Every finding on record at Good Samaritan Society Sioux Falls Center

Based on South Dakota Department of Health (SD DOH) facility reported Incident (FRI), interview, and policy review, the provider failed to protect three of three residents (1, 2, and 3) from verbal abuse by certified nursing assistant (CNA) D who yelled and cursed at resident 1, slammed resident 2's door after the resident requested to be assisted by a female staff member, and yelled at resident 3, who needed assistance with his colostomy (a surgically created opening in the abdomen that collects stool) bag. Resident 1 expressed feeling mad about his treatment by CNA D, resident 2 reported hearing resident 3 cry, and resident 3 was reported by licensed practical nurse (LPN) C to have cried and expressed statements of emotional stress after his treatment by CNA D.Findings Include: 1. Review of the 3/3/26 SD DOH FRI revealed that on 3/3/26 at 3:15 a.m., resident 1 reported to licensed practical nurse (LPN) C that CNA D yelled and cursed at him and then resident 1 told CNA D to leave his room.LPN C then answered resident 2's call light, who stated that CNA D became upset with resident 2 when resident 2 asked for a female CNA to help put her in bed. CNA D then left resident 2's room and slammed the door.Resident 2 reported to LPN C that she heard resident 3 crying when CNA D was in his room. LPN C interviewed resident 3 and he reported that he was trying to explain to CNA D how to empty his colostomy bag and CNA D yelled at him.LPN C notified administrator A of the events, and CNA D's employment was suspended on 3/3/26 while the provider conducted and investigation.2. Interview on 3/18/26 at 2:45 p.m. with resident 1 revealed that he recalled the incident where CNA D yelled at him. Resident 1 activated his call light because he needed help after having a bowel movement. He reported that CNA D had a bad attitude that day and in the past while assisting him. Resident 1 stated he asked me what the [curse word] do you want? I got mad at him and told him to get the hell out of my room.3. Review of resident 1's electronic medical record (EMR) revealed that his 1/27/26 Brief Interview for Mental Status (BIMS) score was 11 (indicating moderate cognitive impairment). His medical diagnoses included above the knee amputation and end stage renal disease requiring dialysis.4. Interview on 3/18/26 at 3:50 p.m. with resident 2 revealed that she recalled the incident with CNA D. She reported that she had activated her call light to get help getting into bed. When CNA D came to her room, she requested a female staff member help her to bed. She stated that she had never had any issues with CNA D in the past, but he became upset, left her room and slammed the resident's door closed.Resident 2 then stated that not long after CNA D left her room, she could hear CNA D arguing with resident 3 who resided across the hallway from resident 2. She reported that she could hear resident 3 crying.5. Review of resident 2's EMR revealed that her 1/8/26 BIMS score was 15 (indicating she was cognitively intact). She had medical diagnoses that included multiple sclerosis (disease of the nervous system, causing communication issues between the brain and body).6. Interview on 3/18/26 at 4:05 p.m. with administrator A revealed that CNA D was employed at the facility for a couple of months when the 3/3/26 incident happened. Administrator A was notified of the incident by LPN C and told her to send CNA D home. Administrator A reported that CNA D denied the allegations made by residents 1, 2, and 3. The provider's investigation confirmed their allegations and CNA D's employment at the facility was terminated.7. Phone interview on 3/19/26 at 9:00 a.m. with LPN C revealed that she recalled the above incidents regarding CNA D. She was notified by resident 1 that CNA D was verbally abusive to him. She confirmed that when CNA D became upset with resident 2 and slammed resident 2's door. She confirmed that when she went to check on resident 3, he was crying. Resident 3 made the statement I'm sorry I'm alive and such a burden. LPN C was able to help resident 3 calm down by apologizing for how resident 3 had been treated and reassuring him that he was not a burden. 8. Interview on 3/19/26 at 9:45 a.m. with resident 3 revealed he recalled the incident with CNA D. Resident 3 had requested to have his colostomy bag emptied and CNA D did not know how to empty it. Resident 3 stated that he wanted CNA D to find another staff member to assist him, but CNA D refused to request help from another staff member. CNA D started to shout at resident 3 in a non-English language and then left the room. Resident 3 indicated CNA D had a bad attitude.9. Review of resident 3's EMR revealed that his 1/5/26 BIMS score was 10 (indicating moderate cognitive impairment). Resident 3's medical diagnoses included Quadriplegia (paralysis affecting all four limbs and torso) and a colostomy.10. The provider's implemented actions to ensure the deficient practice does not reoccur were confirmed on 3/19/26 after record reviews revealed that CNA D's employment was terminated and all staff completed education and policy review regarding abuse and neglect by 3/13/26. All residents with a Brief Interview of Mental Status (BIMS) score of 13 (which indicated their cognition was intact) or greater were interviewed to ensure they felt safe in the facility. Weekly resident interviews and audits regarding resident's feeling of safety and being treated with respect by staff were to continue for six weeks. Audit results would be presented to the QAPI (quality assurance/process improvement) committee for review and recommendations. 11. Review of the provider's 4/7/25 abuse and neglect policy revealed a purpose To ensure the location has an effective system in place that, regardless of the source, prevents mistreatment, neglect, exploitation and abuse of residents/clients and misappropriation of their property. The policy indicated The resident/client has the right to be free from abuse, neglect, misappropriation of resident/client property and exploitation. and that Resident/clients must be subjected to abuse by anyone, including, but not limited to, location employee, other resident/clients, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals.Based on the above information, non-compliance at F600 occurred on 3/3/26, and based on the provider's 3/13/26 implemented corrective actions for the deficient practice confirmed on 3/19/26, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff provided necessary care for four of four sampled residents (1, 2, 3, and 4) who did not receive a bath, bed bath, or shower as scheduled during the reviewed months of February 2026 and March 2026. Findings include: 1. Observation and interview on 3/18/26 at 11:05 a.m. with resident 4 revealed a strong smell of urine coming from his room with the door closed. The urine smell was stronger when the resident's door was opened. Resident 4 was in his wheelchair and wheeled himself out of his bathroom. There was an incontinence (involuntary urine or bowel leakage) protection pad on his bed. There were large urine stains on his bed sheets and incontinence protection pad. There was an empty urinal (a container used to urinate in) on his overbed table. Resident 4 appeared not to have showered or bathed in some time. His skin was dry and flaky, and his hair was greasy and tangled. He confirmed he required assistance with bathing and wished that he could get a bath or shower more than once per week. He expressed excitement about tomorrow (3/19/26) as Thursdays were his scheduled bath days. Observation on 3/18/26 at 2:35 p.m. in resident 4's room revealed that certified nurse aide (CNA) E was changing resident 4's bed linens. 2. Interview on 3/18/26 at 4:43 p.m. with CNA E revealed that resident 4 did not like assistance from the staff. He noticed the strong urine smell coming from resident 4's room and asked the resident if he would like his bed linens to be changed. CNA E stated that resident 4 did not always accept assistance from the staff as he wanted to remain as independent as possible, but he got permission from the resident to change his sheets and his clothes that day. 3. Observation on 3/19/26 at around 10:15 a.m. revealed that resident 4 was being wheeled back to his room by bath aide F, appearing freshly bathed. 4. Interview on 3/19/26 at 12:20 p.m. with administrator A revealed that he was aware of the strong smell around resident 4's room. He mentioned that the resident was very strong natured and strong willed, and did not always accept assistance from the staff. They removed the carpet from his room and replaced it with wood laminate flooring, which made it easier to clean. If the resident was not allowing the staff to assist him, administrator A expected the staff to explain to resident 4 the purpose and importance of cleaning his room, changing his bedding, and changing his clothes. The housekeepers were aware of prioritizing cleaning his room as the resident allowed. 5. Review of resident 4's electronic medical record (EMR) revealed that his care plan did not include his bathing or showering preference or how often he preferred to be bathed. There was a focus area that read, The resident has an ADL [activities of daily living] self care performance deficit R/T [related to] CHF [congestive heart failure], hypothyroidism [a condition where the thyroid gland is under-performing] E/B [evidenced by] Activity intolerance. Two associated interventions read, BATHING: Resident requires assist [the assistance] of 1 staff [member], and PERSONAL HYGIENE: requires assist x [of] 1 [staff member], which were initiated on 12/24/20, and revised on 3/18/24. Review of resident 4's bathing documentation revealed that in the month of March 2026, he received a whirlpool bath on 3/19/26 and there were no bathing refusals by the resident documented. There was no other documentation that be received a bath, bed bath, or shower until 3/19/26. In February 2026, his last documented whirlpool bath was on 2/24/26 and there were no bathing refusals by the resident documented. According to that bathing documentation, the resident went 23 days without receiving a bath or a shower. 6. Interview on 3/18/26 at 2:45 p.m. with resident 1 revealed that he had missed his showers in recent weeks. When asked how many showers, he replied well the bath aide was gone for two weeks. Then I missed a bath because I was at an appointment. He stated that he was showered today (3/18/26). He then stated I felt gross.7. Review of resident 1's bathing documentation review revealed that he had a whirlpool bath documented on 2/18/26. The next documented whirlpool bath was on 3/18/26. There were no resident bathing refusals documented. According to that documentation, the resident went 16 days without receiving a bath or shower.8. Interview on 3/19/26 at 9:45 a.m. with resident 3 revealed that he does not always receive his baths as scheduled. He said sometimes they don't have a bath aide. He felt that missing baths did not happen frequently, but it does happen.9. Review of resident 3's bathing documentation record revealed that he received a whirlpool bath on 2/20/26. The next documented bath was a bed bath on 3/6/26. There were no resident bathing refusals documented. According to the documentation, the resident went 14 days without receiving a bath or a shower.10. Review of resident 2's bathing documentation record revealed that she had a shower documented on 2/24/26. The next documented shower was on 3/17/26. There were no resident bathing refusals documented. According to the documentation, the resident went 21 days without receiving bath or a shower.11. Interview on 3/19/26 at 3:15 p.m. with interim director of nursing (DON) B revealed that residents were to receive a bath each week. There was a schedule that identified which residents were to be bathed each day. She stated that when bath aide F was on vacation, there were CNAs assigned each day to provide the residents' scheduled baths.12. Interview on 3/19/26 at 4:00 p.m. with administrator A revealed he expected the residents to receive a bath once per week. He stated that when bath aide F was on vacation, there was a plan in place to ensure all residents received their weekly bathing. He did not indicate what the plan was.13. Interview on 3/19/26 with bath aide F revealed that she was a full-time bath aide for the past year and was a CNA at the facility for about six years. She reported that she was responsible for giving 14 residents baths per day. Resident baths were scheduled to be given Monday through Friday each week. She was on vacation from 2/23/26 through 3/8/26. She stated that there were times when she was reassigned to work as a CNA, and the residents did not receive baths when that happened.14. Review of the provider's staff schedule from 2/23/26 through 3/8/26 revealed that during bath aide F's vacation, five of ten weekdays did not have a staff member assigned to provide baths to the residents.15. Review of the providers 12/22/25 bathing policy revealed To promote cleanliness and general hygiene, To stimulate circulation of the skin, To promote comfort, relaxation, and well-being, To observe resident's condition, To assist resident with personal care, To promote safety for the resident in the bath.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, observation, record review, and policy review, the provider failed to ensure the safety and staff supervision of seven of seven sampled residents (1, 2, 3, 4, 5, 7, and 8) identified as needing supervision while smoking to prevent physical injury or harm, and specifically one of one sampled resident (1) who subsequently sustained a burn to his face. Findings include:1. Review of the 12/11/25 SD DOH FRI revealed:*On 12/11/25 at 10:20 p.m., resident 1 informed registered nurse (RN) M that he went outside into the facility's enclosed courtyard to smoke. When resident 1 lit his cigarette, an ember began to smolder in his winter hat. He removed his hat and placed it in the snow.*Resident 1 knew the door code to the locked exit door and did not inform any staff members before going out into the enclosed courtyard.*The camera footage review completed by administrator A revealed:-Resident 1 and resident 2 entered the courtyard at 10:20 p.m. At 10:21 p.m., resident 1 tilted his head downward while wearing a brimmed hat, and the brim of the hat began smoldering when the hat touched the lit cigarette. Resident 1's beard was singed near his ear.-Resident 2 assisted resident 1 to put out the smoldering hat.-Both residents remained in the courtyard to finish their cigarettes and entered the facility at 10:26 p.m. and told RN M what had occurred.*RN M completed a skin assessment of resident 1, which revealed a reddened area to the top of his head by his hairline, his beard area on the left side of his face near his ear, and on his left cheekbone, with skin remaining intact. Resident 1 denied pain. RN M applied a cold washcloth to those areas for comfort.*RN M completed a skin assessment of resident 2, and no injury was identified.*Resident 2 stated he knew the door code and, without notifying any staff members, he entered the door code, which deactivated the door alarm, so that he and resident 1 could enter the courtyard to smoke.*Resident 1 and resident 2 were educated on the facility's smoking protocol. Tobacco Use Assessments were completed on all residents who smoked at the facility, and a resident smoking council meeting was held on 12/17/25.*Education was provided to all staff members to ensure the door code remains unknown to the residents.*Resident 1's family provided smokeless/vaping alternatives for resident 1 to prevent future incidents from occurring.*The facility purchased fire-resistant beard covering for resident 1 to wear while vaping in the courtyard.*Maintenance supervisor P evaluated the door, alarms, and magnetic locks to ensure all were functioning, and changed the code to the door leading to the courtyard. 2. Observation and review of the provider's sign-out book on 2/3/26 at 8:00 a.m., revealed:*Resident 3 was outside the front door of the facility in his power wheelchair, picking up cigarette butts off the ground with his reacher stick (a device used to increase a person's reach to grab objects).*He did not sign out in the sign-out book located on the windowsill of the closed receptionist's window at the front door. 3. Review of resident 1's Electronic Medical Record (EMR) revealed:*He was admitted to the facility on [DATE].*His 12/11/25 Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated his cognition was moderately impaired.*His diagnoses included Multiple Sclerosis (a chronic, often disabling autoimmune disease of the central nervous system), paraplegia (the inability to voluntarily move the lower parts of the body), intellectual disability, and tobacco use.*His 4/26/25 Tobacco Use Evaluation indicated it was related to: Smoking/Vaping.- Has the resident had any incidents of dropping a cigarette, falling asleep while smoking, burning self, furniture or clothing, or other unacceptable tobacco-related behavior in the past? was marked yes and resident with previous incident- new safety implementations placed.--It did not indicate what those safety implementations included.-Resident 1 needed supervision during smoking times for safety reasons, was sometimes able to light his own cigarette, and required a smoking apron and supervision.*There was no documentation that a Tobacco Use Evaluation was completed quarterly in July or in November 2025. *A 12/11/25 incident report indicated resident 1 reported to his nurse that he went outside to smoke and his lighter ignited his hat.-The nurse's assessment revealed a minor burn to the frontal hairline, beard area, and left cheekbone.-Resident did not inform staff prior to going outside.*His 12/11/25 Tobacco Use Evaluation indicated it was related to: Smoking/Vaping.-Resident 1 had dexterity problems that affected his ability to smoke/vape, needed assistance opening doors, and his cognition was moderately impaired. He had a previous incident of burning clothing and needed supervision during smoking times for safety reasons. He was sometimes able to light his own cigarette and safely operate his e-cigarette device, and required a smoking apron and supervision.*His care plan indicated:-A 3/24/24 Focus area that The resident has a history of elopement R/T [related to] disregard for signing himself out and neglecting to advise staff that he was leaving the building, with a goal that the resident will not leave the facility unattended except for planned community outings.-A 3/24/24 Focus area that The resident uses tobacco products E/B [evidenced by] use of cigarettes/e-cig. Interventions included. remind resident to utilize smoking safety equipment including smoking apron, fire retardant jacket and flame retardant beard protector.- Resident must have staff accompany him when he smokes.- Resident allowed to have cigarettes in [his] room. Encourage resident [1] to keep [his] lighter at [the] nurse's station. Resident [1] routinely refuses to return [his] lighter. Continue to provide education of risks associated with the lighter in the room.*There was no documentation that resident 1 vaped or where his vape was stored. 4. Review of resident 2's EMR revealed:*He was admitted to the facility on [DATE].*His 11/20/25 BIMS assessment score was 15, which indicated his cognition was intact.*His 9/16/24 Tobacco Use Evaluation indicated Resident able to use cigarettes independently, however, facility protocol states residents to be supervised while smoking, and he required a smoking apron and supervision.*There was no documentation that a Tobacco Use Evaluation was completed quarterly or annually between 9/16/24 and 12/16/25.*His 12/16/25 Tobacco Use Evaluation indicated he required a smoking apron and supervision.*His care plan had an 11/27/25 goal that Resident [2] will safely use tobacco products in designated areas. Interventions included, Facility protocol states that all residents are to be supervised while smoking. Resident [2 is] known to go out to the courtyard on [his] own. He was provided with and expected to follow designated smoking times, to wear a smoking apron, and to store his lighter at the nurse's station. Resident [was] known to refuse to give up [his] lighter. 5. Review of resident 3's EMR revealed:*He was admitted to the facility on [DATE].*His 11/28/25 BIMS assessment score was 15, which indicated his cognition was intact.*His 12/16/25 Tobacco Use Evaluation indicated he required a smoking apron and supervision.*His care plan had a 1/6/26 goal that he would safely use tobacco products in designated areas.-Interventions included:-- Resident [3] is independent with tobacco use per assessment; however, per facility protocol, [he] will only smoke in designated areas with supervision at all times. Resident 3 was known to be non-compliant, and education was provided on the importance of his compliance.--Resident 3 was to be supervised at all times and allowed to smoke in the courtyard only.-- Put smoking apron on resident.-- Keep lighter at nurses' station. Resident 3 was known to refuse to hand over [his] lighter. 6. Review of resident 4's EMR revealed:*She was admitted on [DATE].*Her 11/26/25 BIMS assessment score was 15, which indicated her cognition was intact.*Her 3/12/24 Tobacco Use Evaluation indicated that she was educated on smoking/vaping in designated areas. There was no adaptive equipment needed for resident safety. There was no indication of what level of supervision she required.*There was no documentation that a Tobacco Use Evaluation was completed quarterly or annually since 3/12/24.*Her 4/3/24 updated care plan indicated she used tobacco products with a goal that she would safely use tobacco products in [the] designated area. Interventions included that she was able to smoke with supervision in designated smoking areas while on facility property, she was to face the windows if the staff members were unable to be outside with her. She was encouraged to wear two smoking aprons at all times, one across her chest and one across her legs for safety. She often refused the second apron. Continue to encourage. She was allowed to have her cigarettes in her room. Encourage [the] resident to keep [her] lighter at the nurses station. 7. Review of resident 5's EMR revealed:*She was admitted on [DATE].*Her 1/14/26 BIMS assessment score was 15, which indicated her cognition was intact.*Her 12/16/25 Tobacco Use Evaluation indicated that she was needing more help with ADL's [activities of daily living], wore oxygen, was able to remove her oxygen when she smoked, was sometimes able to light her own cigarette, and required a smoking apron and supervision.*Her 9/9/25 updated care plan indicated she used tobacco products with a goal that she would safely use tobacco products in [the] designated area. Interventions included that she was independent with tobacco use. She understood and followed the smoking schedule. Remove the resident's oxygen prior to smoking. put smoking apron on [the] resident, and monitor resident during the use of smoking. 8. Interview on 2/3/26 at 8:41 a.m. with resident 3 in his room revealed:*There were changes made to the smoking policy after resident 1 burned himself while smoking. There were specific times when he was allowed to smoke in the courtyard, and the door code to the courtyard was changed. He was not allowed to know the new door code.*He thought that staff members were required to stay by the courtyard doors when he went out to smoke in the courtyard, but they did not. He was frustrated that there were times he got stuck out there waiting for the staff to answer the doorbell to let him back inside.*He was independent with his power wheelchair for his mobility and preferred to smoke outside the front of the facility building because he was allowed to go out there to smoke anytime.*He kept his cigarettes and his lighter with him and did not need to let staff members know when he went outside the front doors to smoke.*He was told that he needed to sign out in the book on the receptionist's desk when he left the facility and to go across the street or down to the corner of the block to smoke. He smoked outside the facility's front doors when it was cold in the evening or early in the morning. He was not sure if he had signed out in that book when he went outside to smoke that morning (2/3/26).*He used his reacher stick to pick up the cigarette butts on the ground outside the facility's front doors because there was no receptacle for them. He knew that other residents smoked out there, and he didn't want the staff members to have to clean up after them because then the staff members would not let him smoke out there.*The front doors of the facility were not locked during the day and would open automatically for him. He knew the front door code, and he entered and exited the facility through those doors in the evening and on the weekends, when the receptionist was not working. 9. Observation and interview on 2/3/26 at 8:50 a.m. with resident 2 in his room revealed:*He recalled the evening that resident 1's hat caught on fire while he was in the courtyard smoking. He had helped resident 1 remove his hat and had thrown the hat on the ground to put out the fire. He did not think resident 1 was hurt, but was frustrated that the smoking rules changed after that incident.*He was independent with his power wheelchair for his mobility and was allowed to smoke in the courtyard or to leave through the front doors and smoke out front and down a block.*There were no specific times when he smoked. He kept his cigarettes and his lighter with him and went outside through the front doors of the facility to smoke whenever he wanted. He did not need to tell the staff members or sign out in a book.*He did not smoke in the courtyard very often because there were specific times, he did not know the door code, and he did not like waiting for staff to answer the doorbell to let him back inside when it was cold. He knew the code to the front doors of the facility and did not have to wait for staff to help him.*He needed to wear a smoking apron if he smoked in the courtyard, but did not wear one when he smoked out front. 10. Observation on 2/3/26 at 8:59 a.m. of the resident smoking area revealed:*The smoking area was in the courtyard, located outside the activities room. There was a locked door with a keypad.*There were smoking aprons, an umbrella, and a fire blanket near the door.*The sign posted on the door indicated there were five scheduled smoking times. The first scheduled smoking time was half an hour from 6:30 a.m. to 7:00 a.m. The remaining four scheduled times were for one hour, with the last scheduled smoking time scheduled from 6:00 p.m. to 7:00 p.m.*There were several cigarette butts on the ground. There was a large outdoor cigarette receptacle for cigarette butts. What appeared to be a ceramic bowl and a tin can on the table also contained cigarette butts. 11. Interview on 2/3/26 at 9:03 a.m. with certified medication assistant (CMA) F regarding residents who smoked revealed:*She worked on both day and evening shifts.*She knew which residents smoked and if they kept their cigarettes or lighters with them or if those items were stored at the nurses' station, because it was listed in the residents' care plan (personalized plan that addresses a resident's care needs, goals, and interventions).*Residents were care planned to smoke in the courtyard, but she knew at least two residents, resident 2 and resident 3 would go outside the front doors to smoke without staff assistance.*The courtyard door code was recently changed, and there were specific times when residents were allowed to smoke in the courtyard. She thought there were five times during each day and that those times were for approximately half an hour each.*She was aware that a resident was burned while smoking about a month ago. She was not working that day. It was after that incident that the courtyard door code was changed, and the facility began enforcing specific smoking times. Before that incident, residents were constantly wanting to be let in and out of the courtyard doors, and it was chaotic.*During the day, the activities staff members let residents who smoked in and out of the courtyard doors.*When the activities staff members were not working (during the first and last scheduled smoking times and on the weekend), the nursing staff let the residents out into the courtyard to smoke by entering the door code, and then let them back in when they rang the doorbell.*There were no specific nursing staff members assigned to assist or supervise the residents when they smoked during the scheduled times. She felt like all the staff members worked as a team to let the residents outside in the courtyard and to answer the doorbell when the residents wanted to come back in.*Most residents had their own cigarettes and lighters and were able to smoke without staff assistance. She knew that two residents who were not smoking very frequently had their cigarettes and lighters stored at the nurses' station. 12. Interview on 2/3/26 at 9:21 a.m. with CMA D regarding residents who smoked revealed:*Most residents were allowed to keep their cigarettes with them in their rooms, but all resident lighters were to be stored at the nurse's station. He knew that residents 2 and 3 refused to return their lighters and kept them in their rooms.*There was a change in the smoking policy about a month ago, after resident 1 was burned while smoking. The courtyard door code was changed, and residents were no longer allowed to go in and out of the courtyard on their own to smoke. A staff member had to enter the door code to let them out and answer the doorbell when the residents wanted to come back in. 13. Observation and interview on 2/3/26 at 9:27 a.m. of the residents' smoking area with activities director (AD) C revealed:*There were between eight and ten residents who smoked each day outside in the courtyard during the scheduled smoking times.*The new smoking times were scheduled so that the residents' smoking times did not interfere with the activities that were scheduled in the activities room. A schedule of activities was posted on the door to the courtyard to remind residents who smoked of those activity times, because opening and closing the courtyard door allowed the cold air and smoke from outside to drift into the activities room.*Activities staff members took turns assisting the residents who smoked by entering the courtyard door code and assisting the residents through the doors during the day, but the nursing staff assisted residents on the weekends and for the first and last scheduled smoking times during the week, when the activities staff were not working.*When it was nice outside, she would sit outside with the residents, but when it was cold, she watched the residents from the window next to the door.*Resident 4 and resident 7 were outside smoking, both of whom wore a smoking apron. They were facing away from the window and door. AD C stated that she liked it when the residents faced the door and window, but it was their right to move about outside in the courtyard while they smoked.*She assisted some residents with lighting their cigarettes, and others were able to light their own.*She thought all the residents who currently smoked kept their cigarettes with them in their rooms, and most of the residents had their own lighters.*Residents were allowed to leave the facility grounds to smoke by going directly across the street or down the sidewalk to the end of the facility grounds. 14. Observation and interview on 2/3/26 at 9:43 a.m. at the nurses' station with CMA F revealed:*A basket on the counter contained two lighters and two packs of cigarettes labeled with resident 9's name and one pack of cigarettes labeled with resident 10's name.*CMA F stated that residents 9 and 10 were not allowed to keep their cigarettes or their lighters in their rooms. 15. Observation and interview on 2/3/26 at 11:51 with resident 1 in his room revealed:*He used a power wheelchair for mobility. He sat with his power wheelchair reclined and had a hard time holding his head up when he spoke. He wore a brimmed hat and rested his head downward between each response.*He remembered his hat and beard were burned when he went outside to smoke about a month ago with resident 2.*Resident 2 knew the door code and was able to hold the door open for him. Staff did not go outside with him when he smoked.*His brother provided him with a vape, and he was told he needed to use that now when he wanted to smoke. He kept that vape with him and in his room. 16. Observation on 2/3/26 at 12:32 p.m. of the residents' courtyard smoking area revealed:*Resident 5 arrived at the courtyard door in her power wheelchair and put on a smoking apron.*Activities assistant G entered a code on the keypad and opened the courtyard door for resident 5 to enter the courtyard, then returned to her desk behind the partition wall.*Resident 8 arrived at the courtyard door in his power wheelchair and put on a smoking apron.*Activities assistant G entered a code on the keypad and opened the courtyard door for resident 8 to enter the courtyard, then walked away from the doors.*Resident 4 arrived at the courtyard door with her walker, and resident 7 arrived in her wheelchair. They each put on a smoking apron, and activities assistant G repeated the task of entering the door code to allow them to enter the courtyard.*While residents were in the courtyard, smoking activities assistant G carried items from the cabinets to her desk, assisted a resident who was leaving the dining room, and sat at her desk behind the partition wall. She occasionally looked out the window next to the door.*Resident 3 drove past the courtyard door in his electric wheelchair and told the surveyor he was going to the front of the facility to smoke because he did not like smoking in the courtyard, because he could not get back in.*When residents rang the doorbell, activities assistant G returned to the door and entered the code so the residents could come inside.*Activities assistant G did not provide cigarettes or lighters to any residents, did not assist the residents with lighting their cigarettes, or attempt to collect any cigarettes or lighters when the residents came inside from smoking. 17. Interview on 2/3/26 at 12:56 p.m. with activities assistant G regarding residents smoking revealed:*She confirmed that all residents had come back inside after smoking.*Each resident had their own cigarettes and lighter, and she did not need to assist those residents with lighting their cigarettes. The one resident who needed assistance with lighting his cigarette did not smoke at that time.*Residents did not know the new door code, and she assisted the residents by entering the door code and opening the door.*She was not allowed to leave the activities room while residents were outside smoking because she needed to enter the door code and let them back in when they were finished smoking. She did not need to stand at the door because she could hear the doorbell anywhere in the activities room.*Resident 1 arrived at the courtyard door, and activities assistant G assisted him in putting on a smoking apron. She stated that resident 1 vaped most of the time but occasionally bummed cigarettes from other residents. Activities assistant G entered the door code and opened the door so that resident 1 could go outside into the courtyard.-She did not put a flame-retardant beard protector on resident 1. 18. Interview on 2/3/26 at 1:47 p.m. with minimum data set/registered nurse (MDS/RN) O regarding residents who smoked revealed:*She completed a Tobacco Use Evaluation on all the residents who smoked when they were admitted , quarterly, annually, and with any significant changes regarding their care needs.*She observed the resident while they smoked to determine if they required assistance with lighting their cigarettes, if they needed to wear a smoking apron, or if there were any issues with their safety.*Some residents were independent with smoking, and other residents required supervision. She thought only a couple of residents required assistance with smoking.*She confirmed residents 1, 2, 3, 4, 5, 7, and 8 required supervision when they smoked in the courtyard during the designated smoking times.*She reviewed the smoking rules with the residents when she completed their Tobacco Use Evaluations and expected the residents to smoke in the courtyard during the designated smoking times.*Staff members were expected to sit outside with the residents or stand at the window to supervise while the residents were outside smoking.*Some residents were allowed to leave the facility to smoke. They needed to leave the facility property and were not allowed to smoke near the front doors of the facility, but not all the residents followed the smoking rules.*Residents 9 and 10 were not allowed to keep their cigarettes and lighters with them. They were stored at the nurses' station.*She used the same Tobacco Use Evaluation for residents who vaped or smoked.*Resident 1 vaped and was allowed to keep his vape with him in his room.*Resident care plans indicated whether residents were independent or what level of assistance a resident required when they smoked. 19. Interview on 2/3/26 at 4:12 p.m. with RN M revealed:*On 12/11/25, sometime after 10:00 p.m., resident 1 told her that he and resident 2 were outside in the courtyard smoking and that his hat had caught on fire. They did not notify her or any other staff that they were going out there.*The residents had an evening smoking time, she thought, around 6:00 p.m. to 7:00 p.m., and the nursing staff members assisted residents into the courtyard to smoke and then answered the doorbell when they were ready to come back inside. Residents were not allowed in the courtyard after 7:00 p.m.*She completed a skin assessment of resident 1 at that time and found a small burn to his forehead and his cheekbone. The front of his hair, his beard, and his left eyebrow were burned and smelled like smoke. Resident 1 stated he did not have any pain, but she placed a cool washcloth over those areas to clean and cool them.*She reported the incident to resident 1's brother, his physician, and the administrative staff members. Resident 1 used a vape now because that was safer for him.*Some residents were independent with their wheelchairs and could use the elevator, go downstairs, and out the front doors of the facility to smoke. Those residents did not tell her when they went downstairs to smoke because they were independent and could sign out. 20. Interview on 2/3/26 at 4:45 p.m. with director of nursing (DON) B regarding residents who smoke revealed:*A Tobacco Use Evaluation was completed on each resident who smoked annually, and if there was an incident that occurred while they were smoking. She did not expect that evaluation to be completed quarterly.*It was their policy that all residents were assessed to determine if they required supervision while they smoked and to only smoke in the courtyard.*The courtyard was the residents' designated smoking area. There were specific times that the residents could smoke, and she expected any staff member who assisted a resident into the courtyard to smoke to be outside with that resident or, when it was cold, to stand at the window to ensure constant supervision.*She expected the residents to sit facing the window so that the staff member supervising could see them.*She confirmed residents 1, 2, 3, 4, 5, 7, and 8 required supervision when they smoked in the courtyard during the designated smoking times.*A staff member who was talking to other residents in the activities room and seated at the desk was not considered supervision.*She was aware that some residents left the facility property to smoke, and she expected them to go to the corner down the block or across the street when they smoked to be off the facility's property.*The Tobacco Use Evaluation addressed residents' smoking on the facility's property, not when they left the facility to smoke.*She felt that residents 2 and 3 were safe leaving the facility property independently to smoke and expected them to tell a staff member and sign out in the sign-out book near the front door. She was unsure if any other residents left the facility property to smoke.*She was unsure if an assessment was completed of residents 2 and 3's ability to leave the facility in their power chairs in the winter on their own, or if residents' care plans indicated they left the facility independently to smoke off the property.*On 12/11/25, residents 1 and 2 went into the courtyard without notifying staff members, and resident 1 was burned by his cigarette.*Resident 1 was unable to leave the facility or open the door independently. Resident 2 opened the door and assisted resident 1 out into the courtyard and back inside that day.*She agreed that it was cold in December and there were risks of residents being outside smoking without staff knowledge, related to the cold and getting burned.*After resident 1 was burned, his brother provided vapes for him. His Tobacco Use Evaluation did not differentiate between smoking and vaping, and resident 1 was not assessed as unsafe to smoke, but it was strongly encouraged that he vaped because there was no active flame.*She was unaware that resident 1 bummed cigarettes from other residents, but felt that he was safe to smoke outside while he was supervised by a staff member. 21. Observation and interview on 2/4/26 at 8:55 a.m. with resident 5 in her room revealed:*She used a power wheelchair and wore oxygen. She stated she removed her oxygen when she smoked.*She was allowed to keep her cigarettes and her lighter in her room with her.*Sometimes she smoked in the courtyard during the designated times, and other times she went downstairs and smoked in front of the facility. She knew the door code to open the front door, but she did not know the door code for the courtyard door.*There was a smokers' meeting recently, and they were told they needed to sign out in the book at the front door and leave the facility's property when they wanted to smoke outside of the designated smoking times in the courtyard. 22. Observation on 2/4/26 at 9:00 a.m. of the residents' courtyard smoking area revealed:*Resident 4 walked to the courtyard door holding her lighter and a cigarette in her hand. Activities assistant H entered the door code and opened the door for resident 4 to go out into the courtyard. Activities assistant H then stood about eight feet from the door and read a book.*While resident 4 was outside smoking, activities assistant H walked over to the desk behind the partition wall. AD C told activities assistant H to stand next to the door, and she returned to the door.*A few moments later, activities assistant H walked away from the door and assisted a resident as they left the dining room by wiping her face. Administrator A told activities assistant H to stand next to the door, and she returned to the door.*Activities assistant H stood at the door, read her book, and glanced out the window occasionally. When resident 4 rang the doorbell, activities assistant H opened the door and she did not collect resident 4's lighter. 23. Interview on 2/4/26 at 9:10 a.m. with resident 4 in her room revealed:*She kept her cigarettes and her lighter in her room.*She usually smoked in the courtyard during the day when the staff members would enter the door code and open the door for her.*She sat on her walker outside the front doors of the facility to smoke in the evening because the staff members were not available to open the courtyard door past 7:00 p.m.*She knew the door code to the front door of the facility and smoked whenever she wanted. She did not need to tell the staff members or sign out in a book. 24. Interview on 2/4/26 at 9:25 a.m. with activities assistant H regarding residents smoking revealed:*She assisted residents by entering the door code to let them out into the courtyard to smoke and answered the doorbell when they were done and ready to come back in.*She stayed in the activities room and checked on the residents when they were outside smoking, but she did not need to watch them the whole time.*Most of the residents were independent with smoking and kept their own cigarettes and lighters.*There was only one resident she needed to help light his cigarette, but she was unsure if he still smoked. 25. Interview on 2/4/26 at 10:10 a.m. with administrator A regarding residents' smoking revealed:*He held a smokers' resident council on 12/17/25 to educate the residents on the facility's smoking policy after resident 1 was burned while smoking.*The door code to the courtyard door was changed, and he expected residents to smoke in the courtyard during the designated times.*He expected the staff members to stand by the window and watch the residents outside while they smoked. He confirmed that activities assistant H did not supervise resident 4 the entire time she was outside smoking.*Some residents left the facility property to smoke, and he expected them to let a staff member know when they were leaving or to sign out in the book near the front door.*He was unaware that residents knew the front door code and that they went out those doors in the evening to smoke.*Residents who smoked had a Tobacco Use Evaluation completed, and he expected that the staff members and residents followed the recommendations made in that evaluation.*He was unsu

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to report a known serious bodily injury within the required time frame for one of one sampled resident (6) who fell and sustained a hip fracture. Findings include:1. Review of the provider's 11/11/25 SD DOH FRI (a required reporting of unexpected or adverse events) report revealed:*Resident 6 slipped out of her wheelchair, landed on her left hip, and reported left hip pain on 11/10/25 at 2:20 p.m.*Resident 6's physician ordered an X-ray of her left hip.*Administrator A and director of nursing (DON) B were notified of the fall.*The X-ray results showed resident 6 had a left intertrochanteric fracture of the femur (a common type of broken hip occurring in the upper part of the thigh bone [femur]), and the resident's daughter-in-law wanted to talk to the rest of the family before transferring the resident to the emergency department (ED).*On 11/11/25 at 7:30 a.m., resident 6's daughter-in-law informed clinical care leader (CCL) E that the family decided they wanted resident 6 sent to the ED.*Resident 6 was transferred to the ED on 11/11/25 at 7:55 a.m., was admitted to the hospital, and later passed away.*The FRI report was reported to the SD DOH by administrator A on 11/11/25 at 12:54 p.m. 2. Review of resident 6's electronic medical record (EMR) revealed that on 11/10/25 at 6:45 p.m., a progress note written by RN L stated resident 6's X-ray results indicated she sustained a left hip fracture, and the results were faxed to her physician. 3. Interview on 2/3/26 at 4:43 p.m. with CCL E revealed a portable X-ray technician came to the facility to complete resident 6's X-ray. 4. Interview on 2/4/26 at 11:35 a.m. with DON B revealed:*Administrator A and she completed incident reporting to the SD DOH.*Reporting to the SD DOH was to be completed within 24 hours after outside medical attention was provided.*A confirmed hip fracture, even when an X-ray technician came to the facility to take it, would need to be reported to the SD DOH within two hours. 5. Interview on 2/4/26 at 12:40 p.m. with administrator A revealed:*He thought that since resident 6 did not receive outside medical attention immediately after her fall, in which she sustained a hip fracture, the incident would need to be reported to the SD DOH within 24 hours.*He considered a hip fracture a serious bodily injury and would need to follow their policy regarding when to report the incident to the SD DOH. 6. Review of the provider's 4/7/25 Abuse and Neglect policy revealed:*Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency.*If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident/client property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made.*If there is an allegation that does not involve abuse and there is no serious bodily injury, then it will be reported not later than 24 hours after the allegation is made.

Based on observation, interview, record review, and policy review, the provider failed to follow standard food safety practices to ensure:*A clean and sanitary environment was maintained to store, prepare, and serve food to residents in one of one kitchen, one of one kitchenette, one of one dining room serving counters, and two of two dining rooms. *Proper hand-washing and glove use by any observed kitchen staff during the preparation and serving of residents' food items.*Food temperatures were monitored and documented to ensure meals were served at a safe serving temperature to prevent the spread of food-borne illness. *Two of two kitchen personnel (cook H and food service worker X) wore beard nets according to the provider's policy. Findings include: 1. Observation on 9/2/25 at 1:15 p.m. of the main dining room revealed: *More than half of the tables had dirty dishes from lunch on them. *There were approximately 35 residents at tables getting ready for an activity, although there were still dirty dishes on those tables. Observation on 9/2/25 at 1:50 p.m. of the kitchen revealed: *The hand-washing sink in the kitchen lacked paper towels. *The hand-washing sink in the dish room had food stains and debris in the bowl and on the sides of the sink. *The walk-in freezer contained opened boxes with the plastic liner pulled down over the outside of the box that exposed hamburger patties, mixed vegetables, uncooked chicken pieces, breaded chicken patties, garlic bread, and cookie dough. *Grease buildup was observed on the light bulbs above the flat top grill and fryer. *Cobwebs extended from the lights to the front of the stove hood above the flat top grill and fryer. *Grime was present on the floor around the three-compartment sink and on the cleanout box. *Food particles were visible on the floor and the tile grout throughout the kitchen. *The clean plate rack had numerous food particles in the bottom where plates rested. *The lower shelf and legs of the prep table were unclean. *Dried liquid spills and food debris were present on the clean plate shelf under the steam table. *Breadcrumbs were observed on the counter around the toaster and in the catch tray. *Brown liquid was pooled on the dish room floor below the clean dish counter. *The wall behind the prep table was greasy and sticky to the touch. *The wall behind the flat top grill and stove was greasy and sticky to the touch. *The oven handles were sticky and greasy. Observation and interview on 9/2/25 at 2:00 p.m. in the kitchen with director of dietary services (DDS) G revealed: *The food was prepared at and would arrive from the central kitchen shortly after 4:00 p.m. *Temperatures of the food items were taken and recorded on arrival, and those foods would be heated or cooled as appropriate for serving. *No additional food temperatures were taken after that initial check. Observation and interview on 9/2/25 at 4:00 p.m. in the kitchen with DDS G revealed the residents' supper meal food items had already arrived and consisted of all cold items so it didn't need to be temped [temperature checked]. Observation on 9/2/25 at 4:00 p.m. in the kitchen of food service worker (FSW) X revealed: *He placed a clean pair of gloves and his phone on the counter next to the hand-washing sink. *He washed his hands. *He proceeded to the dish room, where he moved some empty dishwasher racks and a serving cart. *He returned and put on the pair of gloves that were on the counter. *With those gloved hands, he picked up his phone and put it in his pocket. *He did not have his two-inch-long goatee hair covered. Observation on 9/2/25 at 4:00 p.m. in the kitchen of the handling of resident menu cards revealed: *The resident menu cards were a half sheet of paper in a plastic sleeve. *They listed the residents' diet orders, assistive device needs, allergies, and food preferences. *Certified nursing assistants (CNAs) handed the menu card to DDS G or cook H when the resident arrived at the dining room. *The menu cards were: -Handled by DDS G and cook H with and without gloved hands. -Dropped and picked up from the floor multiple times. *Placed on the resident's meal tray for the CNA to take to the table. *The CNA then returned the menu card to a container on the dining room serving counter. Observation on 9/2/24 at 4:08 p.m. in the kitchen of cook H revealed: *He wore a small chef beanie that did not cover any hair below his ears. *He did not have his full beard covered. *Placed frozen raw hamburger patties on the flat top grill. *Pushed a serving cart to another area of the kitchen. *Used a spatula to turn and remove burgers from the grill. *Tore off aluminum foil, covered a pan of cooked hamburgers, and took the pan to the prep table. *Pushed open the kitchen door and went to the dining room. *He wore the same pair of gloves during all of the above observations. Observation on 9/2/25 at 5:04 p.m. in the kitchen of cook H revealed that with his gloved hands, he: *Leaned and touched both of his hands on the counter. *Opened a drawer and removed a food serving scoop from the drawer. *Returned that scoop to the drawer and retrieved another one from a different drawer. *Removed buns from a bag with those same gloved hands and placed them on plates. *Carried the plates with the buns to the prep table. *Opened the kitchen refrigerator and retrieved a sleeve of cheese slices. *Removed individual cheese slices from that package and placed them on the buns. *Pulled the sleeve wrapper around the remaining cheese and returned it to the refrigerator. *Removed his gloves and without washing his hands, he put on a new pair of gloves. *He continued preparing residents' supper meal trays. Observation on 9/2/25 at 5:13 p.m. in the kitchen of FSW X revealed that with his gloved hands, he: *Pulled the silverware cart by the handle. *Touched individual pieces of silverware while rolling them up in a napkin. *Pushed open the kitchen door and delivered the rolled silverware to residents at tables. *Re-entered the kitchen by pushing open the door. *Repeated that same process of handling silverware, opening the kitchen door, and delivering the silverware to the residents. *Placed bowls of fruit on residents' trays. *Opened soup cans and slapped the bottoms to remove contents. *Touched the microwave door and buttons. *Served bowls with his thumb on the inside rim of the bowl. *He used those same gloved hands during all of the observations above. Observation on 9/2/25 in the kitchen beginning at 5:15 p.m. of dinner meal service revealed: *Plate covers were placed on plated meals on a tray and delivered to the residents. *The plate covers were stacked on a serving tray and reused. *Approximately 10 plate covers were reused throughout the meal service. Observation on 9/2/25 at 5:21 p.m. in the kitchen of DDS G revealed that with his gloved hands, he: *Touched the menu cards in a plastic sleeve that a CNA handed to him. *Picked up a sandwich and placed it on a plate for a resident. *Touched several menu cards that had been handed to him by CNAs. *Opened the refrigerator door. *Touched several menu cards again. *Picked up and plated four ready-to-eat sandwiches for residents with those same gloved hands. *Removed toast from the toaster with those same gloved hands and put it on a plate. *DDS G used the same gloved hands during all of the above observations. Observation on 9/2/25 at 5:22 p.m. in the kitchen of cook H revealed that with his gloved hands, he: *Opened the refrigerator. *Touched unwrapped, ready-to-eat sandwiches and put them on plates. *Touched menu cards between handling sandwiches and plates. *Repeated that process of serving the sandwiches with those same gloved hands. *Removed a grilled cheese sandwich from the refrigerator and placed it on a clean plate. *Touched the microwave door and control buttons to heat the sandwich. *Touched several resident menu cards again. *Removed a hamburger bun from a bag. *He wore the same gloves during all of those observations. Observation on 9/2/25 at 5:34 p.m. of FSW GG in the kitchen revealed: *While wearing the same pair of gloves he had used for serving residents' meals, he lifted the top piece of bread from a sandwich. *He removed the cheese and placed that piece of bread back on top of the sandwich. *He then returned to his serving position. *A CNA at the window told him he needed to wash his hands. *He then washed his hands and put on a clean pair of gloves. Observation and interview on 9/2/25 at 5:45 p.m. in the main dining room with CNA K revealed: *She was observed asking for corrections to several resident meal trays. *The CNAs who were serving residents' meals had frequently experienced issues with the kitchen staff following the residents' diet requirements and fulfilling the residents' specific meal requests. *As a result, they knew to check the menu cards and meal tray closely before serving the residents' meals to them. Interview on 9/2/25 at 5:45 p.m. with cook H in the kitchen revealed: *He was expected to wear gloves at all times while he was in the kitchen. *He was unable to describe when gloves should be removed or when handwashing was required. Observation on 9/3/25 at 4:55 p.m. of the main dining room and kitchen floors revealed: *The main dining room was approximately 80 percent full of residents. *The floor was soiled with debris from previous meals. *The kitchen floor appeared to be soiled with the same debris as observed the previous day (9/2/25). Observation on 9/3/25 at 5:02 p.m. in the kitchen of FSW Y revealed that while wearing the same pair of gloves, she thumbed through menu cards, scooped ice into glasses from the ice well, and poured milk from a jug into glasses, which were served to the residents. Observation on 9/4/25 at 8:00 a.m. of the kitchen revealed: *Additional grime from previous observations was present below the three-compartment sink, around the cleanout box, and along the wall behind it. *Food debris was present in the sink's drain, which appeared to be ravioli from the previous evening's meal. *The walls behind the prep table were visibly dirty and sticky to the touch. *The prep table was soiled with food debris and had a soiled wet towel and a food processor on it. The food processor had drips and food particles on its base and cord. *The shelf above the prep table had substantial amounts of food particles, flour, and unknown debris on it, which could fall onto the food below it. *Food debris was present on the clean bin shelf below the prep table. Observation and interview on 9/4/25 at 10:18 a.m. in the kitchen with DDS G revealed: *Cook H used the same gloved hands to touch the refrigerator handle, cheese packaging, remove ready-to-eat cheese, and retrieve bread from a bag. *DDS G did not respond when asked if that observation demonstrated safe food handling practices, nor did he address those observations with cook H at that time. Observations and interview on 9/4/25 at 3:08 p.m. with DDS G in the kitchen revealed he: *Agreed the oven was dirty with charred food and built-up grease on the sides, bottom, inside the door, on top of the door, and on the door handle. *Agreed that the Robo Coupe food processor had built up food grime on the rim, base, and cord. *Agreed that the top edge and sides of an ingredient cart holding clean cups had food and dirty handprints on it. *Agreed that the clean plate rack had many different food particles on the bottom where the plates rested. *Agreed that the speed rack (tray rack) had built-up food and a sticky substance on the tray rails. *Agreed that the prep table, the shelf above it, and the shelf below it were soiled with food particles and debris. *Agreed that the plate shelf below the steam table was soiled with food spills. *Agreed that the steam table knobs had areas of sticky foods and built-up grease. *During the walk-through, he used his bare hands to pick at and touch many of the unclean surfaces, and then responded to a staff request for a glass of soda for a resident by putting a glove on his left hand and picking up a glass with that gloved hand. He then used his right unwashed bare hand and removed the ice scoop from the holding bin and scooped from the ice well into the glass. He then handed the glass of soda to the staff member. *He did not wash his hands before putting the glove on his left hand or before handling the ice scoop with his other bare hand. *When asked if he should have washed his hands before donning the glove and serving the soda, he did not respond. *He stated there were no steam table temperature logs as staff did not monitor the temperatures of the steam table or food once placed in the steam table. *He confirmed that the kitchen staff were responsible for stocking and cleaning the serving counter in the dining room, which tea bags, creamer packets, sugar packets, hand sanitizer packets, and brown sugar for oatmeal. Observation on 9/4/25 at 3:30 p.m. of the serving counter in the main dining room revealed: *A jar of brown sugar had a screw-on lid and a single spoon inside of it. *A bowl of hand sanitizing wipes that had a black dried liquid inside the bowl on the counter. *Cook H carried several bunches of bananas from the storeroom to the kitchen while holding them between his shirt and bare arms. Observation and testing on 9/5/25 at 8:12 a.m. of a sample breakfast tray from the kitchen revealed: *The menu for the day included biscuits and gravy, scrambled eggs, oatmeal, and a banana. *The meal tray had scrambled eggs, a biscuit with thin tan gravy and several bits of sausage, a banana, a glass of milk, and a cup of coffee on it. Oatmeal was not included. *The food plate had a cover on it, and food temperatures were taken within two minutes of the meal tray being prepared by the kitchen staff. *Recorded food temperatures were: -Scrambled eggs: 103 degrees Fahrenheit (F). -Gravy in pool on plate: 103 degrees F. -Gravy on top of biscuit: 100 degrees F. -Milk: 47 degrees F. -Coffee: 146 degrees F. Observation on 9/5/25 at 11:00 a.m. of the dining room and kitchen revealed that all the unclean surfaces previously observed and noted on 9/2/25, 9/3/25, and 9/4/25 remained uncleaned. 2. Observation on 9/2/25 at 2:56 p.m. in the rehab unit dining room revealed: *There was food on the table in at least two place settings, and a circular, ring-shaped sticky spot in three areas. *What appeared to be diced carrots and other unidentified food crumbs were scattered on the floor under three tables. *There were small pieces of white paper and plastic wrappers on the floor near the serving window and in several places throughout the dining room. *A cabinet with a coffee maker on the counter had a significant amount of coffee spills on the top of the counter, in the drawer of that cabinet, down the front of the cabinet, and on the carpet around that cabinet. Observation and interview on 9/2/25 at 5:32 p.m. in the rehab unit dining room revealed: *Those same tables observed above had the same food items and sticky spots on them, but now also had utensils, wrapped in napkins, and a cup at each place setting. *The food, paper, and plastic remained on the floor. *The cabinet and the counter with the coffee maker remained dirty. *Resident 95 stated that the spot where she and resident 94 were seated had food on it and pointed to two other spots on the table that were dirty. *Resident 94 stated that the table where she was seated to eat her dinner was sticky and that it had been that way at lunchtime. Observation and interview on 9/2/25 at 5:46 p.m. with CNA R in the rehab unit dining room revealed: *Resident 95 stated that the tables were dirty, and she began to clean those tables. *CNA R thought that it was the kitchen staff's responsibility to clean the kitchenette and the tables between resident mealtimes. She thought that housekeeping cleaned the floors in the dining room between resident mealtimes. *She expected that the tables would have been cleaned before the kitchen had set the table for the next meal. Observation and interview on 9/2/25 at 5:49 p.m. with cook H in the rehab unit dining room revealed: *He arrived with an insulated cart that contained the residents' meals. He had a beard and a mustache. He wore a black cap but was not wearing a beard net. *He placed the tin pans that contained sandwiches and broccoli slaw into the steam table, which contained an orangish colored water and food particles, including particles of corn. *He washed his hands, then tried to put on a pair of gloves. He stated that he needed large gloves, but that there were none. He wore those gloves partway up his hand, with the fingers of the gloves dangling. With those partially gloved hands, he: -Took a can of pop from the fridge. -Used his gloved hand to pick up a sandwich and place it on a plate, then he scooped salad onto the plate and placed the plate on the counter above the steam table. -He repeated that process for each plate of food. While completing that task, he: --Touched a butter packet on the counter, wiped his right hand on his shirt, and touched his cheek. --Picked up a box of gloves and handed them to CNA R. --Repeatedly used his right hand to adjust his left glove. --Opened the refrigerator and took out the mustard and mayonnaise. *Cook H stated that he tried to use one hand when he touched the sandwiches and the other hand when he touched other things in the kitchenette. *At 5:58 p.m., cook H removed his gloves and washed his hands. While washing his hands, he splashed water on the walls and the counter around the sink. He then put on another pair of gloves, opened the food cart, removed the dessert cups, placed them on the counter, and then quickly left the kitchenette. Observation on 9/3/25 at 8:35 a.m. in the rehab unit dining room with DDS G revealed: *He brought the breakfast cart to the dining room from the main kitchen and got set up to serve breakfast. *He sanitized a thermometer to check the temperatures of the food items in the steam table and recorded them in the food temperature logbook. *He put on a pair of gloves, took four pieces of bread out of the bag, and put them in the toaster. *With those same gloved hands, he went to the steam table, picked up a plastic container, and moved it to the counter. *He went back to the toaster and with those same gloved hands, he picked up the slices of toast and put them in the steam table. *He then put four more pieces of bread in the toaster. *At 8:45 a.m., with those same gloved hands, he began to plate the breakfast food for the six residents in the dining room. *He removed his gloves and put on a new pair of gloves, but did not first wash his hands. *He picked up the lids from the steam table and put them on the counter. *With those same gloved hands, he plated seven room trays using tongs for the eggs but used his gloved hand to pick up the toast and put it on the plates. *He then removed his gloves and threw them away, and again did not wash his hands. *When asked about glove use and hand washing, he stated he would wash his hands before putting gloves on, and after her removed his gloves. Observation on 9/4/25 at 7:55 a.m. with DDS G in the rehabilitation dining room kitchenette revealed he: *Placed the pans into the steam table and washed his hands. *Got his cell phone out of his pocket and appeared to type a text. *Got a key out of his pocket and attempted to open the suggestion box that was mounted on the wall in the dining room. *Went back into the kitchenette and got his phone out of his pocket, and appeared to have typed another text message. *Put on a pair of gloves and started plating the residents' food. *Plated eleven residents' room meal trays. *Removed his gloves, put the pans from the steam table back in the cart, and wheeled it back to the main dining room. *Did not wash his hands. Review of the provider's September Rehab Temperature Log Book in the dining room revealed: *The breakfast food temperatures were the only meal temperatures recorded on 9/1/25. *No food temperatures were recorded for 9/2/25. *DDS G had recorded the breakfast food temperatures for 9/3/25 Review of the provider's June, July, and August Rehab Temperature Log books for 2025 revealed: *June was missing 24 of 90 food temperature documentations. *July was missing 12 of 93 food temperature documentations. *August was missing 41 of 93 food temperature documentations. Interview on 9/4/25 at 2:32 p.m. with DDS G regarding food temperatures, glove use, and hand hygiene in the rehab unit kitchenette revealed: *The kitchen staff takes the food temperatures in the main kitchen, and then they take them again when they get to the rehab unit kitchenette to ensure proper temperatures are maintained. *He expected the staff to document the food temperatures for all meals. *He agreed that it was not being completed for all meals. *He expected the staff to: -Wash their hands before they put on their gloves. -Take the trays out of the cart and put them in the steam table. -Remove the gloves and wash their hands. -Put on new gloves and plate the food for the resident's meal. -Remove gloves and wash their hands. -Put on new gloves. -Put the pans back in the cart. -Clean the countertops, steam table, and common area of the kitchenette. -Remove the gloves, wash their hands, and return the cart to the main kitchen. 3. Interview on 9/2/25 at 4:31 p.m. with DDS G revealed: *He expected the kitchen staff to wear gloves at all times. *He thought the chef beanie provided adequate for hair coverage. Interview on 9/3/25 at 4:00 p.m. with DDS G about complaints made by residents to surveyors about meal substitutions or omissions revealed: *There was ham on the breakfast menu for Monday, but sausage patties were served. *There was bacon on the breakfast menu for Wednesday, but sausage patties were served. *He stated that the kitchen lacked the equipment to prepare ham or bacon in quantities sufficient for all residents. *He explained that the sausage patties were easier to cook and hold at temperature. *He agreed that the food served to the residents did not match the menu. *Substitutions did not require approval if they were considered like items, such as substituting one meat for another or toast for a muffin. *Residents were not notified of substitutions of like items. Interview on 9/4/25 at 9:05 a.m. with infection prevention specialist (IPS) I revealed she: *Expected the kitchen staff to follow hand washing and glove use practices according to their facility's policy and food safety training. *Had limited oversight of the kitchen as food service was provided by a contracted company, with DDS G responsible for kitchen operations. *Had discussed clean versus unclean practices with DDS G, including touching clothing and the face. *Expressed uncertainty regarding the effectiveness of those conversations. Interview on 9/4/25 at 1:00 p.m. with DDS G revealed: *The steam tables in the kitchen and rehab unit kitchenette were to be drained and cleaned every night. *DDS G agreed that the rehab unit kitchenette steam table was not clean and had dirty water and kernels of corn in the water from a meal served five days earlier. *The kitchen staff were responsible for cleaning the tables in the rehab unit dining room. *He agreed that kitchen staff should not have set the tables for supper without wiping them down after lunch, especially while food debris remained. *He was unaware that the rehab unit kitchen counters were soiled with food debris and were not cleaned after lunch. *He was unaware that the food temperature log in the rehab unit kitchenette had not been completed. *He had not verified that the cleaning was completed in the kitchen, dining room, or rehab unit dining room. *He thought the dirty meal dishes sometimes remained on the tables in the main dining room when activities started because some residents were still eating. *Lunch was to be served from 11:45 a.m. to 12:45 p.m. *He reported that the kitchen staff had a large onboarding manual to read before their first shift. *He did not provide additional kitchen staff training on-site. *He agreed that the menu cards, used in the main dining room, listed important information, including diet textures and allergies, which were critical to the residents' safe consumption of meals served. *He was unaware that the diet cards used in the rehab unit dining room did not contain that same information. *He acknowledged that plate covers are reused multiple times during the meal service, but did not believe this posed a cross-contamination risk. *He did not acknowledge or respond when asked whether kitchen staff using gloved hands to touch phones, refrigerator handles, menu cards, reused plate covers, and ready-to-eat foods demonstrated safe food handling. *He believed the chef's beanie provided adequate hair coverage. *He believed facial hair only needed to be covered when it reached a certain length. *When asked if he was aware of the facility policy regarding hair covering, he stated he was not. Interview on 9/4/25 at 3:00 p.m. with FSW X revealed he: *Had been employed and worked in the kitchen for approximately five months. *Had not received training when he started, as he claimed prior kitchen experience. *Was unable to describe a process for handwashing or glove-changing. *Acknowledged he had touched his phone with gloved hands while preparing residents' food and admitted that this likely occurred frequently. *Asked whether his gloves could be washed after touching contaminated surfaces. *Had not been instructed to cover his facial hair. Interview on 9/4/25 at 3:05 p.m. with DDS G revealed: *He agreed that kitchen staff should ensure dining trays and meals served reflected correct resident preferences, diets, and adaptive equipment. *He was solely responsible for adding diet orders to menu cards. *He thought CNAs were responsible for managing resident preferences. *He was the only kitchen staff member with ServSafe for Food Manager's training. *There were no plans in place to have another current employee complete the ServSafe training. Interview on 9/5/25 at 8:30 a.m. with dietitian BB revealed: *She was the dietitian for the contracted food service responsible for preparing lunch and supper meals at the central kitchen. *She approved all menus for meals prepared at the central kitchen and served at the facility. *The oversight of the facility dining service was designated as the responsibility of DDS G. *Breakfast was to be prepared based on the menus she approved. *The substitution of like items, such as a meat for a meat or toast for a muffin, did not require her approval, but she expected the menu to be followed as closely as possible. *She agreed that the documented temperatures of the scrambled eggs, biscuit and gravy, or milk on the sample tray were not within safe food serving ranges. Interview on 9/5/25 at 9:40 a.m. with DDS G regarding breakfast tray temperatures revealed: *He did respond when asked if the temperatures were within safe food serving guidelines. *When questioned about the unsafe temperatures on the sample breakfast tray, he said the biscuit was still okay. *He confirmed that food temperatures were not checked during or after meal services. Interview on 9/5/25 at 9:50 a.m. with administrator A regarding glove use, hand washing, and food temperatures revealed: *He expected that the kitchen staff would follow the facility's policy for hand washing and glove use. *His expectations for food temperature documentation were that the staff would follow the policy and document temperatures for each meal. *He agreed that it was not being done. Interview on 9/5/25 at 10:00 a.m. with FSW Y revealed: *She had been employed at the facility for approximately two and a half weeks. *Her onboarding training primarily consisted of extensive reading. *She reported difficulty retaining the information due to the volume of content. *She was unable to describe the proper procedure for handwashing and glove use. *She stated she followed the practices of her coworkers. *She had not received on-site training on kitchen processes and procedures beyond the initial onboarding reading. Interview on 9/5/25 at 10:15 a.m. with administrator A revealed: *He expected kitchen staff to: -Adhere to facility policies regarding hair and facial hair coverings, hand washing and glove use, kitchen cleaning, food temperature monitoring, and hygiene. -Follow physician diet orders, address allergies, accommodate assistive device needs, and honor food preferences. -Be responsive to food council suggestions and resident choices to the extent possible. *He expected DDS G and all kitchen staff to comply with food safety guidelines. *He agreed that the breakfast sample tray items did not meet safe food serving temperature standards. *He was aware of complaints about hot food being served cold and the frequent serving of cold food items such as sandwiches. *He stated the process for gathering feedback on food choices was through the resident food council, and conducting informal audits of five residents at a time about food taste, food temperature, and choice. Interview on 9/5/25 at 11:20 a.m. with administrator A revealed he: *Thought that contract dietitian FF or DDS G met with residents when they were admitted to the facility to discuss resident choices. *Was not aware that contract dietitian FF was not meeting with residents about preferences. 4. Review of the provider's 12/16/24 revised Food Temperature Monitoring policy revealed: *Food is cooked, reheated or cooled to ensure proper holding temperatures before each meal service. *Food temperatures are taken and recorded before each meal service. Review of provider's hand washing and glove use – food nutrition services policy dated 6/6/25 revealed: *The purpose was to provide guidelines regarding hand hygiene and glove use to reduce the risk of cross-contamination when serving highly susceptible populations. *Highly susceptible populations were defined as persons who are more likely than other people in the general population to experience foodborne disease, including: -Older adults. -Obtaining food at a nursing home. *Acceptable food barriers were defined as utensils, deli papers, and appropriately used disposable gloves (single task, uncontaminated). Hand washing and hand sanitizer are not

Based on observation, interview, and policy review, the provider failed to ensure proper infection control practices were followed by allowing clean resident lift slings to lay on the floor, failing to properly clean resident lifting devices, and allowing water to leak from ceiling in a storage closet.Findings include:1. Observation on 9/2/25 at 4:45 p.m., of a sit to stand lift (a mechanical lift used to assist from a seated to a standing position) had an unknown substance build-up where residents would place their hands while being lifted. 2. Observations on 9/3/25 at 1:30 p.m., 9/4/25 at 8:50 a.m., and again on 9/5/25 at 11:20 a.m. in the clean storage room on the second floor revealed:*Several lift slings were lying on the floor, and multiple slings that had been hanging on three of the four walls had been touching the floor.*Inside the storage room where the lift slings were stored, a sign was posted above the slings that had a red stop sign it and stated ALL STAFF PLEASE MAKE SURE SLINGS ARE NOT TOUCHING THE GROUND THANK YOU! 3. Interview on 9/4/25 at 9:00 a.m. with certified nursing aide (CNA) J revealed:*CNAs would hang the lift slings up when they were received from laundry.*She was aware that slings should not have been lying on or touching the floor.*She reported that slings were touching the floor all the time.*She stated It's kind of gross regarding using lift slings after they had been on the floor. 4. Interview on 9/4/25 at 10:20 am with certified medication aide (CMA) JJ revealed:*He reported that lift slings were hung up by the laundry staff members after they had been cleaned.*He did not believe that the clean slings should have been touching the floor.*He stated that lift slings were still used to assist the residents even if they were touching the floor. 5. Interview on 9/5/25 at 10:50 a.m. with infection prevention specialist I revealed:*After lift slings had been washed, they were brought to the storage closet by the laundry staff members and put away by the CNAs.*She reported that she had not noticed the slings touching the floor.*She reported it was an infection control problem for them to be used after lying on the floor.*She acknowledged that the slings laying on the floor were considered dirty and should not have been used. 6. Observations on 9/4/25 at 3:00 p.m. and 9/5/25 at 11:25 a.m. in the main level clean storage room next to the conference room revealed a hole in the ceiling with an unknown black speckled substance around it where water was dripping into a plastic bin. 7. Interview with infection prevention specialist I revealed she was aware of the hole in the ceiling and reported that it had been there since around May of 2025.*She reported that maintenance staff had attempted to repair the hole and the leaking water, but was unsuccessful.*She acknowledged that the leaking hole in the ceiling was an infection control concern and needed to be fixed. 8. Review of the provider's 12/2024 Infection Prevention and Control Program policy revealed:*Purpose, To establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, and record review, the provider failed to provide meals to meet the residents' satisfaction for eight of twenty-five sampled residents (14, 34, 44, 49, 52, 53, 67, and 82) who expressed dissatisfaction with the meal service regarding food quality, temperature, repetition, choices, and not accommodating the residents' food preferences and ordered diets Findings include:1. Observation and interview on 9/2/25 at 2:50 p.m. and again on 9/4/25 at 8:32 a.m. with resident 14 in his room revealed: *He ate his meals in his room and was frustrated about the food that he received. He had filled out a menu with his food choices, but the kitchen had not sent the food that he requested. *He was concerned that the dietary staff had not provided him with the correct diet or with the foods he preferred to eat. *No one had asked him about his meal preferences and the foods he liked to eat, so he often refused the fried food items they served until he requested that his diet be changed to include more protein. He felt that since that change, all he received was meat, usually sausage patties or hamburger patties, eggs, and milk. *He pointed to a sheet of information that he had brought from the hospital regarding Nutrition and Wound Healing and stated that he had hoped to discuss that information with the dietitian so that he received the foods that he preferred to eat. *He would tell the certified nursing assistants (CNAs) what he wanted to eat, but he was unsure if that information was relayed to the kitchen. *He avoided carbohydrates and did not want potatoes or corn, but would have liked broccoli, cauliflower, beans, or peas. He could not recall having been served any vegetables in the last week. *He stated that on 9/3/25, he was served a hamburger patty and two small pieces of chicken with a bone in them. He had been served french fries and breaded shrimp, and he was angry about that because he had told the staff several times that he would not eat fried foods because they mess up his blood sugars. *On 9/4/25, he was served a cheese omelet and milk and had not been provided with bacon or sausage. He thought that bacon had been on the menu that day, and he would have liked to receive that. Review of resident 14's electronic medical record (EMR) and paper medical records revealed: *He was admitted on [DATE]. *His 8/25/25 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. *His diagnosis included Diabetes Mellitus (a condition involving disruptions in how the body regulates blood sugar), esophageal reflux (a condition where stomach contents flow back into the esophagus causing irritation), and pressure ulcers (skin and/or underlying tissue injury from prolonged pressure). *His 8/20/25 physician's orders indicated he was to be provided with CCHO [Consistent Carbohydrate] diet.All protein diet, and Boost Glucose Control with all meals. *An 8/20/25 Diet Notification Form (a form used by nursing to communicate diet orders to the kitchen) indicated he was to be provided a Consistent Carbohydrate (Diabetic Diet), but it did not indicate his need for a high protein diet, supplements, or his food preferences. *His undated diet card indicated CCHO. The food preferences, dislikes, and supplements sections had not been filled in on that card. A yellow sticky note attached to that card indicated extra protein, no carbs, no desserts. *His 8/20/25 care plan indicated a goal that the resident will express that his/her nutritional needs are being met, and he/she feels supported in dining decisions. His food preferences were not listed in his care plan. *His Amount Eaten by Mouth task documentation since his admission indicated that 33 out of 41 meals had been documented. Of those 41 meals, 16 were marked as Resident Refused, Not Applicable, or that he had eaten 0-25% (percent) of the meal. 2. Interview on 9/2/25 at 5:01 p.m. and again on 9/4/25 at 1:15 p.m. with resident 67 in his room revealed he: *Ate most of his meals in his room and was unhappy with the quality and quantity of food he had been offered. *Stated there was a menu that he filled out with his food choices on Saturdays for the week. He thought that the menu was provided to the kitchen, but was unsure because he did not receive the items he had indicated on that menu. *Recently had gall bladder surgery and had to be careful about what he ate. He avoided processed and spicy foods. He often selected the alternative items, but did not receive them. *Recalled that one night they had a choice of chili dogs or a BLT (bacon, lettuce, tomato) salad. He ordered a double portion of the BLT salad but was told they had run out after serving the residents upstairs. He was offered the chilidog but felt he should not eat that, so he had ordered a sandwich from a restaurant to be delivered. *Stated he had run out of money from ordering food out from restaurants, so a friend had brought him more money and some tuna. *Told the CNAs who delivered his meal tray when he did not like certain foods or could not eat them. The CNAs would then offer to make him a bowl of soup or toast. Review of resident 67's EMR revealed: *He was admitted [DATE]. *His 8/17/25 BIMS assessment score was 15, which indicated his cognition was intact. *His diagnosis included Diabetes Mellitus, cholecystectomy (removal of the gall bladder), esophageal reflux, and obesity (overweight). *His 8/11/25 physician's orders indicated he was to be provided a Regular diet. *His allergies included corn. *An 8/11/25 Diet Notification Form indicated Regular Diet. It did not include his allergy to corn or his food preferences. *His undated diet card indicated Reg [regular diet]. It did not include his allergy to corn. The food preferences, dislikes, and special instructions sections had not been filled in on that card. *An 8/12/25 care plan goal, Residents will show evidence of adjustment to nursing home by eating meals and dining room. and an intervention, Provide resident with as many choices as possible which give control over [the] resident's environment and care delivery. *His Amount Eaten by Mouth task documentation since his admission indicated that 56 out of 65 meals had been documented. Of those 56 meals, 19 were marked as Resident Refused, or Not Applicable. 3. Interview on 9/2/25 at 5:45 p.m. with cook H in the Sunrise Suites dining room revealed: *All of the residents on the first floor who ate in the dining room or in their rooms were served the same meal, except for one who just received hamburger patties for dinner. *Dinner that night, 9/2/25, was to include a cold sandwich, broccoli salad, and mandarin oranges. Three-bean salad had been on the menu, but he had dropped it on the floor and made a broccoli salad instead. *There was no alternative meal available that day because the [NAME] was not working. *If a resident asked for something else, they could have had soup, a sandwich, or a burger, and sometimes there was salad. 4. Interview on 9/2/25 at 6:01 p.m. with CNA R in the Sunrise Suites dining room revealed she: *Confirmed that for dinner that evening, all but one resident had received the same meal. *Stated that if the residents refused their meal when she brought it to them, she would make them a bowl of soup. 5. Interview on 9/4/25 at 8:58 a.m. with CNA N regarding meal service in the Sunrise Suites dining room revealed: *There was no meal ticket system (where resident meal preferences were recorded) like they used in the upstairs dining room because the residents admitted and discharged more quickly. *The main kitchen brought the food that the residents were served, and they all received the same thing unless they refused it. *Residents did not receive a meal choice at breakfast, but a menu was provided for lunch and dinner. She was unsure if the kitchen used that menu to prepare the residents' meals. *The residents would tell her what they liked, and she would try to make sure they got what they wanted. *She would know their diet orders because it was listed in the EMR on the residents' care plan. She was unaware if there was a list of residents' food preferences, but when they told her what they preferred, she tried to remember that. 6. Interview on 9/4/25 at 2:39 p.m. with director of dietary services (DDS) G regarding meal services in the rehab unit revealed: *He received the Diet Notification Form from nursing that indicated the resident's diet and allergies. With that information, he made a diet card that was kept in the rehab unit dining room. He expected staff to use that card to know the resident's ordered diet and allergies when serving the resident their meals. *The residents who resided in the rehab unit received the standard menu items at each meal. *The dietary staff did not meet with the residents to discuss their food preferences or dislikes. He expected the CNAs who served the residents to let the kitchen know if the resident did not like the meal they were served. *The residents could come to the kitchen and let the dietary staff know if they did not like something. *He was aware that the residents who ate in their rooms on the first floor or in the rehab unit dining room had complained about getting too many sandwiches. *He was aware that the kitchen sometimes ran out of food before the rehab unit residents were served. When they ran out of food, he expected the cook to fill out a substitution log and prepare something else. *He was unaware that residents had stated that they ordered food from restaurants and had it delivered because they could not get the food they wanted at the facility. *He expected that the facility would meet the residents' nutritional needs and felt that the menus were adequate. *Dietitian BB oversaw the central kitchen where the meals were prepared and developed the menu. *He expected that contract dietitian FF would have met with the residents and ensured that their nutritional needs were met. 7. Interview on 9/5/25 at 8:34 a.m. with dietitian BB revealed she: *Oversaw the development of the central kitchen menu. *Had no clinical oversight of the residents whose meals were provided in this location. She expected that dietitian FF managed the clinical needs of the residents. 8. Interview on 9/5/25 at 11:42 a.m. with dietitian FF revealed: *She was a contracted dietitian who worked at the facility one to two days a week. *She received the residents' scanned information from the facility, reviewed their EMR, and then met with the residents. *She could not recall when she had met with residents 14 and 67, but thought that it had been a while ago. *When she met with residents, she addressed dietary restrictions or allergies, chewing or swallowing needs, insulin use, and skin concerns. She did not discuss the resident's food preferences or dislikes with the resident. *She expected that the resident's meal preferences would be obtained by the dietary department. It could be the dietary manager or one of the food service workers. She expected that would have occurred within 72 hours of their admission to the facility. 9. Interview on 9/3/25 at 8:50 a.m. with resident 44 revealed: *They are served cold sandwiches for three to four suppers every week. *She would prefer something warm in the evenings. *When she asked for something warm, she was not given a choice but provided mashed potatoes and gravy. *She did not receive any fruit or dessert the previous evening. *She dislikes hot dogs and does not like when they are served. *She is not aware of other food choices. 10. Interview on 9/3/25 at 9:15 a.m. with resident 82 revealed: *The food is frequently very dry and hard for her to eat due to her lack of teeth. *Foods that should be served hot are more often cold than they are hot. 11. Observation on 9/2/25 beginning at 4:00 p.m. in the kitchen of handling of resident menu cards during the evening meal service revealed: *The resident menu cards were a half sheet of paper in a plastic sleeve. *They listed the residents' diet orders, assistive device needs, allergies, and food preferences. *CNAs gave the menu card to director of dietary services (DDS) G or cook H when the resident arrived to the dining room. 12. Interview on 9/2/25 at 4:31 p.m. with DDS G revealed the residents' menu cards are filled out with their food choices on Saturdays for the next week but sometimes the nursing staff did not pick them up and give them to the kitchen. 13. Observation on 9/2/25 at 5:34 p.m. with food service worker (FSW) GG revealed: *A sandwich was returned to him by certified nursing assistant (CNA) K who stated the resident couldn't have cheese. *FSW GG removed the cheese and returned the sandwich to CNA K to serve to the resident. 14. Observation and Interview on 9/2/25 at 5:45 p.m. with CNA K revealed the CNAs who were serving residents' meals had frequently experienced issues with the kitchen staff following the residents' diet requirements and fulfilling the residents' requests correctly, so the CNAs knew to check the menu card closely. 15. Interview on 9/3/25 at 4:00 p.m. with DDS G about resident menu complaints revealed: *There was ham on the breakfast menu for Monday, but sausage patties were served. *There was bacon on the breakfast menu for Wednesday, but sausage patties were served. *It was easiest to cook and hold the temperature of sausage patties. *He agreed that the menu did not match the food served. *They were not required to get a substitution approved if it was a like item, such as a meat substituted for a meat or toast substituted for a muffin. *He felt the residents' complaints about cold food were due to the CNAs taking too long to deliver room trays. *He did not think hot foods served in the dining room was cold. *Cold sandwiches were served for many suppers were because they were on the summer menu. *He did not know when the fall menu would start. *The fryer had been inoperable on 9/1/25 and 9/2/25, but had been fixed today (9/3/25). 16. Interview on 9/4/25 at 9:30 a.m. with CNA K revealed: *She had been trained as a food service worker, and had helped in the kitchen. *She and other CNAs were frustrated with having to ask for many corrections to the meal trays when kitchen staff were seeing the same menu card as the CNAs, and it led to delays serving the residents. *The menu card process is for nurse managers to give the diet to DDS G, who updates the menu card as the first check that the meal being served is correct. *Cooks and FSWs are the second check, and the CNAs serving are the third check that the resident is being served the correct meal. *Menu cards frequently don't get updated by the kitchen with changes. *Kitchen staff disregard resident's likes and dislikes and forget to use adaptive items. *CNAs had to make sure that the residents' meal trays contain the divided plates, covered cups, or assistive silverware that residents need, as those items were frequently missed by the kitchen staff. 17. Interview on 9/4/25 at 2:00 p.m. with social worker (SW) HH revealed: *She had been an employee at the facility for approximately three weeks. *She had heard meal complaints from three residents that included: -They were not receiving meat for breakfast. -They were not receiving the food item that the menu showed. -A complaint about the serving of succotash. *She had discussed those complaints with the lead social worker. 18. Interview on 9/4/25 at 2:05 p.m. with lead social worker (LSW) II revealed: *She thought that residents' food complaints seemed to occur in intermittent streaks. *Food complaints were to be discussed at the resident food council meetings, which were held in addition to the resident council and attended by residents, administration, and DDS G. *She thought that since the contracted company provided the food service, communication options were limited beyond the food council. *Residents had expressed dissatisfaction with the effectiveness of the food council recommendations. 19. Observation on 9/5/25 at 8:00 a.m. of the breakfast service in the dining room revealed: *The CNAs asked the kitchen staff for corrections on 14 of 15 residents' meal trays before they could serve them. *Corrections included telling the kitchen staff they needed a clean plate instead of just removing the scrambled eggs due to a resident's egg allergy. *Other corrections included the need for a divided plate, a Kennedy cup (a spill-proof drinking cup used with a straw), lids for cups, and the removal of items that the residents had marked as a dislike or had not marked as a choice. 20. Observation and testing on 9/5/25 at 8:12 a.m. of a sample breakfast tray from the kitchen revealed: *The menu for the day included biscuits and gravy, scrambled eggs, oatmeal, and a banana. *The meal tray had scrambled eggs, a biscuit with a tan gravy, and several bits of sausage, a banana, a glass of milk, and a cup of coffee on it. It did not contain oatmeal. 21. Interview on 9/5/25 at 8:30 a.m. with dietitian BB revealed: *She was the dietitian for the contracted food service that prepares the lunch and supper meals at the central kitchen. *She approved all menus at the central kitchen location. *The oversight of the facility dining service would be the responsibility of DDS G. *She did not agree that sausage patties should be substituted for all breakfast meat items, as they were easier for the kitchen to prepare. *She agreed that the kitchen staff were responsible for following the menu card for resident diet orders, allergens, assistive device needs, and preferences. *She did not think the CNAs having to correct a large quantity of meal trays, including 14 of 15 at breakfast that morning, reflected a good food service process. *She agreed that not serving all items on the menu could reduce the nutritional value of the meal. *She expected that resident preferences be strongly considered when making breakfast choices or when ordering lunch and supper from the central kitchen. *She would not expect the facility to be running out of food items for lunch and supper unless they did not order enough from the central kitchen. 22. Interview on 9/5/25 at 10:15 a.m. with administrator A revealed he would expect the kitchen staff to: *To accommodate the residents' physician diet orders, allergies, device needs, and food preferences. *Be responsive to the food council suggestions and resident choices to the extent possible. *The process for gathering information about food choices was the food council, an their informal auditing of five residents at a time about food taste, food temperature, and choices. 23. Observation and interview on 9/5/25 at 10:55 a.m. with DDS G revealed he was not aware that CNAs had requested items from the always available menu (a menu of food options available to residents who did not want the scheduled meal) but did not receive them, particularly in the rehab unit dining room. 24. Interview on 9/2/25 at 4:55 p.m. with resident 52 revealed: *The food here isn't very good. *They serve chicken at least three or four times a week *We complain, but nothing changes. I take what they serve me. 25. Interview on 9/3/25 at 11:50 a.m. with resident 49 revealed: *She reported that the food is often cold when it is served to her. *She reported that this was her third meal in a row where she received chicken noodle soup. -They are serving chicken noodle soup because the fryer is broke. *She reported that residents were not given adequate options for their meals. Interview on 9/3/25 at 10:15 a.m. with resident 5, current president of the resident council, revealed he: *Had been the resident council president for the past few years. *Provided his permission to review the previous resident council meeting minutes. *Stated residents had expressed concerns at the resident council meetings regarding the meal service and the food served. *Felt the provider had responded to the concerns discussed at the resident council meeting. 26. Interview on 9/3/25 at 1:30 p.m. with residents 4, 11, 16, 24, 38, 47, 49, 52, 53, 56, 57, 62, 63, 75, and 83 revealed: *One of the fifteen residents attended the resident council meetings on a regular basis. *The other residents stated they had not attended the resident council meetings regularly, with the following responses given: -The same concerns were addressed over and over. -They felt the meeting was a waste of time and was just talk with nothing getting resolved. -The leadership staff that attended would respond with I just don't [do not] know what I can say, and I'll see what I can do, but then nothing was done. *The residents agreed on the main food concerns they had included: -The lunch and evening meals took too long to get served, with some residents having to wait up to one hour for their meal to get served. -The provider would run out of peanut butter, individual coffee creamers, butter, sugar, bread, and milk. -The provider's pop machine would also run out of pop, without being refilled timely. 27. Interview on 9/4/25 at 9:05 a.m. with activity director EE regarding the resident council revealed: *She had worked at the facility for four years. *She helped to coordinate the resident council meetings, which met every other Monday at 11:00 a.m. *The residents' special dietary meetings were held monthly on the second to last or last Monday, depending on when the resident council met, to avoid having both meetings on the same day. -The provider's contracted dietary services had asked that those special dietary meetings would continue to be held. *After the resident council meeting, she would complete the resident council's meeting minutes and pass out copies of the meeting minutes to administration, dietary, social services, and nursing. *She expected those departments to review the resident council meeting minutes and take action to address the concerns related to their department. *She would ask those departments, before the next resident council meeting, and discuss any progress or resolution that department had made regarding the resident council's concerns. 28. Review of the resident council meeting minutes revealed that, on average, fourteen residents attended the resident council meetings: *On 7/15/24, the residents had concerns that the cranberry juice was watered down, they requested more fruit choices, and that the menus be changed more frequently. One resident expressed a concern with the staff not responding timely to his call light. *On 8/26/24, the minutes reflected that a new process was being implemented for serving the meals in the dining room. *On 9/23/24, the residents agreed that the Dietary Meetings would be held once a month moving forward. *On 11/18/24, the residents expressed the concern for more flavor in the food that was served. *On 12/2/24, the residents expressed appreciation for the dietary improvements made with food temperatures and the timeliness of the meal service. *On 1/6/25, the residents expressed they would like to see more beef served and less chicken. They also indicated the table rotation was working out well for the meal service. *On 2/3/25, the residents decided to discontinue the dietary meetings as their dietary concerns were mostly being worked out. *On 2/17/25, the residents decided to continue the dietary meetings due to some changes that happened in dietary. *On 4/28/25, the new DDS G was introduced. *On 5/19/25, the residents requested that more meatloaf be included on the menus. *On 6/16/25, the residents requested the following food items: drumstick ice cream treats, small pizzas, and brats be included on the menus. *On 7/21/25, the residents requested that pork and beans be included on the menus. *On 8/11/25, the residents expressed concerns regarding the temperatures of the food served and the quality of the food. 29. A review of the resident dietary meeting minutes revealed the group met: *On 12/30/24 at 11:00 a.m., with 21 residents in attendance. *On 1/29/24 at 11:00 a.m., with 13 residents in attendance. *On 3/31/25 at 11:00 a.m., with 18 residents in attendance. *On 6/30/25 at 11:00 a.m., with 14 residents in attendance. *On 7/28/25 at 11:00 a.m., with 14 residents in attendance. The dietary meeting minutes indicated concerns with the timeliness of the meal service, getting the food items requested, food temperatures with food not being served hot, fresh vegetable and fruit options, and the cleanliness of the dining room. 30. Interview on 9/2/25 at 4:03 p.m. with resident 53 in his room revealed: *He was sitting in his wheelchair with his feet on his bed. *He stated he worked in the restaurant business for several years, and the food was not good here. *He preferred to eat in his room for most meals. *He had a standing order for a cheeseburger and french fries for supper every night because he did not like the food options for the supper menu. *The dietary staff had forgotten his supper meal on multiple occasions, so he did not receive a supper room tray. *On one occasion, he had gone to the kitchen to request his cheeseburger and french fries and was told the kitchen was closed for the night. *A CNA went to a fast food restaurant down the street and brought him a cheeseburger and french fries that evening. *Those fries were hotter than the ones he had previously been served from the kitchen. 31. Interview on 9/3/25 at 10:26 a.m. with resident 34 in her room revealed: *She preferred to eat her meals in her room. *She was served a cold brat with a bun for supper on Saturday. *The plate was even cold, like it had been in a refrigerator. *A CNA took it to the microwave and warmed it up. *She stated there had been other days when her food was cold. 32. Interview on 9/4/25 at 2:31 p.m. with DDS G regarding food temperatures revealed: *He was a contracted dietary manager and started working at the facility in May of 2025. *He expected that the staff would take the temperature of the residents' food before all meals. *Residents who requested room meal trays were served after the main dining rooms. *Room meal trays were kept in the refrigerator if a resident was not in their room when it was delivered. Review of the provider's 12/16/24 revised Food Temperature Monitoring policy revealed: *Food is cooked, reheated or cooled to ensure proper holding temperatures before each meal service.

Based on observation and interview, the facility failed to ensure that three of three residents (44, 81, 82) were provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and dietary needs. 1. Interview on 9/3/25 at 8:50 a.m. with resident 81 revealed:*Hot food is frequently served cold.*She would sometimes not eat an item if it was not at an acceptable serving temperature because it was unpleasant to her.*The previous evening, they were served a cold sandwich and a cold bean salad. *No fruit or dessert was provided. 2. Interview on 9/3/25 at 8:50 a.m. with resident 44 revealed:*They are served cold sandwiches for three to four suppers every week.*She would prefer something warm in the evenings.*When she asked for something warm, she was not given a choice but provided mashed potatoes and gravy.*She dislikes hot dogs and doesn't like it when they are served.*She is not aware of other food choices. 3. Interview on 9/3/25 at 9:15 a.m. with resident 82 revealed:*The food is frequently very dry and hard for her to eat due to her lack of teeth.*Foods that should be served hot are more often cold than they are hot. 4. Interview on 9/3/25 at 4:00 p.m. with director of dietary services (DDS) G about resident menu complaints revealed:*There was ham on the breakfast menu for Monday, but sausage patties were served. *There was bacon on the breakfast menu for Wednesday, but sausage patties were served.*He did not feel they had the equipment to prepare ham or bacon for the number of residents they served.*It was easiest to cook and hold the temperature of the sausage patties.*He agreed that the menu did not match the food served.*They were not required to get a substitution approved if it was a like item such as a meat substituted for a meat or toast substituted for a muffin. *He attributed complaints about cold food were due to the certified nursing assistants (CNAs) taking too long to deliver room meal trays. *He did not believe that hot food served in the dining room was cold. *Cold sandwiches were served for many suppers were because they were on the summer menu. 5. Interview on 9/4/25 at 9:30 a.m. with CNA K revealed:*She and other CNAs expressed frustration over frequent corrections needed for the residents' meal trays despite the kitchen staff having access to the same resident menu cards (a card used at each meal that describes the resident's physician-ordered diet, choice from the menu, food preferences, allergies, and dislikes) as the CNAs.*She explained that each resident had a menu card. The nurse managers were to give the residents' diet information to DDS G, who updated the menu cards, and that was considered as the first check that the meal served to the residents was correct. *Cooks and FSWs preparing and plating the meals was considered the second check, and the CNAs serving those meals was considered the third check that the resident was served the correct meal. *Menu cards were frequently not updated by the kitchen staff.*She felt the kitchen staff disregarded residents' diet needs and preferences and failed to provide them with adaptive items some of the residents needed to eat. 6. Interview on 9/4/25 at 1:00 p.m. with DDS G revealed:*He agreed that the menu cards contained important resident information, including food preferences, ordered diets and food textures, and food allergies, which were critical to the residents' safety. Interview on 9/4/25 at 2:00 p.m. with social worker (SW) HH revealed:*She had been an employee at the facility for approximately three weeks.*She had heard three meal-related complaints from residents that included:-They were not receiving meat for breakfast.-They were not receiving the food item that the menu showed.-A complaint regarding the serving of succotash. *She had discussed these complaints with the lead social worker. 7. Interview on 9/4/25 at 2:05 p.m. with lead social worker (LSW) II revealed:*She thought the resident's food complaints occurred in intermittent streaks.*Food complaints were to be discussed during the resident food council meetings.*She thought that since the contracted company provided the food service, communication options were limited beyond the food council meetings, which were a monthly meeting separate from the resident council meeting for residents, facility leadership, and DDS G to talk about the food served at meals.*DDS G attended the resident food council meetings. *Residents had expressed dissatisfaction with the effectiveness of the food council recommendations.Observation and interview on 9/4/25 at 3:05 p.m. with DDS G revealed:*He agreed that kitchen staff should ensure the residents' dining meal trays reflected the correct resident preferences, diets, and adaptive equipment.*He was solely responsible for adding the residents' diet orders to the menu cards.*He thought the CNAs were responsible for managing residents' meal preferences. Observation on 9/5/25 at 8:00 a.m. during the breakfast meal service in the dining room revealed the CNAs had requested corrections on 14 of 15 prepared resident meal trays before they could be served to the residents. 8. Interview on 9/5/25 at 8:30 a.m. with dietitian BB revealed: *She was the dietitian for the contracted food service responsible for preparing the residents' lunch and supper meals at the facility's central kitchen.*She approved all of the menus at the central kitchen. *The oversight of the facility's dining service was designated as the responsibility of DDS G.*Breakfast was to be prepared based on the menus she approved.*The substitution of like items such as a meat for a meat or toast for a muffin did not require her approval, but she expected the menu to be followed as closely as possible. *She disagreed with substituting sausage patties for all breakfast meat items solely for ease of preparation.*She agreed that the kitchen staff were responsible for following the residents' menu cards, including the residents' diet orders, allergies, assistive device needs, and preferences.*She agreed that the documented temperatures of the scrambled eggs, biscuit and gravy, or milk on the sample tray did not meet safe food serving temperatures. 9. Interview on 9/5/25 at 10:15 a.m. with administrator A revealed:*He expected kitchen staff to:-Adhere to facility policies regarding hair and facial hair coverings, hand washing and glove use, kitchen cleaning, food temperature monitoring, and hygiene.-Follow physician diet orders, address allergies, accommodate assistive device needs and honor food preferences.-Be responsive to food council suggestions and resident choices to the extent possible.Was aware of complaints about hot food being served cold and the frequent serving of cold food items such as sandwiches. *He stated the process for gathering feedback on food choices was the food council, and they conduct informal audits of five residents at a time about food taste, food temperature, and choice.

Based on observation, interview, record review, and policy review, the provider failed to complete a baseline care plan and provide a written summary of the baseline care plan to the resident within 48 hours of their admission to the facility for four of six newly admitted sampled residents (14, 64, 67, and 85) reviewed who admitted to the facility in August 2025.Findings include:1. Observation and interview on 9/2/25 at 2:50 p.m. with resident 14 in his room revealed he:*Was frustrated about the communication he had received about his care since he had been admitted to the facility. He felt that the nursing staff had not given him enough information about his wound care and his positioning needs.*Felt that the dietary staff had not provided him with the correct diet or with the foods he preferred to eat.*Had not received a list of his medications or a copy of his baseline care plan when he was admitted to the facility approximately two weeks ago.*Pointed to an admission packet and stated that was the information he had received when he was admitted to the facility. That information did not contain a baseline care plan. Review of resident 14's electronic medical record (EMR) revealed:*He was admitted on [DATE].*His 8/25/25 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact.*There was no documentation that indicated the resident's baseline care plan was developed and reviewed with him, or that he had been provided or offered a copy of his baseline care plan within 48 hours of his admission. 2. Interview on 9/4/25 at 1:15 p.m. with resident 67 in his room revealed he: *Had not received a list of his medications or a copy of his baseline care plan when he was first admitted to the facility.*Felt that there was miscommunication between his therapy team and the nursing staff regarding his discharge goals. Review of resident 67's EMR revealed:*He was admitted [DATE].*His 8/17/25 BIMS assessment score was 15, which indicated his cognition was intact.*There was no documentation that indicated the resident's baseline care plan was developed and reviewed with him, or that he had been provided or offered a copy of his baseline care plan within 48 hours of his admission. 3. Interview on 9/2/25 at 2:20 p.m. with resident 64 in her room revealed she did not recall having received a baseline care plan when she was first admitted to the facility. Review of resident 64's EMR revealed:*She was admitted on [DATE].*Her 8/21/25 BIMS assessment score was 15, which indicated her cognition was intact.*There was no documentation that indicated the resident's baseline care plan was developed and reviewed with her or that she had been provided or offered a copy of her baseline care plan within 48 hours of her admission to the facility. 4. Review of resident 85's EMR revealed:*She was admitted on [DATE].*Her 8/11/25 BIMS assessment score was 15, which indicated her cognition was intact.*There was no documentation that indicated the resident's baseline care plan was developed and reviewed with her or that she had been provided or offered a copy of her baseline care plan within 48 hours of her admission to the facility. A request was made on 9/4/25 at 7:43 a.m. to administrator A for documentation that baseline care plans had been developed and the resident or their representative was offered a copy within 48 hours of their admission to the facility for newly admitted residents 14, 64, 67, and 85. No further documentation was provided. Interview on 9/4/25 at 12:54 p.m. with director of nursing (DON) B revealed:*Baseline care plans had been completed, but had not been provided to residents 14, 64, 67, and 85.*DON B expected that the resident's baseline care plans would be completed within 48 hours of their admission to the facility, and a copy would be provided to the resident.*Baseline care plans for residents 14, 64, 67, and 85 were to be completed by the Minimum Data Set (MDS)/registered nurse (RN) U. Interview on 9/4/25 at 1:20 p.m. with MDS/RN U revealed she:*Would initiate the comprehensive care plan in the EMR on the day that the resident was admitted to the facility.*Completed all the sections of the care plan, printed that care plan, and provided a copy of it to the resident. She would document in the EMR when she had completed the baseline care plan and had provided the care plan to the resident.*Had been on leave from the facility for approximately three weeks. Residents 14, 64, 67, and 85 were admitted to the facility while she was on leave.*Stated that residents' 14, 64, 67, and 85's baseline care plans had been completed by MDS/RN T, but had not been provided to them or documented as having been completed. Review of the provider's 12/2/24 Care Plan policy revealed:*Baseline care plan- Includes instructions needed to provide effective and person-centered care to the resident that meet professional standards of quality care.*A baseline care plan will be developed upon admission according to federal and state regulations. The location must provide the resident and the resident representative with a written summary of the baseline care plan. Use the PN Care Conference Note . to document that the meeting occurred with the resident and representative and any significant discussion that occurred.

Based on observation, interview, record review, and policy review, the provider failed to ensure an air mattress safely fit the resident's bed frame and did not impede the use of assist bars for one of one sampled resident (44) who had an air mattress to relieve pressure from a pressure ulcer and used assist bars for mobility and positioning while in bed, which may have put the resident at risk for accidents and injury. Findings include:Based on observation, interview, record review, and policy review, the provider failed to ensure that the air mattress for one of one sampled resident (44) was safely fitted to the bed frame and did not present an accident hazard. 1. Observation and interview on 9/3/25 at 8:50 a.m. with resident 44 revealed:*Her bed had an air mattress on it that extended approximately five inches over the open side of the bed frame.*The air mattress was covered with a smooth nylon cover and designed to be used without a bottom sheet.*She had been using the air mattress for several months because she had a pressure ulcer (skin and/or underlying tissue injury from prolonged pressure).*There were assist bars (bed/side rails) attached to both sides of the bed frame but she was only able to use the one on the wall side of the bed.*She used the assist bar on the bed's wall side to help turn over.*She previously used the assist bar on the open side for assistance with turning and getting up from the bed.*The assist bar on the open side of the bed was no longer able to be used due to the air mattress being larger than the bed frame.*The nursing staff would place the long side of her bedside table against the bed at night to remind her not to get too close to the edge.*She was afraid of falling out of bed, and she felt it disturbed her sleep. 2. Interview on 9/4/25 at 9:45 a.m. with director of nursing (DON) B revealed:*She had created the work order for an air mattress to be placed on resident 44's bed.*Maintenance staff would install an air mattress when there is a work order for one.*She was not aware of an issue with the air mattress size or that the assist bar on the open side of the bed could not be used.*She agreed that an air mattress that was larger than the bed frame would be an accident hazard. 3. Interview and observation on 9/4/25 at 9:50 a.m. with maintenance mechanic (MM) Z and maintenance technician (MT) C revealed:*They agreed that resident 44's mattress did not fit properly and was not safe.*The air mattress being too large for the bed frame was an accident hazard.*Resident 44 could slide out of bed and onto the floor.*The bed rail on the open side of the bed could not be raised.*MM Z did not know who had installed the air mattress on resident 44's bed. 4. Review of work order #2822 revealed:*The request to add an air mattress to resident 44's bed was created by DON B on 6/10/25.*It was assigned to MM Z on 6/11/25 at 8:53 a.m. and marked set to: completed on the same date and time by LMM AA. 5. Review of the 6/13/25 bed and side rail inspection log completed by MM Z revealed the areas:*Inspect mattress gap between side rails/assist bars.*Verify side rail[s] are fully functional and free of obstructions. 6. Interview on 9/4/25 at 12:30 p.m. with lead maintenance mechanic (LMM) AA revealed:*Resident 44's bed frame was not an acceptable size for that air mattress.*They had bed frames that were the appropriate size for the air mattress.*It would not be acceptable for the bed rails not to be used.*The bed and side rail inspection log completed by MM Z on 6/13/25 was not accurate.*Agreed that it was an unsafe environment for the resident. Review of resident 44's electronic medical record (EMR) revealed:*Resident 44 had a Brief Interview for Mental Status (BIMS) Assessment score of 15, which indicated that her cognitive function was considered normal and not impaired. *A 6/5/25 physician's order to provide an air mattress for resident 44 due to a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer.*Her current care plan had a 6/4/25 initiated focus area of an ADL self-care performance deficit related to her deconditioning post hospital stay, with interventions that indicated she:-Used assist/grab bars to position up in bed, turn side to side, move from lying to sitting, and to move from sitting to lying, which were initiated on 6/5/25.-Was able to utilize assist/grab bars appropriately, which was initiated on 6/5/25.*Had an air mattress for pressure relieving, which was initiated on 6/5/25 and revised on 9/4/25.*Her current care plan had a 6/5/25 initiated focus area that indicated the resident was at risk for falls related to new onset atrial fibrillation and her deconditioning post hospital stay.-An intervention for that focus area indicated that staff members were to educate the resident and her family about safety reminders. 5. Interview on 9/5/25 at 9:50 a.m. with minimum data set (MDS)/registered nurse (RN) revealed:*She had completed the education with resident 44 as indicated on the physical device and restraint evaluation on 8/24/25.*She pushed the air mattress out of the way with her shoulder to be able to raise the rail.*Resident 44 would not have been able to raise the rail herself.*She recognized that the air mattress was too big for resident 44's bed frame and had meant to let nursing or maintenance know.*She had not notified anyone about the air mattress being too big for the resident's bed frame. 6. Interview on 9/5/25 at 10:15 a.m. with administrator A revealed:*An assessment would be required to ensure the proper fit of the mattress to the bed frame and ensure the safety of the resident.*The air mattress assessment completed by MM Z was not accurate. Review of the physical device and/or restraint evaluation and review for resident 44 revealed:*It was signed as completed by Minimum Data Set/Registered Nurse (MDS/RN) T on 8/24/25.*It indicated a recommendation for the use of an assist rail (quarter rail used for turning and mobility).*It indicated that informed consent had been obtained for use of the assist rail.*It indicated that general device education was provided and specifically that she showed the resident how to use/remove the assist rail. Review of the provider's 2/2/24 reviewed/revised bed safety and side rail entrapment resource policy revealed:- Hazards refer to elements of the resident environment that have the potential to cause injury or illness.- Free of accident hazards as possible refers to being free of accident hazards over which the facility has control.* F689 [federal regulation] states: The facility must ensure that the resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents.* A resident's bed should be a place of comfort and relaxation, a safe place. When the bed system does not fit correctly . the resident's bed is no longer a safe place.*The bed system includes the bed frame and mattress as well as any side rails or assistive devices.*Review manufacturer's guidance for use of the various types of mattresses such as air mattresses.*It is important to remember that not all rails and mattresses fit all bed frames.-Inspect the bed system for proper fit of mattress in the bed frame.The air mattress manufacturer's instructions were requested from the provider but not received prior to survey exit on 9/5/25.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, and interview, the provider failed to withhold cardiopulmonary resuscitation (CPR) for one of one resident (100) who had a do not resuscitate (DNR) code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) and was found unresponsive.Findings include:1. Review of the provider's [DATE] SD DOH FRI revealed:*On [DATE], resident 100 was found unresponsive by restorative nursing aide (RNA) V.*Director of nursing (DON) B initiated the provider's code blue process.*CPR [cardiopulmonary resuscitation] was initiated [by a facility staff member] and EMS [Emergency medical services] [was] called prior to the [resident's] DNR order being brought to the resident room. Code status was found via the advanced directive binder on the crash cart (a cart that stores medication and equipment for use during a medical emergency) per policy/procedure.*Upon EMS's arrival at the facility, the resident's code status was confirmed to be DNR.*[The provider's] Policy was followed. 2. Review of resident 100's electronic medical record (EMR) revealed:*She was admitted to the facility on [DATE].*An [DATE] physician's order for ADVANCE DIRECTIVE: Do Not Resuscitate (DNR). 3. Interview on [DATE] at 11:20 a.m. with DON B, who worked on [DATE], revealed:*On [DATE], RNA V found resident 100 unresponsive during the morning water pass.*DON B's office was in the area of resident 100's room. She entered that room, assessed resident 100, and determined she was not breathing.*DON B asked certified nursing assistant (CNA) K resident 100's code status, and was told by CNA K that the resident's code status was a full code (all life-sustaining measures, including CPR, should be used during a medical emergency to attempt to restart a patient's heart and lungs).*Registered nurse (RN) W brought the crash cart to resident 100's room, and gave a second verbal confirmation that resident 100 was a full code.*DON B initiated CPR on resident 100, requested the automated external defibrillator (AED), and requested 911 to be called.*DON B provided CPR to resident 100 until emergency medical technicians (EMTs) arrived and assumed resident 100's emergency treatment.*DON B looked at the advanced directives binder and read that resident 100 had a DNR code status.*That written DNR code status was provided to the EMTs, and CPR was stopped.*DON B stated if she had known that resident 100 had a DNR code status, she would not have started CPR on resident 100. There had been a miscommunication. 4. Interview on [DATE] at 9:31 am with CNA K, who worked on [DATE], revealed:*She had responded to resident 100's room after resident 100 was found unresponsive.*CNA K told DON B that resident 100 was a full code.*CNA K had not looked at the advanced directives binder when she told DON B that. She thought that resident 100 was a full code. 5. Interview on [DATE] at 10:43 p.m. with clinical learning development specialist (CLDS) F revealed:*She was a CPR instructor and conducted the nursing staff skills fair and competencies.*When a resident was found unresponsive, staff were trained to check the resident's vitals (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate), obtain the crash cart and the advance directives binder to confirm the resident's code status before initiating CPR.*The advance directives binder and the residents' EMR identified each resident's physician-ordered code status.*She expected that CPR would not be initiated if a resident had a DNR code status. *She stated that it was the facility's policy for the nurse to check the resident's code status before starting CPR. *Review of the provider's [DATE] Advance Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) policy, revealed:*If cardiac arrest occurs, CPR must be initiated unless the resident has: a. A valid DNR order on file that includes the medical order issued by a physician.

Based on observation, interview, record review, and policy review, the provider failed to ensure bathing was provided and documented for two of two sampled residents (14 and 64) who were dependent on staff assistance with bathing. Findings include:1. Observation and interview on 9/2/25 at 2:50 p.m. and again on 9/4/25 at 8:32 a.m. with resident 14 in his room revealed:*He was told that he could shower, but he had not received a shower since he was admitted to the facility.*He had only received bed baths since he was admitted , but he felt that the bed baths were not very thorough. He wanted his hair washed.*On 9/4/25, a staff member had washed his back in the morning, and he wondered if that was considered his bath for the day. Review of resident 14's electronic medical record (EMR) revealed:*He was admitted on [DATE].*His 8/25/25 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact.*His diagnoses included paraplegia (partial or complete loss of movement and/or sensation in the legs and lower part of the body), multiple sclerosis (a chronic autoimmune disease that causes symptoms, including vision problems, muscle weakness, fatigue, numbness, balance and coordination issues, and cognitive difficulties), and pressure ulcers (injury to skin and underlying tissue from prolonged pressure).*His 8/20/25 care plan indicated Resident requires [the use of a] shower chair, [and] 2 staff assist [assistance of two staff].*An 8/20/25 physician order indicated May shower, do not allow direct water pressure to dressing/incision. Keep dressing clean and dry. No tub until directed.*His 8/25/25 Minimum Data Set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) indicated he felt choosing between a tub bath, shower, bed bath, or sponge bath was Somewhat important.*The bathing task documentation options included shower, tub [bath], whirlpool [bath], sponge bath, shampoo only, unavailable and refused.There was no documentation that resident 14 had received a shower, tub [bath], whirlpool [bath], a sponge bath, a shampoo only, or that he was unavailable or refused bathing, since he was admitted . 2. Interview on 9/2/25 at 2:20 p.m. with resident 64 in her room revealed she: *Had only received one shower since she had been admitted to the facility. She would have liked to have received more showers because her hair felt dirty and her skin felt very dry. *Showered three times a week at home. She thought that she would have received one or two showers each week while at the facility.*Thought that she was not offered showers because she required more assistance than the staff could provide. Review of resident 64's EMR revealed:*She was admitted on [DATE].*Her 8/21/25 BIMS assessment score was 15, which indicated her cognition was intact.*Her 8/15/25 care plan indicated, Resident requires bathing options, shower chair 1 staff assist [assistance of one staff].*Her 8/21/25 MDS assessment indicated she felt choosing between a tub bath, shower, bed bath, or sponge bath was Very important.*Her bathing task documentation indicated she had received a shower on 8/24/25.-There was no documentation that resident 64 had received a tub [bath], whirlpool [bath], a sponge bath, a shampoo only, or that she was unavailable or refused bathing, since she was admitted . 3. Review of the current Sunrise Suites Bath Schedule revealed:*Residents' bathing was assigned by room number.*All [new resident] admits [admissions] [are] to receive a bath the day after [their] admission- this is REQUIRED.*Makeups can be completed on Sunday- openings on Wednesday/Thursday evening for [new] admits.*Resident 14 was scheduled for bathing on Mondays and Thursdays during the evening shift.-Resident 14 had not been provided his scheduled bathing on 8/21/25 (the day after his admission), 8/25/25, 8/28/25, or 9/1/25.*Resident 64 was scheduled for bathing on Mondays and Thursdays during the evening shift.-Resident 64 had not been provided her scheduled bathing on 8/16/25 (the day after her admission), 8/18/25, 8/21/25, 8/25/25, 8/28/25, or 9/1/25. 4. Interview on 9/4/25 at 10:58 a.m. with licensed practical nurse (LPN) O regarding resident 64's bathing revealed:*Resident 64 was allowed to shower if her dialysis port dressing was covered.*She stated that certified nursing assistant (CNA) N had assisted resident 64 to shower that morning (9/4/25).*LPN O expected that resident 64's showers provided or refusals to shower would have been documented in the EMR. 5. Observation and interview on 9/4/25 at 11:12 a.m. with CNA N and occupational therapist (OT) S in resident 64's room revealed:*CNA N had just finished assisting resident 64 with showering. This was the first time she had assisted resident 64 to shower.*CNA N documented when she completed a resident's shower in the resident's EMR under bathing tasks.*OT S stated that she had not assisted resident 64 with showering. When therapy provided residents assistance with bathing or showering, they would tell the CNA so that shower would be documented in the residents' EMR. 6. Interview on 9/04/25 at 11:13 a.m. with LPN O regarding resident 14's bathing revealed:*Resident 14 was allowed to shower as long as his wound dressings remained dry. She was unaware of any reason that the resident would not have been provided a shower or a bed bath.*LPN O thought that resident 14 had been refusing to shower and those refusals should have been documented in the EMR.*LPN O was unable to find documentation that resident 14 refused showering.*LPN O stated that resident 14 had been provided bed baths and those bed baths should have been documented in the bathing task section of the EMR. She was unable to find documentation that resident 14 had received bed baths. 7. Interview on 9/5/25 at 9:10 a.m. with director of nursing (DON) B regarding resident 64's bathing revealed:*Resident 64 was allowed to shower if her dialysis port was covered.*DON expected resident 64 to have showers twice a week and expected those showers to have been documented in the EMR. 8. Interview on 9/5/25 at 10:36 a.m. with DON B regarding resident 14's bathing revealed:*There was no documentation that resident 14 had received a bed bath or a shower.*Resident 14 had been refusing to get out of bed or shower.*DON B expected those refusals to shower to have been documented.*She thought that resident 14 was provided with a bed bath when he refused to shower and expected those bed baths to have been documented.*If a resident was unavailable or refused a shower or a bed bath, she expected the CNA to have offered the resident a shower or a bed bath on another day, and any bathing activity to have been documented in the EMR. Review of the provider's 8/29/25 Bathing policy revealed:*Purpose- To promote cleanliness and general hygiene, To promote comfort, relaxation, and well-being, To observe [the] resident's condition, To assist [the] resident with personal care.*Perform.document[ion] where/when appropriate.

Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to protect the resident's right to be free from neglect and abuse for one of one sampled resident (4) who complained of prolonged wait times for his call light to be answered by staff and felt that had caused him to be incontinent of urine or bowel at times. The resident expressed that those instances caused him to feel less than human. Findings include:1. Review of the 2/7/25 SD DOH complaint intake report regarding resident 4 revealed:*Resident 4 had slept so long that he was incontinent of urine.*He turned on his call light, and after 30 minutes no one answered so he called the front desk.*He waited an additional 30 minutes before someone came to assist him.*He sat in urine for over an hour. 2. Review of resident 4's electronic medical record (EMR) revealed:*His Brief Interview for Mental Status (BIMS) assessment score on 12/5/24 was 15 which indicated his cognition was intact.*His Braden score on 12/2/24 was 16 which indicated he had a mild risk for skin breakdown.*He had diagnoses of:-Mixed incontinence (a condition of stress and urge voiding).-Open wound to right buttock (skin breakdown).-Spinal stenosis (narrowing of spaces between spinal bones).-Adjustment disorder (inability to adapt to situations in society).-Hypertensive heart disease with heart failure (high blood pressure which damages the heart over time).-Morbid Obesity (excessive weight that significantly impacts health and well-being).-Major depressive disorder, single episode, severe (feeling of sadness and loss of interest that interfere with daily living).-Generalized anxiety disorder (persistent worry and fear about everyday situations).*His right buttock wound discovered on 1/15/25 and was due to incontinence.-He had orders to receive Triad Hydrophilic wound dressing paste (wound healing product) to the wound and to cover the wound with Mepilex dressing once daily and as needed.*Numerous documentations in his progress notes indicated his refusal of activities of daily living, repositioning, medications and treatments.*Resident 4's care plan indicated he was bedfast all or most of the time and he preferred bed baths. That was initiated on 9/19/24.-His bathing preference was updated on 2/7/25 that indicated his preferred a shower weekly on Thursday morning. 3. Review of resident 4's call light log from 1/19/25 to 2/7/25 revealed these times that were over 20 minutes in length:*On 1/20/25 at 12:57 a.m. his call light was on for 23 minutes.*On 1/20/25 at 8:20 a.m. his call light was on for 43 minutes.*On 1/22/25 at 5:11 a.m. his call light was on for one hour and seven minutes.*On 1/26/25 at 12:16 p.m. his call light was on for 25 minutes.*On 2/3/25 at 5:10 a.m. his call light was on for 22 minutes.*On 2/3/25 at 8:52 p.m. his call light was on for 39 minutes.*On 2/6/25 at 9:54 p.m. his call light was on for 24 minutes. 4. Interview on 9/3/25 at 8:08 a.m. with resident 4 revealed:*He had some depression and anxiety.*He showered once a week on Thursday morning.*He had been left lying in urine and bowel movement several times in his bed after turning his call light on and waiting for assistance.*He required a treatment to his right buttock open area daily.*His call light could be on for 20 minutes to two hours before it was answered at times.*He stated, He felt disgusting and less then human when they do not answer his call light, how can another person do that to another person. Interview on 9/3/25 at 10:55 a.m. with certified nursing assistant (CNA) K revealed:*She has worked at facility for about three years.*Resident 4 did not exhibit negative behaviors toward her.*She had at times observed resident 4 screaming at other staff and throwing things in his room.*Resident 4 had periods when he would cry and bang on things.*Resident 4 had refused cares such as toileting, and bathing at times.*The expected time for staff to answer a resident's call light was two minutes. Interview on 9/3/25 at 5:00 p.m. with certified medication aide (CMA) L revealed:*Resident 4 had episodes when he will yell and scream at staff at times.*She felt resident 4 had a hot temper and could go from being calm to hot in a short period of time.*Resident 4 was able to use his call light.*If resident 4 had an incontinent episode it could set him off and he will get upset. Interview on 9/4/25 at 2:28 p.m. with director of nursing (DON) B revealed:*Resident 4's preference for bathing prior to 2/7/25 was to take a bed bath to allow for his smoking time preference.-He changed to a weekly shower on 2/7/25.*Resident 4 would at times refuse staff assistance with toileting, bathing, showering, repositioning, and wound care.*Resident 4 does attend care conferences.*She thought the staff answering a call light was within 20 to 30 minutes of it being turned on would be a prompt response and that was her expectation. Interview on 9/4/25 at 3:10 p.m. with administrator A revealed:*His expectation regarding the staff answering a resident call light, was it would be answered in an appropriate time, and that would depend on the resident and the resident's needs.*When asked if an hour was too long to wait, he stated that would depend on what the resident's needs would be. 5. Review of the provider's revised 7/8/25 Call light Policy revealed:*Purpose to ensure residents always have a method of calling for assistance and to promptly answer resident's call light. Review of the provider's revised 4/7/25 Abuse and Neglect policy revealed:*The resident/client has the right to be free from abuse, neglect, misappropriation of resident/client property and exploitation. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Residents/clients must not be subjected to abuse by anyone, including but not limited to, location employees, other residents/clients, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals.

Based on observation, interview, and policy review, the provider failed to ensure: *Food items were appropriately labeled and stored in one of one observed walk-in cooler in one of one kitchen. *The minimum water temperature of the dishwashing machine was used for the cleaning and disinfecting of dishes. *Food was prepared and served in a safe and sanitary manner by two of two dietary staff (dietary director K and cook M) who did not perform appropriate hand hygiene during one of one observed meal service. Findings include: 1. Observation on [DATE] at 8:01 a.m. of the kitchen revealed: *Metal storage shelves in the walk-in cooler which contained the following food items: -One opened bottle of Mayonnaise with no open, or discard date, or printed use by date. -An opened bottle of BBQ sauce with an open date of [DATE] and a discard date of [DATE]. -An opened bottle of Dijon mustard with an open date of [DATE] and a discard date of [DATE]. -An opened bottle of coleslaw dressing bottle with ,d+[DATE] written on the top of it with no discard date on it. -There was an opened bottle of balsamic vinegar with no open or discard dates. -A container marked tuna salad with open ,d+[DATE] and discard ,d+[DATE] written on it. -An opened whipped topping piping bag with an exposed tip and no open or discard date on it. -An opened bag of crumbled blue cheese with no open or discard date on it. 2. Observation on [DATE] at 8:06 a.m. and 2:59 p.m. of the kitchen walk-in cooler revealed: *There was an opened half-full milk with no open or discard date on it. *An open cardboard container of heavy whipping cream with no open or discard dates on it. 3. Observation on [DATE] at 8:20 a.m. and 11:10 a.m. of the kitchen's dishwashing machine and temperature documentation revealed: *The dishwasher utilized a low temperature wash and a chemical sanitizing process. *The manufacturer's information plate on the front of the dishwasher indicated the minimum wash and rinse temperatures were to have been 120 degrees F. *The posted June dishwashing machine log on the dishwasher revealed: -Wash Temp: 120 degrees [F]. -Temperatures on the log ranged from 120 to 150 degrees F. -No dishwasher temperatures were documented on that log for [DATE], [DATE] or [DATE] for any meal services. *At 11:10 a.m. temperatures were noted to have been added to the log for [DATE], [DATE] and [DATE]. 4. Observation, testing, and interview on [DATE] from 11:37 a.m. through 11:55 a.m. with dietary assistants (DA) N and dietary server (DS) H revealed: *DS H put the breakfast dishes in the dishwasher to complete a dishwashing cycle. *DA N placed the digital thermometer in the protruding drain on the outside of the machine giving a temperature of 113 degrees F. *DS H plunged the digital thermometer into the liquid that was still in the dishwasher after a washing cycle was completed. *Neither was sure if there was a policy on how to obtain the temperature of the dishwasher. *Temperatures of the dishwasher via a digital holding thermometer was placed inside the dishwasher on a dish rack that indicated: -At 11:45 a.m. the wash cycle was 113 degrees F. -At 11:50 a.m. the wash cycle was 116 degrees F. -At 11:55 a.m. the wash cycle was 120 degrees F. 5. Observation and interview on [DATE] at 8:21 a.m. with dietary director K revealed: *She wore gloves while cracking and handling eggs and used egg shells. *While wearing those same gloves she handled resident plates and placed toast on those plates. *She discarded those gloves and did not wash her hands before she put on a new pair of gloves. *She again cracked and handled eggs and egg shells, placed toast on another plate and then served that plated toast to a resident. *She then stated, she should have performed hand hygiene when she changed her glove changes and should not have used the same pair of gloves when she cracked eggs and then touched residents' food items. *She was not sure if there was a policy on when to change gloves. 6. Observation and interview on [DATE] at 8:21 a.m. with cook M revealed: *He wore gloves and cracked and handled eggs and egg shells. *With those same gloved hands he picked up a piece of bacon and placed it on a resident's plate. *With those same gloved hands he touched a fried egg and repositioned it on a resident's plate. *He stated that he had only been working at this facility for three days and had never cooked in a nursing home before. *Stated the dietary director said she would train with him. 7. Interview on [DATE] at 4:20 p.m. with dietary director K and kitchen general manager L regarding food storage and dishwasher temperature revealed: *They would have expected staff to document the temperatures of the dishwasher on the log. *They were not aware of the expired foods in the cooler. *The walk-in cooler was to have been checked daily and weekly for expired items. *They stated that each item in the walk-in cooler should have an open and discard date on it. *They stated each item in the walk-in cooler should have had a sticker with the opened date and the discard date for three days later. *They had asked management for the dishwasher water temperature to be turned up. *They stated the dishwasher would have to have been run five to six times for the temperature to have reached 120 degrees F. *Kitchen general manager L stated he had never seen the temperature for the dishwasher reach 150 degrees F. *They would have expected items in the walk-in cooler to have been labeled with the open and discard dates and the dishes would have been washed in the dishwasher at the proper temperature of 120 degrees F. 8. Review of the provider's [DATE] Food and Supply Storage policy revealed: *Procedures: -Foods past the use-by , sell-by, best-by, or enjoy-by date should be discarded. -Cover, label, and date the unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate labeling system. Products are good through the close of business on the date noted on the label. *Refrigerated Storage Life of Foods: -Use manufacturer's expiration date for products before they are opened. If there is no expiration date on the package, add the time listed here to the date the food is received. Add the time in the opened column to the date when the food is prepared or opened. Label when product is opened. 9. Review of the provider's [DATE] Hand Hygiene policy revealed: *1. Gloves are never to be reused or sanitized. 2. Hand hygiene should be performed after glove removal. 10. Review of the provider's [DATE] Dishmachine Temperatures policy revealed: *Low Temperature Machine: -Wash Temperature 120 degrees F. *Director: -Confirms the wash and rinse temperatures listed on the manufacturer's data plate on the dishmachine. Modify the dishmachine temperature record as necessary. *Low Temperature dishmachine-record on Dishmachine temperature record form: -Wash temperature during each period of use.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices had been followed for: *One of two observed administrations of nutritional formula and fluids through a gastric tube (G-tube) feedings for one of one sampled resident (67) by one of two licensed practical nurse (LPN) (F) . *One of one sampled resident (333) tested for signs and symptoms of clostridium difficile (C-Diff) (bacteria that can infect the bowel and cause diarrhea). Findings include: 1. Observation on 6/11/24 at 9:30 a.m. of LPN F during administration of resident 67's nutritional formula and fluids revealed LPN F: *Entered the room and had gloves and a gown on. *Had two unopened 500 cubic centimeter (cc) bottles of sterile water, a 60 cc tube feeding syringe, and an enteral (intestinal) nutrition feeding bag. *Opened the doors to the room and bathroom and filled two eight-ounce glasses with water from the bathroom sink with those same gloved hands. *Placed the syringe on the overbed table without sanitizing the surface of the table or placing a barrier on it. *Entered the bathroom a second time and retrieved several paper towels. *Lifted resident 67's shirt, unwrapped his abdominal binder, and took his G-tube out from under the binder. *Placed the paper towels under the end of his G-tube. *Moved a folding chair closer to sit on. *Wiped the end of the G-tube with alcohol. *Opened the door, took keys out of her pocket, and retrieved a different feeding syringe from the medication cart, all with those same gloved hands. *Removed the glove from her right hand, and without washing her hand, retrieved a new glove from the same pocket her keys were in and put that new glove on her unclean right hand. *Filled the syringe with water and administered 300 cc of water through the G-tube in 60 cc increments. *Opened the two bottles of the nutritional formula and poured then into the G-tube feeding bag. *Placed the bag on the pole and primed the tubing, connected the tubing to the G-tube, and started the gravity flow of nutritional formula. *Collected the garbage. *Went into the bathroom, removed her gloves, and washed her hands for approximately 10 seconds. *Came out of the bathroom and removed her gown, and left the room. Interview on 6/12/24 at 10:00 a.m. with LPN F confirmed she: *Should have checked for placement of the G-tube prior to starting the water administration.*Had not changed her gloves between tasks, such as going out to the medication cart and moving the folding chair. *Should have put down a barrier on the overbed table before placing the tube feeding supplies on it. *Should not keep extra gloves in her uniform pocket with the keys and pen she used frequently. 2. Observation on 6/11/24 at 9:00 a.m. of resident 333's door revealed no signage had been placed after a physician's order had been received for precautions for C-Diff. Random observations on 6/11/24 from 1:00 p.m. through 5:00 p.m. revealed no contact precaution signage had been placed on resident 333's door. There were no specific trash or laundry bins in his room. 3. Interview on 6/12/24 at 9:00 a.m. with registered nurse T regarding resident 333 revealed she was not aware he had been tested for C-Diff on 6/11/24. She was not aware of what type of hand hygiene or cleaning products were to have been used when a resident had tested positive for C-Diff. 4. Interview on 6/12/24 at 10:29 a.m. with resident 333 revealed: *He had a colostomy that he cared for himself, which included emptying the bag and changing the appliance that holds the bag. *He had not been feeling well with abdominal cramps and his bowel movements had been very foul-smelling. *He was not aware the physician had ordered a test for C-Diff. *He had not been educated on what C-Diff was or what type of precautions should have been started. 5. Random observations on 6/12/24 from 8:00 a.m. through 5:00 p.m. revealed no contact precaution signage had been placed on resident 333's door. There were no specific trash or laundry bins in his room. 6. Interview on 6/13/24 at 9:42 a.m. with laundry technician P regarding what would be done if a resident had C-diff revealed she explained all the proper steps to avoid cross-contamination. She had not been informed resident 333 had been tested for C-Diff. 7. Interview on 6/13/24 at 10:17 a.m. with LPN Q regarding resident 333 revealed she was not aware he had been tested for C-Diff. It had not been passed on in shift report. She was not sure what type of precautions should have been put in place. 8. Interview on 6/13/24 at 1:30 p.m. with LPN Q revealed she had read the policy regarding C-Diff precautions. She agreed contact precaution signage should have been put up when he had been tested and he was symptomatic. 9. Interview on 6/13/24 at 2:30 p.m. with environmental services technician S revealed she had not been informed of resident 333's C-Diff. status. She showed the chemicals she would have used to clean the room. It was not a bleach product. She did not know she would have had to clean with a different product. 10. Observation and interview on 6/13/24 at 4:40 p.m. with maintenance supervisor U regarding what product was used for sanitizing for C-Diff revealed:*The product to have been used was Rapid Multi Surface Disinfectant Cleaner. *This list of organisms it would have been effective against did not include C. Diff. *He stated the supplier had told him it was effective against C.Diff. 11. Interview on 6/13/24 at 5:00 p.m. with DON B confirmed contact precautions should have been initiated when an order for testing C. Diff had been received for resident 333. 12. Review of the provider's 5/3/23 Clostridium Difficle policy revealed:*When C. Diff infection was identified all department directors were to have been informed. *Contact precautions for residents with known or suspected C.Diff. *Gown and gloves would be worn prior to entering the room and removed before exiting the room. *Hand hygiene with soap and water would have been performed after removing gloves. *Cleaning of any shared medical equipment with appropriate sporicidal disinfectant or bleach solution would have been performed. *The resident's hand would been washed frequently with soap and water. 13. Review of the provider's 4/2/24 Standard and Transmission Based Precautions policy for contact precautions revealed:*Clear signage on the door or wall outside the resident room indicated the type of precautions and personal protection equipment (PPE) to have been used. *Soap and water for hand hygiene when in the room and when leaving the room. *Linen was to have been placed in a bag linen prior before it was removed from the room. *Disposable resident care equipment was to have been used.

Based on observation and interview, the provider failed to have available, prepare, and serve, resident preferred and selected menu items requested by four of four sampled residents (33, 46, 71, and 335) for two of two observed meals (breakfast and noon). Findings include: 1. Interview on 6/11/24 at 11:45 a.m. with resident 335 revealed: *She state she was supposed to be on a heart-healthy diet. She was not sure if what she received for meals were heart healthy. *She had received macaroni and cheese, pork and beans, a bun, and dessert for the evening meal on 6/10/24. She did not think this was a heart-healthy meal. *She felt staff did not want to go upstairs to the main kitchen to get things that were forgotten and stated they often did not have ketchup available. 2. Observation and interview on 6/11/24 from 12:10 p.m. to 1:00 p.m. with certified nursing assistant (CNA) O and dietary server H in the Sunrise Suites dining room revealed: *All residents received the same meal. *The meal included: Asian braised beef, fried rice, braised cabbage, and lemon poppyseed bread. *When asked how they ensured each resident received the correct diet CNA O removed dietary cards from an open area to the left side of the serving counter. *There were cards for each resident that included the residents name, diet ordered, food likes, and food dislikes. *They both stated the dietary cards were not used and the residents received the same meal or an alternative if they had requested one. 3. Observation and Interview on 6/11/24 at 12:24 p.m. with resident 33 revealed: *He had ordered chicken strips, fries, and coleslaw. He was served the braised beef, fried rice, and braised cabbage. He told dietary server H he was not going to eat that. Dietary server told him they did not have what he had ordered, and they were out of chicken strips. *Resident 33 stated no staff had informed him prior to the meal of not having chicken strips. He was not offered any substitute. *Neither dietary server H and CNA O offered to go to the kitchen to get an acceptable substitute for him. *Resident 33 stated Forget it, I'll go and talk with [name of dietary director K]. *He then aggressively left the dining room in his electric wheelchair. 4. Interview on 6/11/24 at 12:26 p.m. with dietary server H and CNA O revealed: *They usually did not know before a meal if a resident had requested a substitute. *They did not know what was not available. *They were not sure if anybody visited with the residents if the substitute ordered was not available. 5. Observation and interview on 6/12/24 from 8:00 a.m. through 9:00 a.m. with dietary server H in the Sunrise Suites dining room revealed: *The food from the kitchen was brought to the dining room at 8:04 a.m. *There was no staff in the dining room at that time. The first resident served breakfast at 8:21 a.m. *Dietary server H did not refer to the dietary cards. *The menu had the following food items listed: orange juice, fresh fruit cup, oatmeal, cheese strata, bacon, and whole wheat toast. *The meal that was served included: oatmeal, cheese strata, sausage patty, and french toast sticks. *There was no fruit cup or whole wheat toast. *Each resident was offered coffee and apple, orange, or cranberry juice. *No condiments such as syrup, brown sugar, or milk were offered. *At 8:30 a.m. CNA G went upstairs to the main kitchen to get the brown sugar residents 46 and 335 had asked for. *At 8:35 a.m. dietary server H had dished residents 33 and 71's food onto plates and covered them the plates. *At 8:39 a.m. residents 33 and 71 had not received their breakfasts as there were no staff to serve them. They were complaining the were hungry. *Interview at 8:45 a.m. with dietary server H regarding the observed meal service revealed he: -Dished the residents' meals when there were no staff present to serve them because he was not allowed to serve the meals to the residents. *Was not able to answer why the condiments were not available in the dining room at the time the meal was served. *Stated he supposed he could have called the main kitchen for additional requested or needed food items. he stated he*Between 8:35 a.m. and 8:55 a.m. he had dished other residents' breakfasts who had entered the dining room *At 8:55 a.m. CNA R entered into the dining room. The dished meals had remained on the tray line counter until that time. CNA R had to reheat the meals for each resident. *At 9:05 a.m. CNA G returned to the dining room. She stated she had not been able to go to the main kitchen to bring any brown sugar for residents 46 and 335. She stated she had helped another resident get ready for the day.

Based on observation, interview, and policy review, the provider failed to ensure seven bottles of one bulk medication that was expired were appropriately discarded. Findings include. 1. Observation and interview on 6/13/24 at 8:00 a.m. of the medication cart for the city view residents and the second-floor medication storeroom with certified medication aide's (CMA) I revealed: *CMA I confirmed the hand written dates on the medication bottles indicated the dates the bottles were opened to administer to the residents. *There were three bottles of aspirin 325 milligrams (mg) in the medication cart, two of the three bottles were expired. One on 2/2024 (February) and one on 1/2024 (January). *CMA J stated all medications should be checked for the date they were opened and the date they would expire before administering the medications to the residents. *The storeroom cupboard on the second floor had eleven bottles of chewable aspirin 81 mg. *Four of the eleven chewable aspirins expired on 5/2024 (May). *CMA J stated, expired medications should be removed from the carts and everyone who administered medications was responsible for that. Interview on 6/13/24 at 9:00 with director of nursing B revealed: *She stated she was frustrated she missed these medications because she went through the stock medications monthly in the carts and storeroom cupboard and removed those that were close to their expired dates. *She stated everyone who administered medications is responsible for checking expiration dates before administering them to the residents. Review of the provider's 3/29/24 medication receiving, dispensing, and storage policy revealed: *6. The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations. *11. All the medications (including medication samples or other medications dispensed by the physician) are packaged in accordance with the location dispensing system and state pharmacy rules. These medications must be labeled according to state pharmacy regulations. Cautionary and accessory instructions, as well as the expiration date, will be included. New labels will be applied by the pharmacist or the pharmacist's agent as needed.

Based on the South Dakota Department of Health (SD DOH) complaint intake information, record review, interview, and policy review, the provider failed to ensure consistent repositioning for one of one sampled resident (1) who was completely dependent on staff for all activities of daily living (ADLs) that included mobility and had a high risk for skin breakdown on admission. Findings include: 1. Review of the SD DOH complaint intake information revealed: *Resident 1 was admitted to the facility on [DATE] after an extended stay in an acute care facility due to a cardiac arrest with subsequent anoxic brain injury. *The resident had a large pressure wound to the sacral area. *Her tailbone was visible through the resident's sacral area. *The resident was unable to move or speak. *The resident was unable to perform any ADLs independently and was completely dependent on staff. 2. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her age was [AGE] years. *Her diagnoses included the following: -Anemia. -Atrial fibrillation. -Heart failure. -Orthostatic hypotension. -Seizure disorder. -Anoxic brain damage. -History of cardiac arrest. -Gastrostomy (feeding tube). -Tracheotomy (breathing tube). -Incontinent of bowel and bladder. *The 9/29/23 quarterly Minimum Data Set (MDS) indicated the following: *She was incontinent of bowel and bladder. *She was dependent on staff for all ADLs and mobility. *Her Braden scale score on admission was 10 indicating she was at high risk for skin breakdown. 3. Review of resident 1's 8/16/23 comprehensive care plan revealed the following: *The resident had ADL self-care deficits related to her anoxic brain injury and was totally dependent on staff for ADLs. -Bed mobility: Turn from Side to Side: resident is totally dependent on staff for this activity. -Bed mobility: Lying to Sitting: resident is totally dependent on staff for this activity. -Bed mobility: Sitting to Lying: resident is totally dependent on staff for this activity. *The resident had bowel and bladder incontinence related to anoxic brain injury and required total assistance with ADLs. -Resident will remain free from skin breakdown due to incontinence and brief use through the review date. -Resident uses soaker pads for incontinence due to resident having an air mattress. -Turn and reposition in bed every two hours. Initiated two days after her admission to the facility on [DATE]. *A revision date of 10/3/2023 regarding The resident has an impairment to skin integrity R/T [related to] anoxic brain injury and inability to reposition her E/B [evidenced by] wound sacral area and bil [bilateral] ears. *Interventions included the following: -Reduce risk of skin impairment. Sling to remain under resident while in the chair. -High risk for skin injury - use extra caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. -Keep skin clean and dry. -Turn and reposition in bed every two hours. -Weekly skin observation by licensed nurse. Schedule tx [treatment] to ears and sacrum. -Revision date of 11/02/2023: Resident has an air mattress on her bed and a pressure reducing cushion on her chair. Cushion change to high pressure ROHO cushion for pressure relief on 8-22-23. 4. Review of resident 1's 8/16/2023 Braden Scale for Predicting Pressure Sore Risk Admission revealed: *The score was 10 indicating the resident was at high risk for skin breakdown. *The intervention guide for a high risk score included the following: -Frequent Turning with a Planned Schedule. -Supplement with Small Shifts in Position. -Manage Moisture. -Manage Friction and Shear. 5. Review of resident 1's 8/16/23 Nursing Admit Data Collection form revealed: *Skin Integrity: -Color was normal. -Temperature was warm. -Moisture condition was moist. -Turgor was normal. -The resident had abrasions to the right great medial toe. -The sacrum was slightly reddened and blancheable (able to return to normal color when pinched). -There was no history of a previous healed pressure ulcer. -The resident had a potential for pressure ulcer development. -There was paralysis of upper and lower extremities and the resident was unable to move any extremity. 6. Interview on 11/6/23 at 10:35 a.m. with occupational therapist (OT) D regarding resident 1 revealed she: *Had conducted pressure mapping (evaluation of the skin for pressure between the individual's body and the surface of the bed or chair) of the resident's wheelchair on 9/15/23. *Had conducted pressure mapping of the residents bed on 9/21/23. *Thought the pressure wound on the residents sacrum was from extended periods of time without being repositioned. 7. Interview and record review on 11/6/23 at 10:50 a.m. with registered nurse (RN) wound nurse C regarding resident 1's wounds revealed: *She had started as the wound nurse approximately a year ago. *Her training had consisted of online courses in wound care. *The wound on resident 1's sacral area first presented as a deep purple and discolored like a deep tissue injury (is a form of a pressure ulcer or pressure sore. Pressure ulcers are localized areas of tissue damage of necrosis that develop because of the pressure of a bony prominence). *The resident had no pressure ulcers on admission. *Pressure mapping was completed by occupational therapy (OT). *She had been completing wound measurements weekly and documented those findings in the EMR. *She had never received a job description of her role and responsibilities as the wound nurse. *On 9/12/23 the sacral wound measured 5 centimeters (cm) by (X) 4 cm and had no depth to the wound. *On 9/26/23 the sacral wound had two opened areas a distal area that measured 2 cm X 1.5 cm and a proximal wound that measured 1.5 cm X 1.0 cm. *On 9/26/23 the proximal wound to the sacrum measured 1.5 cm X 2 cm with no depth. and the distal wound measured 2 cm X 2 cm. *On 10/3/23 The sacral wound was worsening and measured 5 cm X 3 cm with a denuded (removal of the skin) area measuring 1.5 cm X 1.5 cm X 0.5 cm. That was when the Triad paste was increased to twice daily. *On 10/9/23 the sacral wound measured 6 cm X 3 cm X 0.3 cm. A new specialty air mattress was applied. *On 10/16/23 the sacral wound measured 4 cm X 3 cm X 1 cm. *On 10/23/23 the wound measured 5 cm X 3 cm X 1 cm. *On 10/30/23 the wound measured 6 cm X 4 cm X 2 cm. 8. Interview on 11/6/23 at 2:15 p.m. with administrator A regarding resident 1 revealed: *He had started his employment about a year and a half ago. *The wound process was revamped adding a wound nurse to evaluate, monitor, and document on resident wounds. *Education reminders were given to staff frequently. *There was a weekly resident council meeting for residents to voice any concerns they had with the care that was provided. 9. Interview on 11/6/23 at 3:00 p.m. with director of nursing (DON) B regarding resident 1 revealed: *She provided daily huddles for staff at alternating times to include all staff. *If staff could not attend a huddle information from the huddle was available for staff to read. *She had provided frequent education of the importance of thorough charting. *She had completed resident chart reviews for completion of documentation. *She had educated and re-educated staff regarding the proper positioning of residents. *Resident 1 had continuous incontinent liquid stools and before her admission she had a fecal management system while she was in the hospital. That type of system was not possible at the facility. 10. Review of resident 1's 8/16/23 Order Summary Report revealed: *HOB [head of bed]: Elevate HOB [head of bed] 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped. *Heel Lift Boots For heel protection or pressure reduction for patients (residents) with high risk for skin breakdown when in bed. *On 9/13/23 Mepilex to sacral area. Change every 3 days and PRN loose or soiled one time a day every 3 days for skin breakdown. *Occupational Therapy to evaluate and treat order date was 8/17/23. *SKIN/WOUND CARE: SKIN BREAKDOWN RISK: 1) Assess bony prominence's. 2) Turn/reposition every 2 hours. 3) Heels up/off bed. 4) Protect skin. Keep clean and dry. 5) Moisture barrier for incontinence. 6) Use lift pad. 7) Speciality bed if indicated or air mattress overlay per facility protocol. *9/14/23 WOUND CARE: Apply Triad paste to sacral area twice daily for sacral wounds related to PRESSURE-INDUCED DEEP TISSUE DAMAGE OF SACRAL REGION. *10/26/23 WOUND CARE: Apply Triad paste to sacral area twice daily for sacral wounds related to PRESSURE-INDUCED DEEP TISSUE DAMAGE of SACRAL REGION 11. Review of resident 1's August 2023 through October 2023 Turn and reposition in bed every two hours documentation revealed: *There was extensive periods where no documentation for repositioning was found for the following dates and times: -8/18/23 at 5:14 p.m. until 8/19/23 at 5:11 a.m. that was a 12 hour period of time. -8/19/23 at 2:01 p.m. until 8/19/23 at 11:09 a.m. that was a 9 hour period of time. -8/23/23 at 3:19 p.m. until 8/23/23 at 10:02 p.m. that was a 9 hours period of time. -8/25/23 at 6:01 a.m. until 8/25/23 at 4:28 p.m. that was a 10.5 hour period of time. -8/26/23 at 8:02 p.m. until 8/27/23 at 5:27 a.m. that was a 9.5 hour period of time. -8/27/23 at 10:06 a.m. until 8/27/23 at 7:50 p.m. that was a 9 hours period of time. -8/28/23 at 3:52 p.m. until 8/29/23 at 12:22 a.m. that was an 8 hour period of time. -8/30/23 at 9:30 p.m. until 8/31/23 at 12:30 p.m. that was a 15 hour period time. *There were multiple lapses in August for every two hour repositioning that went from 3 hours to 15 hour periods of time with no documentation of repositioning resident 1. -9/10/23 at 11:25 a.m. through 9/11/23 at 10:22 a.m. that was a 10 hour period of time. -9/14/23 at 2:00 p.m. through 9/14/23 at 11:01 p.m. that was a 9 hour period of time. -9/19/23 at 1:33 p.m. through 9/20/23 at 12:30 a.m. that was an 11 hour period of time. -9/28/23 at 1:21 p.m. through 9//28/23 at 9:32 p.m. that was an 8 hour period of time. -9/29/23 at 9:22 p.m. through 9/30/23 at 12:32 p.m. that was a 15 hour period of time. *There were multiple lapses in September for every two hour repositioning that went from 3 hours to 15 hours periods of time with no documentation of repositioning resident 1. -10/1/23 at 5:45 a.m. through 10/1 12:58 p.m. that was a 7 hours period of time. -10/3/23 at 2:10 p.m. through 10/4/23 at 1:15 a.m. that was an 11 hour period of time. -10/7/23 at 5:06 p.m. through 10/8/23 at 2:55 a.m. that was a 9.5 hour period of time. -10/11/23 at 4:48 a.m. through 10/11/23 1:03 p.m. that was an 8 hour period of time. -10/14/23 at 1:48 a.m. through 10/14/23 at 10:17 a.m. that was an 8.5 hour period of time. -10/17/23 at 1:51 p.m. through 10/17/23 at 11:19 p.m. that was a 9 hour period of time. -10/18/23 at 9:00 p.m. through 10/19/23 at 1:01 p.m. that was a 16 hour period of time. -10/19/23 at 9:22 p.m. through 10/20/23 at 10:43 a.m. that was an 11 hour period of time. -10/28/23 at 9:27 p.m. through 10/29/23 at 12:35 p.m. that was a 15 hour period of time. *There were multiple lapses in October for every two hour repositioning that went from 3 hours to 16 hours periods of time with no documenting of repositioning resident 1. 12. Interview on 11/7/23 at 5:45 a.m. with licensed practical nurse (LPN) E regarding repositioning and care for resident 1 revealed: *She worked for a staffing agency and was on an eleven week assignment. *Worked only one night shift on resident 1's floor. *She would have to suction the resident every hour. *The resident could not be totally repositioned on her sides due to her tracheotomy. *She had a specialty air mattress. *The HOB was elevated at 30 to 45 degrees during her feeding. *The only reason she had worked the night shift on that floor was a nurse had called in sick for that night. *She felt the CNAs had done a good job. 13. Interview on 11/7/23 at 6:00 a.m. with certified nursing assistant (CNA) F regarding repositioning and care for resident 1 revealed: *She had been employed as a CNA since December 2023. *She worked the night shift. *One to two CNAs work the night shift. *She had a routine to ensure residents were checked and changed every two hours. *The resident had a speciality air mattress. *Staff would use pillows and or wedges to attempt to keep the resident off of her bottom. *Staff were to document the repositioning every two hours. *The resident had frequent loose stools. *Disposable chux pads were placed underneath the resident for the loose stools. *The last time she had observed resident 1's wound it was an open area the size of an egg but she could not give an exact date. *She had put the Triad paste on the sacral wound one time during care. 14. Interview on 11/7/23 at 6:15 a.m. with LPN G regarding repositioning and care for resident 1 revealed she: *Worked for a staffing agency. *Was on a 13 week contract. *Had shadowed another employee for one day prior to working independently. *Had not been shown where to find the policy and procedures for the facility but had worked for another sister facility and felt she knew the policy and procedures. *Had cared for resident 1 twice when the wound care nurse was assisting her with care because a nurse had called in sick and she was in charge of 13 to 14 residents. *Was responsible for medication and treatment administration for the residents. *Trusted the staff to complete repositioning and care for the residents. *She would monitor the activity on the floor. 15. Interview on 11/7/23 at 6:41 a.m. with director of nursing B revealed: *CNAs were to have been checking in with the charge nurses prior to leaving for the day. *She was going to implement at affidavit that would have to be signed by the CNAs to ensure repositioning and care was completed and documented prior to leaving the shift. *The Braden scale interventions were utilized but liked to individualize the interventions toward the needs of the residents. *A stand-up meeting occurred daily for any significant changes that occurred in the residents. *She has completed extensive education and re-education with all the CNAs regarding thorough and complete documentation. *Her expectation was that CNAs would be held accountable for following through on the implemented interventions that were put in place for residents care. *Due to staffing issues the facility had to utilize agency staff. 16. Interview on 11/7/23 at 7:15 a.m. with administrator A revealed there were no policy and procedures to ensure thorough and complete CNA documentation. 17. Review of the provider's 2/10/23 Pressure Ulcer policy revealed: *The purpose of the policy was to have provided appropriate assessment and prevention of pressure ulcer, as well as treatment when necessary. *Based on the resident's comprehensive assessment, prevention and assessment interventions would have been used to ensure that a resident entering the facility without pressure ulcers would not develop a pressure ulcer unless the individual's clinical condition demonstrated that the pressure ulcer was unavoidable. *Residents would receive appropriate assessments and services to promote and maintain skin integrity. If a resident's clinical condition would make the compromise of skin integrity clinically unavoidable, that information would have been documented in the medical record. *The comprehensive care plan was an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that were to have been furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being. *The Federal Regulation F686 was the federal regulation regarding pressure sores. It states the following: 1. A resident who enters the facility without a pressure sore does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

Based on observation, interview, record review, and policy review, the provider failed to ensure sufficient personnel and resources to meet the needs of the 58 residents on Memory Lane, Country View, and Magnolia Heights with specific unmet needs identified for 5 of 18 sampled residents (9, 30, 50, 67, and 68). Findings include: 1. Observations, interviews, and record review of three Memory Lane residents (30, 50, and 67) revealed unmet resident needs: a. Observations and interviews with resident 30 and staff and review of resident 30's medical record revealed supervision of dressing and transferring was not provided as care planned. Refer to F656, finding 1. b. Observations and interviews with resident 50 and staff and review of resident 50's medical record revealed activities of daily living (ADL) care was not provided using a person-centered approach consistent with her cognitive capabilities. Refer to F656, finding 2. c. Observations and interviews with resident 67 and staff and review of resident 67's medical record revealed his preferred morning routine was not honored on 6/28/22. Refer to F677, finding 7. 2. Interview on 6/28/22 at 6:00 p.m. with two nurses on the day shift and two nurses on the night shift at the same time (registered nurse (RN) X, RN T, licensed practical nurse (LPN) V, and LPN Y) revealed consensus on the following comments: *The staff to resident ratio was not good. *They did not know how ratio was determined. *Management told them the staffing ratio was the amount allowed. *They rarely, if ever, see management on the floor. *The MDS [Minimum Data Set] nurses [clinical care leaders (CCL)] stay in their offices. *Communication between staff was a challenge because they do not have radios. *The call light bells can only be heard when they are close to the nurse's station. *The nurses would help the certified nursing assistants (CNAs) with transfers and provide personal care for residents when the CNAs are not available or within sight. *They are not able to oversee the care provided by the CNAs during the shift because they are so busy getting their tasks completed. *RN X reported she would punch out for her break but continue working just to get the work done. Interviews with CNA S revealed: *On 6/29/22 at 4:55 p.m.: -There were not enough staff. -They had to turn on the emergency call light or call out for someone to help when a second staff was needed. -They used to have radios. *On 6/30/22 at 2:20 p.m.: -The CNAs have a shift-to-shift report, and the evening shift was supposed to pass information from the morning report to the night shift CNAs. -Staff were supposed to turn on the green [call] light [button] when they are assisting a resident to let the other staff know where they are. Review of the provider's Safety Rounds for CNA shift changes revealed: *The 14 bulleted tasks included last time of rounds and times last repositioned, and who is dressed from nights to days. *Also utilize: PCC [Point Click Care] Communication tab, nurse to nurse shift change report, and daily stand-up: huddle. Review of the provider's CNA Duties and Routine revealed: *Communication is key! Work as a team to get everything done. *Day shift CNAs: -Start at 6:00 a.m. rounding with the overnight CNAs and begin getting residents up. -Between 7:30 a.m. and 9:00 p.m., Encourage all residents to go down [to the dining room (DR)] after they are up. Assist in DR when you have all your residents up. Help all residents out of DR back to room, toilet it needed. -Between 9:00 a.m. and 11:00 a.m., work together to decide who does what, including passing out water, emptying garbage, exchanging the linen carts, and taking breaks. -Between 11:00 a.m. and 12:45 p.m., get residents up for lunch, assist with lunch, and take residents back to rooms. -Between 1:00 p.m. and 2:00 p.m., toilet residents, lay down, or take them to activity. -Between 2:00 p.m. and 2:15 p.m., rounding with evening CNAs. *Evening shift CNAs: -After rounding with day shift CNAs, between 2:15 p.m. and 4:30 p.m., pass supplies to resident rooms, get residents toileted and up for activities/supper. -Between 5:00 p.m. and 7:00 p.m., assist residents to DR, pass trays, assist resident back to room, and take turns with breaks. -Between 7:00 p.m. and 10:00 p.m., provide evening cares, 2nd [second] rounds on those that went to bed early, and pass snacks. -Between 10:00 p.m. and 10:30 p.m., rounding with overnight CNAs. *Overnight shift CNAs: -After rounding with evening shift CNAs, pass supplies to resident rooms and exchange linen cart. -Starting at midnight, 1st [first] rounds to check every resident and provide care as needed. -At 4:00 a.m., last rounds and Start getting residents dressed on lists - at least 2! *Float CNA: -Take the spot of the one [CNA] missing if absent . -Get list of which residents you are doing cares for on each hallway. Even it out! Make sure your co-workers know who you are taking. -Floats on overnights you need to dress on from each hallway. -Take a task from each hallway to help them out. -Floats will help the other staff get their break in and then take their break after. -Help with answering lights on all halls and try to split your time evenly. -Communicate with the other staff to let them know when you are leaving the hallway and going to the next. -Let the staff member doing rounds know anything that needs to be shared to next shift. 3. Interview on 6/29/22 at 9:02 a.m. with resident 9 revealed: *She had been asked three times by staff members how her breakfast was. -That was not a normal occurrence. -I just have to laugh and shake my head because you see how many people are running around today? This is not normal. They are putting on a show for you. 4. Interview on 6/30/22 at 9:46 a.m. with RN M regarding staff-to-staff communication revealed if she needed help with a task, she would see if an aide or another nurse was walking by, otherwise she would leave the resident's room to walk around and find someone to assist her. Observation on 6/30/22 from 10:20 a.m. to 10:30 a.m. revealed: *Surveyor was looking for CNA J on the first floor hallway. *Surveyor asked purchasing assistant K for help locating CNA J. She was in the central supply room which was on the first floor hallway. Purchasing assistant K indicated that she did not know where CNA J was. *She: -Walked down the hallway saying, I'm looking for the green light [above the resident's door] but I don't see one on. -Asked an unidentified staff member if he knew where CNA J was. He said that CNA J was in resident 56's room. --The unidentified staff member was in the nurse's office with the door open just a crack. It was not initially apparent that there was anyone in the nurse's station due to the door being almost shut. -Checked the resident's room and confirmed that CNA J was in there. --The light above the resident's door was not turned on, creating a lack of communication among the staff. Interview on 6/30/22 at 11:11 a.m. with CCL L revealed: *The facility had radios before the COVID-19 pandemic, but the radios disappeared quickly. *She thought the radios may have been stolen or staff forgot to return them. *The facility used the lights above the resident's doors to indicate when a staff member was in the room with the resident. -The lights were color-coded for different tasks. -If the light was on above a resident's door, a light would also turn on at the main board in the nurse's station. Interview on 6/30/22 at 12:15 p.m. with CNA J revealed: *She did not have a consistent area in which she worked. *Sometimes she was pulled to another area. Interview on 6/30/22 at 2:23 p.m. with administrator A and director of nursing (DON) B revealed: *The facility had communication radios before the pandemic started. *They removed the radios from use after several radios went missing, and they had to spend money to replace the lost radios. *They could not remember when the radios were discontinued. *They understood the importance of effective communication amongst staff members. *The leadership team were in discussions to bring back the communication radios. 5. Review of resident 68's grievance dated 3/23/22 on the provider's Suggestion or Concern form regarding her concern with getting towels to her bathroom included a notation to (see attached sheet also). The attached sheet had five three inches by three inches sticky notes that revealed: *3/20 Sun[day:] -No washcloth and hand towel had been delivered to her room or trash removed that morning. -No hand towel had been delivered to her room that evening. *3/21 Mon[day:] -No washcloth or hand towel had been delivered to her room that morning. -No bedtime snack had been offered. -After she had asked, a hand towel had been delivered to her room that evening. She had 2 min discussion about whether they should do it or not & whether it was nessesary [sic]. *3/22 Tue[sday:] -No washcloth, hand towel, or water mug had been delivered to her room that morning. -Call light on 45 min[utes] 8:55 - 9:40 a.m. before it had been answered. -No bedtime snack had been offered. -No water mug or hand towel had been delivered to her room that evening. *3/23 Wed[nesday:] -No washcloth or hand towel had been delivered to her room or trash removed that morning. -No water mug had been delivered to her room that evening. *3/24 Thur[sday:] -No washcloth or hand towel had been delivered to her room that morning. -After she had asked, a hand towel had been delivered to her room that evening. *All the notes had been signed with the resident's first name. The provider's Suggestion or Concern form included the resolution of having reviewed the concern at CNA and nurses' meeting and provided coaching to the eleven CNAs that had worked the shifts noted on the concern and was signed Completed by director of nursing B on 3/30/22. This form was also reviewed and signed by administrator A on 3/31/22 and social services supervisor C on 4/7/22. Review of a document completed by resident 68 of daily environmental tasks revealed three separate sheets of paper labeled April 2022, May 2022, and June 2022 (the June 2022 sheet had been completed up to the date the survey started, 26 days). Over those three months, the resident's documentation revealed out of 84 opportunities (the resident had been out of the facility three days): *The morning washcloth and hand towel had been passed 1% of the time, once on 5/14/22. *The morning water mug had been passed 60% of the time (51 days). *The bedtime snack had been offered 37% of the time (31 days). *The evening water mug had been passed 2% of the time, on two days, 5/2/22 and 5/26/22. *The evening hand towel had been passed 33% of the time (28 days). Interview on 6/28/22 at 12:53 p.m. with resident 68 regarding her tracking of environmental tasks revealed she: *Had given these to DON B who said she would review them. *She had not received a response to her concern. 6. Interview on 6/30/22 at 10:56 a.m. with CNA O and CNA S regarding staffing revealed: *They had been assigned to provide care to the section of the unit that included 30 beds. -Two of those beds had been unoccupied. -They had been responsible to provide care for 28 residents from 6:00 a.m. to 2:00 p.m., the day shift. *The staffing pattern for this section had been like this for the past year. *CNA O stated We could use more [CNAs] as not all the tasks assigned could get done with two CNAs for 28-30 residents on the day shift. -CNA S had agreed with CNA O's statement. 7. Interview on 6/30/22 at 3:00 p.m. with administrator A and DON B revealed: *Communication with staff on the care needs of the residents were completed by: -Having stand-up meetings on weekday mornings. -Staff that attended those meetings included the management, supervisory, clinical care coordinators, and the charge nurses. -Any changes in a resident's care or other communication was placed on the electronic medical record (EMR) dashboard. -When a staff person logged into the EMR a note would pop-up with the new information. -There was no monitoring if staff had checked the dashboard or not.

Based on observation, interview, record review, and policy review, the provider failed to have a system to maintain the resident environment in a neat and tidy manner with: *Cleanable surfaces and ability to maintain one of one mechanical stand lift, one water fountain on the City View hallway, and wallpaper in the south elevator. *The tidiness of resident rooms on City View and Memory Lane for 12 of 18 sampled residents (1, 9, 15, 20, 26, 46, 50, 54, 55, 57, 66, and 67). Findings include: 1. Observation on 6/27/22 at 3:46 p.m. of resident 55's room revealed: *The bed was not made, and several fitted sheets were sitting on top of the mattress in crumpled [NAME]. *There were many books scattered around the room; several books on top of the bed, recliner, and furniture, and books completely covering two tables in the room. 2. Observation on 6/27/22 at 3:59 p.m. of resident 9's room revealed: *There were items on the floor including at least three separate piles of food crumbs, a surgical face mask, a broken plastic medicine cup, and a stack of folded clothes. 3. Observations at the below dates and times of resident 26's room revealed: *On 6/27/22 at 4:00 p.m. there were three packages of incontinent briefs on top of a wheelchair and bedside commode in the room, two vases of dried flowers were on the dresser beside the TV, and parts of the dried flowers and leaves were on top of the dresser. *On 6/28/22 at 9:30 a.m. the packages of incontinent briefs and the dried flowers were still present. *On 6/29/22 at 10:00 a.m. the packages of incontinent briefs were still present. 4. Observations at the below dates and times of residents 46 and 66's shared room revealed: *On 6/27/22 at 4:10 p.m. there was paper litter scattered across the floor, resident personal care items were on top of the dressers, and a layer of dust was on the dressers and bedside tables. *On 6/28/22 at 9:30 a.m., the condition of the room remained the same. *On 6/29/22 at 8:30 a.m., the floor had been swept and mopped, however the rest of the room remained the same. 5. Observation and interview on 6/27/22 at 4:15 p.m. with resident 54 in his room revealed: *Most of the time the staff forgot to change the bed sheets. *He had to ask someone to change the bed sheets. *The May 2022 activity calendar was still hanging on his bulletin board. *The June 2022 activity calendar was taped to the outside of his door. *There was a soggy pile of wet tissue paper on the bathroom floor. 6. Observations on the below dates and times of resident 50 revealed: *On 6/27/22 at 4:30 p.m., her wheelchair armrests were cracked, which resulted in an uncleanable surface. There were food stains on the wheelchair cushion cover. *On 6/28/22 at 12:15 p.m., the wheelchair armrests and cushion cover were noted in the same conditions and her overbed table was soiled with dried water and food spots. *On 6/29/22 at 11:10 a.m., the conditions of the wheelchair and the overbed table remained the same. Interview on 6/29/22 at 11:15 a.m., with environmental services technician (EST) H revealed she: *Explained I didn't get in [resident 50's room] yesterday because she would not let me in her room. *Asked, Do they have a right to do that? *Had to go to the social worker once before because she wouldn't let me clean. *Cleaned the overbed tables daily. She was not responsible for the wheelchairs. Interview on 6/29/22 at 4:50 p.m. with supervisor of ancillary services (SAS) G revealed he was not aware of the condition of resident 50's wheelchair armrests and confirmed the nursing or housekeeping staff should have reported that. 7. Observations at the below dates and times of resident 1's room revealed: *On 6/27/22 at 4:30 p.m.: -There were personal care supplies on the dressers. -Her bulletin board was dangling on the wall by one screw. -The overbed table had an unknown sticky substance on approximately one-half of it. A partial box of gloves was on the overbed table. -Two vases of flowers were on her bedside table. The flowers were dry with petals and leaves falling on top of an oxygen concentrator which was next to the bedside table. -No other residents resided in the room, but the extra bed in the room was unmade. -A suction machine was on the bedside table. A partial roll of toilet paper was on the shelf under the suction machine. *On 6/28/22 at 8:45 a.m., resident 1's room was in the same condition. EST AA was cleaning a spill off the floor near the window. *On 6/29/22 at 9:30 a.m.: -There were personal care supplies on the dressers. -Her bulletin board was dangling on the wall by one screw. -Two vases of flowers were on her bedside table. The flowers were dry with petals and leaves falling on top of an oxygen concentrator which was next to the bedside table. -The other side of the room had been cleaned and extra items were removed. 8. Observation on 6/27/22 at 5:13 p.m. in the hallway between rooms 228 and 230, the mechanical stand lift had a crumpled tissue sitting on the base, the protective covering around the base was chipped away which exposed sharp edges, and there was an unknown reddish-brown discoloration on the foot base. 9. Observation on 6/27/22 at 5:16 p.m. revealed the water fountain on City View had rust and mineral buildup around the waterspout. When the button was pressed only a small trickle of water came out from the fountain. 10. Observation on 6/28/22 at 8:21 a.m. in the south elevator revealed a 12-inch by 12-inch L shaped tear in the wallpaper. The wallpaper was easily pulled back which revealed an unknown blue sticky substance used to hold the wallpaper in place. 11. Interview on 6/28/22 at 8:24 a.m. with resident 9 revealed: *Staff did not fold or put away clean laundry or tidy up her room. She needed to ask staff to assist her with putting laundry away. Staff encouraged her to complete the task on her own. *The crumbs and broken plastic medicine cup were still on the floor from the previous day. *There were more stacks of folded clothes in the bathroom sink, on top of her bedside table and dresser. 12. Interviews on 6/28/22 at 8:26 a.m. and 10:41 a.m. with lead environmental services technician (LEST) Q revealed: *A full room cleaning was done after a resident was discharged . *Necessary repairs were reported to SAS G and recorded in the maintenance book. *She would also notify maintenance if a room was cluttered with personal belongings on the floor. *She was responsible for cleaning the rooms on the lower level. *The housekeepers assigned to the upper-level rooms should be tracking and scheduling rooms for full cleaning. 13. Observation and interview on 6/28/22 at 8:50 a.m. with resident 15 revealed: *The wall behind her recliner had multiple gouges and scrapes exposing the sheetrock. *She had reported her chair was too close to the wall most of the time. Interview on 6/29/22 at 11:39 a.m. with EST H revealed she: *Reported repairs to maintenance mechanic (MM) I, or SAS G, or wrote the repair requests on the maintenance sheet. *Said, Thank you for letting me know about [resident 15's] wall, I'll make sure to write it down. Observation and interview on 6/29/22 at 3:55 p.m. with SAS G and resident 15 revealed: *SAS G was not aware of the condition of the wall behind resident 15's recliner. *Resident 15 told him the condition of the wall was because the chair gets pushed back too far. *He told her he would repair and paint the wall while she temporarily moved to another room until the paint vapors were gone. 14. Observation and interview on 6/28/22 at 9:00 a.m. with EST AA revealed she was cleaning up the floor in resident 1's room. She stated there was a sticky spill under the window. She was in that room until approximately 10:00 a.m. She did not answer surveyor's questions regarding how often each room was cleaned and what cleaning was completed each day. Observation and interview on 6/29/22 at 9:07 a.m. with LEST Q revealed: *EST AA was not working that day. *She and EST H were cleaning the rooms in the south part of City View. *Usually, it was ESTs H and AA who worked on the second floor, and she worked on the first floor. *She stated rooms were cleaned daily. *She agreed that the rooms on the south part of City View looked like they had not been cleaned thoroughly for a few days. *There was a lot of debris on the floors, under the beds, and the floors had been mopped. *She stated, Need to talk to [name] SAS G about duties the ESTs were supposed to do. She continued with, The room cleaning has been a problem for a while now. An interview on 6/29/22 at 9:17 a.m. with certified nursing assistant (CNA) O revealed the EST assigned to the south part of City View was not particularly good. The rooms always looked bad. Interview on 6/30/22 at 6:00 p.m. with SAS G and administrator A revealed: *They were aware of the cleaning problems with EST AA. *SAS G stated he did not complete any audits to ensure resident rooms were cleaned per policy. *Administrator A stated more training needed to be completed. 15. Observation and interview on 6/28/22 at 9:36 a.m. with resident 67 revealed: *His recliner was reclined as far back as it could go against the wall. *He explained the nurses move the chair too close to the wall. *He kept shifting in his chair during the conversation and said he would be more comfortable if his chair would recline more. Observation and interviews on 6/29/22 at 3:55 p.m. with SAS G and resident 67 revealed, *The recliner was away from the wall at that time. *Resident 67 confirmed, it gets pushed back too far. *SAS G said he would find a way to prevent the chair from sliding back too far. *He confirmed either housekeeping or nursing staff should have reported this as a concern. 16. Observation and interview on 6/28/22 at 10:47 a.m. with resident 20 in her room revealed: *There was no toilet paper on the toilet paper holder next to the toilet. *There were three toilet rolls which were wrapped and in a holder under the sink. *The resident stated: -The toilet paper holder had been that way for days and she had discussed this with director of nursing (DON) B and received the reply I'll watch that. -She regularly attended resident council meetings and had mentioned concerns repeatedly. After discussion of the provider's response, the resident stated, nothing ever gets done. 17. Observation on 6/28/22 at 12:58 p.m. of resident 57 in his room revealed: *A phone cord was laying across the floor from his dresser to his overbed table. The phone cord was in the walking space. *Books were stacked on the bedside table, and several books fell to the floor when he reached for a book. -He almost fell out of his wheelchair when he tried to catch the falling books. *Several books were sitting on the bed, in a box on the floor, and stacked in piles on the floor next to the box of books. *A used plastic medicine cup, an unknown black substance, and his denture brush were found sitting in his bathroom sink. *Red stains which looked like blood were on his pillowcase. 18. Interview on 6/29/22 at 11:34 a.m. with EST H revealed: *If she saw a problem, she would write the issue in the maintenance request book, or directly inform SAS G or MM I of the issue. *The CNA cleaning tasks included cleaning catheter bags, sanitizing lift equipment and resident wheelchairs, and cleaning/removing urine and feces. *The housekeepers sanitized the areas and surfaces that had urine or feces on them. *The housekeeping department: -Was responsible for smaller cleaning, like wiping down the overbed tables, and cleaning spills/crumbs/stains on the floors or furniture. -Rotated which rooms were deep cleaned. She selected two or three of the dirtiest rooms and deep cleaned those each week. She indicated she tried to deep clean each resident's room at least two to three times per month. -Did not have a system for tracking which rooms had been deep cleaned or when the room was deep cleaned. *SAS G or MM I wrote maintenance issues and requests in their logbooks. Interview on 6/29/22 at 3:54 p.m. with SAS G revealed: *They did not have a system of tracking which rooms had been deep cleaned. *He mentioned he was going to implement a tracking form after the survey was completed. *Staff would verbally let him know if something needed to be repaired in a resident's room and he wrote the concerns in his logbook. *Each housekeeper picked two of the dirtiest rooms on their assigned floor and deep cleaned the rooms once per week. On 6/29/22 on the requested facility information form, surveyors requested a deep cleaning policy for resident rooms and a schedule for deep cleaning. However, neither was provided by the end of the survey on 6/30/22. 19. Review of the policy and procedure for work orders dated 1/14/22 revealed: *Under background, efficiency in work can only be achieved if all work that needs to be done is identified .work orders provide a source for collecting and analyzing this information. *Under policy, management will document work orders on a specific form or software system. *Under procedure: -Encourage residents to request maintenance work using one of two forms. A verbal request should be transferred to a work order form or software system. -Staff members should submit maintenance requests on a work order form or software system. *Under assigning work orders and follow-up: -Prioritize the work orders based on the type of work and whether the request was generated by the resident. Give consideration to work orders that are more than 72 hours old. -Respond to all resident requests within 24 hours with either a fix or a plan of action. 20. Review of the provider's revised 10/19/21 Environmental Cleaning Principles policy revealed: *The policy mainly reviewed cleaning related to infection control. *It defined high touch areas, low touch areas, semi-critical items, and non-critical items. *Roles and responsibilities of environmental cleaning in the infection control program. -Environmental cleaning plays an important role in an infection control program. While most infections result from person-to-person transmission, the spread of infections from contaminated surfaces is significant and supports the need for good procedures and practices related to cleaning and disinfecting of surfaces. -All staff members play a role and should be aware of the general principles of environmental cleaning and safety. *There were no procedures on how to or how often to clean resident rooms and common use areas. *The was no procedure on how often to complete deep cleaning of each resident's room.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (59) had interventions in place to prevent a pressure ulcer (PU) from developing. Findings include: 1. Review of resident 59's medical record revealed: *He was admitted on [DATE]. *Multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *He was at-risk for developing a PU. *No skin issues were documented on the admission assessment. *On 6/6/21 a small open area was noted to his coccyx. *On 6/10/21 the open area had been noted as a stage II pressure ulcer: -His physician was notified. -A Roho cushion had been in his wheelchair (w/c). *On 6/11/21 a new order for [MEDICATION(S)] to be applied to the pressure ulcer had been received. *On 6/17/21 a Roho cushion had been added to his recliner as he sometimes slept there as well. Observation and interview on 6/22/21 at 9:16 a.m. with resident 59 revealed he: *Was sitting on a cushion in his w/c. *Stated he had a PU and it was healing well. *Denied pain or discomfort to the area. Review of resident 59's care plan revealed: *He had a potential for skin impairment related to fragile skin. *A stage II PU had been noted to his coccyx on 6/6/21. *Interventions put in place on 6/1/21 included: -Provide pressure relieving/reducing devices on (SPECIFY: bed and in w/c). --It did not specify where those pressure relieving device should have been. *Interventions put in place on 6/10/21 included: Provide pressure relieving/reducing devices. Roho cushion in w/c. *Intervention put in place on 6/17/21 was: Roho cushion in w/c and recliner (sometimes sleeps there). Interview on 6/23/21 at 11:49 a.m. with director of nursing (DON) B regarding the above observation, interview, and record review revealed: *When a nurse finds a wound, they filled out a new skin condition sheet and left it for the wound care nurse. *Registered nurse (RN) F did wound care rounds every Thursday. *She: -Did not know why interventions had not been put in place until 6/10/21. -Would have expected the doctor to be notified when the nurse noted the PU on 6/6/21. -Thought she should change the procedure to have the on-call nurse notified when a wound was noted on a weekend. Interview on 6/23/21 at 3:50 p.m. with RN F regarding resident 59's PU revealed: *He had told her he had previously had an open area on his coccyx in the hospital that had healed. *It was her expectation that the nurse who discovered a wound measured it, put interventions in place, and notified the physician. *She did wound care rounds on Thursdays. *On 6/10/21 she had done wound care rounds and updated the his care plan. *On 6/17/21 she had found that he was sleeping in his recliner at times, so she had added a Roho cushion to the recliner. *She agreed interventions should have been put in place prior to development of a PU. *She stated all residents had a Roho cushion in their w/c upon admission. -Agreed there had not been any supporting documentation to indicate resident 59 had a Roho cushion in his w/c upon admission. Review of the provider's 2/10/21 Pressure Ulcer policy revealed: Based on the resident's comprehensive assessment, the location will use prevention and assessment interventions to ensure that a resident entering the locations without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable. Review of the provider's 4/21/21 Skin Assessment Pressure Ulcer Prevention and Documentation Requirements policy revealed: *Braden Scale for Predicting Pressure Sore Risk was utilized to identify residents at risk for skin breakdown. *When a nurse identified a PU the physician was to be notified and the measurements and characteristics of the wound should be documented in the medical record.

Based on observation, interview, and policy review, the provider failed to ensure proper infection control practices for the coronavirus (COVID-19) pandemic with the potential for exposing residents and staff to serious harm or death including specifically ensuring: *Separate donning (putting on personal protective equipment (PPE)) and doffing (taking off PPE) stations for two of two COVID-19 positive areas: -The COVID-19 unit on the first floor for the building entrance and exit (lobby). -The COVID-19 positive residents' rooms (210, 216, 220, 222, 223, 226, and 230) in the City View and Memory Lane units on the second floor. *All authorized staff entering the COVID-19 unit including the social service director (SSD) D, laundry assistant I, occupational therapy assistant (OTA) O and housekeeper J wore all required PPE: gown, glove, N95 mask, and eye protection for all staff while on the dedicated COVID-19 unit (facility wide). *The face mask worn into a COVID-19 positive room/unit was not worn into a non-COVID-19 room/unit, by all staff who had been wearing one face mask for all areas of the building (facility wide). *Used N95 masks and disinfected face shields/eye coverings were stored separately to prevent cross-contamination for all staff reusing N95 masks and face shields (facility wide). *Gowns and gloves of all staff were removed and discarded according to national guidance (facility wide). *Hands had been sanitized prior to putting on PPE for one of one physical therapy assistant (PTA) N. *Gloves had been worn when disinfecting: -Face shields (facility wide). -Multi-use equipment for one of one OTA (O). *A face shield had been disinfected after leaving a COVID-19 positive room and before entering a COVID-19 unknown status room for one of one certified nurse assistant (CNA) (L). *New employees had consistently worn face masks and practiced social distancing during their orientation for two of three observed newly hired employees (registered nurse (RN)) (M), and certified nursing assistant (CNA) (H). These failures have a potential to expose all residents, staff, and visiting essential personnel to COVID-19, a [MEDICAL CONDITION] infection that could lead to serious harm or death. NOTICE: On 11/18/20 at 6:10 p.m. an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Notice of immediate jeopardy was given verbally to the administrator, director of nursing, and infection preventionist, with phone conference with the regional vice president, regional nurse, and quality consultant. Specifically, the provider failed to ensure: Staff and visitors had been screened for signs and symptoms of COVID-19; Donning (putting on clean personal protective equipment (PPE)) and doffing (removing soiled PPE) stations were separated for the COVID-19 unit (first floor) and for COVID-19 positive residents on the second floor; All staff entering the COVID-19 unit (Specifically the social worker, housekeeping and laundry staff) wore all required PPE (mask, gown, gloves, and face shield); A face mask worn into a COVID-19 positive room/unit was not worn into a non-COVID-19 room/unit (widespread); Used N95 masks were stored separately away from disinfected face shields (widespread); Soiled gowns and gloves were removed and discarded according to national standards (widespread); Hand hygiene was completed prior to donning PPE for one observed physical therapy assistant (N); Gloves were worn while disinfecting face shields (widespread); Face shields were disinfected after leaving a COVID-19 positive room (one staff member passing meal trays (L)). At the above time the administrator was asked for an immediate plan of correction (POC) to ensure all staff working in the COVID-19 positive unit and the COVID-19 unknown status areas with commingled COVID-19 positive residents received education and competencies for nationally recognized infection control procedures. PLAN: On 11/20/20 at 7:55 p.m. the administrator provided the surveyor with an email that included the final written POC. That POC was approved by the surveyor on 11/20/20 at 8:00 p.m. A removal plan was accepted and the Immediate Jeopardy was removed on 11/23/20 at 12:38 p.m. after the implementation of the plan was verified by the surveyor. After removal of the Immediate Jeopardy, the scope/severity of this citation is level L. The facility provided the following acceptable removal plan on 11/20/20: 1. Train people screening to ensure all individuals are screened upon entry for temperature and all the CDC identified list of symptoms, new onset of symptoms including chills, shortness of breath, difficulty breathing, new or change in cough, sore throat or new loss of taste or smell, new sputum production, congestion, runny nose (rhinorrhea) or fatigue, muscle or body aches, headache, nausea or vomiting, or diarrhea. Action: Immediate action was taken by DNS to retrain on duty screener on 11/18/20. DNS and IP are retraining our 4 primary screeners they came on duty and sent a message to all nurses about proper screening procedure. Expectations are posted at the screening station and each staff member who may be responsible for screening will be trained by 2:30pm on 11/20/20. Competency will be verified by re-demonstration observed by DNS or designee. Training and competency will be documented by signature of staff and witness on competency validation sheet. QAPI Coordinator or designee will monitor by auditing 5 screenings. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the QAPI committee. 2. Dedicated donning and doffing stations to prevent cross contamination. Action: Infection Preventionist and DNS set up stations for cleaning face shields for each Red room on co-mingled halls and on the downstairs COVID unit. Education on don/doff technique has been was completed by 9:00pm on 11/18/2020 for all staff on duty. All other staff will be re-educated by 2:30pm on 11/20/20. By 4pm on 11/20/20 2 COVID units were set up. The downstairs unit is exclusively positive residents. The fire doors to the unit are closed. There is a station with sanitizer, gloves, and gowns on the entrance side. As they approach the entrance, staff are already in N95 and face shield. They perform hand hygiene, don gloves and gown, and enter unit. Before leaving the unit at the end of shift, there is a garbage can and laundry receptacle set up so staff can doff gloves, gown and perform hand hygiene, they exit and then doff face shield complete disinfection and storing, doff and store N95 and leave wearing a surgical mask. For taking breaks a doffing station is set up outside the break room door, and inside the break room, is a face shield cleaning station, space to store N95 during break. When returning to the floor, staff sanitize their hands, don N95 and face shield, and cleaning station set up to put on fresh gown and gloves before returning to the unit. For the upstairs COVID unit, one end has a vestibule erected from 2 temporary walls with zippered entry in each temporary wall. Staff perform hand hygiene and don gloves and gowns in the vestibule, before opening the 2nd temporary wall and entering the unit. For leaving the unit, a doffing station for staff to remove gown and gloves is next to the temporary wall. A face shield cleaning station is inside the temporary vestibule. At the 2nd entrance of the upstairs COVID unit, which opens to the bistro/elevator area, are gowns, gloves, hand sanitizer and a face shield cleaning station. Inside the fire doors there is a garbage can and laundry receptacle set up so staff can doff gloves, gown and perform hand hygiene, then exit. On the co-mingled unit, there are primarily red rooms. 1 room is yellow and occupied by a married couple who refused to move. They have been educated on risk and this has been documented. A recovered resident, was previously down stairs, moved back into her room. She was educated on the risks and this has been documented. Both keep their doors closed. Outside both of those rooms, is a face shield cleaning station and drawers with sanitizer, gloves, and gowns. Staff put on clean gowns, a disinfected face shield and yellow designated N95, and perform hand hygiene before entering these 2 rooms. When leaving the room, they change back to their red designated N95. Quality Assurance Performance Improvement (QAPI) Coordinator or designee will monitor compliance by auditing 2 staff on each hall. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the QAPI committee. 3. If they dedicate a COVID unit, all staff must wear the required PPE at all times in the unit, Action: On 11/18/2020, signage posted outside COVID Unit that no one may enter without proper PPE, gown, gloves, N95 and face shield. All personnel entering COVID unit(s) (Red Zone) will perform hand hygiene and don gown, gloves, N95, and face shield. Staff on COVID unit will be required to wear PPE, gown, gloves, N95, and face shield at all times in hall ways and resident rooms. While in nurse's station, staff may disinfect work station and doff gloves. Education for these expectations was given to staff working on 11/18/20 and staff were educated as they reported to work on 11/19 and 11/20. Face to Face education is done with all staff as they came in for COVID testing on 11/20/20. For staff who are recovered and not coming in for testing and who did not work on the 18th or 19th and receive the education in a huddle, the Infection Preventionist or designee will complete training with them by 4pm on 11/20/20. The office staff were moved off the COVID unit on 11/19/20. If they would have a need to collect something from their office, they will don full PPE to enter the unit and retrieve items, then doff PPE prior to exiting the unit. Point of care testing was completed on 11/19/20 for all negative resident; all tested negative. 11/20/20, point of care testing was completed for all negative staff, and all tested negative. QAPI Coordinator or designee will monitor compliance by auditing the 4 staff on the COVID unit(s) for proper PPE use, Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the QAPI committee. 4. Dedicate masks for the use in red rooms/areas different from masks in the yellow rooms/areas with appropriate donning and doffing stations to store the mask. Action: On 11/19/20 by 4:30pm, direct care staff who are assigned to a co-mingled hall, are issued a 2 nd N95. 1 to use with residents who have tested positive (Red Room) and a separate one to don prior to working with residents who have not tested positive (Yellow Room). Staff were educated by Infection Preventionist on hand hygiene, donning/doffing of N95, and storage. On 11/18/20 purchasing attempted to order additional N95s from our supplier McKesson and were told none were available. On 11/20/20 made request to SDDOH for N95 masks. For extended use of N95s, we deferred to https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html and https://www.cdc.gov/niosh/topics/hcwcontrols/recommendguidanceextuse.html. We use a cleanable face shield over an N95 respirator to reduce surface contamination of the respirator. The N95 is stored in a paper bag when not in use. N95s are replaced after 3 - 12 hour shifts or after 5-8 hour shifts and as needed if soiled. For staff who have been assigned to the COVID Unit, their designated red room mask is stored outside the business office, next to the temporary vestibule entry to the unit while they are not on shift. While they are on the unit, there are extra paper bags, 1 for red and 1 for yellow, staff store one mask while using the other. The bag will be hung from a string, out of resident reach when not in use. QAPI Coordinator or designee will monitor compliance by auditing the 4 staff on the co-mingled unit for proper use of N95s. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the QAPI committee. 5. Ensure the contaminated mask is stored separately from the disinfected face shield. Action: Completed on 11/19/2020 by 4:30pm. All staff were provided with 2 bags, 1 for face shield, and 1 for N95. Bags are labeled with each staff members name and whether the bag is for the face shield or N95. For those staff with a separate N95 designated for yellow and red rooms, they will have 3 bags; 1 for each N95 and 1 for the face shield. Bags shields and yellow N95s and N95s for staff dedicated to downstairs COVID unit are stored in the screening area. One unit is co-mingled and those staff who work there have bags for red N95s are stored across from the business office. QAPI Coordinator or designee will monitor compliance by auditing 5 employees bags. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months Results will be reported to the QAPI committee. 6. Consistently transport gowns from the resident room to avoid cross-contamination. Action: Completed by DNS and Infection Preventionist on 11/18/2020 throughout the evening to re-educate all staff on shift on procedure for doffing, bagging and transporting used gowns to soiled linen container. Disposable gown will be doffed inside resident room and placed into a plastic bag, ensure the gown is entirely contained in the bag, close the bag and taken to trash can in the hall. For washable gowns, doff gown and place into a plastic bag before leaving resident's room, ensure the gown is entirely contained in the bag, close the bag and take to soiled laundry cart in the hall. The carts are dedicated to the unit. At 6am 11/19/2020, DNS and Infection Preventionist met with oncoming staff to provide this education and will continued to train staff as they arrived to work on 11/19/20. Change of shift education will occur until all nursing department staff have received this education. Education was sent via OnShift message system to all staff in all departments. Attendance at huddles on 11/18 and 11/19 was recorded by the DNS and Infection Preventionist. Going forward, staff will sign to confirm receipt of education. QAPI Coordinator or designee will monitor compliance by auditing the 2 staff on each hall for proper doffing and disposal. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the QAPI committee. In the COVID unit, the hall is also considered dirty, that's why don't have staff walking through without PPE. The receptacles are lined with plastic bags and have lids, and we have staff bagging the gowns as they remove them, so we end up with bagged items, inside a 2nd plastic bag in a container with a lid. In this instance, taking gowns out each time is more efficient and safer for staff. If we were to go through and periodically collect them from inside resident rooms, staff would need to use a new gown to go into the room and collect the garbage and linens, resulting in an unnecessary interaction with a COVID positive resident and waste of PPE. Normal practice is to remove dirty linens and garbage 1-2 times a shift and in the case of a soiled brief to remove right away to prevent smells in the room. The policy/procedure refers to linens soiled with bodily fluids, these linens are not contaminated with fluids. While the building is in COVID outbreak, our practice is to empty garbage and soiled linen carts as needed when they are full and at the end of the shift. During a normal day, the soiled linen carts are on the floor 2-3 hours. They are returned to the soiled utility room after AM and HS cares. After those peak times, staff take directly to the soiled utility rooms. Laundry rounded daily to collect from the soiled utility room. 7. Hand hygiene performed prior to donning PPE; staff must wear gloves when disinfecting face shields and equipment; ensure faces shields are disinfected after a COVID room and prior to entering a non COVID area/room. Action: Completed by DNS and Infection Preventionist on 11/18/20 as they began reeducation with all staff on duty. Cleaning stations were set up and supplied with hand sanitizer, EPA approved wipes, gloves, and garbage cans on 11/18/20. On 11/19/2020 at 6am, DNS and Infection Preventionist met with oncoming staff to complete education and have continued at change of shift. Attendance at huddles on 11/18 and 11/19 was recorded by the DNS and Infection Preventionist. Going forward, staff will sign to confirm receipt of education. QAPI Coordinator or designee will monitor compliance by auditing the 2 staff on each hall for hand hygiene and proper technique for using and cleaning face shields. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the QAPI committee. Findings include: 1. Observation on 11/18/20 at 8:30 a.m. upon entering the facility lobby revealed: *A wall covered with hanging paper bags with staff names written on them. *Each staff member had one bag containing their reusable PPE including an N95 mask and face shield in the same bag. *That wall was located in front of the doors to the COVID-19 unit. *Across the room was a stairway leading to the second floor, where residents with COVID-19 and residents with an unknown COVID-19 status were located. *There was one table against the wall to the COVID-19 unit. Beside that table was a wall-mounted hand sanitizer. There was no garbage can beside that table. *Another table was about eight feet away from the first table in the middle of the lobby across from the hanging bags containing PPE. The second table had a garbage can beside it, but no hand sanitizer. *It was not clear how staff put on and removed their PPE. An entrance conference on 11/18/20 at 9:10 a.m. with administrator A, director of nursing (DON) B, infection preventionist (IP) C, and two federal surveyors revealed: *The first positive COVID-19 test occurred on 10/27/20. *The DON, IP, and administrator stated the lobby area was where all staff entered and exited the facility. *They were expected to don (put on) PPE, and doff (take off) their PPE, disinfect their face shield, and store their reusable N95 mask and face mask in their bag hanging on the wall before they left the building. *Employees received one new surgical mask each day they worked and were expected to wear a surgical mask into the building when they came to work. *Those with N95 masks: -Were reusing them either for three twelve-hour shifts or five eight-hour shifts. -Covered them with a surgical mask. -Covered the masks with a face shield. *Their N95 masks remained on throughout their work day. *IP C stated: -The provider followed National Institute for Occupational Safety and Health (NIOSH) recommendations for N-95 masks. -Because the N95 masks were covered with a face shield throughout the building staff were able to move in and out of the COVID unit on the first floor and between COVID-19 positive and COVID-19 unknown status rooms without changing their masks. *Face shields were to have been disinfected between red zone residents (those with positive COVID-19) and yellow zone residents (those with unknown COVID-19 status). *There were no green zone (COVID-19-free) residents. *The provider had prepared a COVID-19 outbreak plan months ago. *When the COVID-19 outbreak occurred the rehabilitation (rehab) unit was closed on the first floor, and that area was turned into a COVID-19 unit. *Those who were not COVID-19 positive were moved up to the second floor. *The outbreak grew very quickly and the COVID-19 unit had no more beds. *The provider had attempted to dedicate staff to only the COVID-19 unit, but due to staff illness employees moved between the COVID-19 unit and other COVID-19 unknown status areas of the facility. *Administrator A, DON B, and IP C stated they had attempted to keep the COVID-19 positive residents to one area of the second floor, but the outbreak became out of control and they could not keep up with the COVID-19 outbreak. *The second floor COVID-19 positive residents were occupying seven rooms between the City View and Memory Lane units and were separated by rooms containing unknown COVID-19 status residents. *All yellow zone and green zone residents were then considered suspicious for COVID-19. -At that time both green and yellow categories were changed to yellow zone and quarantined. *The Magnolia Heights unit on the second floor had remained a yellow (quarantine) zone. *DON B stated We were doing the best we could do with the rapid outbreak and reduced staffing due to staff becoming ill with COVID-19 as well. *DON B stated the provider: -Had supplied sister facilities with their supply of gowns and masks when they had not needed them. -Was now getting low on N95 masks and their supplier notified them that there were no N95 masks to send them. -Had received more gowns the day before the survey, but not N95s. -Had not contacted the South Dakota Department of Health to locate a supply. 2a. Observation on 11/18/20 between 10:25 a.m. and 12:00 noon on the second floor revealed: *A sign was attached to the door of each occupied resident room: *An updated 11/9/20 Yellow Room sign indicated: -Quarantine. -Only nursing and designated staff were allowed to enter. -Resident room doors were to have remained closed unless their care plan had indicated they were to have a plastic barrier covering the doorway rather than a door. -Prior to entering the room staff were to put on a gown, surgical mask, and face shield. An N95 mask covered with a surgical mask was to have been worn if staff were doing any aerosol treatments. -Prior to leaving the room the staff were to have removed their gloves and gown inside the room. -Gowns and gloves worn into this room may not be worn outside this room. -The sign had not mentioned when to doff masks. -Timing of cares: If possible, care for residents and clean yellow rooms before red rooms. Whenever going from a red room to a yellow room, be sure to don new PPE and clean face shield/goggles prior to entering yellow room. -Nursing staff were instructed to wipe down high touch areas at the end of each shift. *An undated Red Room sign indicated: -Isolation Room. -Only nursing and housekeeping staff were allowed to enter. -Full PPE required. -Staff were required to wear gloves, gown, N95 mask, and a full face shield. -Before leaving the room staff were to remove and discard gloves and gown inside the room. -Clean face shield, complete hand hygiene, and disinfect touch surfaces and lifts. -Gowns worn into this room may not be worn out of this room. -Timing: provide services to residents in a yellow rooms prior to enter red room. *There was no written direction regarding removal of the masks worn in the red rooms or yellow rooms. *There were plastic carts/donning stations with bins in the hall by the residents' doors containing clean isolation gowns, gloves, and disinfectant wipes. -The carts had not contained hand sanitizer to perform hand hygiene. *There were covered garbage cans with signs identifying they were to contain soiled cloth gowns. *There were no garbage cans outside the doors to place soiled gloves and used disinfectant wipes after disinfecting their face shields when the staff left the room. *During the observations IP C placed bottles of hand sanitizer at every donning station. Interview at 11:00 a.m. with IP C revealed staff were supposed to: *Use one disinfectant wipe for the inside of the shield and a second wipe to disinfect the outside of the shield. -Allow the disinfectant to dry for the correct amount of time while holding the head band of the shield in their hand or around their arm. *There was not enough area on the donning/doffing station: -To correctly disinfect the shields safely without contaminating the shield with bottles of hand sanitizer and disinfectant wipes. -To allow the face shields to dry without holding them. b. Observation on 11/18/20 between 12:00 noon and 1:00 p.m. of the COVID-19 unit on the first floor revealed: *Two entrances: -The main entrance was located off the lobby area. -An elevator entrance was located approximately in the middle of the hall outside the laundry room. --That elevator went to the second floor where both COVID-19 positive and COVID-19 unknown status residents were located. *Observations of the main entrance revealed staff: -Entered through that door wearing an N95 mask and a face shield. -Exited through that door after they performed hand hygiene using the wall-mounted hand sanitizer near the door. *There was no garbage can near the exit to doff any additional PPE such as gowns and gloves. *Nursing staff were observed entering and exiting COVID-19 rooms wearing the same N95 mask, face shield, and gown. *Social services director (SSD) D, housekeeper J, and laundry assistant A had moved through the halls wearing only an N95 mask and a face shield for PPE. *Observation on 11/18/20 at 11:50 a.m. of occupational therapy assistant (OTA) O in the hallway of the first floor COVID-19 unit revealed she was: -Not wearing a gown. -Cleaning a multi-use electronic machine. -Not wearing gloves while using the disinfectant. *A male maintenance employee opened the lobby entrance slightly to ask where he could get a gown before he entered with supplies for storage. -There were no gowns in the hallway. -There were no gowns in the lobby for staff to don before entering the COVID-19 unit. *Resident 5 in room [ROOM NUMBER] was sitting in front of her open door. Interview on 11/18/20 at 12:20 p.m. in the first floor COVID-19 unit with licensed practical nurse (LPN) P regarding use of PPE revealed: *All nursing personnel were required to use gowns, gloves, N95 masks, and face shields. *Gowns, N95 masks, and face shields could be worn between resident rooms on the COVID-19 unit. *Gowns were not required in the hallway. *Gowns were worn by non-nursing staff only if they were going into the residents' rooms. *When asked why resident 5's door was open she stated the resident probably opened it herself. -LPN P walked away from the open door without closing it. Interview on 11/18/20 at 12:40 p.m. with laundry assistant I regarding her use of PPE revealed: *She put on her N95 mask and face shield from her hanging bag each day she worked and entered the COVID-19 unit. *She used full PPE (gown, gloves, N95, and face shield) while she separated soiled linen/clothing. *She did not require a gown when she was outside the laundry room on the COVID-19 unit unless she was entering a resident room. *She brought the clean covered linen and clothing to the elevator and the second floor staff brought it to the second floor to deliver it. *At the end of her shift she would exit the COVID-19 unit, disinfect her face shield, and then return her N95 mask and the disinfected reusable face shield to the same hanging paper bag. *She stated the N95 mask could be worn for multiple shifts if it was not soiled or damaged. Interview on 11/18/20 at 12:50 p.m. with SSD D regarding PPE requirements on the COVID-19 unit revealed: *She entered the COVID-19 unit with only an N95 mask and a face shield.*She had an office on the COVID-19 unit. *She stated she wore an N95 mask and face shield but did not require gloves and gown if she was only moving from the entrance to the hallway and to her office. 3. Further observations on 11/18/20 from 10:25 a.m. to 12:00 noon on the second floor revealed:*At 10:30 a.m. environmental service director E: -Opened resident door 247 on the Magnolia Heights unit. -Carried an unbagged disposable gown in his ungloved hand out the door. -Placed the unbagged gown into the garbage can outside the door. -Left the gown partially hanging out of the garbage can. --That garbage can had a sign stating only cloth gowns were to have been stored in the garbage can. Observation at 11:30 a.m. in the Magnolia Heights hallway revealed an employee wheeling the large garbage tub containing bagged PPE from the soiled utility room and down the hall. -The container was overflowing and caused the lid to remain partially open. Observation of unlicensed assistive personnel (UAP) Q during a medication pass for resident 6 residing in a yellow room revealed he: *Performed hand hygiene and donned clean PPE. *Entered the resident's room and left the door open. *Gave the medication to the resident. *Removed the soiled PPE and sealed it in a bag. *Exited the room and placed the bag inside the metal can outside the resident's door that was marked for cloth/reusable gowns. *Performed hand hygiene and then shut the door. Interview at that time with IP C and DON B regarding staff removing soiled PPE from the residents' rooms revealed: *Staff: -Were instructed to remove their gown and gloves inside the residents' rooms. -Placed them into a plastic bag and sealed the bag. -Performed hand hygiene. -Carried the bag down the hall to a soiled utility room and placed it in a large container. -Were to have placed soiled cloth gowns in the marked cans in the hallway. *That practice was done to prevent more employees from entering the COVID-19 positive and COVID-19 unknown status resident's rooms. *Environmental service director E should have placed the gown in a bag, worn gloves, and carried it to the soiled utility room. Random observations during that time on the second floor units revealed multiple occasions nursing staff were not wearing gloves to disinfect their face shields after exiting COVID-19 positive rooms. Observation of PTA N preparing to enter a yellow resident's room [ROOM NUMBER] revealed he: *Placed his laptop computer on a table outside the room. *Opened and gathered PPE from the PPE cart drawers. *Put on the PPE. *Picked up his laptop and entered the resident's room. *Had not used hand sanitizer before placing his hands in the PPE cart. There was no hand sanitizer on the PPE cart or in close proximity of the resident's room. Observation on 11/18/20 at 11:45 a.m. of staff delivering meals to the residents in 226 and 228 on the commingled City View unit revealed one staff person held the meal tray while CNA L donned a gown and gloves. She then: *Removed food from the tray to enter a COVID-19 positive room. *Entered the room and left the door slightly opened. *Exited the room carrying a bagged disposable gown in her ungloved hands. *Carried the gown approximately ten feet to a metal bin, opened the bin with her foot, and placed the bag in the overflowing bin. *Left the bag in the bin with the lid partially open. *She then: -Performed hand hygiene and put on clean gown and gloves. -Gathered a meal for the next resident who lived in a room with a yellow sign that indicated it was a COVID-19 unknown status room. *CNA L had not disinfected her face shield after leaving the COVID-19 positive room and entering a COVID-19 unknown status resident. *When CNA L was asked if she should have disinfected the facemask before moving from a COVID-19 positive room to a COVID-19 unknown status room she had agreed she should have. 4. Observation on 11/18/20 at 11:55 a.m. of employees RN H and CNA M sitting in the second floor City View solarium revealed: *They were sitting at a small table beside each other approximately one foot apart. *A third employee sat across the room. *Laptop computers sat in front of RN H and CNA M on the table. *Both RN H and CNA M had pulled their face masks down to their chin. *An N95 mask sat in front of RN M. *When questioned they reported they were in the building for orientation to their new jo

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being for all sixty-six residents in the facility. Findings include: 1. Interviews, observations, record reviews, and policy reviews throughout the course of the survey revealed the administrator and the director of nursing (DON) had not ensured the safe management and overall well-being of all residents in the outbreak of a pandemic (COVID-19). Review of the provider's August 2016 Director of Nursing job description revealed the DON would: *Be held accountable for complying with all related laws, regulations, and company policies and procedures pertaining to her position and her obligations under the provider's corporate compliance program. *Acquire resources and means to promote a quality work environment. *Be kept abreast of and implemented new programs or practices. *Exercise sound judgment and decision-making. *Directly supervise assigned employees. *Carry out supervisory responsibilities in accordance with the organization's policies, procedures and applicable laws. *Ensure responsibilities had included training employees, planning, assigning, and directing work. Review of the provider's May 2018 Administrator II job description revealed the administrator: *Was responsible for the overall leadership and management of the facility including ensuring regulatory and organization compliance, directing and coordinating work, and demonstrating leadership. *Was responsible for proactively communicating any necessary changes, issues and concerns to families, staff and other members of the community. *Assigned responsibility to individuals for daily management of infection prevention and control activities. *Provided equipment, supplies and access to information needed to support the infection prevention and control program. *Communicates upward and downward within the organization appropriately and in a timely fashion. *Works with department teams and consultants to oversee operations of the campus. *Is the compliance liaison of the facility, with the responsibility to support the Chief Compliance Officer in carrying out the compliance program. *Was to have an understanding of state and federal regulations. Refer to F880, findings 1, 2, 3, 4, and 5.

Based on interview, record review, policy review, job description review, and manufacturer's instruction review, the provider failed to ensure one of one certified nursing assistant (CNA/bath aide (A) had the appropriate training and education for the safe operation of the whirlpool tub used by one of one sampled resident (1) who was not secured with the safety belt during and after bathing, fell out of the whirlpool chair, and fractured her hip. Findings include: 1. Interview on 12/12/19 at 10:00 a.m. with the director of nursing service (DON) and staff development registered nurse (RN) C regarding resident 1's event on 11/29/19 involving the fall from the whirlpool chair after the bath revealed: *Since the incident all the safety belts for the whirlpools had been located. *All staff that gave baths have had competency evaluations regarding the use of the safety belt during whirlpool bathing. *They could not locate the manufacturer's instructions for the Penner whirlpools. *Both the DON and the staff development RN had completed competency evaluations with all the staff that administer whirlpool baths. *New staff attend general orientation that would include lift training. *If a resident would become aggressive during bathing the DON's expectation would have been the staff member would stop the bathing or whatever it was that was making the resident have aggressive behavior. Review and interview regarding the Bathing Clinical Skill Checklist from 12/3/19 through 12/12/19 for CNAs A and B and five other unidentified CNAs with the DON and staff development RN C revealed: *CNA A had completed her competency evaluation on 12/3/19. *CNA B had completed her training on 12/12/19. *The checklist included the following: -Use appropriate safety measures and equipment to prevent accidents: safety belts used for bathing units, shower chairs, and bathing lifts used at all times. Manufacture's directions should have been followed for the use of bathing equipment. *The DON had contacted the maintenance man to obtain the manufacture's instructions from Penner. She was unable to find any manufacture's instructions for the safe operating of the Penner whirlpool. *The DON and staff development RN C agreed the competency checklist was not applicable, because the staff were not given or shown the manufacturer's instructions regarding the safe use of the whirlpool tub. Interview on 12/12/19 at 10:38 a.m. with the DON regarding the use of the Penner whirlpool tub revealed: *There were two safety belts that could be utilized during whirlpool baths. *If the resident was unable to sit upright independently there was a belt that went across the chest area. The other belt would have been secured around the resident's waist. Review of resident 1's 11/14/19 Minimum Data Set revealed she: *Had usually understood others. *Was easily distracted and had a difficult time keeping track of what had been said. *Had disorganized thinking. *Had physical and verbal behaviors towards others. *Had symptoms of hitting or scratching herself, pacing, rummaging, or disruptive sounds. *Rejected care one to three days per week. *Was totally dependent on staff with bathing and required one person physical assistance. Review of resident 1's 10/27/17 initiated care plan focus area regarding activity of daily living self care performance deficit related to limited mobility revealed the only information for bathing was: *The resident required extensive assistance of one: Offer and encourage resident the washcloth to assist in washing face. *There was no documentation related to anything specific for the resident's bathing needs. Review of resident 1's 11/26/18 revised care plan focus area regarding the risk for falls revealed to remind resident not to bend over to pick up dropped items. Interview and observation on 12/12/19 at 11:40 a.m. with CNA/bath aide A regarding the reenactment of the incident in the whirlpool tub room on 11/29/19 involving resident 1 revealed: *The resident was always anxious before baths. *She felt she had a good rapport with the resident and could calm her down. *The resident became anxious during the end of the whirlpool bath. *She attempted to calm her down while the water was draining from the whirlpool tub. *The water drained from the tub and she opened the door to the whirlpool tub. *She dressed the lower part of the resident then the resident had become more anxious. *The resident's feet did not touch the floor when the whirlpool chair was at the lowest level. *She had just moved slightly to the right of the chair and the resident. *The resident leaned forward, attempted to put her feet on the floor, and she fell . *She had training at other facilities on the safety belt use during the whirlpool bath. *There was an undated 8 X 10 piece of paper on a clip board that read, Reminder safety belts (2) are required for tub bathing. *CNA/bath aide A had never observed that piece of paper before. She thought the clip board contained how to clean the whirlpool and Material Safety Data Sheet instructions due to the chemicals used in the whirlpool tub. *She had never had any training or education on safety belt use with whirlpool baths since her employment with the provider. *She had never observed any safety belts in the whirlpool bathing rooms until after the 11/29/19 incident involving resident 1. *She had never been trained on the manufacture's instructions for the Penner whirlpool. Interview and observation on 12/12/19 at 11:50 a.m. with CNA/bath aide B in the whirlpool tub room revealed: *She had been a CNA for twenty plus years. *She had been hired at the facility in (MONTH) 2019. *Today was the first day she was giving baths independently to residents. *She had been educated last week to use the safety belts during whirlpool baths. *There were three call systems in the whirlpool room: -The emergency call light was by the entrance to the whirlpool room. -The other was by the end of the whirlpool tub. -The third call light was in the shower stall. *There was no safe way to call for assistance when you were in the whirlpool room with a resident without leaving the resident unattended for a short period of time. Review of the provider's (MONTH) (YEAR) revised Bathing procedure revealed: *The use of the safety belts as a safety feature could have been considered a restraint. *Each resident should have been assessed to determine if the definition of restraint applied in each case. *Questions regarding if a safety device restraint should have been discussed with the Good Samaritan Society nurse consultant for clarification. *Use appropriate safety measures and equipment to prevent accidents safety belts were used for bathing units, shower chairs, and bathing lifts. *Manufacture's directions for operating and maintaining equipment should have been followed. Review of the 11/7/17 Penner Cascade Patient Transfer Lift System revealed: *Route the safety belt through the safety belt loops of the chair frame prior to placing the resident into the chair. *The safety belt would then be brought around the resident to the buckle connector. *All residents must always be securely safety belted at the waist when using all of the Penner Swivel Lift systems. *For a resident who had been unable to support themselves in an upright position Penner supplied a second chest safety belt that allowed the staff member to secure the resident in an upright position. Review of the provider's 8/17/16 Bath Aide job description revealed the employee would demonstrate safe use of lifts and all other equipment. Interview on 12/12/19 at 12:50 p.m. with the director of nursing service and the administrator revealed: *The competencies performed after the incident on 11/29/19 were not applicable due to the fact there had been no Penner manufacturer's instructions discussed with the CNA/bath aides. *There had been no Penner manufacture instructions in the building on 12/12/19 until those instructions had been requested by the survey team.

Based on observation, interview, record review, and policy review, the provider failed to ensure *Appropriate assessment, interventions, and documentation had been completed for one of one sampled resident (67) who had a facility acquired pressure ulcer. *Documentation for a pressure ulcer had been completed correctly for one of two sampled residents (14). Findings include: 1. Observation and interview on 5/14/19 at 8:35 a.m. with resident 67 revealed: *She was in the facility due to having a major infection. *She had a knee replacement that had become infected. -They had to take out that knee replacement to get rid of the infection. -She was supposed to have it replaced on 5/23/19. *She was sitting in a wheelchair with her left leg in a brace. *Her leg was propped up on the foot rest and positioned straight out in front of her. *She had a sore on her ankle she stated was due to the brace. -It always slid down and rubbed on that part of her ankle. -It had started as a bruise, then it opened up. *She was not receiving any physical therapy right now due to not having a knee. Interview on 5/14/19 at 9:19 a.m. with the director of nursing services (DNS) regarding resident 67 revealed: *She was unaware there was a sore on her ankle. *She had reviewed her medical record for documentation and stated 5/12/19 was the last skin assessment done. That was for the sore on her left knee. *There was no documentation about the area on her left ankle. Observation and interview on 5/14/19 at 10:09 a.m. with registered nurse (RN) J during a dressing change for resident 67 revealed: *The brace was lower then it was supposed to be according to both the resident and RN J. *It slides down all the time. *There were three wounds they were putting dressings on. *The first area was the surgical wound on her left knee. *The second was an area in the middle of her left leg that was approximately one inch in length. *The third wound was on the top of her left ankle. -It was red and bright pink. -The area was approximately the size of a dime. -The center was opened and red while the surrounding area was bright pink. *RN J had known about the ankle wound and stated she thought it had opened sometime over the weekend. *RN J thought the area had opened due to the brace rubbing on the top of her ankle. *She stated they had an order To dress all wounds. *She stated she would contact the physician again. *The resident complained of leg pain on the left side of her leg somewhat under the knee. Review of resident 67's nursing documentation from 5/1/19 through 5/14/19 revealed there was no documentation or physician notification regarding the wounds on her ankle or the second one in the middle of her leg. Review of resident 67's undated current care plan revealed there was no documentation regarding the above second and third wounds they were treating. Observation and interview on 5/15/19 at 9:20 a.m. with the DNS and RN H during a dressing change for resident 67 revealed: *Both the DNS and RN H identified the brace was in the wrong place. -The locked piece was below the knee, --It should have been on the side of the knee to support that part of her leg. -The bottom of the brace landed on the top of the resident's ankle where the third wound was located. *RN H stated the ankle wound had been a brown spot they had been covering. -She was not sure when it had turned pink and opened. -The area was approximately dime sized with the outer area pink, and the center was red and bleeding. *The DNS would have expected if there was a brown spot it would have been monitored. -Especially when it changed. *She would have expected a skin observation to have been done or a wound data collection form or a wound RN assessment. *Each area should have had its own assessment. *She would have measured the outer area and the opened area. *The resident stated the brace rubbed there, and it had opened due to that. *The wheelchair pedal was too short, and the resident complained of leg pain on the left side of her leg. *The bottom of her foot hit the foot pedal, so she had to move her foot to the side of the foot pedal. *The DNS instructed RN H to have the clinic refit her brace at her appointment today. *She agreed the wheelchair should have been sized for her right away when she first came into the facility in (MONTH) 2019. *She would have expected her staff to have adjusted the brace when they saw it lower then where it should have been. Interview on 5/15/19 at 2:05 p.m. with the DNS revealed: *She could only find where the physician addressed the wound on her knee and not the other two. *There was no physician's notification or orders to dress the second and third wounds. *She was not sure when the second or third wounds had developed due to the lack of documentation and assessments for them. 2. Review of resident 14's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *On 5/3/19 he had been admitted to hospice services. Observation on 5/14/19 at 8:27 a.m. during the dressing change of the wound on resident 14's left buttock revealed: *There had been an opened area approximately the size of a half dollar. -Unable to determine the depth of the wound. -A 4 X (by) 4 piece of gauze that had been saturated in Dakin's solution had been lightly packed into the opened space of the wound. -The wound had been covered with a 4 X 4 gauze, a folded abdominal pad, and secured with [MEDICATION NAME] tape. *He cried out Ow every time the nurse touched in and around the wound. -He had been premedicated with pain medication prior to the dressing change. On 5/14/19 at 5:30 p.m. wound documentation for the left buttock/left gluteal fold, care plan, and the physician's orders [REDACTED]. On 5/14/19 at 6:25 p.m. the care plan, physician's orders [REDACTED]. On 5/15/19 at 7:00 a.m. received wound documentation for March. Review of resident 14's (MONTH) 2019 Wound Data Collection forms revealed: *Only two forms dated 3/19/19 and 3/20/19 were received. *On 3/19/19: -The form indicated it was not the initial data collection on that wound. -Site was the left buttock. -The wound description indicated: --2.5 centimeters (cm) by 2.0 cm. --Reddened area with dark serosanguineous fluid noted to dressing. -Surrounding tissue had been pink and intact. -No odor present or tunneling. -Dressing and/or Treatment: --Area cleansed with wnd (wound) cleanser, patted dry and [MEDICATION NAME] applied. -No indication of how often to change dressing. *No other Wound Data Collection forms had been received for (MONTH) 2019. Review of resident 14's (MONTH) Wound Data Collection forms revealed: *The 4/5/19 form had been completed for the left buttock. -Described as a pressure wound. -No measurements had been indicated. -Foul smelling, yellow/green drainage. -Complained of pain related to the wound. -Dressing and/or Treatment: --Zinc barrier, alginate, abd. (abdominal) pad, [MEDICATION NAME] tape, QD (every day). -No documentation provided from 4/6/19 through 4/12/19. *Documentation completed for 4/13/19 through 4/15/19. -Site was the left gluteal fold. -Missing documentation on 4/16/19. *Documentation completed for 4/17/19 through 4/19/19. -Missing documentation from 4/20/19 through 4/23/19. *Documentation completed for 4/24/19 indicated: -Left gluteal fold. -Dressing to be changed every night. -Missing documentation for 4/25/19 and 4/28/19. Review of resident 14's (MONTH) 2019 Wound Data Collection forms revealed there had been documentation missing for 5/3/19 through 5/7/19. Interview on 5/15/19 at 8:04 a.m. with the Minimum Data Set assessment nurse (MDS) F regarding documentation of wounds revealed: *When skin or wound issues were found the nurse would complete a Skin Issue Identification Checklist/Work Sheet and give it to her. *Once the skin identifier form had been completed she would notify the resident's primary physician or the medical director. *She would then log it in her skin book. -That was her own personal tracking system. -She used it to help her on weekly rounds with the medical director. *The licensed practical nurse on the floor should have been doing a wound data collection form when assessing the wound or doing the dressing change. -She would have expected the nurse completing the Wound Data Collection form to indicate if that had been the initial data collection for that wound. *The Wound RN assessment form was completed weekly on Thursdays. -She completed the form. -The medical director accompanied her during skin rounds. -Wound measurements would have been done at that time. -Treatment orders or changes were made at that time. Observation and interview on 5/15/19 at 8:41 a.m. with MDS nurse F regarding wound documentation and resident 14's wound revealed: *She presented a Wound RN Assessment form dated 3/21/19 of an abrasion to the left buttock. *She stated that form had been the initial assessment of the left buttock wound. -There had been nothing on the form to indicate that was the initial assessment. Review of resident 14's March, April, and (MONTH) 2019 Wound RN Assessment forms revealed on 3/14/19 an assessment had been done on the left buttock wound. However a follow-up interview and review of the Wound RN Assessment form on 5/15/19 at 9:09 a.m. with MDS nurse F regarding verification of initial documentation of resident 14's left buttock wound revealed: *She verified there was nothing on the form to indicate it had been the initial documentation. *A Wound RN Assessment had been completed on 3/21/19. -She stated that was the initial assessment as it had been the first assessment she had found with documentation on the wound. 3. Review of the provider's (MONTH) 2019 Skin Assessment, Pressure Ulcer Prevention, and Documentation Requirements policy revealed: *All residents would be identified for their risk of developing pressure ulcers on admission/readmission by a registered nurse using the Braden Scale for Predicting Pressure Sore Risk UDA. -Those residents determined to be at risk would have the Braden Scale completed weekly for the first four weeks following admission. -Otherwise it would have been completed quarterly or when the resident would have had a change in condition. *All residents would have a comprehensive skin inspection done by a licensed nurse on admission/readmission to identify any skin issues present including, but not limited to pressure ulcers and the results would be documented in the legal medical record. *A comprehensive assessment would be completed by the registered nurse evaluating the resident's risk factors, the resident's skin condition, and the nature of the pressure to which the resident might be subjected. The assessment should have identified which risk factors could be removed or modified. *A systemic skin inspection would be done daily by the nursing assistant assigned to those residents at risk for skin breakdown. -The nursing assistant would report any abnormal findings or signs of skin impairment to the licensed nurse. *Residents who were unable to reposition themselves independently as indicated on the Sit-Stand-Walk Data Collection Tool UDA should have been repositioned as often as directed by the care plan. *Development of an individualized repositioning schedule was required for those residents unable to position themselves. *The Positioning Assessment and Evaluation UDA was a required tool that was used to determine an individualized repositioning schedule. -The positioning schedule should have been communicated to the nursing assistants using the Kardex. -Any resident at risk would be placed on a pressure redistribution surface as determined appropriate. *If a pressure ulcer was identified cleanse the area prior to observations being made to allow the wound bed and depth to be more accurately observed. *The registered nurse should have recorded the type of wound and the degree of tissue damage on the Wound RN Assessment UDA. *The licensed nurse recorded the location of the area, the measurements, and the ulcer/wound characteristics on the Wound Data Collection UDA. *Notified the physician/practitioner of the ulcer and resident's condition to obtain orders for a treatment. -It was recommended to use the Wound Care Treatment/Prevention and Dressing Recommendations. -Fax communication to Physician for Wound Care Treatment/Prevention and Dressing. --There was a wound template set to use when entering orders. --Inquired whether physician/practitioner believed it was clinically necessary to see resident. --Fax sheets would be scanned into the medical record when no file was available. *Notified resident and/or family of the pressure ulcer, orders, and planned interventions. *Dietary was notified by an alert that occurred when the Wound Data Collection UDA was signed and locked. *The Interdisciplinary team should determine any modifications that were necessary to the resident's plan of care. -Interventions should have focused on physical, mental, and psychosocial aspects that might be impacted. -Treatments and interventions should have been consistent with the resident's goals. -Education provided to the resident and/or family. *When a pressure ulcer was present, daily monitoring (with accompanying documentation when a complication or change is identified) should have included the following: -An evaluation of the ulcer if no dressing was present. -An evaluation of the status of the dressing if present (whether it was intact, draining, if present, or was not leaking). -The status of the area surrounding the ulcer. -The presence of possible complications such as signs of increasing area of ulceration or soft tissue infection. -Whether pain was present and was being adequately controlled. *If the pressure ulcer was not determined to be clinically unavoidable, the ulcer should have showed signs of improvement within two to four weeks. -Signs of improvement might have included decrease in size of wound, decrease in amount of exudate, and improvement in the tissue type. *The pressure ulcer should have been assessed and evaluated at least weekly and documented on the Wound RN Assessment UDA. -If the resident was on Medicare document daily on the Wound Data Collection UDA with every treatment change. *Observations of the ulcer's characteristics should have been documented by a licensed nurse and should have included at least the following: -Measurements: length, width, and depth. -Characteristics of the ulcer: including wound bed, undermining and/or tunneling, exudate, surrounding skin, etc. -Presence of pain. -Current treatments. Review of the provider's (MONTH) (YEAR) Pressure Ulcer Practice Guidelines revealed: *These guidelines were meant to provide an overview of preventive skin care and pressure ulcer management practices. *Each resident should have initial skin observations completed by the licensed nurse at the time of admission/readmission and documented on the Nursing Admit Re-Admit Data Collection UDA. -An assessment should have been performed by a registered nurse during the shift of admission/readmission using the Braden Scale for Predicting Pressure Sore Risk. *Risk factors that could increase a resident's susceptibility to develop or impact healing times of pressure ulcers. They included but were not limited to: -Impaired/decreased mobility and decreased functional ability. -Co-morbid conditions. *Prevention strategies should have been developed and implemented at the time of admission based upon the initial assessment of the causative factors that contributed to the resident's risk for skin breakdown. *Prevention strategies were ongoing and would have been individualized based on the areas or the level of risk determined. -Include those prevention strategies on the resident's care plan. *Resident's at risk for pressure ulcer development and those with pressure ulcers/wounds should have been monitored daily for changes in their skin condition. *That might have occurred during the course of the resident's daily care and/or bathing where the certified nursing assistant should have performed a head-to-toe check of the resident's skin, paying particular attention to: -The surfaces of the skin that would have come in contact with the bed and chair. -Bony prominences. -The surfaces of the skin that would come in contact with each other and any orthotic device, tube, brace, or positioning device. *Any abnormal findings/changes should have been documented in the Skin Module on the Kiosk and reported to the licensed nurse assigned to the resident for assessment and follow-up.

Preceptor: Based on observation, interview, record review, and policy review, the provider failed to ensure the psychosocial and overall physical well-being for two of three sampled dependent residents (1 and 4). Findings include: 1. Review of resident 1's entire medical record revealed: *She had declined in the physical abilities necessary to have complete activities of daily living during the last five months. *She had been lethargic (sleepy) since her hospitalization in June 2013. *She had four medications scheduled that all had sedation and/or drowsiness as a side effect. -There was no rationale documented for the addition of the antipsychotic medication [MEDICATION NAME]. -The monitoring and evaluation of the side effects of those medications had not been documented. *Her behaviors had consisted of yelling and resisting care at times. -There was no documentation available that identified nonpharmacological (things other than medications) interventions having been attempted with behaviors during the last month. *She had a 13.9% unplanned weight loss in the last six months. *She had been served cooked cereal for all three meals each day since 8/30/13. *She had been routinely only included in activities involving music. *Undated care plan printed on 10/22/13 was not complete, updated, or followed. Observations on 10/22/13 from 8:00 a.m. through 10/23/13 at 6:00 p.m. revealed: *On 10/22/13 from 10:00 a.m. through 4:45 p.m.: -She was unable to move or reposition herself and unable to answer questions asked by this surveyor. -She sat in her wheelchair in the alcove with her head bent to her chest and eyes closed. She was not repositioned from the seated position in the wheelchair during that time. -She had slept through the music that was played in the alcove. -The noon meal had been eaten in the dining room and consisted of cooked cereal, ice cream and apple juice. She ate 10% of the meal with total assistance. -Her Tabs monitor (alarm that alerts staff of resident attempting to get out of the wheelchair) was sitting on the chest of drawers in her bedroom. -Fluids had been offered once when the midmorning snack had been offered, at the noon meal and with medication administration -No fluid intake or output was measured. -She had been transferred with the assistance of one staff person instead of the two as indicated on the care plan. *On 10/22/13 from 4:45 p.m. through 6:00 p.m.: -She was awake sitting in her wheelchair with a Tabs monitor attached to her wheelchair and her clothing. -She was able to give short answers to questions. -She had required extensive assistance of staff to reposition or move. -The evening meal had been eaten in the alcove. The meal consisted of cooked cereal, yogurt, and juice, of which she had eaten 30% and was not yet finished at the time of this observation. *On 10/23/13 at 8:52 a.m.: -She was awake. -She was able to give short answers to questions -She was able to reposition herself with the assistance of one staff person *On 10/23/13 at 5:53 p.m.: -She was awake and seated in the alcove in her wheelchair. -She had eaten 30% of the evening meal and was not yet finished. -She stated the food was "good" when asked. Interview on 10/22/13 at 10:24 a.m. with RN L revealed resident 1: *Was lethargic in the morning at times. *Had declined (decreased in her abilities to care for self and walk) in the last few months. Interview on 10/22/13 at 3:06 p.m. with CNA Q revealed resident 1's behaviors consisted of yelling occasionally. Interview on 10/22/13 at 3:06 p.m. with LPN M regarding resident 1 revealed: *Behaviors consisted of yelling occasionally and sometimes she sang in her native language. *Had declined in the last few months; she used to walk and feed herself. Interview, care plan review, and policy review on 10/23/13 at 9:25 a.m. with the activities director (AD) revealed: *She had documented a one-to-one activity for resident 1 on 10/22/13 without a one-to-one activity having been completed. *The care plan for resident 1 had not included an activity program. *The care plan had no specific directions for one-to-one activities for resident 1. *Resident 1 was included in only musical activities. *She stated she was responsible for the care planning of activities. *She agreed the care plan for resident 1 did not meet the expectations listed in the provider's activity policies. Interview on 10/23/13 from 12:45 p.m. through 3:45 p.m. with the certified dietary manager, registered dietician, consultant pharmacist, infection control nurse, director of nursing, medical director (MD), and medical director for the Good Samaritan system geriatric program regarding resident 1 revealed: *All present agreed the resident had declined in the last few months, particularly since the last hospitalization s in May, June, and August. *All present agreed the resident remained on four medications that could cause drowsiness and sedation. *The MD agreed the resident's lethargy needed to be investigated. *The MD agreed there was no rationale documented for starting the antipsychotic medication [MEDICATION NAME]. *The infection control nurse agreed there was no documentation of the monitoring for or evaluation of the resident concerning the possible side effects of the medications ordered. *All present agreed there was a 13.9% unplanned weight loss in the last 6 months. *All present agreed the physician's orders [REDACTED]. *All present agreed the care plan was not: -Complete as it was missing a focus on activities program and a specific plan including description of one-to-one activities. -Updated as dietary focus not individualized to specific meal plan (cooked cereal three times a day), best environment for eating, or intake and output of fluids. -Followed as evidenced by fluid intake not being monitored and other shared observations. Review of the provider's September 2012 physician's orders [REDACTED]. *Clarification of orders was needed when physician's orders [REDACTED]. "Never attempt to guess or determine what an order might say." Review of the provider's September 2012 Care Plan policy revealed: *Care plans would be reviewed, evaluated, and updated when there was a significant change in the resident's condition and/or in accordance with state guidelines. *The plan of care would be modified to reflect the care currently required/provided for the resident. Review of the provider's September 2012 Comprehensive Care Plan and Care Conferences procedure revealed; *"Care area assessments (CAA) guide interdisciplinary team through a comprehensive assessment of resident's functional status. Intent is to review all aspects of an individuals life with the goal of assisting that person to function at his or her highest practicable level of well-being." *"The care plan is driven by identified resident issues/conditions and their unique characteristics, strengths and needs." *"The interdisciplinary team will ensure that the care plan is comprehensive by incorporating: -All CAAs triggered (activities). -Approaches to specific concerns or needs of the resident. -Adverse consequences and warnings for medications." Review of the provider's September 2013 Comprehensive Care Plan and Care Conferences procedure revealed: *The purpose was to provide an ongoing method of assessing, implementing, evaluating, and updating the resident's care plan to help maintain the resident's highest level of functioning. Refer to F 248; F 325; and F 329, finding 1. 2. Observation on 10/22/13 from 7:49 a.m. to 11:40 a.m. of resident 4 revealed she: *Was sitting in her wheelchair the entire time. *Was not wearing her thigh high ted hose (support stockings) as ordered by the physician on 9/27/13 for swelling in her legs. The stockings should have been worn during the daytime and had been taken off at bedtime. *Complained of right shoulder discomfort at 10:20 a.m. She had refused the offer of Tylenol by the registered nurse (RN). The RN had pulled her upper body slightly forward and had placed a small pillow behind her right shoulder. *Turned her call light on at 11:30 a.m. and said she needed to use the bathroom. *Was assisted into bed by two certified nursing assistants (CNA) D and E using a full mechanical lift at 11:40 a.m. She had a large incontinent bowel movement in her adult brief. Interview on 10/22/13 at 11:45 a.m. with CNA D and E regarding resident 4 revealed: *They had not put her in her recliner after breakfast like they usually did, because the family was going to clean the chair. *She had been assisted into her wheelchair at 6:30 a.m. *She had a body position change when the nurse had pulled her upper body forward to place a pillow behind her right shoulder at 10:20 a.m. *She had not been out of her wheelchair since 6:30 a.m. *She was not toileted as she had a catheter (tube in the bladder to drain urine). *She had not had her thigh TED hose on for a couple days, as they were in the laundry. She might also have refused to wear them. Interview on 10/22/13 at 11:50 a.m. with resident 4 revealed: *She had two pair of thigh-high TED hose. There was only one sock hanging in the bathroom on the towel bar. *She had not refused to wear them as they had felt good on her legs. Review of resident 4's 4/18/13 care plan revealed: *"Resident is not toileted. She is checked/changed every two to three hours. Refuses to use a commode or toilet." *"Requires total staff assistance to transfer." *"Requires one to two staff participation to reposition and turn in bed every two to three hours for skin integrity." *"Assist to turn/reposition at least every two hours. Reposition with one to two people." *The use of the thigh-high TED hose was not addressed.

Preceptor: Based on observation, interview, record review, and policy review, the provider failed to identify, monitor, and document the combined effects of psychopharmacological (medications that affect the mind) and pain medications for 2 of 16 sampled residents (1 and 8) with pain and dementia (difficulty remembering) with behaviors. Findings include: 1. Observation on 10/22/13 from 10:00 a.m. through 6:00 p.m. of resident 1 revealed: *From 10:00 a.m. through 1:35 p.m. she had remained with her head bent to her chest, her eyes closed, unresponsive to verbal cues, and had a runny nose. *From 1:55 through 4:45 p.m. she had rested in her bed in the same position on her side with her eyes closed. *At 4:45 p.m. she had been positioned in her wheelchair with her feet elevated and was in her room. She remained awake and was able to respond to verbal questions. Observation on 10/23/13 from 8:00 a.m. through 10:00 a.m. of resident 1 revealed: *At 8:00 a.m. she had been laying in her bed in her room. *At 8:45 a.m. she had been awake with her head raised and was speaking. *At 5:30 p.m. she had been awake, seated in her wheelchair in the alcove, had been assisted by staff with eating mashed potatoes with meat and gravy. When asked how her meal was she had responded "good." Review of resident 1's complete medical record revealed: *She had [DIAGNOSES REDACTED]. *She understood and spoke limited English as English was not her native language. *Her vision was poor. *Her behaviors were identified as lethargy, yelling out, resisting cares, and struggling to communicate. *Her care plan for behaviors written and revised on 2/22/13 included: -Administer medications as ordered. -Monitor for side effects. -Review at Quality of Life meeting as needed. *There was no documentation of other interventions attempted for behaviors. *She had been hospitalized in June 2013 and had returned from the hospital with two pain medications, ([MEDICATION NAME] and [MEDICATION NAME]), one antipsychotic ([MEDICATION NAME]), and one antihypertensive ([MEDICATION NAME]), all of which had side effects of sedation or drowsiness. *Goals of the undated care plan printed on 10/22/13 included the resident would: -Have improved mood state: calmer, more comfortable, less screaming, with PHQ-9 (tool used to measure depression) of less than 15. -Resume usual activities without further incident (fall). -Maintain current level of function in transfers, eating, toilet use, and personal hygiene. *Documentation of behaviors regarding the resident during the month of October revealed a pattern of her screaming at bedtime, sometimes in the middle of night, and in the morning with occasionally resisting care at the same time. No documentation as to circumstances of those instances was included. *Review of the 5/15/13 consultant pharmacist notes regarding the resident revealed: -She was fearful to sleep in her room. -She had not wanted staff to turn the light off in her room. Interview on 10/22/13 at 10:24 a.m. with RN L revealed resident 1 was at times lethargic in the morning. Resident 1 had declined in the last few months. Interview on 10/22/13 at 3:06 p.m. with CNA Q revealed behaviors for resident 1 consisted of yelling occasionally. Interview on 10/22/13 at 4:45 p.m. with LPN M regarding resident 1 revealed: *Her behaviors had consisted of yelling occasionally and sometimes she had sung in her native language. *She had declined in the last few months, and she used to walk and feed herself. Interview on 10/23/13 from 12:45 p.m. through 3:45 p.m. with the certified dietary manager, the registered dietitian, the consultant pharmacist, the infection control nurse, the director of nursing, the medical director (MD), and the medical director for Good Samaritan system geriatric program regarding resident 1 revealed: *On 6/25/13 she had returned from hospitalization on a scheduled dose of [MEDICATION NAME] for agitation. That had been started due to hallucinations (seeing things that are not really there). [MEDICATION NAME] had been discontinued on 7/16/13 for a trial period due to lethargy (sleepiness). Following reported increased behaviors and hallucinations she had been restarted on another antipsychotic, [MEDICATION NAME] twice a day on 7/22/13. Due to lethargy that dose had been reduced to once a day at bedtime on 8/5/13. *All present agreed the resident had declined in the last few months, particularly since the last hospitalization s in May, June, and August. *The MD agreed the resident's lethargy needed to be investigated. *The MD agreed there was no rationale documented for starting the antipsychotic medication [MEDICATION NAME]. *The infection control nurse agreed there was no documentation of the monitoring for or evaluation of the resident for side effects from the medications. Review of the provider's September 2012 Psychopharmacological Medications and Sedative/Hypnotics policy revealed the purpose was to: *Evaluate behavior interventions and alternatives before using psychopharmacological medication and sedative/hypnotics. *Eliminate unnecessary psychopharmacological medications and sedative/hypnotics. Review of the provider's September 2012 Psychopharmacological Medications and Sedative/hypnotics procedure revealed the purpose was to: *Evaluate behavior interventions and alternatives before using psychopharmacological medications and sedative/hypnotics *Eliminate unnecessary psychopharmacological medications and sedative/hypnotics. 2. Review of resident 8's medical record revealed: *She had been hospitalized from [DATE] through 6/17/13 due to pain after a fall with several broken ribs. *She had been started on [MEDICATION NAME] (an antipsychotic medication used to treat the symptoms of [MEDICAL CONDITION] (abnormal thinking)) in the hospital after she had been diagnosed with [REDACTED]. When her pain became controlled the [MEDICAL CONDITION] symptoms had decreased. *On the day prior to discharge the physician had reported she had been alert and oriented to person, place, and time. *She had returned to the provider on 6/17/13 with the [MEDICATION NAME] and [MEDICATION NAME] (a narcotic pain patch). *She had been seen by her physician on 6/25/13 for a follow-up visit after the hospitalization . The physician had written "In no apparent distress. Alert and oriented." He had not acknowledged the [MEDICATION NAME] use nor had he discussed the [DIAGNOSES REDACTED]. *The provider's pharmacist had recommended the [MEDICATION NAME] be discontinued on 8/22/13, because she had been having more falls. The physician had discontinued it. *Her physician had seen her again on 8/28/13. He had written "in no apparent distress. Alert and oriented." There had been no mention of [MEDICAL CONDITION]. The resident had denied pain. He had made no mention of the [MEDICATION NAME] use. *Her interdisciplinary progress notes regarding behaviors revealed her most recent delusional (hallucination) behaviors had been on 9/3/12 at 12:20 p.m. with the resident believing she had to leave for an appointment. On 8/23/13 she thought she had needed to help care for babies and clean the house. Other behaviors were restlessness and getting out of bed. *The 9/20/13 care plan revealed there had been no documentation regarding the use of [MEDICATION NAME]. Interview on 10/22/13 at 8:00 a.m. with RN I revealed resident 8 had [MEDICAL CONDITION] symptoms in June with seeing her brother and hearing her daughters. But she was no longer exhibiting [MEDICAL CONDITION] symptoms. She stated the resident had consistently denied pain when she had been asked. Interview on 10/23/13 with the provider's pharmacist revealed she had asked the physician to decrease the [MEDICATION NAME] on 10/22/13, but she had not received a response yet. She agreed [MEDICAL CONDITION] was a short-term problem and would not have expected it to last for months. Interview on 10/23/13 at 5:15 p.m. with the DON revealed: *She agreed [MEDICAL CONDITION] was a short-term problem. *They had visited with the pharmacist on 10/22/13 in regard to the [MEDICATION NAME] use. *Her expectations were: -The care plan should have addressed antipsychotic use ([MEDICATION NAME]) and monitoring for the effects of the drug. -The doctor should have addressed the [MEDICATION NAME] use. Review of the provider's revised September 2013 Comprehensive Care Plan and Care Conference procedure revealed: *The interdisciplinary team would ensure the care plan was comprehensive (all-inclusive). *This was done by incorporating the physician's orders [REDACTED]. Review of the provider's September 2012 Psychopharmacological Medications and Sedative/Hypnotics policy revealed: *The resident was to have been free from any chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. *Each resident's drug regimen was to have been free from unnecessary drugs. *An unnecessary drug was any drug when used: *For excessive duration. *Without adequate monitoring. *Without adequate indications for its use. *Antipsychotic drugs were not to be given unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the clinical record.