of care will be modified to reflect the care currently required/provided for the resident.

Based on observation, interview, record review, and policy review, the provider failed to ensure a resident (19) who was admitted without pressure injury but was identified as a high risk for development of one did not develop pressure inurys. Findings include: 1. Observation on 5/11/21 at 3:40 p.m. of resident 19 during a brief change revealed: *She was laying on her right side in her bed. *She had foam boots on. -She had a pillow between her knees. *Nursing assistant (NA) O and unlicensed assistive personnel (UAP) P were conducting the brief change. *Resident 19 had a 3.5 inch by 3.5 inch border foam dressing on her coccyx area that fell off during the removal of her brief which revealed a wound to that area. -That wound was approximately the size of a half dollar. -Was opened and was able to be looked into approximately one inch. -Was reddened around the outside of the area. -Had a tan colored sticky material at the edge of the bottom portion of the wound which stretched onto her buttock. *That tan colored sticky material was cleansed away by licensed practical nurse (LPN) N who had come into the room to replace the dressing and conducted wound care. *She cleaned the area with Dermal Wound Cleanser and covered the area with a boarder foam. *She stated: -Yesterday the wound had a thin covering over the area that was now open. -They had faxed paperwork to the physician earlier that day for a new order to Pack the tunneling. -They did not have a current wound nurse, they all took care of wounds. *NA O stated It looks way worse than it was. -She had last worked and seen the wound five days prior. 2. Record review of resident 19's Minimum Data Set (MDS) revealed: *She had an admitted [DATE]. -She was an extensive assist with a two person physical assist for: --Bed mobility, transfers, dressing, toilet use, and personal hygiene. *She had no current pressure ulcers or skin wounds but was at risk of developing them. *She had no open wounds to her heels or feet. *She frequently had urinary incontinence and always had bowel incontinence. *Her Braden scale for predicting pressure ulcers on 3/5/21, 3/12/21, and 3/19/21 were all 18 and on 3/26/21 her score was 17, all indicating she was at risk of developing pressure ulcers. *She had a pressure relieving Panacea mattress on her bed and a wheelchair cushion. *She was not on a turning or repositioning schedule. 3. Record review on 5/12/21 of progress notes revealed: *4/17/21 1945 [7:45 p.m.] Communication/Visit with Physician -Resident noted to have stage II pressure ulcer to left heel, clear fluid filled blister. Will leave open to air, offload and apply foam booties when in bed. PCP [Primary care physician notified]. *There had been no prior progress notes related to this wound before 4/17/21 when it was documented as a stage II pressure ulcer. *4/19/21 14:22 [2:22 p.m.] Health Status -Resident noted to have red, open area to her coccyx, measuring 2.8 cm [centimeters] x 1 cm. [MEDICATION(S)] cream applied, staff reposition and keep area dry. *4/27/21 15:27 [3:27 p.m.] Health Status .[Name of certified nurse practitioner (CNP) Q] will also send prescription for a pressure-relieving mattress and pressure-relieving cushion to be used to prevent further skin breakdown. She will also send a prescription for wound tx [treatment] to open area at coccyx. *5/7/21 1150 [11:50 a.m.] Communication/Visit with Physician Faxed advising of change in wound to coccyx requesting to change treatment to santyl and cover with foam dressing. Also asked if antibiotic would be advised. Requested multivitamin as well per request from dietician. *5/10/21 13:26 [1:26 p.m.] Communication/Visit with Physician Late entry -Received orders agreeing to Santyl and foam dressing. Also received orders for wound culture . *That order was different from what LPN N used on the wound during the 5/11/21 3:40 p.m. wound care that was performed as documented above in finding one. *5/11/21 09:56 [9:56 a.m.] Communication/Visit with Physician R.D. [Registered Dietician] recommends 8 oz. [ounces] Ensure + BID [two times a day] for calories and protein. *5/12/21 13:58 [1:58 p.m.] Communication/Visit with Physician -Wound evaluation today, see assessment note with concern over hard induration of pressure ulcer at 12-3 o'clock alert sent to MD [medical doctor] for further evaluation and for wound care orders. *5/12/21 14:11 [2:11 p.m.] TC [text communication] to wound care consultant, plans on coming in on Monday May 17 to assess wound, discussed wound care recommendations and alert of MD of induration. *There had been no prior progress notes related to this wound before 4/17/21 when resident 19 was noted to have a red, open area to her coccyx, measuring 2.8 cm [centimeters] x 1 cm. 4. Review of resident 19's undated care plan and progress notes revealed: *Intervention dated 3/22/21: -Provide pressure redistributing Panacea mattress on bed to help reduce pressure when resident is on her bed, and provide a pressure reducing cushion in resident's wheelchair. *A health status progress note dated 4/27/21 at 3:27 p.m. revealed: -CNP Q will also send a prescription for a pressure-relieving mattress and pressure-relieving cushion to be used to prevent further skin breakdown. *Interventions dated 4/17/21: -Monitor location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to health care provider. -Elevate heels off bed. -Resident needs protection for the feet, foam booties, when in bed. *There was no mention of a stage II pressure ulcer to her left heel. *Those interventions had been put into place after they had found the wound on her left heel and had staged it as a stage II pressure ulcer. *There was no documentation that interventions for her left heel pressure ulcer had been put into place proactively. *There was no documentation in the care plan that she had a pressure ulcer to her coccyx. *There was no documentation in the care plan that she was to be repositioned. 5. Review of Wound Data Collection for resident 19's left heel revealed: *The initial data collection was on 4/17/21 at 7:22 p.m. * The wound measured: -Length 3.25 centimeters (cm). -Width 4.0 cm. *No other measurements were taken through 5/12/21 at 11:48 a.m. when it was documented as: -1. Stage one possible. -2a. Was this pressure ulcer present on admission/re-admission? --b. No. *Other -1. Wound healed: discontinue weekly RN [registered nurse] assessment. 6. Review of Wound Data Collection for resident 19's coccyx revealed: *The initial data collection was on 4/27/21 at 1:19 p.m. *The wound measured: -Length 2.8 cm. -Width 2.1 cm. *The wound was documented as a stage II pressure ulcer. -2a. Was this pressure ulcer present on admission/re-admission? --b. No. *Documentation on 5/5/21 at 3:17 p.m. indicated: -Length 3.0 cm. -Width 1.6 cm. -Depth 0.2 cm. -Slough 100%. -Reddened. -Indurated. *Documentation on 5/8/21 at 5:00 p.m. indicated: -Length 2.6 cm. -Width 2.4 cm. *Documentation on 5/10/21 at 6:35 p.m. indicated: -Length 2.6 cm. -Width 2.7 cm. -Depth 0.5 cm. *Documentation on 5/12/21 at 1:32 p.m. indicated: -Length 3.0 cm. -Width 2.0 cm. -Depth 1.5 cm. 7. Interview on 5/13/21 at 3:26 p.m. with the director of nursing B concerning resident 19 revealed: *When questioned she was hesitant to agree that they had been more reactive than proactive with resident 19's left heel and coccyx pressure areas. *She could not be positive of when the pressure ulcers began and relied on the progress notes. -Progress notes had not indicated a problem until both areas were staged as pressure ulcers. *She stated she could tell the coccyx wound was tunneling but the wound bed had been covered by a thin layer of skin. -She was not aware the wound bed area was currently open. *She stated resident 19 was not on a repositioning schedule. *She stated they did change her mattress to an air mattress to relieve pressure. *The progress notes revealed the air mattress was discussed ten days after the pressure ulcer to her left heel and eight days after the open red area to her coccyx had been noted. -She was unable to confirm the date the air mattress and wheelchair (w/c) seat cushion had been implemented. *The facility used Point Click Care for documentation. *When care plan's are updated that information carries over to the tasks (Kardex) which can be seen by the nursing staff. -Nurse aides conduct their documentation in the task area when they complete a task intervention. -If interventions are not entered into the care plan then nurse aides do not see the interventions in the task area. *She believed that nursing standards play a part and a repositioning schedule should not have to be care planned or put into the task area of PCC to ensure the task was being completed. -They should just know how to do that. -She could not provide me with documentation that repositioning had occurred for resident 19 when she was in her w/c or in her bed. *She was unable to confirm how the resident received the two facility-acquired pressure ulcers. *She agreed resident nine's care plan needed to updated.-She stated all nurses were responsible to update them but it was ultimately up to the MDS coordinator to ensure they were correct. 8. Interview on 5/13/21 at 9:42 a.m. with MDS coordinator R revealed:*She had not worked from 4/15/21 through 5/10/21.*When she completes the MDS's she updates the care plan's.*She does attend stand-up meetings on Monday through Friday mornings.-That is where she got most of her information on residents to be able to update the MDS's.*Nurse's are responsible to update the care plan's.-She update's them when she completes the required quarterly and significant change MDS's.9. Continued interview with MDS coordinator R concerning resident 19's undated care plan revealed:*3/25/21 Focus-The resident has COVID 19 positive test results.*Interventions-When possible, all services brought to resident in room.-Contact precautions .*The MDS coordinator stated Ow, I need to update her COVID information. *She also agreed that the care plan needed to be updated to include the resident's current status.-Things go better when we have a specific wound care nurse. 10. Review of the revised 7/8/20 Wound and Pressure Ulcer Management-Rehab/Skilled Policy revealed:*Programs should include:-Good Samaritan Society (GSS) skin care [skincare] systems, guidelines and protocols that are consistent with acceptable standards of practice .-Up-to-date care approaches consistent with GSS protocols and policy (employee knowledge, competency and consistency in following policy and acceptable standards of practice).-A comprehensive management program to prevent development of a pressure ulcer or other skin conditions (Braden, following interventions identified on care plan, nutritional intervention, specialty surfaces, etc.

Based on record review, interview, policy review, and job description review, the provider failed to ensure: *One of nine sampled residents (2) had not had a significant medication (med) error incurred by one of one certified medication aide (CMA) D that affected his health and safety. *Six of nine sampled residents (3, 4, 5, 6, 7, and 8) and one of one randomly reviewed resident (11) had not had med errors that could have affected their health and safety. Findings include: 1. Review of resident 2's medical record revealed: *He had an admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had a physician order [REDACTED]. -Order read to give 0.5 ml by mouth every two hours as needed for terminal agitation/anxiety related to restlessness and agitation. -There had been a start date of 4/10/17. -It had a discontinuation date of 7/12/17. Review of the 6/1/17 through 8/1/17 interdisciplinary progress notes related to medication errors revealed: *There had been a late entry in the nurses progress notes on 6/29/17. *Documentation on 6/29/17 at 9:30 a.m. by the registered nurse (RN) stated Resident received 5ml of [MEDICATION NAME] instead of the ordered 0.5ml due to a measurement error. *Family and physician had been notified. *On 6/30/17 at 5:40 a.m. the progress note confirmed: -The entry had been a summary of the 6/29/17 night shift that had started at 10:00 p.m. -He had been very 'somnolent' after receiving [MEDICATION NAME] earlier on the day shift. -When the RN had assessed him she had not been able to understand the minimal words he had tried to say. -His blood pressure had been slightly low. -He had oxygen levels in the 70s. --Oxygen had been placed on the resident increasing his levels to the 90s. --He had been 'weaned' off the oxygen around 1:30 a.m. Review of the medication incident report for 6/29/17 revealed: *A medication error had occurred on 6/29/17 at 9:33 a.m. *The above error was reported on 6/29/17 at 10:30 p.m. -More than twelve hours had passed before the medication error had been reported. *The registered nurse (RN) had received a phone call at 10:30 p.m. from the day shift medication aide. -He had informed the RN he had given the wrong dose of [MEDICATION NAME]. -He had stated the eye dropper dispenser that came with the bottle had not worked, so he had used a medication cup to dispense the medicine. *5mls of a 2mg/1ml [MEDICATION NAME] concentration (10mg) had been given instead of the physician ordered 0.5ml. *Results of the internal facility investigation stated: -Liquid [MEDICATION NAME] had been removed from the facility. -Corrective action had been issued. -Staff education had been provided. -The investigation had been signed and dated on 7/3/17 by the director of nursing (DON) and the administrator. -The form had been signed and dated on 7/5/17 by the social service coordinator. -Behind medical director it had said optional in brackets. --The medical director had not signed the investigation report. Surveyor: Interview on 8/2/17 at 10:30 a.m. with CMA D regarding medication administration and resident 2's med error revealed: *He had been trained in-house to be a med aide and had been doing so for about a year and a half. *When he gave resident 2's PRN [MEDICATION NAME] liquid he thought it was within the med aides capability. -After the med error occurred he thought it should have been a nurse administering that medication. *He thought there was a list of what med aides could and count not do related to med administration, but he was unable to find a copy of it. *He stated the nurse directed the med aides when to give a PRN medication. *On 6/29/17 resident 2 was starting to get agitated, so LPN/QA nurse A directed him to give the resident his PRN [MEDICATION NAME]. *He was supposed to give the resident 0.5 ml of the [MEDICATION NAME]. *He did not think the med dropper that came with the liquid [MEDICATION NAME] was working properly when he tried to measure 0.5 ml. -So he made the decision to use a plastic med cup instead. *He filled the medication to 5 ml on the med cup and administered that amount to the resident. *He did not inform LPN/QA nurse A of the problem with the med dropper or using a med cup instead, and he should have. *When he and the night nurse registered nurse (RN) B did the narcotic count she stated it looked like more was gone from the liquid [MEDICATION NAME] than there should have been. -It was difficult for them to get an accurate count of the [MEDICATION NAME] in the bottle though because of the bottle's labeling and color. -During their count he told her he had given the resident a dose earlier that morning. --At that time he did not realize he had given the resident too much. *After he left the facility from his shift he thought about the [MEDICATION NAME] more and realized he had given the wrong dose. *He called back to the facility and told RN B what he had done. *During his day shift he was aware the resident was sleeping after he had given the [MEDICATION NAME]. -He he did not think too much of the resident sleeping, because the resident frequently slept soundly. *When he came into the facility to fill out the med error paperwork the DON talked to him about the med error. -He did not receive any formal education paperwork or sign that he had been educated. -He thought he might have read a policy, but he was unsure. *No one had watched him do med administration following the med error. *He had been audited on med administration in the past by a pharmacy employee. Phone interview on 8/2/17 at 11:30 a.m. with RN B regarding med errors revealed: *She had started working there in May 2017 and worked night shifts. *She had worked the night shift on 6/29/17. *In report from the day charge nurse that day she had been told resident 2 had been having behaviors. -He had been given a dose of [MEDICATION NAME] that morning. *She completed the narcotic count with CNA/med aide D prior to him leaving his shift. *During the count she commented on resident 2's liquid [MEDICATION NAME] appearing less than the last time she worked. -She stated it was difficult to get an accurate count on the liquid [MEDICATION NAME] though due to the bottle and labeling. *CNA/med aide D told her he had given a dose earlier that morning. *At 10:30 p.m. that night CNA/med aide D called the facility. -He stated he thought he had given resident 2 the wrong dose of [MEDICATION NAME] that morning after he had thought about it more. *She immediately went to assess the resident and noted the resident was difficult to awaken, had a low blood pressure, and was hypoxic with low oxygen saturation levels in the 70s. *She applied oxygen on the resident and called the e-LTC physician to update on the med error and resident's status. *The e-LTC physician directed her to monitor the resident closely and continue the oxygen. *She continued to do vital signs and assessed the resident frequently during her night shift. *She thought the resident had slept until 1:00 p.m. the next day. *She was unsure if it was within a med aides role to administer liquid [MEDICATION NAME]. -She confirmed it was a high risk med. *She knew med aides were supposed to get direction from the nurse to give PRN meds. *She had not been told of any education or system changes since resident 2's significant med error had occurred. *She thought there was a nursing meeting scheduled for 8/3/17, but she was unsure what the education topics were going to be. Surveyor: Interview on 8/2/17 at 1:20 p.m. with LPN/QA nurse A revealed: *She had been the charge nurse working the day resident 2's medication error occurred. *He had been getting agitated, so she had directed the medication aide to give him some [MEDICATION NAME]. -She had been unaware that it was liquid [MEDICATION NAME]. -The facility usually had orders for the tablet form of [MEDICATION NAME]. -She was unaware what the facility policy for medication aides administering liquid [MEDICATION NAME] had been. *Throughout the remainder of her shift she had checked on him three times. -Each time he had been sleeping. -Her follow-up documentation stated the [MEDICATION NAME] had been effective. *She had been unaware that a medication error had occurred until she arrived to work the next day. -She would agree that had been a significant medication error. -Thinking about it 'made her sick.' 2. Review of resident 7's medical record revealed: *She had been admitted on [DATE]. *[DIAGNOSES REDACTED]. *She had a physician's orders [REDACTED].>-[MEDICATION NAME] tablet 220 mg by mouth two times a day for arthopathy. -[MEDICATION NAME] capsule (ziprasidone HCI) 40 mg by mouth two times a day for [MEDICAL CONDITION]. -[MEDICATION NAME] capsule 300 mg by mouth at bedtime for [MEDICAL CONDITION]. -[MEDICATION NAME] tablet 15 mg by mouth at bedtime for depressive episodes. Review of the 7/6/17 interdisciplinary progress note revealed: *On 7/6/17 at 9:30 p.m. the RN noticed the resident had not received her evening medications of [MEDICATION NAME], Ziprasidone, [MEDICATION NAME], and [MEDICATION NAME]. *The resident had been in bed by 9:30 p.m. Review of the medication incident report for 7/6/17 revealed: *The above mentioned medications had been scheduled for the PM medication pass. *Those times had been changed to earlier due to a request by the resident. *Staff education had been provided to check medication administration record and treatment administration record before the shift ending to confirm all medications had been given and/or communicated with the oncoming shift any medications left to be given. *No ill effects had been noted. Surveyor: 3. Review of resident 3's 6/1/17 through 8/1/17 interdisciplinary progress notes related to medication errors revealed: *On 6/20/17 at 2:01 p.m. Medication omission on 6/18/17; Mybetric ER 25 mg omitted in error during AM pass. No ill effects reported or observed. *On 6/27/17 at 10:40 a.m. on 6/1/17 inadvertently entered an order for [REDACTED]. Review of resident 3's medication incident reports for 6/1/17 through 8/1/17 revealed: *On 6/1/17 the report included: -Description of: received order for senna prn, was inadvertently entered as sched, resident received 32 doses before this was noticed. -Notes on 6/28/17 were See nurse notes. Staff education provided in regards to careful transcription of orders received. 24 hour check to also carefully review orders before signing off as this is our second check. No ill effect noted. physician and family notified. *On 6/18/17 the report included: -Description of: Medication, Myrbetriq ER 25 mg was omitted in error during AM pass. No ill effects were observed. -Note on 6/20/17 was Med omission on 6/18/17; Myrbetric ER 25 mg omitted in error during AM pass on 6/18/17. -Note on 6/21/17 was nurse aware of medication omission, no ill effects. Nurse to check cards carefully after each major medication pass and observe the Rights of medication administration. *The specific staff member who was involved with the med error was not identified. *Both reports had been revised on 6/28/17. *Immediate action taken had been left blank on both reports. Review of resident 3's investigation report for the above 6/1/17 med error revealed: *Date incident occurred: 6/1/17. *Date incident reported: 6/1/17. *Date(s) of investigation had a staff name written in it and no date. *There was no documentation to support: -If there had been any witnesses. -Who the caregivers/staff had been for the past seventy-two hours. -What time the incident had occurred. *Summarization of factors that might have contributed to that incident: Noted off order for Senna - entered as sched (scheduled) but order was for PRN (as needed) - med given as sched for 32 doses. *Actions taken to prevent recurrence of this incident: Employee education/training or re-instruction. -No documentation to support who required the education. *Who would complete the above corrective actions: DNS (director of nursing services). *Results of investigation: See nurse notes. Staff education to carefully check orders when transcribing and 24 hr. checking. -No documentation to support how that education was provided and the process for the accuracy checks. Review of resident 3's investigation report for the above 6/18/17 med error revealed: *Date incident occurred: 6/18/17. *Date incident reported was left blank. *Date(s) of investigation: 6/20/17 *There was no documentation to support: -If there had been any witnesses. -Who the caregivers/staff had been for the past seventy-two hours. -What time the incident had occurred. *Summarization of factors that might have contributed to that incident: Probably in a hurry; I usually check all cards (after) I have punched meds out. Evidently I missed this one. I will continue the checks I normally do. *Actions taken to prevent recurrence of that incident: Employee education/training or re-instruction. -No documentation to support who required the education. *Who would complete the above corrective actions: DNS. *Results of investigation: Staff education to check cards carefully after each major medication administration & observe the rights of med administration. -No documentation to support how that education was provided. 4. Review of resident 11's medication incident reports for 6/1/17 through 8/1/17 revealed: *On 7/2/17 the report included: -Description of: PM dose of [MEDICATION NAME] 5mg was missed on 7/2/17 when passing meds. -Immediate action taken was: Unaware of error until 7/3/17. -Notes on 7/5/17 were See nurse notes. Staff education to avoid distraction and observe the 10 Rights of medication administration. Nurse to not pop pills from cards until ready to administer to resident per policy. *The specific staff member who was involved with the med error was not identified. Review of resident 11's investigation report for the above 7/2/17 med error revealed: *Date incident occurred: 7/2/17. *Date incident reported was left blank. *Date(s) of investigation was left blank. *There was no documentation to support: -If there had been any witnesses. -Who the caregivers/staff had been for the past seventy-two hours. -What time the incident had occurred. *Summarization of factors that might have contributed to that incident: This nurse could not find the original card on 6/30 and used PM dose from a new card - on 7/2 punched the dose for 6/30. *Actions taken to prevent recurrence of that incident: -Employee education/training or re-instruction. -Will stop what I am doing when visitors or residents need to visit (with) me. -No documentation to support who required the education. *Who would complete the above corrective actions: DNS - nurse to avoid distractions & observe the 10 rights of medication administration. Nurse to not pop pill before ready to administer as per policy. *Results of investigation: See above - staff education. -No documentation to support how that education was provided. Surveyor: 5. Review resident 6's interdisciplinary progress notes related to a medication error revealed: *On 6/29/17 at 2:51 p.m.: -Transcription error discovered, resident received order for Tylenol 325 mg one po (orally) Q (every) 6 hours, was entered in MAR (medication administration record) as two tabs (tablets). -No ill effects noted. -MD (medical doctor) and wife notified. *No date documented to support when the medication error had occurred. Review of resident 6's investigation report for the above medication error revealed: *Date incident occurred: 6/14/17. *Date incident reported: 6/29/17. *Date(s) of investigation: 6/29/17. *No documentation to support: -If there had been any witnesses. -Who the caregivers/staff had been for the past seventy-two hours. -What time the incident had occurred. *Summarization of factors that might have contributed to that incident: Order for sched. (scheduled) Tylenol was transcribed incorrectly - entered for two tabs Q6 hours rather than one tab Q6 hours. *Actions taken to prevent recurrence of that incident: Employee education/training or re-instruction. -No documentation to support who required the education. *Who would complete the above corrective actions: DNS. *Results of investigation: Staff education to carefully take orders and 24 hr. (hour) check for accuracy. -No documentation to support how that education was provided and the process for the accuracy checks. Review of resident 6's 6/29/17 medcation incident report revealed: *On 7/5/17 the report had been revised and included: -Nursing Description: found that a transcription error has occurred, order for Tylenol on 6-14-17 was entered wrong, instead of one tab Q6 hours it was entered two tabs Q6 hours. -Immediate Action Taken: corrected in MAR, faxed MD and called wife to update. -Notes: See nurse notes. Transcription error. No ill effects noted. Physician and family notified. Staff education to carefully enter orders and 24 hours check for accuracy. *The specific staff member who was involved with the med error was not identified. *The report was not initiated until fifteen days after the medication error had occurred and had not been finalized for twenty-one days. *No documentation to support why there was a delay in initiating the report and finalizing the investigation. Surveyor: 6. Review of resident 4's medical record revealed: *[MEDICATION NAME] had been ordered 4/22/14 for back pain. *She was to get 50 milligrams twice daily. *She had a [DIAGNOSES REDACTED]. Review of resident 4's 7/16/17 interdisciplinary progress notes revealed: *At 7:02 a.m. it was noted the medication nurse had administered an extra 75 mg of [MEDICATION NAME] on 7/15/17 at the bedtime medication pass, in error. -No ill effects were noted. -Family and physician were notified. *At 8:02 a.m. no adverse effects. -The nurse would have continued to monitor. -Resident 4 verbally acknowledged her understanding. Review of the medication incident report dated 7/16/17 at 7:30 a.m. revealed: *The incident had occurred on 7/15/17, no time indicated. *Resident had been given an extra 75 mg of [MEDICATION NAME] at bedtime. *No adverse effects had been noted. *The nurse had accidentally popped out [MEDICATION NAME] 75 mg from another resident's card. -When counting narcotics the nurse thought she had forgotten the resident's 50 mg dose and gave it at that time. *Director of nursing services had spoken to the nurse on 7/17/17. -She wanted her to slow down and pay attention. -Observe the the rights of medication administration. Surveyor: Phone interview on 8/2/17 at 11:00 a.m. with LPN C regarding med errors revealed: *She had been working there since July 2016 and worked primarily on the night shift. *She recently had a med error for resident 4 in the evening. -When her and the night nurse were doing the narcotic count she thought she missed resident 4's dose and gave her her the scheduled dose at that time. -The next morning when doing the narcotic count again staff realized she had given the resident two doses of [MEDICATION NAME], one of which was a different residents. *On 7/30/17 she had missed a different resident's dose of an antidepressant. *She confirmed she had two medication errors in a couple weeks. *She confirmed she had not followed the rights of medication administration. *She had not received any education related to the med errors other than her and the other nurse talking about it. *The DON had followed up with her by phone later, but she had not received specific education. Surveyor: 7. Review of resident 5's medical record revealed: *His [DIAGNOSES REDACTED]. *[MEDICATION NAME]34 units every morning had been ordered on [DATE]. -That was a long acting insulin. *His blood sugar had been 175 in the morning. -He was on an insulin sliding scale, so he should have received 3 units of Humolog rapid acting insulin. -Instead he had received [MEDICATION NAME] 3 units. *His blood sugar at 11:00 a.m. was 339. Review of resident 5's interdisciplinary progress notes revealed: *On 7/19/17 at 5:46 p.m. it was noted the wrong insulin had been given. *The physician had been notified. Review of resident 5's medication incident report revealed: *The resident had received 3 units of [MEDICATION NAME]instead of 3 units of Humolog insulin. *No date of when the incident had happened. *Report was written 7/19/17 at 9:00 a.m. *Director of nursing services had spoken to the nurse on 7/20/17. -She wanted her to slow down. -Observe the the rights of medication administration. -Verify the medication to the medication administration record before administration. 8. Review of resident 8's complete medical record revealed: *On 4/5/17 she had been ordered [MEDICATION NAME] 5 mg for pain. -She had been titrated up to that dose. Review of resident 8's interdisciplinary progress notes revealed: *The nurse had inadvertently omitted the bedtime dose and it had not been given. *No increased pain was noted. *Her son and physician were notified. *Director of nursing services had spoken to the nurse on 7/20/17. -She wanted her to slow down. -Observe the the rights of medication administration. -Check medication cards after medication pass to ensure all meds had been passed. Surveyor: 9. Review of the provider's 8/1/17 risk management home screen on Point Click Care (PCC) revealed there had been two med errors in the last seven days and twenty-six med errors in the last six months. Review of the provider's historical risk management reports from May 2016 through 8/1/17 related to med errors revealed: *May 2016, two errors. *June 2016, one error. *July 2016, three errors. *August 2016, two errors. *September 2016, two errors. *October 2016, three errors. *November 2016, four errors. *December 2016, one error. *January 2017, two errors. *February 2017, three errors. *March 2017, six errors. *April 2017, five errors. *May 2017, one error. *June 2017, four errors. *July 2017, five errors. *Those med errors included wrong doses given, omission errors, transcription errors, wrong med given errors, and others. *The staff person that was involved with the med error was not listed in most of the reports. -The person who prepared the report was documented, and the notes were completed by the DON. Surveyor: Interview with the DON on 8/2/17 at 8:45 a.m. revealed: *She confirmed: -There had been an increase in medication errors for the past three to four months. -The investigations were incomplete, and should have identified the staff member involved in the medication error. -The improper dosing of the [MEDICATION NAME] had been considered a significant medication error. *She had provided verbal warnings and education on all of the above medications errors. -There was no documentation to support those verbal warnings. -She stated Verbal warnings and education are not documented. -She had instructed the staff members to review certain documents pertaining to medication administration. -She had no documentation to support the staff members had reviewed any of those documents. *There had been no corrective action provided for any of the medication errors thus far. *She could not identify a process on how she determined when corrective action should have occurred. *She stated (Staff member's name) was scared he was going to lose his job after giving too much [MEDICATION NAME]. I told him, no, but now if the resident had been hospitalized then he probably would have. *After resident 2's significant med error had occurred they discontinued the liquid [MEDICATION NAME]. -She confirmed that was a quick fix to the med error. *There had been no internal medication administration audits completed on the staff since the identification of an increase in med errors. -She stated The pharmacy consultant completes medication audits quarterly. *She had contacted the consultant pharmacist and was providing an in-service for the staff on 8/3/17. -That agenda had been provided to the surveyors upon request and stated med errors. Surveyor: Interview and record review on 8/2/17 at 9:15 a.m. with the staff development nurse regarding med errors revealed: *She had not been informed of med errors other than when they were talked about in quality assurance meetings. *She thought the DON handled the med errors and education to staff related to them. *She had not been told about resident 2's med error. -After reading the med error report she confirmed it was a significant error. -There should have been documented staff education to support the education had occurred. *For any med error caused by staff their education should have been documented to support it had been done. *As the staff development nurse she assisted with all staff education including for nurses and med aides. -As a result of the increase in med errors further staff training and education should have been completed. *She had started doing yearly competency audits of the nurses and med aides for medication administration. -She had not completed LPN C, LPN/QA nurse A, or RN B's competencies yet. -Certified nursing assistant (CNA)/med aide D's had been completed by the pharmacist in December 2016. *Review of the pharmacy's medication administration observation for CNA/med aide D included: -Three items reviewed had not met expectations and education had been provided. *She was unsure if it was within the med aides role to administer PRN [MEDICATION NAME] liquid. *She stated any PRN medication given by the med aide should have been directed by the nurse. Surveyor: Interview on 8/2/17 at 1:20 p.m. with LPN/QA nurse A revealed: *In her role as the facilities quality improvement coordinator she had been aware of the increased medication error rate. *The facility had not been working on improving the medication error rate in their quality improvement program. *She felt by removing the liquid [MEDICATION NAME] that medication error had been resolved. -All medication error reports were not brought to her attention. -It was unclear if there had been a tracking system to track who was responsible for each medication error. -No tracking or trending information had been provided to her. *She confirmed there might have been more systematic problems with the med errors. -They had not completed root cause analysis of the med errors. *She had access to the same risk management reports in PCC that the surveyors did. Surveyor: Interview on 8/2/17 at 2:15 p.m. with the DON, administrator, and the adminstrator-in-training regarding med errors revealed: *They confirmed there had been a rise in the numbers of med errors according to the risk management reports. -Those med errors included omissions, wrong doses given, medications given to the wrong resident, and transcription errors. *The corrective action and education to staff members involved had not been documented to support it had been done. *The investigations had not indicated which staff member had caused the error and they should have. *The discontinuation of the liquid [MEDICATION NAME] following resident 2's significant med error was a quick fix. -They had not completed a thorough investigation related to that error. *The DON thought the job descriptions or policies indicated which meds the med aides could have administered and which ones the nurses should have been administering. 10. Review of the provider's revised May 2016 Medication Errors policy revealed: *The location will ensure that it is free of medication error rates of five percent or greater and that residents are free of significant medicaiton errors . *Med errors consisted of the following: -Wrong med. -Wrong dose/amount. -Wrong form of med. -Wrong route. -Wrong time. -Wrong resident given the med/unauthorized med (drug administered without a physician's orders [REDACTED]. -Omission of a med ordered. -Use of outdated med. -Failure to document a med. *The procedure included to: -1. Document all medication error occurrences on a new active incident in the Risk Management module in PCC (point click care) . -2. Generate reports in PCC to use for monitoring and follow-up of medication errors. Reports such as incident analysis by type, incident report, administration records, Medication Admin Audit Report (choose all documented), order summary and progress notes and applicable UDAs (user defined assessments) may be helpful in monitoring and follow-up of medication errors. Reports may be generated to use for performance improvement when necessary. Review of the provider's revised May 2016 Medication Administration, Including Scheduling and Medication Aides policy revealed: *Dosage of high-risk medications (e.g. liquid narcotics, insulin) should be double-checked with another nurse prior to administration. *For medication administration by a certified medication aide: -Medication administration is a nursing task. A licensed nurse is accountable to practice in accordance with his or her scope of practice as defined in the respective state's nurse practice act. Nursing assessment is a function of the registered nurse. When the location utilizes medication aides, the delegating nurse is accountable for assessing a situation and making the final decision to delegate. -Prior to delegating The nurse verifies that the medication aide is competent to perform medication administration and supervises the performance of medication administration consistant with applicable state laws for medication administration. Review of the provider's April 2017 Medication Adminstration Education from the pharmacy revealed: *There were seven rights of accurate medication administration that included: -Right resident. -Right drug. -Right dose. -Right dosage form. -Right time. -Right route. -Right to refuse. *The process for oral medications included to ensure the medication matched the resident's medication administration record (MAR). -The med name, dosage, frequency, and directions should have all matched. -After dispensing visually check the MAR and med again to ensure accuracy. *Definitions of med errors were: -Administered contrary to the prescriber's orders, outside the manufacturer's specifications, and contrary to accepted professional standards. *A significant med error was .one which causes discomfort and/or jeopardizes the patient's health and safety. *An additional document stated there was ten rights to med administration that included: -Right drug. -Right patient. -Right dose. -Right route. -Right time and frequency. -Right documentation. -Right history and assessment. -Right to refuse. -Right drug-drug interaction and evaluation. -Right education and information. -Each of these rights should be carefully considered prior to the administration of any drug (legend or OTC). Failure to follow the nursing process, and failure to follow the ten (10) rights of drug administration, may almost certainly lead to more medication errors and harm to the patient the nurse is trying to help. Review of the provider's copy of Nurs

Based on observation, record review, interview, and policy review, the provider failed to prevent a left heel pressure ulcer and maintain treatment to prevent further breakdown of that ulcer for one of one sampled resident (1). Findings include: 1. Review of resident 1's medical record revealed she had returned from the hospital on [DATE]. Review of the resident's skin assessment flow sheet revealed: *On 12/2/11 a pressure ulcer had been identified. *The measurments had been 2.8 centimeters (cm) by 1 cm. It had no drainage but had been red in color and painful. *Further documentation on the skin assessment flow sheet had referred to Good Samaritan form 487, the wound flow sheet. Review of the wound flow sheet regarding resident 1's left heel pressure ulcer revealed: *There had been no documentation of the left heel pressure ulcer before 12/11/11. *On 12/11/11 the ulcer had been 3 cm in length, 2.9 cm in width, and had no drainage. *On 12/19/11 the ulcer had been 3 cm in length and 3 cm in width, had minimum drainage, and no odor. *On 12/23/11 under the progress towards healing notation it was recorded 3.8 cm by 3.5 cm with minimum drainage and no odor. *On 12/23/11 the weekly assessment had recorded there had been no drainage. -That contradicted the above progress toward healing report from that same wound flow sheet. *On 12/28/11 the ulcer measurements had been 3.8 cm by 4 cm with minimum drainage. *On 1/4/12 the measurements had been 3.9 cm by 2 cm and a depth of 0.02 cm with a moderate amount of drainage and had an odor on the old dressing. Review of resident 1's incident detail report dated 12/11/11 revealed: *She had a deep tissue injury to her left heel that: -Measured 3 cm by 2.9 cm. -Was necrotic in color. -Was nonblanchable. *Heel protecters had been put on, lotion had been applied, and her socks had been removed. *Family had been notified on 12/11/11. *The physician had not been notified until 12/13/11. *All nursing and therapy staff were to have been involved in the corrective actions of:-Heel protectors. -Floating heels. -Repostion every hour. *That report stated the she had returned to the facility with a Braden scale score of 12. -Documented Braden scale scores (an assessment for predicting pressure ulcer risk) had been 17 and 18 on those documented assessments. Review of resident 1's Braden scale score revealed she had scores of the following: *An 18 on 11/23/11. *A 17 on 11/30/11. *An 18 on 12/7/11. *An 18 on 12/14/11. Review of the Braden scale reference tool revealed: *Mild risk score of 15 to 18 interventions were to have included: -Protect heels. -Manage friction and shear. -Pressure-reduction support surfaces. Review of resident 1's comprehensive careplan dated 10/21/11 revealed: *She had returned from the hospital on [DATE]. *Her Braden risk score on 11/23/11 had been 18. *An air mattress had been placed on her bed on 11/30/11. *A cushion had been placed in her wheelchair on 11/30/11. *There had been no mention of skin care specific to her heels. Review of resident 1's short-term pressure ulcer care plan initiated 12/2/11 revealed the following approaches had not been added until: *On 12/12/11: -Repostion every hour. -Heel protectors to feet. -Float heels. *On 12/20/11: -Sheet cradle to bed to keep sheets and blankets off toes. -No socks, just for transferring. Review of resident 1's pressure ulcer monitoring form revealed: *Daily monitoring and documenting of the left heel was to have been done. That had included: -Evaluation of the ulcer if it had no dressing. -Evaluation of the staus of the dressing. -Status of the area surrounding the ulcer. -Presence of possible complications. -Pain and pain control. *For information only the following instructions had been included on the pressure ulcer monitoring form: -Twice weekly documentation of the skin assessment flow sheet for information only. -Treatments as ordered for information only. -Notify dietary. -Notify physician for recommendations. -Report to certified nurse aide each shift. *There had been no initials on December 17, 18, 20, 21, 26, 28, 30, and 31 that would have indicated the pressure ulcer monitoring had been completed. Interview with the director of nurses on 1/5/12 at 9:30 a.m. regarding the pressure ulcer monitoring form revealed: *There was no further daily documentation that would have been completed other than the pressure ulcer monitoring form. *By initialing the form it had indicated nothing would have changed; it (the ulcer) was relatively the same. Observations on 1/4/12 at 3:40 p.m., 4:55 p.m., 5:15 p.m., and 5:30 p.m. revealed resident 1's left and right heels were laying directly on the sheet covered air mattress. Her heels had not been floated, and she did not have heel protectors on. There had not been a sheet cradle used. Observations on 1/5/12 at 7:30 a.m., 8:00 a.m., and 8:30 a.m. revealed resident 1's heels had been laying directly on the sheet covered air mattress with heel protectors on. Her heels had not been floated, and there had not been a sheet cradle used. Review of the provider's wound and pressure ulcer management policy dated November 2002 revealed wound care programs and pressure ulcer guidelines had been developed and implemented. They were to ensure that quality services had been provided to the residents. Review of the provider's pressure ulcer policy dated March 2007 revealed: *Residents would have received appropriate assessments and services to promote and maintain skin intergrity. *If a resident's clinical condition would have made compromise of skin integrity clinically unavoidable that information would have been documented in the resident's medical record. Review of the provider's pressure ulcer guidlines dated September 2010 revealed: *Prevention startegies should have been developed and implemented at the time of admission. That would have been based on inital assessments and causitive factors that would have contributed to the resident's risk for skin breakdown. *An evaluation of an in-house-acquired pressure ulcer was to have been completed to determine why the pressure ulcer had developed. It was to identify interventions that would have assisted in preventing and worsening of the pressure ulcer for the resident.

Based on observation, record review, interview, and policy review, the provider failed to individualize care for one of one sampled residents (1) who acquired a pressure ulcer. Findings include: 1. Review of resident 1's medical record revealed: *She had returned to the facility from the hospital on [DATE]. *She had acquired a pressure ulcer to her left heel on 12/2/11. *She had been assessed on 11/23/11, 11/30/11, 12/7/11, and 12/14/11 with a mild risk for developing a pressure ulcer per the Braden scale scores. *Her Braden scores had been conflicting on the 12/11/11 incident report and the Braden scale scores form. *No intervention for heel protection had been implemented until 12/12/11. Refer to F314.