Every finding on record at Good Samaritan Society Sioux Falls Village

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, observation, and policy review, the provider failed to ensure that one of one certified nursing assistant (CNA) (AA) used a gait belt (a waist strap gripped as support for safe mobility and transfers) while ambulating (walking) one of one sampled resident (91) to the bathroom, resulting in a fall and broken femur for resident 91. Findings include:1. Review of the provider's 6/23/26 SD DOH FRI revealed that at 8 a.m. on 6/23/26, resident 91 was ambulating to the bathroom using her front-wheeled walker (FWW) (a device with two wheels on the front legs and rubber tips on the back legs, designed for individuals who need stability and partial weight-bearing support) as CNA AA provided contact guard assistance (CGA) (hands-on physical light touch to support an individual without actively supporting their body weight), but did not use a gait belt. Resident 91 lost her balance and fell and suffered an elbow abrasion and a broken femur that required surgery to repair. Following surgery, resident 91 readmitted to the facility on [DATE]. 2. Review of resident 91's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. She had diagnoses of chronic obstructive pulmonary disease (a progressive, incurable lung condition that makes it hard to breathe), dementia (a group of symptoms affecting memory, thinking, and social abilities), and repeated falls, with a history of traumatic brain injury (caused by a bump, blow, jolt, or penetrating wound to the head that disrupts normal brain functions). Her 6/29/26 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated her cognition was intact. A 6/1/26 fall assessment score of 14 indicated she had a moderate risk for falling, displayed intermittent confusion, had an ambulation status of chairbound, and did not experience any falls during the past three months. Her 6/23/26 fall assessment completed at 1:58 p.m. was six, which indicated she had a low risk of falling, did not experience any falls during the past three months, was alert and oriented, and was chairbound. Resident 91's 6/23/26 care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) indicated that for toileting and transferring, she required one staff member to assist her in a pivot transfer (when assisted to a standing position, the resident then turns their body to move to another surface) using a gait belt, wheelchair, or a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) as needed. 3. Interview on 6/30/26 at 3:12 p.m. with Administrator A revealed that she felt the terminology used in the residents' care plans (personalized plan that addresses a resident's care needs, goals, and interventions) needed to be clarified to avoid misinterpretation of a resident's level of assistance. Before she fell on 6/23/26, resident 91's care plan specified that she needed staff assistance with her activities of daily living (ADLs: routine self-care tasks people perform every day to maintain independence) due to impaired mobility and weakness. Her intervention for ambulation read, CGA with [the] use of [a] FWW. I use [a] wheelchair for primary locomotion. Administrator A wanted to replace CGA, a therapy acronym for contact guard assist, with assist of one staff member with gait belt, so it was clearer for the staff to understand. After resident 91 fell on 6/23/26, Administrator A reviewed all the residents' care plans to update the terminology used for the ambulation and locomotion interventions and to ensure that the resident's fall assessment scores accurately reflected the resident's risk of falling. 4. Observation and interview on 6/30/26 at 4:02 p.m. in resident 91's room with the resident and her family member revealed that before she fell on 6/23/26, for short-distance trips to the bathroom, she used a walker to help keep her balance when she walked. If she left her room, she used a wheelchair and was able to propel it independently. Resident 91 recalled that on the morning of 6/23/26, as she neared the bathroom door, she saw her roommate's pajamas lying on the floor and told CNA AA, Those are in my way. CNA AA replied, Go ahead, you'll be ok. Resident 91 said she moved forward, tripped on the pajamas, and fell backwards, hitting the back of her head on the floor. Her family member said he was surprised CNA AA did not pick up the pajamas or use a gait belt. Resident 91 said the staff does not always use a gait belt when assisting her. It just depends on who's helping me, she said. 5. Interview on 6/30/26 at 4:24 p.m. with registered nurse (RN)/clinical nurse leader I revealed that she expected staff members to reference a resident's Kardex (a report listing the resident's care needs and interventions) to know whether they should use a gait belt when assisting with transfers, walking, and toileting tasks. The staff were to use a gait belt if specified in the Kardex and be aware of all care plan updates posted in the nurse's station. She was aware that resident 91 said she tripped on pajamas that were on the bathroom floor, but CNA AA recalled nothing lying on the floor. RN/clinical nurse leader I said recent complications from resident 91's COPD could have caused resident 91 to become confused. Resident 91 did not require the use of a gait belt when ambulating to the bathroom, and she used a wheelchair when traveling longer distances, such as to the dining room. 6. Interview on 7/1/26 at 11:01 a.m. with certified occupational therapy assistant (COTA) DD revealed that it was standard protocol for the therapy staff to use a gait belt when assisting residents. She did not know whether resident 91 needed to use a gait belt and would prefer that all CNAs used a gait belt when assisting residents, regardless of their status. She said, If someone were to lose their balance while walking, the gait belt is something they can grab onto. 7. Interview on 7/1/26 at 11:20 a.m. with CNA AA revealed that she referenced a resident's Kardex to know whether they required a gait belt when being assisted by the staff. On 6/23/26, she was assisting resident 91's roommate when resident 91 said she needed to use the bathroom. CNA AA did not know if resident 91 needed a gait belt but knew she used a walker, so that's what I did with her. As they neared the bathroom door, resident 91 fell. She said there were clothes on the floor, but I don't think there was anything on the floor, CNA AA stated. 8. Interview on 7/1/26 at 11:30 a.m. with certified medication aide (CMA) Y revealed that she referenced a resident's Kardex to determine their level of assistance and that the Kardex could change frequently. She said, We work with new residents every day, so I always check [the Kardex] if I don't know. 9. Interview on 7/1/26 at 11:33 a.m. with director of nursing (DON) B revealed that she expected the staff to reference a resident's care plan or Kardex to determine the level of assistance they required. Staff members who were helping someone they did not routinely work with should ask another staff member about their needs or refer to the care plan. She said, All staff have access to the care plan and the Kardex. 10. Interview on 7/1/26 at 3:45 p.m. with physical therapist supervisor EE revealed that before she fell on 6/23/26, resident 91 was participating in physical therapy to increase strength and endurance. She stated that although therapy staff used a gait belt when assisting residents, some staff members did not use a gait belt. Therapy will recommend how a resident should transfer, whether that's with a gait belt or a lift and one or two staff [members] assisting them, she said, but the nursing team ultimately specified the resident's assistance needs on the resident's care plan. 11. Interview on 7/1/26 at 3:53 p.m. with CMA BB revealed that she referenced the residents' care plans or the Kardex to determine their needs during a transfer. She said the Kardex would specify the use of a gait belt if a resident required that level of assistance, but she did not think resident 91 needed a gait belt. 12. Interview on 7/2/26 at 9:05 a.m. with CNA/restorative nursing aide (RNA) CC revealed that she was working as a CNA in the special care unit (an area where specialized care is provided in a structured, safe, and supportive environment to meet the unique needs of residents with significant memory and cognitive decline, that is secured to minimize unsafe wandering). Her primary role was to assist residents with restorative therapy exercises (designed to help residents maintain or improve their functional independence). She referenced a resident's Kardex to determine their required level of assistance. She said it's common sense to use a gait belt when helping residents stand up and when walking with residents who are unstable or cognitively impaired. 13. Interview on 7/2/26 at 9:50 a.m. with DON B revealed the nursing team or the therapy team evaluated residents to determine the level of supervision they required for transfers, toileting, and walking. The nursing team conducted fall assessments quarterly, after each fall, and when a resident's health status changed. 15. Review of the provider's 4/30/26 Gait-Transfer Belt policy revealed that gait belts are a device used for stability and/or support for a short time during the actual transfer or ambulation, and should be used with assisted ambulation unless medically contraindicated. 16. Review of the provider's 12/1/25 Care Plan policy revealed that the residents' care plans were reviewed and modified at least quarterly and when there was a significant change in a resident's condition. The care plan should reflect the care currently required/provided for the resident.

Based on the interviews, record review, observation, and policy review, the provider failed to ensure the staff responded promptly to twelve of thirty-one sampled residents (13, 14, 21, 27, 59, 73, 85, 89, 119, 123, 155, and 164) who reported concerns related to extended call light times. Findings include: 1. Interview on 6/28/26 at 4:03 p.m. with resident 13 revealed that he felt call lights were not answered in a timely manner. He stated, These [call lights] don't get answered. 2. Review of resident 13's call light response time report (a report of call light usage and time it took for the residents' call lights to be answered by the staff) from 6/1/26 through 6/30/26 revealed that twenty call light response times were more than 20 minutes long, four were more than 30 minutes, one was more than 40 minutes, two were more than 50 minutes, and one response time was greater than 90 minutes. 3. Interview on 6/29/26 at 2:56 p.m. with resident 59 revealed that he had to wait at least 30 minutes to have his call light answered. He sometimes called the facility phone number to get help. The weekends and holidays had longer wait times, and if a holiday occurred during the weekend, it was worse. Nothing bad had happened to him yet, but he worried and got irritated when he had to wait a long time. 4. Review of resident 59's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 5/7/26 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated his cognition was mildly impaired. His diagnoses included right leg above the knee amputation, anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), major depressive disorder, and Parkinson's disease with dyskinesia (a brain disorder that gradually affects movement, causing symptoms like shaking, stiffness, and slowed motion because the brain loses cells that make dopamine with involuntary, uncontrolled movements). His undated care plan indicated he may need the staff's assistance for long distances in his wheelchair. He needed one staff member's assistance with bathing, bed mobility, dressing, grooming, oral care, personal hygiene, and toilet use. He needed two staff members' assistance for transfers using the total body lift (a mechanical lift and sling used to lift a person's full body). 5. Review of resident 59's call light response time report from 6/1/26 through 6/30/26 revealed he had ten call light response times over 20 minutes long, and one call light response time was 150 minutes long. 6. Interview on 6/29/26 at 3:09 p.m. with resident 164 revealed that she has had to wait up to 20 minutes for her call light to be answered. She said, When I have to go to the bathroom, that gets really bad. I end up peeing, and that makes me feel inhumane. 7. Review of resident 164's EMR revealed she admitted to the facility on [DATE]. Her 6/15/26 BIMS assessment score was 15, which indicated her cognition was intact. Her diagnoses included chronic kidney disease stage 3, history of urinary tract infections (UTIs), and repeated falls. Her 7/1/26 care plan indicated she used a wheelchair for mobility. She needed the assistance of one staff member for bathing, bed mobility, dressing, eating, oral care, personal hygiene, toilet use, and transfers. She was to be toileted after each meal and at bedtime to prevent skin breakdown due to incontinence (involuntary urine or bowel leakage) and brief use. 8.Review of resident 164's call light response time report from 6/2/26 to 6/30/26 revealed she had two call light response times over 20 minutes long. 9. Interview on 6/30/26 at 9:15 a.m. with resident 21 revealed that about a week ago, resident 21's call light was on for over an hour. She had turned her call light on, and no one came to assist her. Resident 21 went down to breakfast and when she returned, her call light was still on. Resident 21 went to restorative therapy, and when she returned, her call light was shut off. No one came to find out what she needed; someone just turned her call light off. She stated, I am scared no one will answer my call light, when I need help. Her roommate, resident 27, used her call light a lot. 10. Review of resident 21's EMR revealed her 6/24/26 BIMS assessment score was 15, which indicated her cognition was intact. Her diagnoses included Diabetes Mellitus Type II (a condition involving disruptions in how the body regulates blood sugar), chronic pain syndrome, muscle weakness, and a history of falling. 11. Review of resident 21's call light response time report from 6/1/26 through 6/30/26 revealed she had two call light response times over 20 minutes long, and one call light response time was 127 minutes long. 12. Review of resident 27's EMR revealed her 5/27/26 BIMS assessment score was 0, which indicated her cognition was severely impaired. Her diagnoses included hemiplegia (complete or severe paralysis of one entire side of the body), and hemiparesis (partial weakness or loss of strength on one side of the body) following a cerebral infarction (stroke) affecting her left side, major depressive disorder, and down syndrome (genetic condition which alters typical development resulting in intellectual disability, development delays and distinct physical characteristics). 13. Review of resident 27's call light response time report from 6/1/26 through 6/30/26 revealed she had ninety-two call light response times over 20 minutes long, and twenty-nine call light response times over 60 minutes long. 14. Observation and interview on 6/30/26 at 8:05 a.m. in resident 85's room revealed she was lying in bed, wearing a hospital gown, and had a tracheostomy tube (a tube surgically placed through the neck into the windpipe to allow airflow) and did not require ventilatory support (a machine to breathe for her). She stated that there was a resident down her hallway that CNAs were in her room for two to four hours at a time, and that she and other residents down that hallway have to wait a long time for staff's assistance. Sometimes, when she had to wait a long time for staff to answer her call light, she needed a nebulizer treatment to loosen her secretions. She did not have any shortness of breath. She was more worried about the other residents having to wait a long time for staff assistance. She completed some of the care for her trach by herself, and she took the cap off to clear the secretions around it. When doing this once, the trach came out. Nothing bad happened when that occurred, and the nurse came in right away and replaced it. 15. Review of resident 85's EMR revealed she admitted to the facility on [DATE]. Her 5/22/26 BIMS assessment score was 15, which indicated her cognition was intact. She had diagnoses of dysphagia (difficulty swallowing), tracheostomy, hypertension (elevated blood pressure), Major Depressive Disorder (a mental health condition that causes a persistent feeling of sadness, emptiness, and loss of interest in activities once enjoyed), atrial fibrillation (irregular heartbeat), and weakness. Her 5/26/26 care plan revealed that she had a tracheostomy and sometimes pulled it out when she adjusted it. She required the assistance of one staff member and the sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) to be transferred and one staff member to get dressed and reposition in bed. She required extensive assistance with using the toilet and for personal hygiene care. 16. Review of resident 85's call light response time report from 6/1/26 to 6/30/26 revealed she had three call light response times over 20 minutes long and one call light response time over 40 minutes long. 17. Observation and interview on 6/30/26 at 9:53 a.m. in resident 14's room revealed she was lying in bed wearing a hospital gown, and had her left arm and both legs propped up with pillows. She stated that it sometimes took staff hours to answer her call light. She stated that sometimes she needed to have the staff position her legs differently, and she experienced pain when she waited a long time for the staff to answer her call light. 18. Review of resident 14's EMR revealed she admitted to the facility in October 2025. Her 5/5/26 BIMS assessment score was 15, which indicated her cognition was intact. She had diagnoses of complex regional pain syndrome of the right upper limb (a chronic neurological condition causing severe, persistent pain to her right arm), depression, generalized anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), muscle spasms (a sudden, involuntary contraction of a muscle), and quadriplegia (the partial or total paralysis of all four limbs and torso). Resident 14's 6/30/26 care plan indicated that she had chronic pain, and non-pharmacological (non-medicated) interventions to reposition her. She required two staff members to reposition her in bed and total staff assistance with getting dressed and her personal hygiene. She required two staff members and a total body lift (a mechanical lift and sling used to lift a person's full body) to be transferred. She was particular about her care and sometimes required three staff members to assist her. 19. Review of resident 14's call light response time report from 6/1/26 to 6/30/26 revealed she had twenty-three call light response times over 20 minutes long, nine call light response times over 30 minutes long, four call light response times over 40 minutes long, one call light response time over 60 minutes long, one call light response times were over 80 minutes long, and one call light response time of 112 minutes long. 20. Interview on 6/30/26 at 10:38 a.m. with resident 73 revealed that he had waited 45 minutes to get his call light answered. He would get anxious when he had to wait a long time for his call light to be answered because he was blind and unable to see anyone to get help. 21. Review of resident 73's EMR revealed he admitted to the facility on [DATE]. His 5/7/26 BIMS assessment score was 15, which indicated his cognition was intact. His diagnoses included legal blindness, sensorineural hearing loss (a permanent type of hearing loss caused by damage to the inner ear), retention of urine, and weakness. His 7/1/26 care plan indicated he required one staff member's assistance for wheelchair mobility, bathing, bed mobility, dressing, grooming, eating, oral care, personal hygiene, and toilet use. He required two staff to assist him with transfers. He had an indwelling urinary catheter (flexible tubing inserted into the bladder to drain urine). 22. Review of resident 73's call light response time report from 6/1/26 to 6/30/26 revealed he had four call light response times over 20 minutes long. 23. Interview on 6/30/26 at 2:30 p.m. with certified nursing assistant (CNA) D revealed that the staff were expected to answer the residents' call lights within five minutes. She carried a radio that alerted her when the residents' call lights were turned on, and monitors located in the hallway near the ceiling alerted the staff of the activated call lights. 24. Observation and interview on 6/30/26 at 3:05 p.m. of resident 155's call light with activity assistant II revealed that she turned on resident 155's call light and was waiting for the staff to transfer resident 155 to her wheelchair. Activity assistant II would then take resident 155 to an activity. Activity assistant II indicated that both CNAs that were assigned to resident 155's hallway were in resident 14's room. 25. Observation on 6/30/26 at 3:06 p.m. in resident 14's room revealed that certified medication aide (CMA) KK and CNA LL were assisting resident 14 with personal hygiene care. 26. Observation and interview on 6/30/26 at 3:24 p.m. revealed that CMA KK answered resident 155's call light. Activity assistant II reported she had to wait almost every day for a long time for staff to transfer a resident for her so she could take them to the activity, and stated, Now the activity is over. There was a teaching cooking activity in the main dining room that resident 155 missed. She said she turned resident 155's call light on about five to seven minutes before talking to her on 6/30/26 at 3:05 p.m. 27. Interview on 6/30/26 at 3:27 p.m. with CNA LL and CMA KK revealed CNA LL started working at the facility in March 2026 and CMA KK started in November 2025. Resident 14 required two staff members to assist her with part of her care. Her morning care could take up to three hours, and her afternoon care took about an hour. Two staff members would be in her room for about 30 to 45 minutes. CNA LL and CMA KK were scheduled to work the 600 hall, and they did not have an extra CNA to help that day. They notified the nurse before going into resident 14's room to help answer call lights. Neither CNA LL or CMA KK had used a radio to communicate with other staff members since they began working at the facility due to there not being enough radios available. 28. Observation and interview on 6/30/26 at 3:40 p.m. with registered nurse (RN) FF and licensed practical nurse (LPN) GG revealed that they were sitting in the nurses' station. RN FF was assigned to work on the 500 hall, and LPN GG was assigned to work on the 600 hall. They did not carry radios and stated that there were two radios in the charging station at the nurses' station, which were usually turned on and would alert them if a call light was activated. They used the monitors hanging in the hallways to alert them if a residents call light was activated, which they could not see from the nurses' station. They verified that CNA LL and CMA KK notified them that they went into resident 14's room. They thought the CNAs on the 500 hall would help watch the 600 hall's call lights since both CNAs were in with resident 14. They used to carry radios, but they either got lost or quit working. When they were in a resident's room, they did not know when another resident's call light was on. They were expected to answer the residents' call lights within the first few minutes or to at least inform the resident that someone was coming to assist them. LPN GG stated that resident 85 had a tracheostomy tube that typically only needed to be suctioned after her nebulizer treatments and did not typically have respiratory problems. Resident 85's tracheostomy tube had fallen out once before and that thankfully the nurse manager was really close and she came back and put one in. The staff does not know what a resident needs when they turn their call light on, and it could be an emergency. 29. Interview on 6/30/26 at 4:10 p.m. with CNA MM and CMA JJ revealed they were working on the 500 hall and were not watching for the call lights on the 600 hall. CNA MM had worked at the facility for three weeks, and CMA JJ had worked at the facility for five days, and was still on orientation. They did not carry a radio or know if they were expected to. They knew when a resident's call light went off because there was a single beep from the monitor in the hallway, and the room number would be displayed on it. If they were in a resident's room, they did not always hear the beep when another resident turned their call light on. 30. Interview on 6/30/26 at 4:15 p.m. with CNA HH revealed he was working the 500 hall. Everyone was supposed to carry the radio, but he did not grab one. When a resident's call light was turned on, the monitor screen in the hallway would make a single beep, and display on the screen. Sometimes the beep could be heard when in a resident's room if the door was not closed. He was not sure if radios were programmed to alert all staff of all call lights or if it was specific to the hallway they were working. The monitor screen on the 500 wing showed call lights for residents on the 500 wing. The monitor screen at the end of the 500 hall and to the 600 hall showed both the 500 and 600 hall call lights. Door alarm alerts went to the radios as well. 31. Interview on 7/1/26 at 8:30 a.m. with CNA D revealed she had worked at the facility since 2019 and worked on the 300 hall. She felt a resident's call light should be answered within three to five minutes. She did not have a radio on her and observed the monitors hanging in the hallways for residents' call lights. 32. Interview on 7/1/26 at 8:38 a.m. with LPN E revealed she had worked for the facility for about two years and worked on the 300 hall. She expected the residents' call lights to be answered within ten minutes in ideal situations. 33. Interviews on 7/1/26 at 10:07 a.m. at the resident council meeting revealed resident 123 stated, there were some wait times for call lights but mostly because there were other residents that needed more help and they would take up more of the staff's time. Call lights have been brought up at resident council, and [the] staff were doing what they could, but it seems like it could take a while to get a call light answered. Resident 89 indicated that she had waited two hours one morning for staff assistance before she took herself to the bathroom. 34. Observation and interview on 7/1/26 at 2:14 p.m. with resident 119 revealed that his call light was on, he was lying in bed, and was using the bedpan. He said his call light had been on for a long time. He was waiting for the staff to help him off the bedpan and then he wanted to go play Bingo. An activity assistant was waiting outside his door to assist him to Bingo. 35. Observation on 7/1/26 at 2:23 p.m. revealed resident 119's call light was answered by CNA HH. 36. Interview on 7/1/26 at 2:30 p.m. with CNA HH revealed he just started his shift at 2:15 p.m. and was working the 500 hall. He was not aware that resident 119 was using the bedpan. CNA LL was working the 500 hall with him. 37. Interview on 7/1/26 at 2:34 p.m. with CNA LL revealed she did not have a radio, and she was not aware resident 199 was on the bedpan. The other CNA just went home after the change of shift. 38. Interview on 7/1/26 at 4:00 p.m. with resident 119 revealed his call light is on for a long period of time, more often than I like. Nothing bad happened when he had to wait for the staff, but it made him feel like he was not important. 39. Review of resident 119's EMR revealed he admitted to the facility on [DATE]. His 6/5/26 BIMS assessment score was 14, which indicated his cognition as intact. He had diagnoses of acquired absence of the right knee, dysphagia, hyperkalemia (elevated potassium [electrolytes]), End Stage Renal Disease (permanent kidney failure), essential hypertension (elevated blood pressure), Major Depressive Disorder, type 2 diabetes (a condition involving disruptions in how the body regulates blood sugar) with hyperglycemia (high blood sugar), and weakness. Resident 119's 6/18/26 care plan indicated he required supervision and touching assistance with repositioning in bed, dressing, and personal hygiene care. He required extensive assistance with using the bathroom. Staff were to offer him the bedpan for using the bathroom. He transferred using the total lift. He had falls on 11/21/25, 12/12/25, and 12/26/25, and the staff was to remind him to use his call light for assistance. 40. Review of resident 119's call light response time report from 5/30/26 to 6/30/26 revealed he had 18 call light response times over 20 minutes long, and 6 call light response times were over 30 minutes long. 41. Interview on 7/1/26 at 2:35 p.m. with CNA N revealed that she felt the resident's call lights should be answered within five to ten minutes. 42. Interview on 7/1/26 at 2:45 p.m. with CNA M revealed that he felt an appropriate time for a resident's call light to be answered was two minutes. 43. Interview on 7/1/26 at 2:58 p.m. with director of nursing (DON) B revealed she expected the resident's call lights to be answered within 20 minutes. She expected the staff to wear radios while working for communication between staff and for notifications of the call lights, and to observe the monitors in the hallways for activated call lights. She was aware of the residents' call light concerns, and educated the staff at every staff meeting to check in with the residents to ensure there were no emergencies, and to let them know the staff will return to assist them. 44. Interview on 7/1/26 at 3:00 p.m. with contract travel RN L revealed that she expected a call light to be answered within two to three minutes. 45. Observation on 7/1/26 at 3:55 p.m. in the 600 hall revealed there was a call light on, it showed on the monitor screen in the 600 hall and on the monitor where halls 600 and 500 met. The call light did not show on the 500 hall monitor screen. 46. Review of the provider's 7/8/25 Call light policy revealed the purpose was To ensure residents always have a method of calling for assistance. To promptly answer resident's call light.

Based on the observation, interview, and record review, the provider failed to ensure medications were securely stored in three of ten observed medication carts by registered nurse (RN) V, RN FF, and certified medication aide (CMA) Z. Findings include:1. Observation on 6/30/26 at 2:10 p.m. in the 700 hallway outside of resident 75's room revealed there was an opened bottle of liquid Amoxicillin-Pot Clavulanate Oral Suspension (an antibiotic) for resident 181 on top of the medication cart. There were no staff members present. 2. Observation on 6/30/26 from 2:10 p.m. to 2:13 p.m. revealed that CMA X, activities assistant W, and two unidentified visitors walked past the medication cart that had the open bottle of resident 181's unsecured antibiotic medication on top of it. 3. Observation and interview on 6/30/26 at 2:13 p.m. with clinical care leader (CCL) S revealed that she removed the bottle of antibiotic medication from the top of the medication cart and was going to return the medication to the refrigerator. RN V was the nurse assigned to that medication cart, and CCL S was unsure how long the antibiotic medication was left on top of the medication cart. CCL S expected RN V to have returned the antibiotic medication to the refrigerator or taken it with her when she left the medication cart. 4. Interview on 6/30/26 at 2:15 p.m. with CMA X revealed that she was not administering any medications that day and was not aware that there was an antibiotic medication left on top of the medication cart when she had walked past that medication cart earlier. 5. Interview on 6/30/26 at 2:27 p.m. with registered nurse RN V when she returned to the medication cart revealed she acknowledged that she had left resident 181's antibiotic medication on top of the medication cart and forgot to return the antibiotic medication to the refrigerator. She wondered where it went and was unaware that CCL S had returned that medication to the refrigerator. 6. Review of resident 181's electronic medical record (EMR) revealed she had a 6/30/26 physician's order for Amoxicillin-Pot Clavulanate Oral Suspension. Reconstituted 400-57 MG[milligrams]/5ML[milliliter] (Amoxicillin & Pot Clavulanate) Give 6.2 ml via [by] NG-Tube [nasogastric tube] two times a day for Acute cystitis without hematuria [a bladder infection without blood in the urine]. 7. Observation on 7/1/26 at 8:21 a.m. of RN FF preparing medications for resident 47 revealed that there was a bottle of Fluticasone nasal spray for resident 89 on top of the medication cart. RN FF prepared resident 47's medications, which included pills and a bottle of Polyethylene Glycol (a laxative). She locked the medication cart, left the bottle of Polyethylene Glycol and the Fluticasone nasal spray sitting on top of the medication cart, walked into the dining room, gave resident 47 her medications, and walked back to the medication cart that was in the hallway. 8. Observation on 7/1/26 at 8:39 a.m. of RN FF preparing medications for resident 150 revealed she prepared the medications, locked the medication cart, left the bottle of Polyethylene Glycol and Fluticasone nasal spray on top of the medication cart, walked into the dining room, gave resident 150 her medications, and walked back to the medication cart that was in the hallway. 9. Interview on 7/1/26 at 8:40 a.m. with RN FF revealed that she left the Fluticasone nasal spray on top of the medication cart so she would not forget to administer it to resident 89, who was eating. RN FF stated, It is not a medication. She was not supposed to leave the Polyethylene Glycol bottle on her medication cart unsecured. 10. Observation and interview on 7/2/26 at 8:43 a.m. in the 200 hallway with RN/clinical nurse leader I and CMA Z revealed an unlocked medication cart with no medication aide or nurse attending it. The medication cart drawers were easily opened. RN/clinical nurse leader I witnessed the medication cart being unlocked and agreed that the medication cart should have been locked while unattended. CMA Z returned to the medication cart and reported that she thought she had locked the medication cart. She agreed that the medication cart should have been locked while it was unattended. 11. Interview on 7/2/26 at 10:00 a.m. with director of nursing (DON) B revealed that she expected medications to be locked in the medication cart and not left on the medication carts unattended, so residents would not be able to have access to them. She expected medications that needed to be refrigerated to be placed back in the refrigerator after they were used. She stated, There are confused residents everywhere. 12. Review of the provider's 3/30/26 Medications: Acquisition Receiving Dispensing and Storage policy revealed that medications will be stored in a locked medication cart, drawer or cupboard. All medications will be stored in accordance with manufacturers' recommendations.

Based on interview, record review, observation, and policy review, the provider failed to protect the resident's rights to dignity and respect for one of thirty one sampled residents (145) who was told by registered nurse (RN) (QQ) to 'stop talking' when asking her about his medications.Findings include:1. Observation on 7/1/26 at 8:44 a.m. of resident 145 sitting in his wheelchair in the hallway talking to RN QQ revealed he asked RN QQ, What time should I be getting my meds [medications]? RN QQ replied, They are at 8:00 a.m., but I am behind today. Resident 145 said, Well, I want to know what I get and when I get them. RN QQ said, I'm behind, and this isn't the time, so stop talking. Resident 145 then sat in his wheelchair in the hallway and waited until RN QQ gave him his morning medications at 8:50 a.m.2. Review of resident 145's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 6/3/26 brief interview for mental status (BIMS) assessment score was 12, which indicated his cognition was moderately impaired.His diagnoses included dependent personality disorder (a long-lasting mental health condition where a person has an excessive need to be taken care of and relies heavily on others for emotional and physical support), anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), obsessive-compulsive disorder (a chronic mental health condition where a person has unwanted, repeated thoughts (obsessions) and feels driven to perform repetitive actions or mental rituals (compulsions) to ease the distress), malignant neoplasm of the brain (is a harmful tumor made of cancer cells that grow and spread inside the brain), schizoaffective disorder (a serious mental illness with symptoms of impaired reality perception, mood swings, disorganized thinking, and altered behavior), and bipolar type.His undated care plan indicated he had impaired thought processes related to his mental illnesses and a history of brain cancer. The care plan's interventions directed the staff to use communication techniques that enhance interactions, allow for adequate time for him to respond, repeat as necessary, do not rush, and request feedback clarification from him to ensure his understanding. The staff were to face him when they were speaking to him, make eye contact, and to explain all procedures, treatments, and medications.4. Interview on 7/1/26 at 2:45 p.m. with certified nursing assistant (CNA) M revealed that dignity was treating the residents with respect, giving them options to help them live comfortably, listening to their concerns, and treating them fairly. If the staff were busy, they needed to find the time to ensure they did not rush the residents. Rushing made mistakes happen.5. Interview on 7/1/26 at 4:06 p.m. with RN QQ revealed that dignity meant giving respect, comfort, and privacy to the residents. Treat them as you would like to be treated. She did not consider the staff telling a resident to stop talking to be treating them with dignity.6. Interview on 7/2/26 at 9:11 a.m. with the director of nursing (DON) B revealed that treating a resident with dignity meant respecting everything about them, as the facility was their home. If the resident asked for something, the staff should get it or educate the resident about their request. Telling a resident to stop talking was not treating them with dignity.7. Interview on 7/2/26 at 9:25 a.m. with administrator A revealed that she would refer to the facility's dignity policy to determine what the dignity expectations were. She did not consider telling a resident to stop talking to be treating them with dignity.8. Review of the provider's reviewed 12/18/25 resident dignity policy revealed the location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The interdisciplinary team will assist all staff members in maintaining the dignity of every resident.

Based on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure that one of one licensed practical nurse (LPN) (K) performed hand hygiene (washing hands with soap and water or using hand sanitizer) when she assisted four of four sampled residents (23, 51, 147, and 161) to eat the evening meal, and that one of one cook (P) wore a hairnet over his beard while preparing food in the main kitchen.Findings include:1. Observation on 6/29/26 from 5:21 p.m. to 5:31 p.m. in the 400-hall dining room revealed LPN K did not perform hand hygiene before she assisted residents 23, 51, 147, and 161 at the supper table with their food. She placed a spoon in resident 23's hand, touched his leg and shoulder, and added the pudding onto his plate from the container. At 5:25 p.m., LPN K handed resident 161 her silverware and bowls to begin eating. At 5:27 p.m., LPN K assisted resident 51 and fed her a spoonful of food. At 5:29 p.m., LPN K assisted resident 147 with his supper. She touched resident 147's clothing protector, wheelchair, and his thumb that was in his mouth, before she used his fork to give him a bite of food. At 5:31 p.m., LPN K picked up resident 51's silverware and helped her take another bite of food. LPN K then touched the top of the cranberry juice glass to give resident 51 a drink. LPN K went back to resident 147 and continued using his fork to give him bites of food. 2. Interview on 7/1/26 at 4:06 p.m. with RN QQ revealed that expected hand hygiene to be completed in between helping residents eat their food. 3. Observation on 7/1/26 at 10:00 a.m. of cook P in the main kitchen revealed that he was preparing raw chicken and did not have a hairnet covering his beard. 4. Interview on 7/1/26 at 10:50 a.m. with cook P revealed that he was not wearing a hairnet over his beard and he should have been. He usually had his beard covered while he prepared food and that he had made a mistake. 5. Observation on 7/1/26 at 12:40 p.m. of cook P at a food preparation table in the kitchen revealed he was preparing food without a hairnet covering his beard. 6. Interview on 7/1/26 at 12:42 p.m. with systems chef O revealed that he expected the staff with beards to have them covered with a hairnet anytime they were preparing food. 7. Interview on 7/2/26 at 8:46 a.m. with infection preventionist (IP) C revealed that she expected the staff to perform hand hygiene in between assisting residents to eat in the dining room. 8. Observation on 7/2/26 at 9:35 a.m. outside of the kitchen entry door revealed there was a bin with bold lettering indicating HAIRNETS and a sign on the door that stated, HAIR RESTRAINT[S] ARE REQUIRED AT ALL TIMES IN THE KITCHEN. 9. Review of the provider's 6/10/26 Employee Hygiene and Dress Code- Food and Nutrition Services revealed a purpose of To promote a professional appearance, safety, and sanitation. The section regarding hairnets stated 1. Hairnets or hair restraints and beard nets or beard restraints are used: a. When cooking, preparing, assembling food or ingredients. This includes dish room and storage areas. 10. Review of the provider's 6/8/26 reviewed hand hygiene policy revealed the purpose is to prevent the spread of infection to residents/patients/clients, employees, and visitors through hand hygiene practices.

Based on observation, interview, and policy review, the provider failed to ensure the staff followed infection prevention and control practices by one of one certified medication aid (CMA) (KK) and one of one certified nursing assistant (LL) who did not wear a gown or perform hand hygiene (wash hands with soap and water or sanitize hands) while providing care to one of one sampled resident (14) on enhanced barrier precautions (EBP) (glove and gown use when providing contact care). Findings Include: 1. Observation on 6/30/26 at 3:06 p.m. in resident 14's room revealed she had a magnet on her door frame that indicated she required EBP. When the surveyor went into her room, CNA LL and CMA KK had gloves on, did not have gowns on, and were providing care to resident 14. Resident 14 was lying partially on her left side, and her nephrostomy tube (a flexible tube surgically inserted into the kidney to drain urine) was clipped and hanging on the right side of the bed. CNA LL and CMA KK placed an incontinence (involuntary urine or bowel leakage) brief under resident 14. CNA LL removed her gloves, discarded them in the trash can, did not perform hand hygiene, put on a clean pair of gloves, and assisted CMA KK with repositioning resident 14 and situating her pillows to her comfort. CMA KK removed her gloves, discarded them in the trash can, did not perform hand hygiene, situated the resident's bedside table, handed resident 14 her tablet and phone, and brushed resident 14's hair. CMA KK put on a clean pair of gloves, grabbed the garbage bag from the trash can and the bag of used linens, and left the residents' room. CMA KK placed the bag of garbage and dirty linens in the dirty utility room, removed her gloves, discarded them in the trash can, and sanitized her hands. 2. Interview on 6/30/26 at 3:27 p.m. with CMA KK and CNA LL revealed that with residents who were on EBP, the staff needed to wear a gown when completing perineal (private area between the legs) care, and not when they repositioned the resident. They verified they did not wear gowns when completing perineal care for resident 14 and they should have. They did not perform hand hygiene every time they removed their gloves in resident 14's room. They were supposed to perform hand hygiene before and after resident personal care, when they removed their gloves, and before putting on a new pair of gloves. 3. Review of resident 14's electronic medical record (EMR) revealed she admitted to the facility 10/27/25. Her 5/5/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. Her diagnoses included calculus of the kidney with calculus of the ureter (kidney stones), and quadriplegia (the partial or total paralysis of all four limbs and torso). Resident 14's 6/30/26 care plan indicated she was on EBP and the staff were to don [put on] gown and gloves when performing high contact care activities including: dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing [her incontinence brief], device care and/or use, and wound care. She had a right-sided nephrostomy tube due to a history of kidney stones. She required two staff members to reposition her in bed, assist her with dressing, and personal hygiene, and to transfer her with a total body lift (a mechanical lift and sling used to lift a person's full body). 4. Interview on 7/2/26 at 10:00 a.m. with director of nursing (DON) B revealed she expected the staff to wear gowns and gloves during all high-contact resident care for residents who were on EBP, which was indicated on the magnet on the resident's door frame. 5. Review of the provider's 4/30/26 Standard, Enhanced Barrier, and Transmission-Based Precautions policy revealed that the purpose of the policy was to prevent the spread of infection and communicable diseases to residents/patients, employees, and visitors through infection prevention and control practices. EBP. refer to the use of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. EBP is used for residents with indwelling medical devices. High-contact resident care activities include transfers, dressing, assisting during bathing, providing hygiene, changing briefs or assisting with toileting,.changing linens, indwelling medical device care or use., and wound care. 6. Review of the provider's 11/13/25 Hand Hygiene policy revealed that the purpose of the policy was to establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settings. The staff were to perform hand hygiene before going into a resident's room, before performing a clean task, after removing their gloves, and when leaving the room.

Based on observation, interview, record review, and policy review, the provider failed to ensure the safety and prevention for potential entrapment or injury for 16 residents (5, 18, 19, 47, 67, 72, 83, 97, 99, 103, 108, 112, 126, 137, and 356) who had side rails on their bed and 10 other residents (5, 17, 22, 73, 83, 103, 106, 123, 137, and 453) who had a risk for entrapment related to their mattresses and headboards or footboards. Concerns were identified with: *The safety of the side rails related to their installation, ongoing maintenance, and risk for entrapment. *Documentation for consents for side rail use, alternatives that had been attempted, and education regarding the risk and benefits of side rails. *The safety of mattresses and the potential for entrapment between the headboard and footboard or the gaps within the footboard. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy of F700 was given verbally and in writing on 4/16/25 at 4:21 p.m. to administrator A regarding: *The provider failed to ensure bedrails were securely attached, mattresses were able to be elevated when the side rail(s)/grab bar(s) were moved, and there were gaps greater than five inches between the end of the mattress and the headboard. These identified concerns were related to the bedrail installation, maintenance, and bed zone safety and entrapment assessments. -Observations made throughout the survey and throughout the entire building on 4/16/25 revealed the following: *In residents 18, 47, 67, 97, 108, and 126s' rooms the side rails/grab bars were not securely attached to the bedframe, that created a risk for entrapment and the potential for injury. *In residents 5, 18, 47, 72, 83, 89, 97, 99, and 112s' rooms the side rails/grab bars were not securely attached to the bed frame, and the mattress on those beds were able to be elevated when the side rails/grab bars were moved, that created a risk for entrapment zone and the potential for injury *In residents 5, 22, 73, 83, 89, 106, and 137s' rooms there were gaps greater than five inches between the end of the mattress and the headboard, that created a risk for potential entrapment and injury. *In residents 86, 100, 122, 133, and 148s' rooms there were a bed rail particle board frames in place under the mattresses. There were no bed rails attached. There were two exposed metal installation holes, where the bed rails would attach, that created a risk for potential injury. *Resident 356 was using side rails and did not have a Physical Device and/or Restraint Evaluation and Review assessment completed. *Other residents who had side rails had not been accurately or fully assessed for the use of side rails *The style of bed rail used with the Hill-Rom spring bed frames was not compatible according to the manufacturer's instructions. *Resident 103's bed rail was broken and not secured to the spring bed frame. When weight was applied to the bed rail as if a resident were to use it for mobility and stability, the bed rail buckled backwards potentially creating a fall hazard. The particleboard grab bar frame was broken in one corner creating potential for injury. *The above concerns had the potential to cause serious harm, injury, impairment or death for residents. *A plan for the removal of the immediacy was requested at that time. IMMEDIATE JEOPARDY REMOVAL PLAN On 4/16/25 at 8:39 p.m. the provider submitted the following immediate jeopardy removal plan for review: *A comprehensive assist bar audit has been completed for the 26 of 159 residents. The 26 residents have been corrected on 4/16/2025 as follows: -Assist bars were removed from the beds of residents 5,18, 47, 67,72, 83, 86, 89, 97, 99, 100, 103, 112, 122, 126, 133, and 148. -The bed footboard was removed from resident 453's bed and the family was notified. -Resident 108's bed was replaced as the resident wished to keep the assist bars. -The footplate to hold the mattress in place to prevent gaps of greater than four inches in resident 5, 22, 73, 83, 99, 106, and 137s' rooms were put into place. -A physical device evaluation was completed on 4/7/2025 and updated on 4/16/25 for resident 356. --The residents who had their assist bars removed, resident was educated-family was called and educated for residents with a BIMs score of under 13 or those who could not comprehend education. *Identification of others: -An audit of all grab bars and mattresses in the facility was completed as of 4/16/2025 in order to identify residents at risk for similar deficient practice. Resident was educated if assist bar needed to be removed from their bed-family was called and educated for residents with BIMs score of under 13 or those who could not comprehend education. During the audit, bed rails that were identified as noncompliant were replaced or removed. Care plan and physical device assessment updated as appropriate. *Process/Systemic Changes to Prevent Recurrence: -1. The facility is currently in compliance with the 'Bed Safety and Side Rail Entrapment Resource Packet' which is an internal [corporate] policy. -2. Physical Device Assessments listed in the policy titles 'Restraints Policy' will be completed on April 16th, 2025. -3. During the daily nurse clinical meeting, the team will review and evaluate all new residents to ensure that a comprehensive physical device assessment has been completed in accordance with the Restraint Policy. -4. The Maintenance Supervisor or designee will complete a preventative maintenance task 'Bed Inspection, Testing and Maintenance' [corporate] audit monthly. Maintenance staff were educated task audit on 4/16/25. *Education and Training: -An On-Shift message was sent to all employees' personal phones educating on entrapment and potential entrapment hazards on April 16 at 5:28 p.m. -Education will be provided by a Clinical Learning and Development Specialist or Designee to all staff by April 16, 2025 or prior to their next shift. All staff members not currently on the schedule will receive education prior to their next shift. This training will cover entrapment risk, immediate interventions to address entrapment, and the appropriate personnel to notify if a resident is identified as being at risk. *Monitoring: -Comprehensive audits will be conducted by Quality RN or Designee on resident assist bars weekly x4 [times four] weeks, then biweekly x2 [times two] for two months. Findings will be presented to the Quality Assurance Performance Improvement Committee for review. -Audits will be conducted by Maintenance Supervisor or designee on mattress gaps to ensure compliance weekly. The schedule includes x4 for Four weeks, then bi-weekly x2 for two months. Findings will be presented at the QAPI for review. *Completion Date: -Please consider this IJ removal plan as the facility action to address the immediate concerns of noncompliance. This plan will be implemented and completed on April 16, 2025. The IJ removal plan was accepted on 4/16/25 at 10:18 p.m. The immediate jeopardy was removed on 4/16/25 at 11:15 p.m. after the survey team verified on site on 4/17/25 at 8:45 a.m. that the provider had implemented their removal plan through observation, document review, and staff interviews. After the removal of the immediate jeopardy, the scope and severity of the non-compliance remained an E. Current census was 159 residents. 2. Observation on 4/14/25 at 3:17 p.m. of resident 103's room revealed she had a white metal grab bar on the left side of her bed. Observation on 4/16/25 at 9:57 a.m. of resident 103's grab bars on her bed: *When the left grab bar was pulled away from the bed, it lifted the mattress and separated from the mattress approximately 45 degrees. *Under the mattress the grab bar was attached to a piece of particleboard with a corner broken off. *There were four securement locations, two near the frame of the bed and two over the bed springs. *Neither the grab bars nor the particleboard was secured to the bed frame or the bed springs. Interview on 4/16/25 at 10:11 a.m. with registered nurse (RN) T regarding resident 103 revealed: *She did not use her grab bar. *She was super stiff and difficult to roll in bed and required staff assistance with bed mobility. Review of resident 103's 2/23/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The assessment had a comment that indicated Resident is able to use grab bar appropriately. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 3. Observation on 4/14/25 at 3:33 p.m. of resident 99's room revealed there were white metal grab bars on both sides of her bed. Observation and interview on 4/16/25 at 10:26 a.m. with resident 99 in her room revealed: *The grab bars on both sides of the bed lifted the mattress when pulled on. *Resident 99 stated she used the grab bars for repositioning herself when in bed. Review of resident 99's 3/3/25 Physical Device and/or Restraint Evaluation and Review revealed: *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 4. Observation on 4/14/25 at 3:37 p.m. of resident 89's room revealed she had white metal grab bars on both sides of her bed. Observation on 4/16/25 at 10:20 a.m. of resident 89's bed revealed: *The right grab bar moved freely when pulled on. -It was not secured to the springs of the bed. *The left grab bar was loose when it was pulled on. Review of resident 89's 2/27/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 5. Observation on 4/14/25 at 3:42 p.m. of resident 112's room revealed she had a white metal grab bars on the right side of her bed. Observation on 4/16/25 at 11:00 a.m. of resident 112's grab bar revealed it was loose and lifted the mattress when it was pulled on. Review of resident 112's 2/11/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 6. Observation and interview on 4/16/25 at 9:58 a.m. with resident 19 in her room revealed: *She had a white metal grab bar on the left side of her bed. *The grab bar was loose and pulled the mattress up from the bed when pulled on. *Resident 19 stated that the mattress pulls up even when she is sitting on the edge of the bed and pulls on the grab bar. Review of resident 19's 1/21/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Alternatives that have been attempted did not have any documented alternatives. 7. Observation and interview on 4/16/25 at 10:06 a.m. with resident 47 in her room revealed: *She had a white metal grab bar on the left side of her bed. *There was movement of the grab bar from side to side and up and down when testing it. *Resident 47 was unsure if she used her grab bar in bed or for transfers. Review of resident 47's 3/20/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 8. Observation and interview on 4/16/25 at 10:09 a.m. with resident 97 in her room revealed: *She had bilateral white metal grab bars on her bed. *When the grab bars were pulled in the mattress was lifted from the bed frame. *Resident 97 stated she used her grab bars while she was in bed, and she felt they were loose when she pulled on them. Review of resident 97's 3/4/25 Physical Device and/or Restraint Evaluation and Review revealed: *The Alternatives that have been attempted did not have any documented alternatives. *Documented education related to the grab bars was given to staff. 9. Observation on 4/16/25 at 10:15 a.m. of resident 126's bed revealed: *She had a white metal grab bar on the left side of her bed. *The grab bar was not secured to the bed frame. Review of resident 126's 1/28/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 10. Observation and interview on 4/16/25 at 10:18 a.m. with resident 18 in his room revealed: *He had a white metal grab bar on the left side of his bed. *The grab bar lifted the mattress when it was pulled on. *Resident 18 stated he used the grab bar for repositioning while he was in bed. Review of resident 18's 3/12/25 Physical Device and/or Restraint Evaluation and Review revealed: *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 11. Observation and interview on 4/16/25 at 10:22 a.m. with resident 108 in his room revealed: *He is lying in bed, leaning with most of his body weight on his left grab bar. *He stated he used the grab bar for repositioning in bed and he had noticed that it did get loose at times. Review of resident 108's 4/10/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 12. Observation on 4/16/25 at 10:53 a.m. of resident 67's bed revealed: *He had a white metal grab bar on the right side of his bed. *The grab bar moved slightly when shaken. *The grab bar lifted the mattress when it was pulled on. Review of resident 67's 3/3/25 Physical Device and/or Restraint Evaluation and Review revealed: *The Alternatives that have been attempted did not have any documented alternatives. *The education documented was given to staff. 13. Observation on 4/16/25 at 10:56 a.m. of resident 5's bed revealed: *He had white metal side rails on both sides of his bed. *The right grab bar was loose when it was pulled on. Review of resident 5's 3/17/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 14. Observation and interview on 4/16/25 at 11:10 a.m. with resident 137 in her room revealed: *She had a white metal grab bar on the left side of her bed. *The grab bar was able to be moved in all directions when pulled on. *Resident 137 stated she used her grab bar to get out of bed. *She was aware her grab bar was loose and indicated she would have tightened it if she had a screwdriver. Review of resident 137's 4/7/25 Physical Device and/or Restraint Evaluation and Review revealed: *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 15. Observation on 4/16/25 at 11:17 a.m. of resident 83's bed revealed: *She had a white metal grab bar on the left side of her bed. *The grab bar was loose when it was pulled on. Review of resident 83's 3/17/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 16. Observation and interview on 4/16/25 at 11:20 a.m. with resident 72 in her room revealed: *She had a white metal grab bar on the right side of her bed. *The grab bar lifted the mattress when it was pulled on. *Resident 72 stated she knew the grab bar was loose but had not thought to ask for someone to tighten it. Review of resident 72's 3/22/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. 17. Observation and interview on 4/16/25 at 11:28 a.m. with resident 356 in her room revealed: *Her bed had bilateral tall, white, metal bed rails. *She was currently in bed and was not feeling well. *She used the bed rails to reposition herself when she wanted to sit on the edge of the bed. *She used the right side more than the left. *A wooden platform was visible under the mattress and it appeared to be how the bed rail was attached to the bed. -We were unable to view the attachment as the resident was in bed. Observation and interview on 4/17/25 at 8:22 a.m. with resident 356 in her room revealed: *She indicated she used the right bed rail more than the left. *The right bed rail was loose and moved a couple of inches towards the top of the bed and a couple of inches towards the bottom of the bed. -It was attached to a wooden platform that was attached to the bed. *The left bed rail was significantly loose and could be lifted several inches off the bed. -It appeared to be anchored in only one of three available places. Review of resident 356's 4/7/25 Physical Device and/or Restraint Evaluation and Review revealed: *The consent for the grab bar was indicated as being given by the resident's physician. *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.) had not been addressed. *The Alternatives that have been attempted did not have any documented alternatives. *There was no documentation of education provided related to the grab bars. Observation on 4/17/25 at 8:33 a.m. with administrator A of resident 356's bed rails revealed. *Administrator A confirmed that the right bed rail was loose and that the left bed rail could be lifted off the bed. *Administrator A stated that the bed rails would be repaired immediately and confirmed that resident 356 would not be allowed to use the bed until it was fixed to ensure her safety. 18. Observations, interviews, and record reviews during the survey identified residents (5, 17, 22, 73, 83, 103, 106, 123, 137, and 453) had concerns with potential entrapment areas on their beds related to the mattresses and the headboard or footboards. Refer to F689, finding 2. 19. Interview on 4/16/25 at 10:43 a.m. with certified nursing assistant (CNA) PP regarding grab bars and side rails on residents' beds revealed: *She had not seen or heard about any issues related to grab bars. *She did not feel resident 103's significant movement of her grab bar was an issue because a resident could have used it to pull themselves up in bed. 20. Interview on 4/16/25 at 11:55 p.m. with administrator B revealed: *Monitoring of the beds was completed monthly with a check mark task by the maintenance staff. *Not all the monitoring was documented in the TELS computerized system. *He was trying to locate more documentation of the beds having been monitored. 21. Interview on 4/16/25 at 12:06 p.m. with administrator A revealed: *A facility-wide assessment of the beds was completed on 2/6/25 and all repairs were completed by maintenance on 2/10/25. *The checklists in the computerized system were not specific to each bed. 22. Interview on 4/16/25 at 12:38 p.m. with administrator B revealed: *Most resident beds that were not in the rehab wing of the building were Hill-Rom beds. *Some of the Hill-Rom beds had pre-installed side rails while others had not. *The Hill-Rom beds that did not have pre-installed grab bars had to have the side rails/grab bars ordered separately by the facility. *Some of the grab bars ordered came from a contracted vendor. *Administrator B did not know if the grab bars ordered from the contracted vendor were manufacturer approved and safe for use for those beds. 23. Interview on 4/16/25 at 3:03 p.m. with registered nurse (RN)/Minimum Data Set (MDS) nurses D and E revealed: *The process for the application of a side rail and grab bars for resident's beds included: -On admission the entrapment evaluation was to be completed, the family would sign a consent and a physician's order for the grab bars would be obtained. -If staff or the resident felt the resident would benefit from a grab bar, the nurse manager would be notified. -If the resident was receiving therapy services, the therapists would be consulted regarding the benefit of the resident getting a grab bar on their bed. -If it was determined the grab bar would be beneficial for the resident, a maintenance work request was to be entered into the electronic maintenance management system (TELS), and the maintenance staff would install the grab bars on the resident's bed. *An entrapment evaluation was to be completed on admission. *The Physical Device and/or Restraint Evaluation and Review was to be completed quarterly, annually, and with a significant change by the MDS nurse. *When the MDS nurse completed the resident's Physical Device and/or Restraint Evaluation and Review assessment they would interview a staff nurse to determine if the resident was using the grab bars. *When asked about education provided as indicated on the Physical Device and/or Restraint Evaluation Review they stated staff were provided education regarding the use of the grab bars or the resident was educated, if the resident was able to understand the education. *If a staff member noticed a loose grab bar a maintenance work order should have been entered for that to be repaired. *Maintenance was responsible for the installation, maintenance, and removal of the grab bars/side rails to ensure resident's safety. 24. Interview on 4/16/25 at 3:41 p.m. with DON R revealed: *The entrapment assessment was completed on the resident's Physical Device and/or Restraint Evaluation and Review. *The MDS nurse would have indicated in the comment box of the Physical Device and/or Restraint Evaluation and Review if they felt the grab bar was an entrapment risk. *There was no formal process for assessing entrapment risks. 25. Interview on 4/16/25 at 4:05 p.m. with administrator B and DON R revealed: *There was no formal process to assess entrapment risk. *Measurements of bed zones was not a portion of the assessment process when grab bars were installed. *Therapy had not assessed all residents' beds or the residents' ability for use related to grab bars to ensure their safety. 26. Review of the provider's resident admission packet revealed: *There was a prefilled consent form for Grab bars on bed. *The consent indicated that prior to the instillation of grab bars the facility must have attempted to use alternatives. *If the alternative interventions attempted were not effective the resident would be assessed for the use of grab bars. -The determination includes a review of risk, including entrapment. The location must ensure the bed is appropriate for the resident and that bed rails [grab bars] are properly installed and maintained. 27. Interview on 4/23/25 at 3:19 p.m. with Social Service Supervisor J regarding resident admissions revealed: *The social services staff completed the admission paperwork with the family or the resident upon the resident's admission. *The consent for the grab bar was in the admission paperwork and was to be presented to all families as an option available to help residents reposition themselves in bed. *The social service staff were to explain to the families the risk of entrapment as well as the other risks identified on the consent form. *The consent form would be readdressed if there was a change in the resident's bed or if there was a request from staff, family, or the resident for a grab bar and there was no consent already on file. *The consent having been completed on admission did not allow for alternative interventions to be attempted prior to determine if there was a need for the grab bar. 28. Interview on 4/23/25 at 4:17 p.m. with DON R revealed: *She agreed with the grab bar consent being completed on admission, there was a potential that no alternatives would have been attempted prior to the application of the grab bar on the resident's bed. *She indicated that often the alternatives would be initiated simultaneously with the application of the grab bar. 29. Review of the January 2010 USER MANUAL for the Resident LTC [long term care] Bed from Hill-Rom revealed: *Use only Hill-Rom parts and accessories. *Do not make modifications to the bed without authorization from Hill-Rom. *Evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could cause serious injury or death. Review of the July 2018 The Transfer Handle For Spring Style Hospital Beds manufacturer's information revealed: *The Transfer Handle [grab bar] is designed to accommodate a range of different manufacturers. If the device does not easily attach to the bed per the instructions or interferes with the sub-frame, or the mattress does not firmly make contact with the Transfer Handle-DO NOT USE. *These guidelines were developed by the FDA [Food and Drug Administration] for Bed Rails to help prevent entrapment. It is important information to be aware of. 30. Review of the provider's 2/2/24 Bed Safety and Side Rail Entrapment Resource Packet revealed: *A resident's bed should be a place of comfort and relaxation, a safe place. When the bed system does not fit correctly and the resident becomes trapped or injured, the resident's bed is no longer a safe place. *Grab bars or assist bars provide a sturdy and secure handhold to assist residents in repositioning and getting in and out of bed. *Conditions such as agitation, delirium, pain, confusion, incontinence, or uncontrolled body movements can cause the resident to be more active in bed or attempt to get out of bed. The proper sizing of the mattress, the fit and integrity of the bed rail or other design elements such as wide spaces between the bars in the rail can also increase the risk for resident entrapment, injury and in some instances death. *The purpose of the Bed Safety-Including Bed Rails/Side Rails/Assist Bars P&P [policy and procedure] is to: promote bed safety with the appropriate use of bed rails when used for medical necessity to reduce the risk of entrapment as well as the least restrictive alternative to side rails. *It is important to remember that not all rails and mattresses fit all bed frames. *Inspect the bed system for: -Proper installation of side rails or assistive devices such as grab bars. -Rails or assistive devices designed for the bed frame manufacturer. -Rails or assistive devices that meet the design elements of bed safety standards to avoid entrapment injuries or death.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of one sampled resident (112) who used a recliner was evaluated for potential safety risks. *Assess for entrapment of mattresses that were on nine of 159 residents (5, 17, 22, 73, 83, 103, 106, 123, 137) beds. *Foot board railing was assessed for risk of entrapment for one of one sampled resident (453). *Safe, secure storage of chemical in two of two sampled residents rooms (55 and 103). Findings include: 1. Observation on 4/14/25 at 3:42 p.m. of resident 112 in her room revealed she was sitting in her recliner with her feet elevated. Observation and interview on 4/15/25 at 10:43 p.m. with resident 112 in her room revealed: *She was sitting in her electric recliner with her feet elevated and her eyes closed. *She had a pillow under her feet in addition to having the footrest elevated that the chair completely reclined. *She began speaking but kept her eyes closed. *When she was asked if she was able to lower the footrest of the recliner, she stated she thought she could but when she attempted to demonstrate this, she indicated she did not know how. Interview on 4/16/25 at 3:03 p.m. with registered nurses (RN)/Minimum Data Set (MDS) nurses D and E revealed: *The Physical Device and/or Restraint Evaluation and Review assessment was competed quarterly, annually, and with a significant change. *If a resident was not able to use an electric recliner the resident's family or staff would use the controls to adjust the chair position. *If the staff placed the resident in the recliner and the resident was unable to use the recliner controls, they would expect staff to check on the resident frequently. *They indicated that if a resident was placed in a recliner, the resident's feet were elevated, and the resident was unable to operate the recliner this could be considered a restraint. Interview on 4/17/25 at 10:34 a.m. with certified nursing assistant (CNA) LL regarding resident 112 revealed: *Staff did not assist resident 112 into her recliner often because she would try to slide herself out of the recliner. *Resident 112 was unable to operate the controls of her electric recliner. Review of resident 112 electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) assessment score was 0, which indicated she rarely understands or is understood. *Her diagnoses included history of falling, generalized muscle weakness, cognitive communication deficit, and Alzheimer's disease. *She had nine falls from her recliner documented between 7/13/24 and 11/24/24. *Her care plan had a focus areas of: -The resident has impaired cognitive function R/T [related to] Alzheimer's/dementia E/B [evidence by]] significant memory loss, family assists with decision making, disorganized thoughts at times, poor safety awareness, impulsive. -The resident has had an actual fall with No Injury, R/T self-transfer E/B slid out of chair that was initiated on 7/15/24. *She required assistance from staff for all her activities of daily living. *Resident 112's care plan did not address the use of the recliner/lift chair. *She had a 2/11/25 Physical Device and/or Restraint Evaluation and Review assessment that addressed her recliner/lift chair. -The assessment indicated Staff and resident use recliner as an alternative seating option. Staff uses [the] controls to assist in repositioning. Staff anticipate resident's needs while in [the] recliner. -The assessment did not include: --Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcomes, etc.). --Alternatives that have been attempted. --General restraint and/or device education provided. Interview on 4/23/25 at 10:16 a.m. with director of nursing (DON) R revealed: *The fall team had not reviewed resident 112's falls from her recliner to determine if her feet were elevated in the recliner at the time of the fall. *DON R stated she had not seen resident 112 in her recliner for months. *She felt resident 112 could operate the controls of the recliner if she wanted to. *It was her expectation if resident 112's feet were elevated in the recliner and she was unable to operate the recliner controls, staff would round on her frequently and if she was anxious staff would take her out of her chair. *She stated there was a potential that the recliner could be viewed as a restraint but resident 112 needed the recliner for pressure off loading to prevent pressure ulcers because resident 112 did not like lying in bed. Observation and interview on 4/23/25 at 4:44 p.m. with licensed practical nurse (LPN) H revealed: *Resident 112 was in her recliner with her legs elevated and a soft touch call light beside her left hip. *LPN H was not aware of any falls from the recliner but did state staff had found her sitting on the footrest of her recliner. *Resident 112 was unable to operate her electric recliner so staff and family would operate the controls for her. *She indicated she was not concerned that the recliner was a restraint because resident 112 was able to scoot herself on to the footrest of the recliner and if she scooted far enough the recliner would tip forward and she could get herself to the floor. Observation and interview on 4/23/25 at 5:21 p.m. in resident 112's room with administrator A and DON R revealed: *Administrator A and DON R were notified of the report by staff that resident 112 has been found sitting on the footrest of the chair and the staff were aware that if resident 112 scooted far enough forward on the footrest the chair would tip forward. *It was demonstrated with resident 112's empty recliner that with pressure applied on the footrest the recliner would tip forward and the footrest would come to rest on the floor. *Administrator A and DON R acknowledged the information but did not offer any further information at this time. Interview on 4/24/25 at 10:29 a.m. with administrator A revealed: *It was her expectation for staff to notify their manager if an area of concern was identified such as a recliner that would tip forward when a resident sat on the footrest. *She did not feel every box of an assessment, such as the Physical Device and/or Restraint Evaluation and Review, needed to be addressed for every single resident. Interview on 4/24/25 at 12:25 p.m. with resident 112's daughter revealed she: *Expressed concern regarding resident 112's recliner having been removed from her room. *Indicated resident 112 had only fallen out of her recliner one time since her admit, nine months ago. *Felt resident 112's dementia had affected her ability to understand that she could no longer stand up and walk. *Stated we don't want her to get out of the chair after the concern for resident 112's safety and the possibility of the recliner being a restraint was described to her. *Felt the recliner was the safest place for resident 112 because there was an alarm to alert staff when resident she moves. 2. Observation on 4/16/25 at 9:57 a.m. of resident 103's bed revealed: *The mattress slid up and down in the bed. *When the mattress was slid to the foot of the bed there was a gap of nine inches between the headboard and the mattress. Observation on 4/16/25 at 10:36 a.m. of resident 123's bed revealed a five-inch gap between the headboard and mattress. Observation on 4/16/25 at 10:56 a.m. of resident 5's bed revealed a six-inch gap between the headboard and the mattress. Observation on 4/16/25 at 11:00 a.m. of resident 22's bed revealed a six-inch gap between the headboard and the mattress. Observation on 4/16/25 at 11:02 a.m. of resident 17's bed revealed a four- and three-quarter inch gap between the headboard and the mattress. Observation on 4/16/25 at 11:10 a.m. of resident 137's bed revealed a seven-and-a-half-inch gap between the headboard and the mattress. Observation on 4/16/25 at 11:17 a.m. of resident 83's bed revealed a seven-and-a-half-inch gap between the headboard and the mattress. Observation on 4/16/25 at 11:22 a.m. of resident 73's bed revealed a five-and-a-half-inch gap between the headboard and the mattress. Observation on 4/16/25 at 11:28 a.m. of resident 106's bed revealed a five-inch gap between the headboard and the mattress. Observation on 4/17/25 at 8:30 a.m. of resident 73's bed revealed: *There was no metal mattress retainer bar on the foot of the bed. *There was a gap measuring five-and-one-quarter inches between the footboard and the mattress. Interview on 4/16/25 at 11:55 p.m. with administrator B revealed: *Monitoring of the beds was completed monthly with a check mark task. *Not all the monitoring was documented in the computerized system. *He was trying o locate more documentation of the beds monitored. Interview on 4/16/25 at 12:06 p.m. with administrator A revealed: *A facility wide assessment of the beds was completed on 2/6/25 and all repairs were completed by maintenance on 2/10/25. *The checklists in the computerized system were not specific to each bed. Interview on 4/16/25 at 3:03 p.m. with registered nurses (RN)/Minimum Data Set (MDS) nurses D and E revealed: *An entrapment evaluation is completed on admission. *Maintenance was responsible to be sure the mattresses fit the beds appropriately. *The Physical Device and/or Restraint Evaluation and Review was completed quarterly, annually, and with a significant change. *Verified there was a location on the Physical Device and/or Restraint Evaluation and Review that addressed Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcomes, etc.). Interview on 4/16/25 at 3:41 p.m. with DON R revealed: *The entrapment assessment was completed on the Physical Device and/or Restraint Evaluation and Review. *There was no formal process or form for assessing entrapment risks. Interview on 4/16/25 at 3:41 p.m. with administrator B revealed: *There was no form or process to assess entrapment risk. *The facility has different sizes of mattresses and beds. *He would expect nurses to complete and assessment to identify if the mattress was the appropriate size for the bed. *He expected staff to notify maintenance if a mattress was identified as being incorrect for the bed or there was an identified gap between the foot or headboard and the mattress staff. -Maintenance was then responsible to resolve the identified issue. Interview on 4/23/25 at 10:45 a.m. with LPN H revealed: *She was not aware if there were any large gaps between the head or foot of the bed and the mattress. *She indicated a large gap between the head or foot of the bed and the mattress could be an entrapment risk. *If she noticed a mattress slid on the bed frame causing a large gap, she would tip up the metal piece at the foot of the bed to hold the mattress in place. *If she was unable to resolve the issue with the mattress, she would notify maintenance. 3. Observation on 4/14/25 at 3:50 p.m. of resident 453's room revealed: *Her room was located in a secured unit for residents diagnosed with memory problems, who had elopement risks or attempts, and exhibited wandering behaviors. *There was a brass footrail on her bed. *The footrail was made up of two horizontal rails and several vertical rails. *The distance between each of the vertical rails was seven and one-fourth inches. Review of resident 453's EMR revealed: *She was admitted on [DATE]. *She had a 4/8/25 BIMS assessment score of 4, which indicated she had severe cognitive impairment. *A progress note indicated the resident's bed had been brought in by her family on 4/10/25. Interview on 4/16/25 at 4:03 p.m. with administrator B and DON R regarding resident 453's bed revealed: *The resident's family had brought her personal bed into the facility. *They were aware the bed had a metal footboard. *They had not assessed the footboard for safety or entrapment risk. *They were unaware that the vertical metal bars of the footboard were a potential entrapment risk due to the large space between each of them. Interview on 4/23/25 at 10:45 a.m. with LPN H revealed: *She was not aware if there were any large gaps between the head or foot of the bed and the mattress. *She indicated a large gap between the head or foot of the bed and the mattress could be an entrapment risk. *If she noticed a mattress slid on the bed frame causing a large gap, she would tip up the metal piece at the foot of the bed to hold the mattress in place. *If she was unable to resolve the issue with the mattress, she would notify maintenance. 4. Observation on 4/14/25 at 3:09 p.m. of resident 55's room revealed a bottle of fingernail polish remover was on a shelf at the foot of her bed and the room was shared with resident 40. Observation and interview on 4/15/25 at 8:19 a.m. with resident 55 in her room revealed she used the fingernail polish remover independently and painted her fingernails with clear polish. Review of resident 55's EMR revealed she had a 1/13/25 BIMS assessment score of 14, which indicated she was cognitively intact. Review of resident 40's EMR revealed: *She had a 2/4/25 BIMS assessment score of 8, which indicated moderate cognitive impairment. *She used oxygen. *She was able to transfer and ambulate. Observation on 4/14/25 at 3:18 p.m. of resident 103's room revealed: *There was a bottle of Febreze air freshener and a bottle of Lysol air freshener on her roommate's over-the-bed table. *The bottle of Lysol had the cap removed. Observation on 4/15/25 at 9:27 a.m. of resident 103's room revealed the bottles of Febreze and Lysol remained on the over-the-bed table. Review of resident 103's EMR revealed: *She had a 2/25/25 BIMS assessment score of 0, which indicated she was severely cognitively impaired. *Her care plan indicated she had a history of wandering/pacing in [her] wheelchair within the facility. Interview on 4/23/25 at 10:33 a.m. with CNA P revealed: *Chemicals were not allowed to be stored in resident rooms for safety of all residents. *Fingernail polish remover and air fresheners were considered chemicals and should not have been stored unsecured in resident rooms. Interview on 4/23/25 at 10:45 a.m. with LPN H revealed: *She was not aware of any resident who had chemicals stored in their room. *If she found a chemical in a resident's room she would have removed it from the room for the resident's safety. Interview on 4/24/25 at 8:13 a.m. with DON R revealed: *The facility has asked residents' families not to bring in chemicals. *If a family did bring in a chemical it needed to be in a locked area to secure it for resident safety. *There was an increased risk to the residents if a flammable chemical was stored in a room with a resident on oxygen. *There was an increased risk for improper use of the unsecured chemical in a room with a resident who had cognitive impairments. Interview on 4/24/25 at 10:29 a.m. with administrator A revealed: *Cleaning supplies were to be locked in a designated area for resident safety. *Fingernail polish remover was to be locked in the beauty salon or locked in activities storage for resident safety. 5. Review of the provider's 2/2/24 Bed Safety and Side Rail Entrapment Resource Packet revealed: *Physical restraint: Any manual method, physical, or mechanical device, equipment or material that meets the following criteria: -Is attached or adjacent to the resident's body; Cannot be removed easily by the resident and; -Restricts the resident's freedom of movement or normal access to his/her body. -'Removes easily' means that the manual method, physical or mechanical device equipment, or material can be removed intentionally by the resident in the same manner as it was applied by the staff. *A resident's bed should be a place of comfort and relaxation, a safe place. When the bed system does not fit correctly and the resident becomes trapped or injured, the resident's bed is no longer a safe place. *Conditions such as agitation, delirium, pain, confusion, incontinence, or uncontrolled body movements can cause the resident to be more active in bed or attempt to get out of bed. The proper sizing of the mattress, the fit and integrity of the bed rail or other design elements such as wide spaces between the bars in the rail can also increase the risk for resident entrapment, injury and in some instances death. *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, no gaps or spaces. Review of the provider's 10/2/24 Housekeeping, Resource Packet revealed No cleaning supplies or cleaning equipment should be stored in the resident rooms. Review of the provider's 7/8/24 Oxygen Administration, Safety, Mask Types policy revealed Avoid use of flammable materials (oil, greases, alcohol or alcohol-based products etc.) near residents using oxygen. Review of the provider's 7/30/21 Safety Data Sheet for Professional LYSOL Disinfectant Spray revealed it has a hazard statement of Flammable aerosol and Causes eye irritation. Review of the provider's 8/24/16 Safety Data Sheet for Nail Polish Remover-Regular revealed: *Precautionary Statements-Storage -Store in a well-ventilated place. Keep container tightly closed -Store locked up. *It has hazardous statements of Causes serious eye irritation, and Flammable liquid and vapor. 51816

Based on observation, interview, record review, and policy review, the provider failed to support residents' choices for five of five sampled residents (85, 139, 356, 361, and 363) on the rehab unit regarding menu options and food preferences at meals. Findings include: 1. Observation and interview on 4/15/25 at 8:22 a.m. with resident 363 in her room revealed: *She was waiting for her breakfast and wanted to know what was being served and when her meal would arrive. *She ate most of her meals in her room and never knew when or what she would be served. *She had not received a planned menu and had not chosen what she was served at her meals. *The breakfast meal was typically good, but she would have liked to have a choice about what she ate for lunch and dinner. Observation and interview on 4/16/25 at 9:37 a.m. with resident 363 in her room revealed she: *Was upset because she had gone to the dining room for breakfast that day and had not enjoyed that experience. She stated that she planned to eat the rest of her meals in her room. *Stated they had not provided her with a planned menu and was frustrated that she did not know what would be served to her. *Was unaware if there was a way to make an alternate meal selection because she did not even know what the meal would be. *Did not have a copy of the planned menu in her room. Interview on 4/22/25 at 2:58 p.m. with resident 363 in her room revealed she stated: *I just want to go home. Don't even ask. We didn't even have ham for Easter. *There are no [food] choices. Review of resident 363's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included nausea, major depressive disorder, and anxiety. *Her Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated she was cognitively intact. *A 4/7/25 social services progress note (PN) indicated resident 363's Patient Health Questionnaire-9 (PHQ-9), an assessment of the degree of depression, interview indicated resident 363 had little interest in doing things, had expressed feeling down/depressed, feeling tired/little energy, poor appetite, feeling bad about herself, having trouble concentrating, and feeling fidgety. *There was no documentation that indicated that the dietary department had discussed food preferences with resident 363. 2. Observation and interview on 4/14/25 at 3:34 p.m. with resident 356 in her room revealed she: *Stated the food is crappy and cold. *Had eaten some meals in her room and others in the dining room. *Had not had a choice about the meals she received. *Had complained to administrator B about the meals, and there had been no improvements. *Did not have a copy of the menu in her room or available to her. Resident 356 was unavailable for further observation and interview during the survey. Review of resident 356's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included myocardial infarction (heart attack), reflux disease, and Type 2 Diabetes Mellitus *Her BIMS assessment score was 15, which indicated she was cognitively intact. *A 4/13/25 nursing PN indicated the writer discussed resident 356's food preferences with her, and she would request that the dietitian visit with resident 356 about her nutrition needs. *There was no documentation that indicated that the dietary department or the dietitian had discussed food preferences with resident 356. 3. Interview on 4/15/25 at 2:38 p.m. with resident 361 revealed she: *Stated lunch was good today, but it's always a surprise. *Had not received a copy of the menu since she was admitted . *Stated she would have liked a copy of the menu. Review of resident 361's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included cerebral vascular accident (a stroke), cognitive communication deficit, and Aphasia (impaired ability to understand or express language). *Her BIMS assessment score was 7, which indicated she was severely cognitively impaired. *A 3/24/25 social services PN indicated resident 361's PHQ-9 interview indicated resident 361 had little interest in doing things, had expressed feeling down/depressed, and had a poor appetite. *There was no documentation that indicated that the dietary department or the dietitian had discussed food preferences with resident 361. 4. Observation and interview on 4/15/25 8:42 a.m. with resident 85 and her son in her room revealed: *She ate all her meals in her room. *She had not received a copy of the menus and had been unaware of what food would be served each day. *She and her son had been unaware that printed menus were available. *She had several food preferences and stated, Here, you get what you get. *She had not had a choice of food she was served at mealtimes. She recalled that they had provided her with something else when she had not eaten anything at one meal, but it had taken A while. *Her call light was on because staff had brought her coffee with no cream or sugar. -She would have preferred a hot chocolate, but she was not given a choice. -She was unaware that there was an additional menu of items that were always available. Observation and interview on 4/15/25 at 2:32 p.m. with resident 85 revealed: *Her son had asked for a menu, and someone had brought her a copy. *She was still unaware of how to choose something different if she did not like what was on the planned menu to be served that day. Review of resident 85's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included nausea, major depressive disorder, and anxiety. *Her BIMS assessment score was 15, which indicated she was cognitively intact. *A 3/24/25 nutritional status PN indicated resident 85 had inadequate protein energy intake related to limited personal food preferences, a history of weight loss and poor intake at times, was particular about the foods that she was willing to accept, and preferred most food be prepared a certain way. Staff were to Encourage resident to continue to request [an] always available [menu] substitution if [she] does not like something. -There were no further notes regarding her food preferences. 5. Observation and interview on 4/15/25 at 10:01 a.m. with resident 139 in her room revealed: *She ate her meals in her room. *The meals came from a central kitchen; she had not had a choice of what she ate at each meal, and she did not know what time the meals were served. -She stated, It is a surprise. *If she did not like the meal that was served, she did not eat it. *She did not have a copy of the menu in her room or available to her. Interview on 4/22/25 at 3:08 p.m. with resident 139 revealed: *She had not been provided with a copy of the menu. *The Easter meal had been fair. There had not been a choice of foods, but she would have liked ham. *She was unsure if she could have selected something different than what she had been served. Review of resident 139's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included irritable bowel syndrome, major depressive disorder, anxiety disorder, and moderate protein-calorie malnutrition. *Her BIMS assessment score was 15, which indicated she was cognitively intact. *A 3/17/25 social services PN indicated resident 139's PHQ-9 interview included she had little interest in doing things, had expressed feeling down/depressed, had trouble sleeping, felt tired/little energy, had a poor appetite, and had trouble concentrating. *A 4/1/25 nutritional status PN indicated that she was at risk for malnutrition, and her appetite was fair. *There was no documentation that indicated that the dietary department had discussed food preferences with her. 6. Observation on 4/15/25 at 11:53 a.m. on the rehab unit revealed: *There was a Spring/Summer Dinner Menu posted, in the hallway on the wall across from the dining room. -That menu listed Week 1, Week 2, Week 3, and Week 4 across the top and the days of the week along the left side. *The meal posted was for Wednesday, April 16th, but it was 4/15/25. *A sign indicated that always available food order forms should have been turned into the kitchen at least one hour before meal service, if possible. 7. Interview on 4/23/25 at 7:57 a.m. with certified medication assistant (CMA) HH revealed: *The menu was posted on the wall in the hall across from the dining room on the rehab unit. *Residents used to get a copy of the monthly menu, but now they used a weekly rotating menu. *If a resident asked her for a copy of the weekly menu, she would provide them with a copy. *Residents could have filled out an always available meal slip and provided that slip to the staff if they did not want what was being served on the regular menu. -Those slips needed to be turned into the kitchen at least one hour before the meal. 8. Interview on 4/23/25 at 9:16 a.m. with assistant director of nursing/infection preventionist G revealed: *She was the nurse manager on the rehab unit. *Residents were educated about their meal choices and provided always available menu slips on admission. *Social worker (SW) II provided residents with a copy of the menu on admission. *If a resident wanted something other than what was on the planned menu, they were to fill out a request slip one hour before the meal. *The staff would assist residents in filling out a request slip and provide it to the kitchen if the resident asked. *Menus were not posted in the residents' rooms to decrease potential infection control risk. 9. Interview on 4/23/25 at 9:45 a.m. with SW II revealed: *She would have provided residents with the menu and an always available menu if nursing had not already provided them a copy. *She made a photocopy of the menu that was posted on the wall outside of the dining room if a resident requested a copy. *Sometimes, there were printed menus in the dining room for the residents to take. 10. Interview on 4/24/25 at 8:46 a.m. with administrator B revealed: *He expected that dietary department staff would educate the residents about the meal choices and how to complete the always available meal slips when they completed their admission assessment. *He expected that dietary department staff would provide residents with the planned weekly menu and always available meal slips at admission. *He thought the nursing staff would assist residents in filling out the always available meal slips if needed. 11. Interview on 4/24/25 at 9:19 a.m. with dietitian CC and dining service director EE revealed: *Dietitian CC completed the dietitian assessment, which included a review of the resident's physician orders and any resident allergies, and a conversation with the resident regarding their food preferences when she completed their admission assessment. *She expected that dining services manager DD would have educated the residents on the menu rotation, the always available menu slips, and to have documented resident food preferences in the resident meal tray ticket system. *The tray ticket system allowed the provider to print the meal ticket to be referenced by dietary and nursing staff to serve the resident their meal. *Menus were posted near each dining room. -Two seasonal planned menus were used, Spring/Summer and Fall/Winter. -Menus were provided to residents at their request. *Recently, there was an increase in residents requesting daily menus, so they changed the menu format on 4/1/25 to a weekly seasonal rotation to reduce the amount of printing. -Residents could now request a copy of the full planned seasonal menu. *The always available meal slips were in the dining room at the front counter in the rehab area. -The residents could take a slip themselves, or a staff member could have provided them with one. *The planned menu and always available menu slips had not been provided to the resident on admission by the dietary department. *They felt that the nurses were pretty good at providing menus to the residents on admission. 12. Interview on 4/24/25 at 9:31 a.m. with dining services manager DD revealed he: *Met with residents within 72 hours of their admission. *Discussed their diets, allergies, and completed a list of their food likes and dislikes. -Those were documented on the residents' meal ticket. *Educated them on their choices and the location of the planned daily and weekly menus. Review of the provider's Resident's Rights booklet stated: *The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. *The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. Review of the provider's revised 4/21/25 Person-Centered Care policy revealed: *To improve resident quality of life and quality of care by honoring preferences that support individuality, independence and choice. *Person-centered care is a central theme in nursing home regulations. Many sections in the regulations (i.e., resident rights, comprehensive person-centered care planning and quality of life) stress the importance of person-centered care. Specifically, the residents' rights section contains many provisions which directly support residents having [a] choice and maintaining control over their lives while residing in a nursing home. *Employees will support residents in achieving the level of well-being that is individually practicable by providing person-centered care. This is done by incorporating personal preferences (food, activities and routines) into daily care and life. Review of the provider's revised 11/14/24 Menu Requirements policy revealed: *Employees will communicate menu options to residents based on the system that the facility has in place. *Residents should have input into menus (e.g., resident council, food committee, individual expression of menu preferences).

Based on observation, record review failed to ensure: *Three of three sampled residents (55,103, and 116), observed with medications stored in their rooms, were assessed for the ability to safely self-administer and store medications, and had physician's orders to self-administer medications according to the provider's policy. *On of One sampled resident's (116) care plan included the resident's self-administration of medications. 1. Observation on 4/14/25 at 3:17 p.m. of resident 103's room revealed: *There was a tube of Triad wound dressing paste (for wound healing) on her bedside table. -The instructions on the pharmacy label read, apply bid [twice daily] as directed. Review of resident 103's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 2/25/25 Brief Interview for Mental Status assessment score was 0, which indicated she was severely cognitively impaired. *She had a diagnosis of dementia with other behavioral disturbance. *She had an order for Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to both buttocks topically two times a day for rash apply on both buttocks twice a day. *There was no physician's order for self-administration of medications. *There was no completed assessment of her ability to safely self-administer medications. 2. Observation on 4/14/25 at 3:18 p.m. of resident 116's room revealed: *There were three partial bottles on her over-the-bed table, one was calcium with vitamin D3 medication, one bottle was a supplement labeled veggie, and another bottle was a supplement labeled fruit. *On the cabinet beside her nebulizer machine (device that converts liquid medication into an inhaled mist), there was an unopened individual vial of ipratropium-albuterol (DuoNeb) nebulizer solution (medication for breathing problems). Observation and interview on 4/15/25 at 9:27 a.m. with resident 116 in her room revealed: *A tube of Neosporin medicated cream was on her over-the-bed table in addition to the calcium with vitamin D3, veggie, and fruit bottles. *The unopened DuoNeb vial remained on her cabinet beside her nebulizer machine. *Resident 116 indicated she did not take the calcium with vitamin D3 anymore, but she did self-administer the fruit and vegetable supplements. *She self-administered the Neosporin on an area on her arm to help it heal faster, but she did not always use it. Review of resident 116's EMR revealed: *She was admitted on [DATE]. *Her 4/1/25 BIMS assessment score was 15 which indicated she was cognitively intact. *A physician's order for DuoNeb Solution 0.5-2.5 (3) MG [milligrams]/3ML [milliliters] (Ipratropium-Albuterol) 1 inhalation inhale orally via nebulizer two times a day for SOB [shortness of breath]/wheezing and every 4 hours as needed for SOB/Wheezing. *A physician's order for Okay for patient to self-administer nebulizer treatments upon completion of setup by nursing. *A physician's order for Calcium 600+D Plus Minerals Oral Tablet 600-400 MG-UNIT (Calcium Carbonate-Vitamin D w/ [with] Minerals) Give 1 tablet by mouth one time a day for Chronic low back pain. *There was no physician's order for self-administration for her calcium with vitamin D. *There was no physician's order for the Neosporin, Veggie supplement, or the Fruit supplement. *There was no physician's order for the self-administration of the Neosporin, Veggie supplement, or the Fruit supplement. *Her 3/31/25 Resident Self-Administration of Medications assessment revealed: -It was a quarterly assessment. -The DuoNeb solution was to be kept on locked med cart, setup/cleanup [was to be done by] nursing. *Resident 116's care plan did not include her self-administration of medications or if those medications were to be stored in her room. 3. Observation on interview on 4/15/25 at 3:09 p.m. with resident 55 in her room revealed: *There were two containers of Vicks Vapor Rub medicated ointment in her cube storage unit beside her bed. *She indicated she applied the Vicks Vapor Rub to her black toenails. *She had a plastic container filled with medicated cough drops on the arm of her recliner. Review of resident 55's EMR revealed: *She was admitted on [DATE]. *Her 1/13/25 BIMS assessment score was 14, which indicated she was cognitively intact. *There was no Resident Self-Administration of Medications assessment found in her record. *There was no physician's order for self-administration of the Vicks Vapor Rub or cough drops. *There was no physician's order for Vicks Vapor Rub or the medicated cough drops. 4. Interview on 4/17/25 at 10:48 a.m. with registered nurse (RN)/clinical care leader (CCL) M revealed: *She was not aware of any residents, in the facility, who were supposed to have medications stored in their rooms. *Only nebulizers were self-administered by residents after a nurse of certified medication aide (CMA) set up the nebulizer medication treatment for administration. *All medications were to be stored in the medication cart until the time of administration. *Triad wound cream was to be stored in the medication cart. *Vicks Vapor Rub required a physician's order and was to be stored in the medication cart. 5. Interview on 4/24/25 at 8:13 a.m. with director of nursing (DON) R regarding residents' self-administration of medications revealed: *She expected the Resident Self-Administration of Medications assessment be completed on admission, quarterly, and if there was a new order for the self-administration of medications for any resident who self-administered medications. *Medications should not be stored in resident rooms without an order. *She expected staff to follow the process for medication self-administration assessment and physician's orders related to the self-administration of medications. *The medications for self-administration were to be stored on the medication cart until the time of administration. *She expected residents' care plans to reflect the current cares the resident was to receive. 6. Review of the provider's 10/29/24 Resident Self-Administration of Medications policy revealed: *Complete the Resident Self-Administration of Medications UDA [assessment] to determine if the resident can safely administer medications and create a plan to assist the resident to be successful in this process. *The interdisciplinary team will determine if the resident has any specific educational needs. *The interdisciplinary team will also determine where the medications will be stored. This can be at the nurses' station, in a locked medication cart, a locked compartment or locked drawer in the resident's room. *Medication cannot be left within reach of another resident and must be under the control of the resident who is self-administering. *A physician's order must be obtained prior to the resident self-administering medications. -The order must be specific to the medication being self-administered. *The care plan must indicate which medications the resident is self-administering, where they are kept, who will document the medication and the location of administration, if applicable. *The resident's ability to continue to safely self-administer medication must be reviewed during the care planning process. It is recommended that this be done at least quarterly and with any significant change. *All medications that the resident stores in his or her room must be reconciled (counted or observed for the amount used, e.g., ointments and inhalers) and documented by a licensed nurse at least weekly on the MAR [medication administration record].

Based on observation, interview, record review, and policy review, the provider failed to ensure three of three sampled residents (139, 361, and 363) who resided in the Rehab unit were provided activities that were meaningful and of interest to maintain their psychosocial well-being. Findings include: 1. Observation and interview on 4/15/25 at 8:22 a.m. with resident 363 in her room revealed: *She ate her meals in her room and participated in therapy. *There had not been any activities or programs for her to attend. *She felt alone and like there was no one to talk to. *She did not have an activities calendar of events happening in the facility. Observation and interview on 4/16/25 at 9:37 a.m. with resident 363 in her room revealed she: *Had been encouraged to go to the dining room for her meals for socialization. *Was upset because she had gone to the dining room for breakfast, hoping to talk to other residents, and had not enjoyed that experience. *Stated that she planned to eat the rest of her meals in her room. Interview on 4/22/25 at 2:58 p.m. with resident 363 in her room revealed: *She stated there had been no activities in the past four days. *She had stayed in her room. *She stated, I just want to go home. Don't even ask. We didn't even have ham for Easter. *She felt that there was nothing to do, and There are no choices. -She was unaware if there had been a church service for Easter and would have wanted to attend that if there was one. *She was unaware that a music program had been held that afternoon and would have wanted to attend that. Review of resident 363's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included nausea, major depressive disorder, and anxiety. *Her Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated she was cognitively intact. *A 4/7/25 social services progress note (PN) indicated resident 363's Patient Health Questionnaire-9 (PHQ-9) (an assessment of the degree of depression) interview indicated resident 363 had little interest in doing things, had expressed feeling down/depressed, feeling tired/little energy, poor appetite, feeling bad about herself, having trouble concentrating, and feeling fidgety. *Section F - Preferences for Routines & Activities of her 4/8/25 Minimum Data Set (MDS) assessment indicated: -Doing things with groups of people and doing her favorite things was marked as somewhat important to her. -Participation in religious activities or practices was marked as very important to her. *Her current care plan indicated: -The resident has potential for activity deficit R/T [related to] acute pain and depression. -She will participate in activities of her choice by next review date. *Care plan interventions for her activities included: -Introduce resident to residents with similar background, interests and encourage/facilitate interaction. -Invite and remind resident of scheduled activities, assisting to and from locations as needed. -Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/s [signs/symptoms] or c/o [complaint of] pain or discomfort. *There was no documentation that indicated resident 363 had participated in or was offered and refused any group or one-to-one activities since her admission. 2. Observation and interview on 4/14/25 at 4:45 p.m. with resident 361 revealed she: *Participated in therapy and went to the dining room for most meals. *Slept a lot because It can get boring. *Did not have an activities calendar of events happening in the facility. *Was unaware if there were activities to attend in the facility. Interview on 4/22/25 at 3:03 p.m. with resident 361 revealed *She stated there had been no activities in the past four days, so she just slept in her chair. *She had not gone to any church services and was unsure if there were any offered. *She requested an activities calendar after her discussion with the surveyor the day before about her participation in activities at the facility, and someone brought her the April activities calendar yesterday (4/21/25). Review of resident 361's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included cerebral vascular accident (CVA) (a stroke), cognitive communication deficit, and Aphasia (impaired ability to understand or express language). *Her BIMS assessment score was 7, which indicated she was severely cognitively impaired. *A 3/24/25 social services PN indicated resident 361's PHQ-9 interview indicated she had little interest in doing things, had expressed feeling down/depressed, and had a poor appetite. *Section F - Preferences for Routines & Activities of her 3/29/25 MDS assessment indicated: -Keeping up with the news and doing her favorite things was marked as somewhat important to her. *Her care plan indicated: -A focus area, The resident has potential for activity deficit R/T CVA, E/B [evidenced by] some cognitive impairment, some memory loss was marked resolved on 3/31/25. -A goal Resident will maintain involvement in cognitive stimulation, social activities as desired through review date was marked resolved on 3/23/25. -An intervention Introduce resident to residents with similar background, interests and encourage/facilitate interaction was marked resolved on 3/23/25. *There was no documentation that indicated she had participated in any group or one-to-one activities since her admission. 3. Interview on 4/15/25 at 10:01 a.m. with resident 139 in her room revealed she: *Ate her meals in her room, went to therapy, and watched television. *She stated there were books available in the dining room, but she was bored a good part of the day. *She had not received an activities calendar and was not aware of any activities that she could do. Observation and interview on 4/22/25 at 3:08 p.m. with resident 139 revealed she: *Stated the past Easter weekend was quiet and that she had sat here all by myself. *Did not have an activities calendar. *Was unaware whether there had been any activities or church services offered at the facility. Review of resident 139's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included major depressive disorder and anxiety disorder. *Her BIMS assessment score was 15, which indicated she was cognitively intact. *A 3/17/25 social services PN indicated resident 139's PHQ-9 interview indicated she had little interest in doing things, had expressed feeling down/depressed, had trouble sleeping, felt tired/little energy, had a poor appetite, and had trouble concentrating. *Section F - Preferences for Routines & Activities of her 3/21/25 MDS assessment indicated: -Participation in religious activities or practices was marked as very important to her. -Listening to music and doing her favorite things was marked as somewhat important to her. *Her care plan indicated staff were to: -Be conscious of my location when in groups, activities, dining room to promote proper communication with others. -Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT/OT [physical therapy/occupational therapy] to evaluate and treat for skilled stay. -Invite resident to food-related activities and offer food, beverages of choice to encourage intake. -Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/s [signs/symptoms] or c/o [complaints of] pain or discomfort. *There was no documentation that indicated she had participated in any group or one-to-one activities in the last 30 days. 4. Observation on 4/15/25 at 11:53 a.m. on the rehab unit revealed the facility activities calendar was posted outside the dining room, by day, for the entire week, and included the location of the activity. -None of those posted daytime activities were listed to or were observed to have occurred in the rehab unit during the survey. 5. Interview on 4/16/25 at 10:17 a.m. with certified nursing assistant (CNA) S revealed: *Residents can participate in the activities listed on the calendar posted near the dining room. *She confirmed that none of the activities occurred in the rehab unit. *If the resident asked, the staff would have taken them to the activity. *Not many residents in the rehab unit asked to go to the activities. 6. Interview on 4/17/25 at 11:44 a.m. with director of nursing (DON) R revealed: *She expected the activities department staff to post the monthly activities calendar in each resident's room on the first of the month. *All residents were to be invited to all activities and could attend activities of their choice. 7. Interview on 4/17/25 at 11:49 a.m. with activities supervisor JJ revealed: *There were no activities staff assigned to the rehab area. -She was working on getting someone hired for that area. --She stated a position had been posted. *No scheduled activities occurred in the rehab area. *Residents who resided in the rehab area could attend facility activities that occurred in other areas of the facility. *She expected the rehab unit staff to bring those residents to activities if they wanted to attend. *Activities were announced at breakfast in each dining room and on the overhead paging system. *A weekly activities calendar was posted in the rehab unit outside the dining room. *She completed an activities assessment when rehab residents were admitted , but was not responsible for their care plans for activities. *There were currently no residents in the rehab unit who wanted to attend group activities. *Independent activities like magazines, books, and puzzles were available in the dining room. *The chaplain visited and provided communion to residents in the rehab unit. *She was unsure if the residents in the rehab unit had activity calendars because she could not recall if she had provided them to social worker (SW) II. *She expected SW II to provide those activity calendars to the residents on the rehab unit upon admission. *One activity that was available for the rehab unit residents was socializing in the dining room at meals. 8. Interview on 4/23/25 at 7:59 a.m. with certified medication aide (CMA) HH revealed: *Most of the residents in the rehab unit do not go to any scheduled activities. -Occasionally, residents would go to church services. *The activities department did not hold activities in the rehab unit for those residents. *Residents had a monthly activities calendar, could let staff know when they wanted to attend, and the staff would bring them. 9. Interview on 4/23/25 at 9:12 a.m. with assistant DON/infection preventionist G revealed: *She was the nurse manager on the rehab unit. *Activities supervisor JJ completed the residents' activities assessments. *She expected activities calendars would be provided to residents by SW II or activities supervisor JJ on admission. *She felt that therapy kept the residents in the rehab unit very busy. *No group or individualized activities were provided in the rehab unit by the activities department. *Residents on the rehab unit were often younger than long-term residents and often had not wanted to participate in facility activities. *Some rehab unit residents had gone to receive hair care at the facility salon. *Some residents had gotten together on their own to play cards. *She encouraged residents to eat in the dining room for social interaction. *The residents were made aware of the facility's activities on admission and that they could join them if they wanted to. *A paper copy of the monthly activity calendar was not hung in the rehab unit resident rooms due to potential infection control issues with the short-term rehab stays. 10. Interview on 4/23/25 at 9:45 a.m. with SW II revealed: *Activities offered at the facility were posted in the hall outside the dining room each week. *Sometimes, she had activities calendars, and would provide those calendars to the residents of the rehab unit when they were admitted . *She confirmed that she did not have the April activities calendars. -Those calendars should have been provided to her by the activities department. *If a resident indicated during their social history that a particular activity was important to them, she would email activities supervisor JJ, to let her know. 11. Interview on 4/23/25 at 11:09 a.m. with administrator A revealed: *She expected activities calendars to have been posted in each resident's room. *She was not aware that the rehab unit residents did not have a copy of the activities calendar. *She stated the activities calendar was posted outside of each dining room. *She expected education about the facility activities would be provided to the residents on admission. *The rehab unit residents were invited to attend all facility activities. *She was unsure if the rehab unit residents were offered individualized or one-to-one activities. *She confirmed there was no documented activity participation or documented offerings and refusals for residents 139, 361, or 363. 12. Interview on 4/24/25 at 8:46 a.m. with administrator B revealed: *He expected that activities supervisor JJ would have provided a copy of the activities calendar to rehab unit residents when she completed their admission assessment. *Rehab unit residents could have attended facility activities, and if they asked, staff were to bring them to the activity. Review of the provider's revised 12/23/24 Group Programming-ACT policy revealed: *The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of the resident, encouraging both independents and interaction in the community. Review of the provider's revised 4/21/25 Person-Centered Care policy revealed: *To improve resident quality of life and quality of care by honoring preferences that support individuality, independence and choice. *Person-centered care is a central theme in nursing home regulations. *Person-centered care includes making an effort to understand . what is important to each resident with regards to daily routines and preferred activities .

Based on observation, interview, record review, and policy review, the provider failed to follow proper infection control practices to ensure *Supplies were not stored under sinks in four of four soiled utility rooms. *Resident care and cleaning supplies were monitored for outdates and disposed of in two of four soiled utility rooms (400 South hall, and 300 hall) and one of four resident shower rooms (100 hall). *Splash guards were properly installed on three of four hoppers (specialized sink for disposing of bodily fluids) in the soiled utility rooms. *One of one biohazard container was covered as directed in the provider's policy to safely contain biohazardous material during storage and transport to prevent leakage, spilling, and potential exposure. *Personal care products (combs, brushes, finger-nail clippers, and personal hygiene supplies) were not shared between residents in four of four shower rooms (100, 200, 300, and 400 hall). *Clean linen was covered while stored and transported as directed in the provider's policy to protect it from potential contamination. *Soiled linen was covered in one of four resident shower rooms (400) to prevent cross-contamination, and the spread of infection as directed in the provider's policy. *Multiple chairs were free of dust, dirt, and food particles in accordance with the provider's policy in the dining room in the 400 hall and in the common areas in the 100 and 400 halls. Findings include: 1. Observation on [DATE] at 3:50 p.m. of the 400 hall lobby area revealed: *A purple dining room chair with a white unknown substance located on the middle front of the seat cushion. *A white and gray chair with an unknown dried yellow stain in the middle of the seat cushion. *A light green colored chair with an unknown yellow stain on the front of the seat cushion. 2. Observation on [DATE] at 3:55 p.m. of the 100 hall day room revealed: *A brown suede recliner with a wet area on the seat, a greasy stain on the headrest, and a brownish-red substance on the arm of the chair. *An empty wheelchair with a solid unidentified brownish yellow crusty substance on the seat. 3. Observation on [DATE] at 5:39 p.m. of the 400 hall dining room revealed: *There were multiple dining room chairs with dried unidentified discolorations to the fabric on the backs and seats of the chairs. *Residents were seated in those chairs for the meal. 4. Observation and interview on [DATE] at 2:51 p.m. in the 200 hall shower room with certified nursing assistant (CNA) W revealed: *On a shelf in the wooden cabinet were two hairbrushes, one black comb, one opened stick deodorant, one opened tube of toothpaste, one partially used tube of skin protectant cream, and a pair of scissors without resident identifiers listed on them. *In the shower was a partial bottle of shampoo. *CNA W stated she was unsure why the partially used containers and brushes were in the cabinet. She indicated she would have used supplies from each resident's room or gotten new supplies from the supply room if needed. *She indicated she would not be able to identify which resident the above personal care items belonged to because there were no resident identifiers on the items. *On the back of the toilet were two containers of personal hygiene wipes. -One of the wipe containers was opened and partially used. *CNA W indicated the containers of wipes were used for multiple residents. 5. Observation and interview on [DATE] at 3:02 p.m. in the 400 hall shower room with CNA K revealed: *There was a bag of soiled linen that was uncovered. *In the wooden cupboard were two razors, partial bottles of body wash, partial bottles of lotion, partial tubes of zinc oxide (medicated) cream, and a nail clipper that did not contain resident identifiers. *CNA K stated if the personal hygiene supplies were for a specific resident, they should have been labeled with resident identifiers. *She indicated she would not have used fingernail clippers or razors on a resident if it did not belong to that resident. *She did use the facility-supplied body washes and shampoos between residents and did not wipe the bottles or have a process in place to prevent potential cross-contamination between residents. *She agreed the nail clipper appeared to have been used and was not clean. *She stated if a fingernail clipper was used between multiple residents, it would need to be cleaned with an alcohol wipe, but she would have obtained a new fingernail clipper from the storage room for each resident. 6. Observation and interview on [DATE] at 3:09 p.m. in the 400 South hall soiled utility room with CNA K revealed: *There was a plastic splash guard on the floor next to the hopper. *CNA K stated the guard used to be mounted on the hopper to protect staff from splashing substances onto themselves or outside of the hopper when they were rinsing soiled linen. *Above the hopper, there was a sign that said, Please wear gown, gloves, and goggles when using the hopper spray. -No gowns and gloves were available in the room. Goggles were present, but they were soiled with a thick layer of dust. *Paint was peeling from the wall and ceiling, making it an uncleanable surface. *The following items were stored under the sink: -A plastic bag that contained a pair of utility gloves. -A gray basin with dried brown and white sediment on the bottom. -A white bucket that had a dried, white, crusty substance in it. -A clear [NAME] jar with dust and a brown coating on it. -Two U shaped metal strips approximately 18 inches long. -A pink bedpan. -A gray basin with a dead spider in it. -A two-compartment black container that contained a toilet brush with holder, a black wireless battery, a skin prep pad that had expired [DATE], two white metal assist bars, a gray commode or toilet lid, and a green folder that contained a Safety Data Sheet (SDS) for Good Sense RTU Odor Counteractant. *On top of a cabinet, there was an Emergency Response kit with no expiration date seen. 7. Observation and interview on [DATE] at 3:19 p.m. in the 400 North hall soiled utility room with environmental services (EVS) technician RR revealed: *A trash bin that did not have a cover to prevent the potential spread of infection, debris, and odor. *The plastic splash guard for the hopper was not attached properly. *There was a large red bin that was overfilled with used, locked sharps containers. It was so full that the lid could not be closed and sealed properly to contain the medical waste. *On a shelf above the sink, there was a suction machine with a cover labeled Return to Central Supply. *The wall had visible clusters of gray dust on it. *The following items were stored under the sink: -A white towel with flecks of unidentified brown, solid material. -A tan colored plastic container that had approximately a half-inch of standing water in it, and the bottom of the container was covered with brown sediment. -A gray circular piece of plastic. 8. Observation on [DATE] at 3:31 p.m. in the 300 hall shower room revealed: *A partial bottle of body wash and a gray basin with a white, crusty substance on the bottom of it on the shower chair. *A Roho cushion (a pressure-relieving cushion) and a wet Roho cushion cover were on a shelf, which in this environment could increase the risk of contamination and potential spread of infection. *In the cabinet were partial bottles of shaving cream, lotion, baby powder, foam cleanser, shampoo, body wash, a black wrist brace, a nail clipper, and a partially used container of washcloth wipes, which were all unlabeled. *There was dust and debris along the outer edges of the floor of the room. 9. Observation on [DATE] at 3:32 p.m. of the 300 hall soiled utility room revealed: *There were flakes of brown residue at the bottom of the basin of the hopper, which could indicate the presence of dirt, organic matter, or other contaminants. *The splash guard on the hopper was covered with a layer of dust. *The following items were stored under the sink: -A bottle of drug destroyer. -A container of peroxide multi-surface cleaner wipes that were dry. -A white plastic bucket. -A white plastic square container with a brown residue covering the bottom that contained a tube of Carmex, a sliver squeegee, a toilet brush holder, and a yellow plunger. -A Facts on MRSA 2009 information paper. -An opened box of surgical masks and goggles with a white, crusty substance on it. -An opened box of masks with visors. -A white bucket that contained an ice cream bucket with green sediment in the bottom of it, and a nebulizer machine. -A wheelchair foot pedal. -A toilet brush and holder. -Two short white metal siderails. -A basin covered with a white and yellowish-brown substance with clear liquid in the bottom of it that contains a bottle of Oxivir disinfectant concentrate that expired [DATE], along with peroxide multi-surface cleaner wipes. 10. Observation on [DATE] at 3:44 p.m. of the 100 hall soiled utility room revealed: *A water bottle was on the floor. *A box of bags was on the counter with a coffee cup on top of it. *A wheelchair cushion cover was on the floor. *Six damp floor mop pads were draped over the sink, which could transfer bacteria to the sink surface, potentially contaminating other items used in the soiled utility room and staff clothing. *The following items were stored under the sink: -A bottle of Pine-Sol. -A clear glass vase. -A black bag that had a toilet seat and cover in it. -Two green plastic containers with two compartments that contained a toilet scrub brush, a bag of utility gloves, seven glass vases, three plungers, a container of wet task wipes, a spray can of matte finish acrylic sealer, and a dustpan. -Those items stored under the sink increase the risk of cross-contamination. 11. Observation and interview on [DATE] at 4:04 p.m. of the 100 hall shower room with CMA O revealed: Clean, folded linen was stored uncovered on the top shelf of a cart near the shower, exposing it to potential contamination from moisture, splashes, and airborne particles. *There was an unlabeled partial bottle of body lotion on the shower ledge. *The cabinet on the wall contained: -An unlabeled electric razor full of gray hair stubble. -An unlabeled partially used package of disposable washcloths. -Ketoconazole 2% (antifungal) shampoo with no resident identifier that had been spilled onto the cabinet shelf. -An unlabeled bottle of Selsun Blue shampoo that expired in [DATE]. -Partially used and unlabeled containers of deodorant, rinse-free foam cleanser, baby powder, body wash, shampoo, conditioner, lotion, barrier creams, and skin protectants. -A fingernail clipper that had a crusty buildup on it. -A spoon. -Two combs with gray hairs and a white crust on them. -A gray hair tie with gray hair attached to it. -A blue bin containing two gray hair brushes with copious amounts of gray hair in them, a pair of resident socks, 13 black combs with white dried material and long gray hair on them, a tube of Chapstick, a partial roll of clear tape, a foot/callous file with white sediment on it, two hair picks with white sediment and gray hair, and an abundant amount of unsecured elastic hair ties. -A clear tub containing a black brush that was full of gray hair and white sediment, a black comb with white sediment, an almost empty bottle of Aveeno baby lotion that expired in [DATE], three opened stick deodorants, one roll-on deodorant, and a nail clipper. *CMA O agreed that the personal care items were not labeled with resident identifiers and stated that some personal care items were shared between residents. 12. Interview on [DATE] at 7:44 a.m. with director of nursing (DON) R and assistant director of nursing (ADON)/infection preventionist (IP) G revealed: *It was their expectation that resident care equipment, such as nail clippers, electric razors, barrier creams, hairbrushes, personal hygiene wipes, creams, and cleansers, was not to be shared between residents because that could lead to the spread of infection. -They indicated these items should have been disposable or designated for a specific resident to limit the potential spread of infection. *Clean linens should have been covered during transportation and storage in the shower rooms to reduce the potential for contamination. *The red biohazard buckets in the soiled utility rooms should be covered. *Nurse managers were responsible to be sure expiration dates were checked on their respective halls. *Chairs in the common areas and in the dining room were cleaned by housekeeping and maintenance would assist as needed. *Agreed PPE should be accessible to staff who used the hoppers in the soiled utility room to prevent contamination from splash when they washed out soiled linen. 13. Observation and interview on [DATE] at 8:30 a.m. in the laundry room with lead laundry technician L revealed: *A linen cart used to transport clean linens had a cover with a rip so large on one side that linens could not be covered. The opposite side of the cover was torn and frayed, making it an uncleanable surface. *Laundry must be covered during transportation. She agreed the cover did not provide adequate protection for clean linens. *Clean laundry should have been covered in public areas, such as a shower room, due to the risk of contamination. 14. Interview on [DATE] at 8:41 a.m. with registered nurse (RN)/clinical care leader (CCL) M revealed: *She was not aware there was a suction machine stored in the soiled utility room. *It should not have been stored in the soiled utility room because it was considered a clean item in a soiled environment. *Residents that required a suction machine had one in their room and if additional suctions machines were needed there were ones on the crash cart or up front. 15. Interview on [DATE] at 8:46 a.m. with administrator A revealed the provider did not have a policy for shared personal care equipment cleaning or a policy regarding supply expiration dates. 16. Interview on [DATE] at 10:02 a.m. with lead environmental technician V revealed: *The soiled utility rooms were not on the environmental service staff's cleaning schedule and did not get cleaned routinely. *Shower rooms were cleaned three times per week. *Chairs in the common areas and dining rooms used to be cleaned by a man who no longer worked there. 17. Interview on [DATE] at 10:33 a.m. with CNA P revealed: *No items were to be stored under sinks. *Each resident was to have their own personal care items such as hygiene supplies, fingernail clippers, and electric razors. *After each use an electric razor was to have the hair emptied, the head of the razor rinsed, and then wiped down with an alcohol wipe. *Clean and dirty linen was to be covered when it was in the hallway and the shower rooms. 18. Interview on [DATE] at 9:58 a.m. with RN/CCL M regarding expiration dates revealed: *The nurses on the floor were responsible for checking for expiration dates on the medication carts. *She would assist the nurses if they did not have time. *There was no schedule in place to check supplies other than medications for their expiration dates. *She expected housekeeping staff to check for outdates on chemicals in the soiled utility rooms. *Any staff could and should have looked for outdated supplies and should have disposed of them appropriately. 19. Interview on [DATE] at 10:29 a.m. with administrator A revealed: *She expected staff to follow the manufacturer's expiration dates and dispose of the item when it was outdated. *Cleaning of the dining room chairs and chairs in the common areas were the responsibility of maintenance staff. -There was no schedule to indicate when the chairs were to be cleaned. -If there was soiled chair identified she would have expected maintenance staff to attend to the chair that day. 20. Review of the provider's [DATE] 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. *Definitions: -Infection Prevention and Control Program- A program that prevents, identifies, reports, investigates, and controls infections and communicable diseases for all residents, staff, and visitors, following nationally accepted standards and guidelines. *Policy: -The infection Prevention and Control Program is a facility-wide effort involving all disciplines and individuals and is an integral part of the Quality Assurance and Performance Improvement Program. -The components of an Infection Prevention and Control Program include, but are not limited to: Program Oversight, Policies and Procedures, Surveillance, Data Analysis, Antibiotic Stewardship, Outbreak Management, Prevention of Infection, Immunizations, and Employee Health and Safety. *Program Components -The skilled nursing facility has designated at least one individual as the Infection Preventionist, who is responsible for the facility's Infection and Control Program. -The facility has developed and implemented written policies and procedures for the provision of infection prevention and control. -Process surveillance (ex, hand hygiene compliance program) and outcome surveillance (ex, monthly infection rates) are used as measures of the Infection Prevention and Control Program effectiveness. Review of the provider's [DATE] Surveillance, AL, Rehab/Skilled, Home Health, Hospice policy revealed: *Surveillance is an activity that a healthcare institution employs to find, analyze, control and prevent nosocomial [healthcare-associated] infections. *Process surveillance reviews practices directly related to resident/patient care in order to identify whether practices comply with established prevention and control policies and procedures. Review of the provider's [DATE] Housekeeping, Resource Packet revealed: *Policy/Procedure: -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. -Adequate safety levels can be achieved for most non-critical [examples include computers, walls, tabletops, and medical equipment surfaces like blood pressure cuffs and lift equipment] and low touch areas by keeping the surfaces visibly clean using water and a detergent or a low-level disinfectant. *Barber/Beauty Shops -A clean, closed, and locked container will be provided for all creams, lotions, soaps, solutions, cosmetics, powders, and other products used in direct contact with residents. *Bio-Hazardous-Infectious Material Collection and Disposal -For these reasons, regardless of the knowledge of diagnosis, all bio-hazardous material should be considered, collected, and handled as potentially infectious substances and should be properly separated, stored, and disposed. -All [provider] locations will comply with applicable federal, state, and local regulations pertaining to the collection, handling, storage, and disposal of bio-hazardous material and will, at a minimum, follow procedures to reasonably limit the potential for cross-contamination. *Common Area Cleaning -Keep all common areas clean, neat and free of litter. -Clean (disinfect if needed or required by regulations) chairs in dining rooms weekly or as needed. -Clean surfaces as often as necessary to keep furniture and equipment free of accumulations of dust, dirt, food particles, etc. -Spot clean walls, door and partitions as needed to remove visible material. Use a soft, clean cloth with disinfectant cleaner solution and wipe dry. -All mops and rags will be handled wearing the proper PPE [personal protective equipment] for the product being used. All used/soiled mops and rags will be stored in an appropriate storage container in accordance with [provider] or local cleaning procedures . *Monitoring and Quality Assurance -Visual assessments of housekeeping and custodial outcomes should be monitored on a regular basis. This monitoring is the responsibility of all staff members working in the building. 51816

Based on record review, interview, and policy review, the provider failed to ensure two of four sampled certified nursing assistant (CNA)/certified medication aides (CMA) (U and KK) who worked in one of one secured memory care unit had an annual performance review completed. Findings include: 1. Review of CNA/CMA KK's personnel records revealed: *She was hired on 11/16/21. *Her last annual performance review was conducted on 5/31/23. -Her annual performance review was more than 10 months overdue. 2. Review of CNA/CMA U's personnel records revealed: *She was hired on 12/28/22. *Her last annual performance review was conducted on 5/31/23. -Her annual performance review was more than 10 months overdue. 3. Interview on 4/24/25 at 11:11 a.m. with administrator A regarding the completion of the annual performance evaluations for CNAs revealed: *She confirmed that CNA/CMA U and CNA/CMA KK's last performance reviews had been completed on 5/31/23. *The provider's human resources department staff tracked the completion of the annual performance reviews. *She was unaware that CNA/CMA U and CNA/CMA KK had not had the required annual performance reviews completed. 4. Review of the provider's revised 6/11/24 Performance Management policy revealed: *The performance management process should be dedicated time for employees and their leaders, to connect. These connections are intended to be frequent meetings throughout the calendar year and personalized based on the work and individual. *Based on the performance expectations of the position, performance management conversations may serve as a reference point when determining career growth, developmental needs . *Leaders should schedule one-on-one meetings with each of their employees to check-in, provide timely meaningful feedback, discuss performance, share performance ratings, and focus on career growth and development consistently throughout the year. *Once per year, depending on role requirements, Employees and leaders will have the opportunity to seek feedback from others they work with . Refer to F725 Finding 8, 11, 12, 13, 14, and 15.

Based on observation, interview, record review, and policy review, the provider failed to ensure sufficient nursing staff for one of one secured unit to safely meet residents' needs, well-being, and the security of 17 of 17 residents (39, 86, 95, 96, 100, 102, 110, 114, 115, 122, 127, 131, 133, 135, 140, 148, and 453). Staff reported concerns with medication errors related to interruptions, difficulty keeping wandering residents within the unit, and difficulty completing all care tasks for residents due to the staffing of the unit. These failures placed those residents at risk for unmet care needs and potentially negative outcomes. Findings include: 1. During the entrance conference on 4/14/25 at 2:45 p.m. with administrator A, she stated the evening meal was served at 5:30. 2. Initial observation on 4/14/25, beginning at 5:34 p.m., of the dining room of the 100 hall, which is the secured unit, revealed: *Many of the residents had already finished eating and were walking around the adjacent day room and hallway. *Some residents had finished eating and were still seated at tables in the dining room. *Some residents required assistance to eat their meals. *Two unidentified staff members were working in the unit and were: -Assisting residents with their meals. -Transferring residents from their dining room chairs to wheelchairs and to recliners in an adjacent room. -Clearing the tables after the residents had finished their meals. -There were 17 residents in the unit. 3. Interview on 4/14/25 at 5:57 p.m. with certified medication aide (CMA) O revealed: *The dinner meal was served at 5:00 p.m. in the secured unit, not at 5:30 p.m. like the rest of the facility. *The unit was staffed with one CMA and one certified nursing assistant (CNA) from 6:00 a.m. until 10:00 p.m., and one CNA from 10:00 p.m. until 6:00 a.m. *At mealtimes, the CMA and CNA were responsible for getting residents into the dining room and seated for meals, serving the meal, assisting residents to eat their meals, clearing the tables, and helping residents who required assistance with transferring and cares after the meal. *In addition to passing medications, the CMA was responsible for getting residents up in the morning and to bed at night, getting weights before breakfast, giving residents showers and filling out a Bath Skin Form, providing personal care as needed, and intervening and redirecting with resident behaviors. *If staff on the secured unit needed assistance, they would use their radio to call the nurse on the 300 hall or a nurse manager. -The nurse on the 300 hall was also responsible for the residents on the secured unit. 4. Observation on 4/15/25 at 11:24 a.m. in the day room of the secured unit revealed: *A group of residents was participating in an activity with an activity assistant. *Many of the doors to residents' rooms were closed. 5. Observation on 4/15/25 at 11:42 a.m. of the dining room in the secured unit revealed: *All the residents' doors were closed except for two. *The activity assistant and an additional staff member assisted CMA O and the CNA with getting residents to the dining room for lunch and with serving the meal. *During the meal, dietitian CC and licensed practical nurse (LPN) H also came to the dining room and stayed on the unit for approximately eight minutes. -They talked to the staff that was already in the dining room, but did not assist with any resident care. 6. Interview on 4/15/25 at 3:49 p.m. with CMA O about the number of staff that were present during the lunch meal earlier that day revealed there were more staff present, and that it was not the normal staffing ratio for the secured unit. 7. Observation on 4/22/25 at 3:49 p.m. in the day room revealed: *Two residents were outside in the courtyard. *They were knocking and pulling on the door, attempting to reenter the day room, and were not able to get in by themselves. *Another resident who was in the day room was able to open the door and let them into the building. *There was no staff member outside in the courtyard, in the day room, or within sight while the surveyor was observing. 8. Interview on 4/23/25 at 3:14 p.m. with CMA O revealed: *She felt she was interrupted multiple times per shift during medication passes because of resident behaviors that required intervention. *She thought the frequent interruptions to staff responsible for medication administration contributed to some of the medication errors that had been happening in that unit because it was challenging for them to maintain their focus on administering medication. *She did not think the staffing was adequate in that unit because she was unable to meet all the residents' needs, and that other areas of the facility had different staffing ratios of staff per residents. -She had been asked by management to increase the amount of charting and documentation regarding the residents in the unit, but did not feel she had enough time to complete more charting because she was too busy doing tasks and providing resident care. -She stated on one occasion, she had been in the shower room assisting a resident with a shower, and the CNA went into a resident's room to help another resident. When she walked out of the shower room, she found a resident lying on the floor who had fallen and needed assistance. *A staff member from the 300 hall was supposed to come to the secured unit to cover the CMA and CNA for breaks, but that did not usually happen. *When the CMA or CNA in the secured unit took a break, there was only one nursing staff member in the unit to care for those residents. 9. A staffing policy had been requested, and the surveyor was given the provider's 6/5/24 Staffing and Scheduling Resource Packet. -This packet contained scheduling guidelines and principles, as well as a formula to calculate the labor per diem (the daily cost of caring for a resident). 10. Interview and record review on 4/24/25 at 8:26 a.m. with staffing coordinator Q revealed: *She had been completing the staff scheduling for approximately four years. *She scheduled the staff for all of the long-term care and rehab units. *She had not seen and was not aware of the provider's 6/5/24 Staffing and Scheduling Resource Packet, and did not use that to guide staffing. *She scheduled staff as she had been trained to by a previous director of nursing (DON). *The 400 wing was staffed with one nurse and two CNAs for the 400 North hall, and one nurse and two CNAs for the 400 South hall. *The 300 hall was staffed with one nurse, one CMA, and two CNAs. *The 100 hall (the secured unit) was staffed with one CMA and one CNA. The nurse for the 300 hall would also cover nursing needs for the 100 hall. *She agreed that there were fewer staff for the 100 hall. 11. Interview on 4/24/25 at 8:43 a.m. with registered nurse (RN)/clinical care leader (CCL) I for the secured unit revealed: *Regarding the staffing ratio in the secured unit, she felt the staffing ratio was common throughout the building. *She felt staffing on the secured unit was adequate. *She felt that the frequent interruptions during the medication pass were not as impactful once the staff got into a routine. *She stated leadership was looking at a time study for the secured unit because they had heard it was getting a little busier. -She did not offer further details of what was busier. *Regarding a medication error where a medication had been documented as unavailable for four days by a CMA in the secured unit, she agreed that their policy had not been followed, and the CMA should have notified the nurse that the medication was not in the med cart. 12. Interview on 4/24/25 at 9:53 a.m. with CMA C about working on the secured unit revealed: *She had been a CMA for over ten years. *Her first medication error happened in that unit. *She described it as overwhelming because of interruptions with medication passes and said the staff were expected to do a lot in the secured unit. *She said she was sometimes asked to do nursing functions like neurological assessments after a resident's fall, and skin assessments. *They would sometimes see a nurse on the unit for only five minutes a day; sometimes they would not see a nurse all day. *Staff from the secured unit had tried to discuss their concerns about inadequate staffing with management, but there had been no follow-through on improvement attempts. *She stated that they were supposed to start being relieved for breaks by a staff member from the 300 hall, but that had only happened about three times. *There were two residents the staff were supposed to try and keep separated because they fight, but stated she felt that was almost impossible if you're the only one [working] back here. *She loved working with the residents who resided in the secured unit, but felt they needed more support from staff. 13. Review of medication error reports for the secured unit from 2/13/25 through 4/19/25 revealed: *There had been six medication error reports from that period. *Only one medication error report was for a single administration error. *Resident 135 had only received 25 milligrams (mg) of his ordered dose of 50mg of Seroquel (an antipsychotic medication) for seven days, from 2/5/25 through 2/12/25. *Resident 86 had received 50 mg of Seroquel instead of his ordered dose of 25 mg for seven days, from 2/5/25 through 2/12/25. -The medication error report indicated that staff had noticed he had been more lethargic during the day, but wakes easily. *Resident 133 had not received her Seroquel at bedtime for four days. -The medication was charted as not available on 3/12/25 through 3/15/25. *Resident 114 had received 60 mg of furosemide (a diuretic or water pill) on Saturday, 4/12/25, and Sunday, 4/13/25, when the order was for Mondays, Wednesdays, and Fridays only. *Resident 110 received 45 mg of mirtazapine (an antidepressant) instead of her ordered dose of 15 mg from 3/20/25 through 4/15/25. -An order was received on 3/20/25 to decrease the dose of mirtazapine from 30 mg to 15 mg related to weight gain. -An order for the 15 mg dose was entered, but the order for the 30 mg dose was not discontinued. -A 4/3/25 progress note for medication regimen review by the consultant pharmacist noted that both doses are active on the MAR [medication administration record], sent communication to DC [discontinue] 30MG [30 mg] dose. -The order was corrected on 4/16/25, 27 days after the order was received. *Resident 127 had received 50 mg of her total ordered dose of 75 mg of sertraline (an antidepressant) on 4/18/25. *Those six medication error reports accounted for 48 medication administration errors from 2/13/25 through 4/19/25. 14. Interview on 4/24/25 at 10:22 a.m. with DON R revealed: *She had no concerns about staff being able to safely care for residents on the secured unit. *Regarding the unit staffing ratios and medication errors potentially related to the frequent interruptions with the medication pass, elopements, and resident behaviors in the secured unit, she stated they had those same types of issues everywhere in the facility. *They had added a CMA to the 300 hall so that the nurse for the 300 hall could be more available to the secured unit. *She stated, And the activity aide is back there. -She acknowledged that the activity aide could not provide personal care for the residents, but they could assist residents with some redirection. *She expected skin assessments to be completed by a nurse and documented by a nurse. 15. Review of the provider's 4/8/25 Medication: Administration Including Scheduling and Medication Aides policy revealed: *Purpose -To administer medications correctly and in a timely manner. *Policy -Medication administration --Pre-setting medications is not an acceptable practice. Once the medication pass has begun, interruptions should be avoided. Unless emergent, no one should interrupt the nurse/med aid during the medication pass. -Medication Errors --A SAFE Event Report will be completed for all medication errors. If a medication is not available for 24 hours, the provider must be notified that the medication is not available and must give direction for how to proceed. *Procedure -Review the MAR [medication administration record] for medications due. -Follow the Six Rights: Right medication, right dose, right resident, right route, right time and right documentation. -Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication . 16. Review of the provider's 2/7/25 facility assessment revealed: *Regarding the number of staff utilized for residents who have behavioral health needs: -They did not identify the number of staff utilized to provide care for residents with behavioral health needs. *Regarding appropriate staffing on all shifts: -They Identify needs daily using census and resident acuity to staff accordingly to help where needed. -They did not indicate the number of staff that would be appropriate.

Based on record review, interview, and policy review, the provider failed to ensure one of four certified nursing assistant (CNA)/certified medication aide (CMA) (KK) reviewed , who worked in the secure memory care unit (MCU), had completed the required annual in-service training. Findings include: 1. Review of CNA/CMA KK's personnel records revealed: *She was hired on 11/16/21. *CNA/CMA KK had documented medication errors from working in the MCU on 3/12/25, 3/13/25, 3/14/25, and 3/15/25. -She received Coaching/Counseling on 3/17/25. -She completed a Plan of Correction training on 6/1/24. *Her last annual performance review was conducted on 5/31/23. -Her annual performance review was more than 10 months overdue. *She had received 4.89 training hours of in-service education since 1/1/24. - Of those training hours 1.96 training hours were completed between 1/1/24 and 11/16/24 and 2.93 hours were completed between 11/16/24 and 2/27/25. *There was no documentation that indicated that the above training included dementia management training or resident abuse prevention training. *There was no documentation that indicated that the above training addressed areas of weakness as determined in her nurse aide performance reviews. *There was no documentation that indicated that the above training addressed the care of cognitively impaired residents. 2. Interview on 4/24/25 at 11:11 a.m. with administrator A revealed: *She confirmed that CNA/UMA KK's last performance reviews had been completed on 5/31/23. *She confirmed that CNA/CMA KK had not completed all her annual training as required. *Clinical Learning and Development Specialist (CLDS) MM tracked the completion of annual training of employees and sent reports to director of nursing (DON) R when staff had not completed their scheduled training. *She expected staff to complete their annual required training. 3. Interview on 4/24/25 at 11:18 a.m. with CLDS MM revealed: *She tracked the completion of employee annual training and sent reports to administrator A and DON R when staff had not completed their required annual training. *She confirmed CNA/CMA KK had not completed her required annual training and that she had notified administrator A and DON R. *She expected administrator A or DON R to follow up with staff when overdue training needed to be completed. 4. Interview on 4/24/25 at 11:24 a.m. with DON R regarding CNA/CMA KK's annual training revealed: *An email notification had been sent regarding CNA/CMA KK's incomplete annual training while she was on leave from work. -There had been an interim DON at that time. *She stated, It got missed. *CNA/CMA KK worked PRN [as needed] and her last shift worked had been on 4/21/25. *She had notified CNA/CMA KK that she had training she needed to complete. *She expected that CNA/CMA KK would complete that training as soon as she could. 5. Review of CNA/CMA KK's Past Due training report revealed: *There were 17 required trainings with a Due Date between 4/30/23 and 10/31/24 that were marked as Registered/Past Due. *Those trainings included: -Protecting Resident Rights in Nursing Facilities, -Behavioral Health, and -Communicating Effectively. 6. Review of the provider's revised 9/17/24 Competency and Mandatory Education Requirement policy revealed: *The provider .is responsible to provide processes for ongoing education and competency achievement. *Employees are responsible to attain and maintain competency and complete mandatory education required within their specific job description. *The provider . requires organizational mandatory education. Additional mandatory education may be required at the department/clinic or the specific job level. *Every department/clinic is expected to ensure ongoing competencies and mandatory education requirements that apply to their employees are completed within the designated frames and documented. *Competency achievements and mandatory education are required to be documented and are reviewed as part of the performance appraisal process. Review of the provider's revised 6/11/24 Performance Management policy revealed: *The performance management process should be dedicated time for employees and their leaders, to connect. These connections are intended to be frequent meetings throughout the calendar year and personalized based on the work and individual. *Based on the performance expectations of the position, performance management conversations may serve as a reference point when determining career growth, developmental needs . *Leaders should schedule one-on-one meetings with each of their employees to check-in, provide timely meaningful feedback, discuss performance, share performance ratings, and focus on career growth and development consistently throughout the year.

Based on record review, interview, and policy review, the provider failed to ensure their policy related to elopement reporting had been followed regarding an incident of elopement (left the area without staff knowledge) from a secure unit for one of one sampled resident (127). Findings include: 1. Review of resident 127's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 1/13/25 Minimum Data Set (MDS) indicated that she was rarely understood or able to understand others and was severely cognitively impaired. *A 12/27/24 revised care plan focus area included: The resident has potential for elopement R/T [related to] dementia, wandering. Resides on the locked memory care unit. *A 2/19/25 progress note indicated Activity staff report to writer that resident was seen in front office area without staff with her. *The resident was then redirected back to the secured unit. *The incident was reported to the charge nurse. 2. Interview on 4/23/25 at 4:10 p.m. with administrator A about their investigation revealed: *They had reviewed camera footage of resident 127's 2/19/25 elopement. -Camera footage was not available for the surveyor to review as it was automatically deleted after 30 days. *The provider had determined that resident 127 had followed a family member who was taking a resident out of the secured unit. That family member did not notice her behind them. *They had implemented an intervention of providing education to the family member who was followed out of the unit. -Investigation documentation indicated that administrator A spoke with the family member on 2/20/25 at 11:30 about safety of residents on the secure unit as another resident had followed her out of the unit on 2/19/25. -Administrator A reminded the family member that she should be cautious and aware of other residents following her out of the unit when exiting and alert staff if she needs assistance. *The chaplain was the staff member who identified that resident 127 was a resident from the secured unit who was not accompanied by staff and was near the front office, by the main entrance/exit of the facility. Administrator A stated she had not reported the elopement incident because resident 127 had not made it out of the building, staff had spotted her, and honestly, it just happened so fast. -She confirmed resident 127 resided in the secure unit, had made it out of the secure area, down the hallway, around the corner, down the next hallway that led to the front door area, where she was then located by the chaplain. *Investigation documentation did not indicate how long resident 127 had been out of the secure unit before she was found by the chaplain. 3. Interview on 4/24/25 at 9:53 a.m. with CMA C revealed: *She was aware of resident 127's 2/19/25 elopement incident and asked, Was that the time she was found in the 400 hall? *She stated the resident had gotten out of the [secure] unit a couple of times. 4. Interview on 4/24/25 at 10:03 a.m. with CMA O revealed: *She was aware of resident 127's 2/19/25 elopement incident. *Staff and family members had received education after the elopement. *She said that the resident had gotten out of the unit on more than one occasion. 5. Review of the provider's 4/7/25 Elopement- Rehab/Skilled & Adult Day Services policy revealed: *Definition -Elopement- When a resident/client who needs supervision leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. *Policy -When an elopement occurs, immediate efforts to locate the resident/client will be taken. All occurrences will be documented and follow-up will be completed as required by state and federal regulations. *Elopement Search -Notify other agencies as required by state and/or federal regulation. 6. Review of the provider's 4/7/25 Abuse and Neglect- Rehab/Skilled, Adult Day Services, Therapy & Rehab policy revealed: *Policy -The location will have evidence that all alleged or suspected violations are thoroughly investigated . -Results of all investigations will be reported to the administrator or designated representative and to other officials in accordance with state law, including to the state survey and certification agency within five working days of the event, or sooner as designated by state law. *Procedure -Notification procedures: --Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (139) was provided daily warm showers according to her preferences and according to her physician's orders during her short-term rehab stay. Findings include: 1. Observation and interview on 4/15/25 at 10:19 a.m. with resident 139 in her room revealed: *She stated she had not showered recently because there was only cold water in her shower. *The bathroom had a walk-in shower with a bench and a hand-held shower head. -After the surveyor ran the water for three minutes in that shower, the water never felt warm to the touch. *Staff had attempted, when she first admitted , about a month ago, to shower her in that shower, and the water was cold. -That day, the staff shower her in the room next door, and she recalled having felt very cold. *Staff had since told her no other shower was available because all the rooms were now occupied by other residents. *She was upset and had complained to the staff and her physician that there was no hot water for her to shower. -It had taken weeks for anyone to look at the shower water temperature. *A plumber had come last Thursday or Friday and told her the shower needed a new cartridge. -He had not returned to make that repair that she was aware of. *She had refused to shower if there was no hot water. 2. Interview on 4/16/25 at 9:48 a.m. with certified nursing assistant (CNA) S revealed: *A master shower schedule for the residents was posted in the nurse's station. *She knew when a resident in her assigned area was scheduled for showering because it would be listed on her daily assignment sheets. *Two showers a week were scheduled based on the resident's room number. *She confirmed resident 139 was scheduled for showering on Tuesday mornings and Saturday evenings. 3. Interview on 4/16/25 at 9:50 a.m. with registered nurse (RN) NN regarding resident showering revealed: *She confirmed the residents' shower schedule was posted at the nurse's station. *Resident showers were scheduled by room number because of the rapid change in residents on the rehab unit. *Each resident was to receive two showers a week. *If changes were made to that schedule, it would be indicated in the resident's care plan. *Sometimes, staff had time to provide residents with an extra shower if the resident requested one and the staff had time. 4. Interview on 4/16/25 at 2:06 p.m. with CNA S revealed: *Resident 139 required the assistance of one staff member for showering and dressing. *She had not provided resident 139 a shower and was unaware that resident 139 had stated that the water in her shower was cold. *She would tell the charge nurse if a resident told her they had no hot water. *Sometimes the water needed to run for a few minutes to get warm. *Resident 139 was scheduled to receive a shower last night (4/15/25). 5. Interview on 4/16/25 at 2:11 p.m. with resident 139 revealed she: *Had received a shower last night (4/15/25) and the water was hot. *Appeared happy and stated it was the first real shower she had had since she was admitted here. *Stated, Of course they waited til I was going home to give me a shower. 6. Interview on 4/22/25 at 3:08 p.m. with resident 139 revealed: *Staff had attempted to shower her that morning. -The water started hot and got progressively colder. *She was upset and stated she could not tolerate it and made them stop the shower. *She was going home tomorrow and was looking forward to taking a hot shower in her own home. 7. Review of the provider's current shower schedule revealed: *Each resident was scheduled to shower on one morning and one evening weekly on the days of the week based on their room number. *Resident 139 was assigned showers on Tuesday day shifts and Saturday evening shifts. 8. Review of resident 139's electronic medical record (EMR) revealed: *She was admitted on [DATE] for a short-term rehab stay following a surgical procedure. *Her diagnosis included fracture of right humerus (upper arm bone), fracture of right femur (upper thigh bone), irritable bowel syndrome, major depressive disorder, and anxiety disorder. *Her Brief Interview of Mental Status assessment score was 15, which indicated she was cognitively intact. *A 3/27/25 physician's order indicated May leave incision right hip open to air. May shower and let water run over, No baths or whirlpools with this incision for 4 more weeks. *A 4/11/25 orthopedic physician's note indicated, Betadine paint on incision after shower daily for 7 days. Patient [resident] needs to be able to shower with warm water may let this run over her incision - please check into getting water heater for shower fixed. *A 4/12/25 physician's order, Betadine paint on incision after shower X7 days one time a day . was documented as completed daily from 4/12/25 through 4/18/25. *Review of residents 139's Task BATHING: documentation revealed: -On 3/18/25 Sponge [bath] was documented. -On 3/22/25 ADL [activity of daily living] activity itself did not occur . Resident refused was documented. -On 3/25/25 One person physical assist [assistance]. Shower was documented. -On 4/1/25 One person physical assist. Bed bath was documented. -On 4/8/25 No set up or physical help from staff. Shower was documented. -On 4/15/25 One person physical assist. Shower was documented. -On 4/19/25 Not applicable ADL activity itself did not occur . was documented. *No documentation in the nurse's progress notes indicated why resident 139 was not provided with showers as scheduled and as ordered by her physician. *Her care plan indicated, I require staff assistance of one with the use of a shower chair. -There was no documentation in the care plan regarding the frequency of her showering. 9. Interview on 4/23/25 at 8:15 a.m. with ancillary services manager QQ revealed he: *Had not been made aware of hot water not being available in resident 139's shower. *Expected maintenance concerns and issues to be entered in the TELS electronic maintenance management system. 10. Interview on 4/23/25 at 8:18 a.m. and again at 10:58 a.m. with maintenance mechanic associate (MMA) OO revealed: *Initially, he had not recalled any issues with resident 139's shower, but after he discussed the situation with administrator B, he recalled that he had replaced and tightened the set screw so the water would be hot. -He had not documented that repair or when it had occurred. *Today (4/23/24) he replaced the cartridge and placed a new screw in resident 139's shower. *He stated the water temperature was now reaching 105 to 110 degrees Fahrenheit. *There was no place for him to document that the repair was completed because there had not been a maintenance request on the TELS system. *He stated that staff would inform him of maintenance issues by writing them in a binder at the nurse's station, entering it in the TELS system, or by telling him in person. *If the staff used the TELS system, it allowed them to see who opened and closed a work order. 11. Interview on 4/23/25 at 8:49 a.m. with assistant director of nursing/infection preventionist (ADON/IP) G revealed: *She was the nurse manager on the rehab unit where resident 139 resided. *Staff could report issues, such as no hot water, to maintenance staff by writing it in a binder at the nurse's station, entering it into the TELS system, or telling maintenance staff verbally. *Staff in the rehab unit typically told her of maintenance issues, and she would tell maintenance staff. *She became aware of resident 139's shower not having hot water when she reviewed the physician's orders and recommendations shortly after the resident's 4/11/24 orthopedic appointment. *She thought the physician's note for the resident to have daily showers was only a recommendation, and they did not provide daily showers. -The most showers a resident could have received weekly was two, unless the resident was independent and could take showers without staff assistance. *She expected that the residents' showers would be completed as posted and scheduled. *Regarding the physician's recommendation that resident 139's shower needed to be fixed, she had notified administrator B, and he had worked with maintenance to get the shower fixed. *She was unaware that resident 139 had continued to have problems with her shower after that time. *She confirmed that there were four documented showers for resident 139 from 4/19/24 through 4/23/24. *There had been a problem within the EMR documentation system related to charting evening showers, and resident 139 may have received more showers than had been documented. -That information was not documented anywhere else. *She thought that the resident refused showers frequently. 12. Interview on 4/23/25 at 8:57 a.m. and again at 9:11 a.m. with administrator B revealed: *After resident 139's 4/11/25 orthopedic appointment, ADON/IP G had informed him that the resident's shower needed to be looked at because it may have had a problem with hot water. *At that time, he and MMA OO looked at resident 139's shower and adjusted the handle to make the water warmer. *There was no documentation of that repair. *No shower water temperature checks or audits had been completed to confirm the shower was fixed. *He had not put that maintenance request in the TELS system. -If a repair was completed immediately, it would not always get put in the TELS system. *He had requested that MMA OO change the shower cartridge today (4/23/25) to ensure resident 139 would have hot water for her shower. *He confirmed that resident 139 was discharged to home today. 13. Interview and review of resident 139's 4/12/25 physician's order on 4/23/25 at 2:15 p.m. with director of nursing (DON) R revealed: *Resident 139 had seen her orthopedic physician on 4/11/25. *The order for Betadine paint on incision after shower daily for 7 days had been documented as completed daily from 4/12/25 through 4/18/25. *She confirmed that resident 139 was documented as having received only four showers in the last 30 days. *She expected there to have been clarification with the physician that the shower would not have been provided every day because, Realistically, there would be no way to do that. *She stated the resident would likely not have agreed to shower every day, and there is no way the staff could give a shower every day to every resident. *She stated the physician doesn't consult with us on those orders. *She declined to answer if that task having been documented as completed would indicate the shower was completed in addition to the Betadine application. *She again stated the order should have been clarified because it was not a realistic expectation and the resident had received the Betadine to her incision. *There had been an issue within the EMR system with documenting evening showers but that issue had been identified and corrected. *There was no additional shower documentation to review for resident 139. 14. Interview on 4/24/25 at 8:46 a.m. with administrator B regarding the physician's order and documentation of showers received by resident 139 revealed: *He thought that resident 139's shower had been fixed. *He was unaware that resident 139 had not received showers as scheduled or ordered. *He expected that the nursing staff would have reached out to the physician and requested that the order be changed or to provide clarification on why the showers would not have been provided as ordered. 15. Review of the provider's revised 4/21/25 Person-Centered Care policy revealed: *Person-centered care is a central theme to federal nursing home regulations. *Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. *Employees will support residents in achieving the level of well-being that is individually practicable by providing person-centered care. Review of the provider's revised 4/6/25 Physician/Practitioner Orders policy revealed: *To provide Individualized care to each resident by obtaining appropriate, accurate and timely physician/ practitioner orders. *Clarification orders are needed when reviewing any type of physician/practitioner order that are incomplete or raise questions. Review of the provider's revised 9/3/2024 Bathing policy revealed: *Purpose: To promote cleanliness and general hygiene. *To promote comfort, relaxation, and well-being. *To observe resident's condition. Review of the provider's undated Work Orders policy revealed: *Encourage residents to request maintenance work orders using the Work Order Request (this is an optional form). *If the request is made verbally .the information should be transferred to .approved maintenance software system. *Respond to all resident requests within 24 hours with either a fix or a plan of action.

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (49), had her PRN (as needed) psychotropic medication discontinued after 14 days as ordered by the physician. Findings include: 1. Review of resident 49's electronic medical record (EMR) revealed: *A 3/27/25 order for Lorazepam (anti-anxiety/psychotropic medication) 0.5 mg tablet by mouth every six hours PRN for anxiety/agitation/restlessness. -The physician's order note regarding that same medication indicated: If PRN, order stop date=14 days. Review of resident 49's March 2025 and April 2025 medication administration records revealed: *She had not been administered the PRN Lorazepam in either month. *The PRN lorazepam order had not been discontinued after 14 days as originally ordered on 3/27/25. 2. Interview on 4/24/25 at 8:35 a.m. with registered nurse (RN)/clinical care leader (CCL) I revealed: *She would review medications and resident's PRN orders and then address the PRN order with the primary care provider (PCP) on the PCP's clinical rounds day while they were in the facility. *PRN psychotropic medications were also addressed at the monthly psychotropic meeting for all residents receiving those medications. *She was unable to find resident 49 on the schedule for the lorazepam order to be reviewed by the PCP. *She confirmed there was no stop date on the order. Interview on 4/24/25 at 8:43 a.m. with director of nursing (DON) R revealed she would have expected PRN psychotropic medications to be reviewed within 14 days by the PCP to renew or for the ordered medication to be discontinued as ordered. 3. Review of the provider's 12/9/22 Psychotropic Medications policy revealed: *7. While the use of PRN psychotropic medications is not encouraged, if a PRN physician's order is received, ensure that the order has clear parameters, i.e., severe agitation that does not respond to other care plan interventions. It is important to initiate other care plan interventions prior to use of PRN psychotropic medications. PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication.

Based on observations, interviews, record reviews, and policy reviews, the provider failed to ensure that one of the sampled residents (103), whose care plan included a fall prevention intervention of a soft touch call light within her reach to notify staff when she needed assistance, was accessible to her while in her room. Findings include: 1. Observation on 4/14/25 at 3:17 p.m. of resident 103's room revealed: *Resident 103 was lying in her bed. *There was a flat soft touch call light attached to the floor to ceiling room divider curtain about halfway up the curtain. *Due to the location of the call light related to resident 103's location she would not be able to access the call light to call for assistance. Observation on 4/15/25 at 9:26 a.m. of resident 103 in her room revealed: *She had been assisted to bed by staff with the use of a sit-to stand mechanical lift (used to assist from a seated to a standing position). *She had not responded to staff when she was spoken to. *Her soft touch call light was clipped to the room divider curtain about halfway up the floor-to-ceiling curtain. Observation on 4/16/25 at 9:32 a.m. of resident 103 in her room revealed: *She is sitting in her wheelchair facing her bed with her eyes closed. *Her soft touch press call light was clipped to the room divider curtain about halfway up the floor to ceiling curtain. 2. Interview on 4/16/25 at 3:03 p.m. with registered nurse (RN)/Minimum Data Set (MDS) nurses D and E revealed: *The flat soft touch call lights were given to a resident that was unable to push the button on a standard call light. *They were not aware of any residents that had been care planned as unable to use their call light. 3. Interview on 4/17/25 at 11:37 a.m. with certified nursing assistant (CNA) X regarding resident 103 revealed: *The resident was unable to use her call light due to her cognition. *Staff placed the call light close to her in case she could access it, but she did not, so staff checked on her frequently to ensure her needs were met. 4. Interview on 4/23/25 at 10:33 a.m. with CNA P regarding call light placement fore residents revealed call lights were to be in reach of a resident while the resident was in their room whether the resident was able to use the call light or not. 5. Interview on 4/23/25 at 10:45 a.m. with licensed practical nurse (LPN) H regarding call lights revealed: *It was her expectation for call lights to be within reach of the residents while they were in their room. *Soft touch call lights were used for the residents that were unable to press a standard call light to call for assistance by placing it beside the resident while in bed, in a recliner, or in a wheelchair, to alert staff the resident was getting up. *The call light clipped to the divider curtain in resident 103's room was not accessible to the resident while she was in her wheelchair or bed and would not alert staff if the resident were to attempt to get out of her bed or wheelchair. 6. Interview on 4/24/25 at 8:13 a.m. with director of nursing (DON) R regarding call lights revealed: *It was her expectation call lights be placed within reach of the residents while they were in their room. *Soft touch call lights were also used as a fall intervention by placing the call light alongside the resident to alert staff when the resident moved. 7. Interview on 4/24/25 at 10:29 a.m. with administrator A revealed it was her expectation that staff follow facility policies and procedures related to call lights. 8. Review of resident 103's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 2/25/25 Brief Interview for Mental Status assessment score was 0, which indicated she was severely cognitively impaired. *She had a diagnosis of dementia with other behavioral disturbance. *Her 4/15/25 care plan revealed: -She had a focus area of The resident has had an actual fall with No Injury R/T [related to] self transferring, impulsive initiated on 2/20/23 with an intervention of Soft touch call light initiated on 3/7/25. -She had a focus area of The resident is at risk for fall R/T dementia without behavioral disturbances, anxiety initiated on 12/14/22 with an intervention of I need my soft touch call light and personal items within reach and my floor clear of clutter initiated on 12/14/22. Review of the provider's 7/29/24 Call Light policy revealed: *PURPOSE -To ensure resident always has a method of calling for assistance. *When leaving the room, place [the] call light within easy reach of [the] resident. *For residents [who are] unable to use [the] call light, care plan appropriate interventions and provide an adaptive call light if applicable.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Proper cleaning and storage of a nebulizer device that converts liquid medication into an inhalable mist) as directed in the provider's policy for one of one sampled resident (116). *Proper storage of nasal cannulas (flexible tubing that delivers oxygen through the nose) while no in use and replacement of soiled nasal cannulas as directed in the provider's policy for one of one sampled resident (116). Findings include: 1. Observation on 4/14/25 at 3:18 p.m. of resident 116's room revealed: *She had an oxygen concentrator and nebulizer machine in her room. *An assembled nebulizer delivery device was lying beside the nebulizer machine on a cabinet. *There was no barrier between the nebulizer delivery device and the cabinet. *A coiled nasal cannula was lying directly on the over-the-bed table. *A nasal cannula that was not contained in a plastic bag was lying on an unmade bed, draped over a chux (protectant pad). 2. Observation of 4/15/25 at 8:41 a.m. of resident 116's room revealed: *The nebulizer tubing was draped over the cushion in the recliner. *The oxygen concentrator was running and resident 116 was not in the room. *A nasal cannula was draped over an unmade bed. 3. Observation on 4/15/25 at 9:07 a.m. of resident 116's room from the hallway revealed: *Resident 116 was wheeled into her room by registered nurse (RN) AA. *RN AA picked up the nasal cannula that was draped over the unmade bed and placed it on resident 116's face for administration of the oxygen. 4. Interview on 4/15/25 at 9:27 a.m. with resident 116 in her room revealed she: *Wore oxygen all the time because her oxygen was too low. *Received nebulizer treatments every day. 5. Observation on 4/22/25 at 2:59 p.m. of resident 116's room revealed: *There were no plastic bags on the oxygen concentrator or the oxygen cylinder device. *A nasal cannula was draped over the back of resident 116's wheelchair. 6. Interview on 4/23/25 at 10:33 a.m. with certified nursing assistant (CNA) P revealed: *Nasal cannulas were to be stored in a plastic bag when not in use to keep them free from contamination. *If a nasal cannula became soiled, such as if it fell on the floor, it would need to be changed. 7. Interview on 4/23/25 at 10:45 a.m. with licensed practical nurse (LPN) H revealed: *Oxygen cannulas were to be stored in a plastic bag when not in use to keep them free from contamination. *Plastic bags were to be changed every Monday when the oxygen tubing and nebulizer delivery devices were changed, and that was documented on the resident's treatment administration record (TAR). *If the nasal cannula fell on the floor, it would need to be changed as it would have been considered soiled. *If a nasal cannula was found on a chux, the nasal cannula would need to be changed because it could not be determined if the chux was clean. 8. Interview on 4/24/25 at 8:13 a.m. with director of nursing (DON) R revealed: *When nasal cannulas were not in use, they were to be stored in a plastic bag attached to the oxygen concentrator, hanging on the wall, or attached to the oxygen cylinder. *She expected the nasal cannula to be changed if it fell on the floor or became soiled. *She would consider a nasal cannula lying on a chux on the bed to be soiled. *The nebulizer delivery device was to be taken apart, rinsed, and laid out to dry after each use. 9. Review of resident 116's EMR revealed: *She was admitted on [DATE]. *Her 4/1/25 BIMS assessment score was 15 which indicated she was cognitively intact. *She had a diagnosis of emphysema (a chronic progressive lung disease). *A physician's order for DuoNeb Solution 0.5-2.5 (3) MG [milligrams]/3ML [milliliters] (Ipratropium-Albuterol) 1 inhalation inhale orally via nebulizer two times a day for SOB [shortness of breath]/wheezing and every 4 hours as needed for SOB/Wheezing. *A physician's order for Oxygen via nasal cannula 1-4 liters per minute as needed for dyspnea, hypoxia, (O2 saturation less than 88%) or acute angina [chest pain]. *There was no order to change the resident's oxygen tubing or the nebulizer administration set. *Her care plan had not addressed her respiratory symptoms, diagnosis, the use of oxygen, or the use of nebulizers. 10. Interview on 4/24/25 at 11:08 a.m. with RN/clinical care leader (CCL) M revealed: *When staff changed the nasal cannulas and nebulizer delivery devices it was to be charted on the resident's TAR. *She verified resident 116 did not have a place to document the changes of the oxygen cannula or nebulizer delivery devices on her TAR. 11. Review of the provider's 7/8/24 Oxygen Administration, Safety, Mask Types policy revealed: *Turn oxygen off when not in use, if appropriate. *All oxygen therapy equipment will be clean, safe, and functional at all times. *When oxygen is not in use, store cannula, face mask or face tent and tubing in zip-lock bag/plastic bag secured to the oxygen cylinder or concentrator. Review of the provider's 12/23/24 Nebulizer policy revealed: *Following medication administration clean nebulizer after each use: -Disconnect the tubing from the nebulizer. -Separate the nebulizer parts (mask/mouthpiece, cup) and wash in warm soapy water and rinse thoroughly. -Place mask or mouthpiece and cup on paper towel and air-dry until the next use. Cover with clean cloth or towel.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, observation and interview, the provider failed to ensure the safety of one of one sampled resident (1) who received a burn from a hot coffee. The citation is considered past non-compliance based on a review of the provider's corrective actions following the incident. Findings include: 1. Review of provider's 11/5/24 DOH FRI revealed: *Resident 1 received a burn was on her abdomen on 10/31/24. -The origin of the burn is suspected to be caused from hot coffee. -Coffee machines and dispensers were found to be above the temperature per the facility's policy guidelines. -The coffee machine vendor was to calibrate the machines on 11/1/24. -All coffee machines temperatures were being regulated by staff prior to the vendor's service. 2. Review of resident 1's record revealed: *Resident 1's admitted was 2/14/24. *Her diagnoses included Alzheimer's disease, and dementia. *She had a Brief Interview of Mental Status (BIMS) score of 9 which indicated she had moderate impairment. *A wound assessment was completed on 11/13/24 that indicated: -The area is healed, and scarring is noted. -She denies any pain. -Treatment of the wound is discontinued. *Resident 1's care plan indicated: -It was revised on 10/31/24 to include impaired ability to manage hot beverages and soups. *She has a difficult time remaining seated in the dining room. -She tends to enter the serving area. -Assist of one [staff]PRN [as needed] at the assisted dining room table for closer monitoring. -Supervision is needed at all times while drinking hot beverages. -She is encouraged to drink hot liquids from a cup with a lid. -She is encouraged to drink hot liquids while sitting. 3. Review of the providers hot liquids - Food and nutrition services policy dated 4/19/24 revealed: *When self-service hot liquids are available in the dining room: -Liquids should be at or below 150 degrees Fahrenheit. -The area of self-service hot liquids should be supervised. -When possible, hot liquids should be pre-poured for residents. 4. Observation of the Sells dining room on 11/13/24 at 5:00 p.m. revealed: *Dining room staff temperature checking all foods and hot beverages prior to service. *Self service coffee machine was monitored by staff during mealtime. 5. Interview on 11/14/24 at 9:30 a.m. with dietary service assistant C revealed she stated: *She worked in the Sells dining room. *She has worked in the facility since March 2024. *Hot liquids are temperature checked prior to being served to residents. *If temperatures were found to be over 150 degrees Fahrenheit, liquids were not served until the temperature decreased to 150 degrees or below. *The self-service coffee machines were monitored during mealtimes and were not available to residents outside of mealtimes. *She had received hot liquid training since resident 1's burn on 10/31/24. *She received and read an email about it sent to staff by the administrator B. *Dietary service assistant C demonstrated how to check the temperature of the coffee to this surveyor. Immediately following the above observation, this surveyor checked the temperature of the self-serve coffee machine, and the temperature was found to be 142 degrees Fahrenheit. 6. Interview on 11/14/24 at 10:48 a.m. with administrator A revealed: *All coffee machines were being temperature-regulated daily and prior to serving hot liquids to residents. *Coffee machines were calibrated on 11/1/24. *A hot beverage handling training was completed with staff on 10/31/24. -Training included How to take the temperature of hot beverages and what to do when the temperature is found to be higher than 150 degrees Fahrenheit. *An email was sent to all staff from administrator B which included the following education: -When hot liquids are available in the dining room, temperatures should be at or below 150 degrees Fahrenheit. -The area should be supervised. -Do not overfill carafes or service containers. -Pre-pour liquids whenever possible into drinking cups with lids. *All coffee machine temperature log audits were planned to be shared at the upcoming December 2024 Quality Assurance and Performance Improvement [QAPI] meeting for further review. The provider implemented action on 10/31/24 to ensure the deficient practice does not recur and was confirmed on 11/14/24 after record review revealed the facility had followed their quality assurance process, education was provided to all direct care staff regarding temperature regulation of hot liquids, observations and interviews revealed staff understood how to correctly check hot liquid temperatures, the resident's care plan was updated to include interventions to avoid hot liquid burns and audits are being performed to ensure hot liquids do not exceed the provider's policy guidelines. Based on the above information, non-compliance at F689 was determined on 10/31/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 11/14/24, the noncompliance is considered past non-compliance.

Based on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure that one of one sampled resident (1) was free from neglect by certified nursing assistant (CNA) (F) who did not provide or a shower as directed in her plan of care. Findings include: 1. Review of the provider's submitted SD DOH FRI revealed: *Staff reported to management that resident 1 did not get her shower or toileting on the day shift on 8/5/24 between 7:42 a.m. and 6:04 p.m. *Camera footage revealed that resident 1 did not get showered and was not assisted to the restroom per her care plan. *Certified Nursing Assistant (CNA) F and CNA G had documented throughout the day that resident 1 did not void, and the resident was repositioned every two hours. *During an interview, CNA F stated that she was not aware that she needed to check on residents and change them during her shift. *Both CNA F and CNA G had been written up with a final corrective reminder due to lack of care and false charting. *Skin assessment was completed for resident 1 with no issues identified. 2. Observation and interview on 9/18/24 at 1:30 p.m. with resident 1 revealed: *She was in her room sitting in her wheelchair watching TV. Resident appeared neatly dressed. *She did not verbally respond to the surveyor's questions. *She did make eye contact and nod at surveyor inconsistently. 3. Interview on 9/18/24 at 3:00 p.m. with CNA D revealed: *This was CNA D's first CNA job and she had worked at the facility for five months. -She received her training from the facility. *CNA D stated that checking on and changing residents (incontinence products or clothing) were tasks CNAs were expected to do during their shifts. *Each CNA was assigned a resident to shower each shift. *It was expected that the CNA would shower the resident, document it, and let the nurse know if there were any problems identified. *It was expected that if the CNA did not complete the resident's shower, the CNA would tell the nurse. 4. Interview on 9/18/24 at 4:30 p.m. with registered nurse (RN) C revealed: *She worked the day shift on 8/5/24. -She recalled it being a very busy day. *She recalled asking CNA F if resident 1's shower had been completed, and CNA F replied that it had been completed. *RN C stated she could not recall having seen resident 1 leave her room to go shower that day. *RN C stated resident 1 did not appear to have been showered. *RN C stated she then asked CNA F again if the shower had been completed, and CNA F replied that it had been completed. *RN C expected that CNA F would have showered and assisted her assigned residents with toileting. *RN C stated if she had been notified by CNA F that resident 1's shower had not been completed, the resident would have been offered a shower later or on a different day. *RN C stated she reported the concern to her unit manager. 5. Interview on 9/19/24 at 8:25 a.m. with director of nursing (DON) B revealed: *DON B expected that residents would be showered on their scheduled day of the week. *She expected that if a shower was missed, it would be communicated to the nurse on shift and the resident would be offered a shower later or different day that week. *Since the incident, there had been increased education to staff about the expectation for showers, repositioning, and documentation being completed and documented accurately. *They were conducting weekly hall meetings to address specific topics of concern. *CNA F was required to train an additional shift with a staff CNA. *CNA F's documentation is audited for accuracy by unit managers. -The audits are not documented and are only performed on CNA F currently. *A skills fair thatwas conducted and required for all staff, topics included abuse and neglect, and documentation. CNA F was present for the skills fair. 6. Interview on 9/19/24 at 9:20 a.m. with administrator A revealed she: *Expected that residents would be showered on their scheduled day. *Expected that if a resident was not showered, the shower would be offered at a different time. 7. Interview on 9/19/24 at 9:25 a.m. with Registered Nurse/Clinical Care Leader (RN/CCL) E revealed: *She expected CNAs would complete resident showers on their scheduled day. *Each CNA was assigned one resident to assist with showering each shift. *If the CNA did not complete the shower, the CNA was expected to inform the nurse and the shower should be offered at a different time or on a different day. *She provided a copy of a printed shower schedule for the CNAs that they were to sign after they completed the resident's shower. -She would review the printed schedule later in the week and would offer a shower to any resident who did not receive their shower on their scheduled day. 8. Review of resident 1's electronic medical record revealed: *She was admitted on [DATE] *In July 2024, her Brief Interview for Mental Status (BIMS) score was 00, which indicated she had severe cognitive impairment. *Her medical diagnoses included: Type 2 diabetes, dementia, major depressive disorder, osteoarthritis, chronic kidney disease, chronic pain, dysphagia, cerebral infarction. *Her care plan indicated that she should have been repositioned by staff every two hours. *Her care plan indicated that she should have been offered toileting assistance and checked for incontinence by staff every two hours. 9. Review of the provider's internal investigation of the incident involving resident 1 revealed: *On 8/7/24, RN C reported her concern that the resident had not been showered, toileted, or repositioned during her shift on 8/5/24. *Review of camera footage revealed that on 8/5/24, CNA F entered the resident's room for the first time at 7:48 a.m. with lift. The resident was then taken to the dining area at 7:54 a.m. -CNA F documented that the resident did not void and was repositioned at 7:04 a.m. *At 8:27 a.m., the resident returned from dining area and was placed in the hall next to the CNA desk. -The resident remained in the hallway until she was taken to the dining area at 11:35 a.m. by CNA F. -CNA F documented resident was repositioned at 9:13 a.m. and 11:32 a.m. -CNA F documented that resident did not void at 9:22 a.m. and 11:32 a.m. *At 12:23 p.m., the resident was brought back from the dining area and was placed in the hallway from 12:26 p.m. until 3:35 pm. -CNA F documented the resident did not void and was repositioned at 12:38 p.m. -CNA G documented the resident did not void at 3:22 p.m. and was repositioned at 3:23 p.m. -At 5:46 p.m., it was documented by CNA G that resident was incontinent. *At 6:03 p.m., CNA G took the resident into her room and CNA F entered the room at 6:04 p.m. with a total lift. -Prior to incontinence at 5:46 p.m. on 8/5/24, the previous incontinence documented on the resident was on 8/4/24 at 3:12 p.m. *CNA F stated that she did not know that she had to check and change residents during her shift. *CNA F confirmed that this was not her first CNA job. -She confirmed that she was required to check and change residents at previous facilities. -She confirmed that she was trained to check and change residents at this facility. *CNA F stated that she did not remember charting (in reference to falsely documented tasks), but assume you were just clicking. 10. Review of CNA F's employee file revealed: *CNA F started employment with the facility on 6/25/24. *Her CNA certification verified 6/10/24 through South Dakota Registry at https://www.sduap.org/verify/ *Her CNA certification was issued 4/20/2023. *She had completed training on: pd-2722, POC Documentation Continence Monitoring Charting: Charting the Toileting Task, completed 7/12/24. *She had completed training on: cc-8745, Module 3 Being a Person with Dementia Actions and Reactions, completed 6/26/24. *She had completed training on: gc-6885, Abuse and Neglect of the Vulnerable Adult, completed 6/26/24. *She had completed training on: gc-6903, Protecting Resident Rights in Nursing Facilities, completed 6/26/24. *A copy of a job description for nursing assistants: Provides assistance with basic health care needs including daily living activities that may include, but are not limited to, bathing, toileting, grooming, dressing/undressing, obtaining and recording vital signs, and providing psychosocial support and other personal care to assigned resident. 11. Review of CNA F's education following the incident on 8/5/24 revealed: *She was re-trained on the floor with staff CNAs (per DON B). *She attended a clinical team meeting on 8/27/24. -Topics included showering expectations, accurate and timely charting, and snacks/hydration. *She attended the mandatory skills fair on 9/11/24. -Topics included: Abuse and neglect, documentation, pressure injury prevention, fall prevention, infection prevention, and other topics. 12. Review of the provider's job description for nursing assistants revealed: *The CNA Provides assistance with basic health care needs including daily living activities that may include, but are not limited to, bathing, toileting, grooming, dressing/undressing, obtaining and recording vital signs, and providing psychosocial support and other personal care to assigned resident. *The CNA Assists the resident in transferring, repositioning, and walking using correct and appropriate transfer techniques and equipment and also provides range of motion and passive exercises. 13. Review of the resident rights pamphlet that was provided to residents upon admission to the facility revealed: *Page 1, section (a) states: The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. -Section (a)(1) states: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. *Page 2, section (c) states: The resident has the right to be informed of, and participate in, his or her treatment, including: -Section (c)(2) states The right to participate in the development and implementation of his or her person-centered plan of care, including, but not limited to: (iv) The right to receive the services and/or items included in the care plan. 14. Review of the provider's July 2024 Abuse and Neglect policy revealed: *The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment and involuntary seclusion.

A. Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview and policy review the provider failed to ensure of one of one sampled resident (3) had been accurately accounted for when a door alarm had been activated. Findings include: Notice: Notice of immediate jeopardy was given verbally and in writing on 5/30/24 at 10:41 a.m. to administrator H and director of nursing (DON) D of the immediate jeopardy related to resident elopement and quality of care at F684. On 5/30/24: * At 10:41 a.m. administrator H and DON D were notified of a request for a removal plan. On 5/31/24: *At 8:35 a.m. the removal was received. *At 8:45 a.m. the removal was accepted. On 6/3/24: *At 8:30 a.m. while on-site the survey team verified the immediacy was removed. Plan: 1.On Monday 30, 2024 at 2:52 p.m. on shift message was sent to all employees that summarized the education summary of elopement. This serves as the immediate education for all employees. If staff are not able to complete education on 5/30. They will be required to complete the make-up prior to their next shift. RN S was educated on 5/28 on the process for call DON/Administrator immediately when resident safety is at risk-including elopements. The nurse was also educated on the next step of the policy to initiate a head count of all residents when a door alarm is sounded with not explanation. 2.Certified nursing assistant (CNA) T, on the top half of 200 on 5/26 from 10 p.m. - 6 a.m. was noted to have missed a toileting round of resident 3 at 4:00 a.m. This would have decreased the time of the residents' elopement. The CNA T received a final corrective action on 5/28/ for lack of rounding during this shift. This standard will be upheld for any employees that are found to have failed to complete their rounding as ordered/recommended. 3.All staff were educated on 5/30 on the importance of rounding on all resident's multiple time a shift. Residents with high fall and elopement to chart in the hallways so residents can be in eye site. 4. All staff were educated on utilizing our call system as all exit doors are on the call system to notify all staff if an exit door is alarm on the scrolling screen and the radios. 5. Monday May 27th-when elopement occurred, assessment of resident was completed, and vital signs taken. 6. Tuesday May 28th an elopement drill was completed with day shift around lunch time. Education was provided to staff involved with elopement. 7. Wednesday May 29th around 5 p.m., an potential elopement alert was initiated due to a phone call from someone in the community stating in a resident was outdoors near [NAME] Road. Staff responded to code and facility did head count and everyone was accounted for. 8. Thursday May 30th, hallway and department education is being completed with all staff regarding elopement processes and policy review. Elopement policy/procedure was reviewed, explained what an elopement is, who is considered an elopement risk, steps to take when a potential elopement occurs, who to notify if a resident does elope and how to respond to door alarms and completing head counts if no residents were found when alarm was responded to. 9.Resident 3's physician was out to facility and updated again on recent elopement events. Resident 3's physician ordered lab work-up on him as this an increase in his normal behaviors. He also would like and update on Monday on how he is doing. 10. Elopement Drills will be completed weekly x4. These will be completed on shifts, different days of the week and different locations within the building. Then every other week x 4 weeks. On 5/31/24 8:35 a.m. the removal plan was received. On 5/31/24 at 8:45 a.m. the removal plan was accepted. On 6/3/24 at 8:30 a.m. while on-site the survey team verified immediacy was removed. Once the immediacy had been removed the scope and severity was a G. 1. Review of the SD DOH FRI revealed: *On 5/27/24 at 5:50 a.m. the report had been submitted that indicated resident 3 had eloped (left without staff knowledge) from the facility. *The resident had been located by staff and brought back to the facility. -His vitals were as follows: Temperature 98.0 Fahrenheit, Pulse rate 109 beats per minute, respiratory rate 10 breaths per minute, blood pressure 131/71, and oxygen saturation (oxygen level in the blood stream) of 97%. 2. Review of resident 3 electronic medical record (EMR) revealed he: *Had been admitted on [DATE]. *Had diagnosis of: dementia with agitation. -BIMS (brief interview mental assessment) completed on 5/13/24 with a score of 4 which indicated severe cognitive impairment. *Had been assessed and determined to have a risk for elopement on : -On 2/7/24. -On 2/8/24. -On 5/27/24. *Had an order for the placement of a wander guard (door activating bracelet) on 2/7/24 and to ensure the wander guard was in place twice a day. *Resident 3's care plan was revised on 5/14/24 for staff to have checked the functioning of the wander guard monthly. 3. Interview on 5/29/24 at 10:10 a.m. with resident 3's wife revealed: *She had not been notified of resident 3's elopement when it had occurred, but had not been updated on the provider's investigation. *He had eloped from another facility before. *Resident 3 had a wander guard on his wheelchair since he was admitted on [DATE]. 4. Interview on 5/29/24 at 2:25 p.m. with registered nurse (RN) E regarding resident 3's wander guard placement and function revealed: *She had only checked the placement of the wander guard. *RN E had known that checking the functionality of the wander was to have been performed monthly. -There had not been any documentation of the functionality of the wander guard. 5. Interview on 5/30/24 at 8:50 a.m. with DON D regarding a progress note and investigation timeline of resident 3's elopement revealed: *DON D stated certified nursing assistant (CNA) T had reported that resident 3 had not been assisted with toileting during the 5/27/24 4:00 a.m. rounds. -It was then when the resident 3 had been identified as missing. *Resident 3 had been found and escorted back into the building on 5/27/24 at 5:39 a.m. *RN S had checked the doors when the alarm sounded at 5/27/24 at 3:25 a.m. and had not identified resident 3 as missing. *She agreed that a progress note had not been created to account for resident 3's elopement on 5/27/24 at 3:15 a.m. and his return into the building at 5:39 a.m. *DON D indicated the nursing assessment upon the resident's return into the building had been documented in the facility's internal incident report. 6. Interview on 5/30/24 at 8:20 a.m. with clinical care leader RN/ C revealed she agreed that there had not been any documentation of the functionality of resident 3's wander guard. 7. Interview on 5/30/24 at 9:11 a.m. with DON D regarding a progress note in resident 3's EMR regarding a second elopement revealed: *She was unsure of why a progress note had been made on 5/27/24 at 9:41 p.m. that indicted resident 3 had been outside of the building waving at cars. *She had not been aware of that elopement or another elopement by resident 3. 8. Review of the SD DOH FRI submitted on 5/31/24 at 4:00 p.m. regarding resident 3's second elopement revealed: *State surveyor was in the building and called out a progress note of an elopement. After further investigation the resident was confirmed eloping. *Investigation conclusion revealed: -Cameras was reviewed and confirmed that resident did exit the building after pushing on the outside door for 15 seconds. Staff responded to the alarm and escorted the resident back inside. Resident left the building at 8:06 p.m. and was escorted back into the building at 8:20 p.m. 9. Review of the provider's July 2023 Elopement policy revealed an elopement was defined as When a resident who needs supervision leave the premises or a safe area without authorization. 49238 B. Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure cares and services were provided to meet the needs for one of one sampled resident (2) with cognitive impairment, who was dependent on staff for all cares, used a call light at times to alert staff of needs, and had a history of falls. Findings include: 1. Review of the SD DOH FRI submitted on 5/20/24 revealed: -*On 5/18/24 at 12:30 p.m. resident 2 was found in her room by a nurse. -She was lying on her back, on the floor next to her bed. -she was naked and covered in feces. -The resident was assessed and no apparent injury was found. -Resident was able to perform range of motion (ROM) per her baseline without per baseline right side was flaccid (a type of paralysis) from a history of a stroke. -She was assisted off the floor with a hoyer lift, cleaned and put back in her bed. 2. Observation and interview on 5/29/34 at 10:23 a.m. with resident 2 and CNA N revealed: *Resident 2 was well-groomed and seated next to the nurse's station. *CNA N stated resident 2 could verbalize yes or no when asked questions and would display facial expressions. 3. Observation on 5/29/24 at 10:27 a.m. of resident 2 during an occupation therapy session with Occupational therapist (OT) U revealed: *OT U placed electrode pads that were connected to a device that stimulated muscle contractions on her right bicep and the palm of her right hand. *Resident 2 performed arm lifts with her right arm, then then performed right-hand clenching motions. *Resident grimaced and denied pain and continued doing her exercises. * No other therapy activities observed were completed with resident 2 at that time. 4. Observation and interview on 5/29/24 at 11:38 a.m. with resident 2 while in her room revealed: *She communicated by whispering and nodding or shaking her head. *She indicated she had fallen at home but had not fallen at the facility. 5. Interview with CNA N on 5/29/24 at 1:43 p.m. regarding resident 2 revealed. *She had fallen more than once since she had been admitted , but had no significant injuries from those falls. *Resident 2's memory is was not consistent. *She would have crawled out of bed if not watched, *CNA N was not aware of resident 2 having had any fall alarms, or anything being discussed with her family about that. 6. Interview with the licensed practical nurse (LPN) R on 5/29/24 at 1:47 p.m. revealed: *Resident 2 had fallen multiple times since she had been admitted . *The day shift was staffed with two nurses and two CNAs. *She has not worked short-staffed on her shifts. *She had placed resident 2 in her recliner per her request. *A couple of minutes later she stood and fell . *She had no injuries from that fall. 7. Interview on 5/29/24 at 2:00 p.m. with LPN O revealed: *Resident 2 room was located across from the nurse's station. -Resident 2 would have wanted to sleep all day and would have refused to get up at times. -She had a high fall risk. -She had fallen two days ago without an injury. *She would stand up on her own at times. *LPN O had been working there five days when resident 2 fell on [DATE]. -She had been shown the call light system during her orientation but was not familiar with it and was not sure about fall alarms. *She had not heard the call light system and stated it had not been making a sound. *She was aware resident 2's call light had been on from 11:41 a.m. until 1:05 p.m. the night she fell . *When she went into resident 2's room she found her on the floor. *Resident 2 had been moved to room closer to the nurse's station for increased monitoring. 8. Observation and interview on 5/30/24 at 7:59 a.m. with the director of nursing (DON) D while reviewing the recorded camera video from 5/18/24 revealed: *There was a long call light for resident 2's room from 11:40 to 1:05 p.m. *The video showed the hall from the nurse's station to the end of the hall where resident 2's was located on the right side of the hall. *There were multiple people who had moved up and down the hall whom she identified as visitors. *CNA K was seated near the nurses station, was on her cell phone, and had not answered the call light. *She would have expected CNA K to have made rounds during that time and to have answered call lights. *She said the nurses appeared to have been busy with other duties as they moved about the hall. *The video showed on at least two occasions, staff members had been together in that hall and had not responded to the call light. *She explained when a resident activated a call light the room number would be displayed on a digital board in the hall and at the nurses's station and it would alert to the staff walkie-talkies. *It would have alerted a nurse manager if the call light was not responded to within 15 minutes, then administration if still not responded to after 20 minutes. *It had a digital voice that would announce over the intercom and would repeat, Bedroom nurse call [room number] or Bathroom nurse call [room number]. *The walkie-talkies could be turned off and the volume could be turned down. *The nurse manager was attending to another resident at that time. *She was not sure why resident 2's call light was not answered timely. *She agreed the needs for resident 2 should have been anticipated due to her admitting diagnoses of an aneurysm affecting her right side, impaired cognition and communication, and Clostridium difficile (C-diff, a condition that can cause frequent diarrhea, colon inflammation, and colon damage). *She agreed that resident 2 was incontinent of her bowels during two of her falls. *She agreed that the resident 2's needs related to C-diff had not been anticipated on more than one occasion. *She stated LPN O had been oriented to the call light system. *She stated the nurse on shift LPN O, would have been responsible for CNA K's care she provided to the residents. 9. Observation and interview on 6/3/24 at 8:34 a.m. with resident 2 and LPN O and LPN R revealed: *LPN O had assisted resident 2 from her room and seated her near the nurse's station. *Resident 2 had a laceration to the right side of her head that was actively bleeding and had a raised area on the back of the left side of her head. *Resident 2 indicated she fell after trying to get herself up. *LPN O stated, she was standing at the med cart outside of resident 2's room and heard her fall but did not see her fall. *LPN O then took resident 2 into her room to clean her wound. *LPN R stated she was completing paperwork for resident 2 to transfer to the emergency room for further treatment. 10. Interview on 6/4/24 at 7:20 a.m. with agency RN P revealed: *Resident 2 had fallen on 6/2/24 while she had been working. *No injuries were noted. *She stated she had placed her on 15-minute checks, but these are not documented anywhere as being done. *The 15-minute checks were not being done before resident 2's fall on 6/2/24. *She stated resident 2 should have one-to-one care. *Nurses were to initiate interventions after a resident had a fall. 11. Interview and observation on 6/4/24 at 7:50 a.m. with LPN O and resident 2 revealed: *Resident 2 opened her closed room door independently while in her wheelchair. *She could not open her door while in the room until LPN O showed her the automatic door open button on the wall and then resident 2 opened the door by pushing the button. 12. Interview on 6/4/24 at 7:56 a.m. with clinical care leader registered nurse RN G revealed: *Resident 2's care plan for falls consisted of toileting every 2 hours. *Resident interventions could be seen in a resident chart in the risk management area. *CNAs were to review the interventions in the residents' care plans. *She stated resident 2 could have a mat on the floor but she would be afraid she would trip over it when she tried to get up independently. *She agreed she was moved to room closer to the nurse's station for increased monitoring but it was not on her care plan. *She stated activities were care planned to keep her busy to help with not transferring herself, she did not find this in her care plan while using her computer during the interview. *She was to be seated at the nurse's station for one-to-one monitoring, and this was not on her care plan. *She was aware of the long call light response wait time that occurred on 5/18/24. *She does not do call light audits unless a situation requires audits. *If the nurse manager on the weekend was too busy to assist with a long call light she could have called for assistance. *No fall alarms of any kind are allowed there. *Agency staff do not have access to their policies. 13. Interview on 6/4/24 at 8:56 a.m. with DON D revealed: *Professional standards are their facility policies. *A Brief Interview for Mental Status (BIMS) was the only cognition tool used at the facility unless there was a drastic change in a resident's score. 14. Record review of resident 2's Minimum Data Set (MDS) dated [DATE] revealed: *Her Brief Interview for Mental Status (BIMS) score was 3. *A BIMS score of 00-07 indicated severe cognitive impairment. 15. Record review of Resident 2's incident reports revealed: *On 5/18/24 she was found in her room on the floor naked next to her bed with feces all over her, without injury. This was an unwitnessed fall. *On 5/21/24 she was found kneeling by her bed with her upper torso and arms lying in bed, without injury. This was an unwitnessed fall. *On 5/27/24 she fell by a nurse at the nurses station across from her room, without injury. This was a witnessed fall. *On 6/2/24 She was found on the floor, without injury. This was an unwitnessed fall. 16. Record review of Resident 2's current care plan revealed interventions that included staff were to:: *Ensure/provide a safe environment: pressure call bell available at all times. Initiated and revision date 5/17/24. *Monitor resident for significant changes in gait, mobility, positioning device, standing/sitting balance, and lower extremity joint function. *Provided occupational (OT)/speech therapy (ST) cue cards into the resident's room due to impaired speech related to a history of stroke. This was dated 5/20/24, there was no revision date. *There were no other fall interventions indicated in her care plan. 17. Record review of resident 2's electronic medical records (EMR) revealed diagnoses including cerebral infarction (stoke)affecting right dominant side, cerebral aneurysm (ballooning of a blood vessel in the brain), Parkinson's disease without dyskinesia without mention of fluctuations, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and transient cerebral ischemic attack (blocked blood flow that may cause stroke-like symptoms). 18. Record review of resident 2's nurse progress notes revealed: *On 5/17/24 the nursing interventions provided/required by nursing to address the resident's medical condition included, medication administration, encouraged and assisted with ADLs, safe transfers, contact precautions applied for cares, antibiotic administration for Clostridium difficile treatment (C-diff). How effective are the interventions/what progress is the resident making, noted as effective. *On 5/18/24 the LPN O went into the resident's room and found the resident on the floor naked covered in feces lying on her back. The resident was on the floor next to her bed. Resident was assessed for injuries, and no apparent injury was found. Resident able to perform Range of motion without per baseline as her right side remains noted flaccid from history of stroke. Resident assisted off the floor via hoyer lift and cleaned and put back in her bed. Facility protocol being followed. *On 5/19/24 Nursing interventions noted, medication administration, encouraged and assisted with ADLs safe transfers, contact precautions applied for cares, antibiotic administration for C-diff treatment. Effectiveness noted, effective. *On 5/22/24 nursing interventions involved, assist with all cares, able to feed self after set up, assisted as needed, therapy as needed. Effective of interventions noted, monitor safety and anticipate needs. *On 5/20/24 nursing interventions included, medication administration, encouraged and assisted with ADLs, safe transfers, contact precautions applied for cares, antibiotic administration for -diff treatment. Effectiveness noted, effective. *On 5/21/24 note involved, resident was noted kneeling by bed and recliner, upper body and arms on bed, knees on floor. Resident had diarrhea noted on linen, resident was checked and was dry 1 hour prior and staff was doing 15 minute visual checks due to risk of falls. She was seen 5-10 minutes prior to fall and was sleeping. She was alert and assisted back to bed after assessment completed with no injuries noted, range of motion with in normal limits (WNL), vitals signs WNL, neurological exam (neuros) WNL. Resident resting in bed, calm at this time. *On 5/22/24 the nursing interventions involved, assist with all cares, assisted as needed, therapy as needed. Effectiveness noted, monitor safety and anticipate needs. *On 5/24/24 nursing interventions involved, will monitor medications, pain, skin integrity, vital signs and mobility. Effectiveness noted, has been progressed to sit to stand. *On 5/25/24 the nursing interventions involved, medications administration, encouraged and assisted with ADLs, safer transfers, contact precautions applied for cares, antibiotic administration for C-diff treatment. Effectiveness noted, cares need to be anticipated. *On 5/25/24 nursing interventions involved, encouraged and assisted with ADLs, safe transfers, contact precautions applied for cares, antibiotic administration for C-diff treatment. Effectiveness noted, Cares need to be anticipated. *On 5/26/24 nursing interventions involved, medication administration, encouraged and assisted with ADLs, safe transfers, contact precautions applied for cares. Effectiveness noted, cares need to be anticipated. *On 5/27/24 nursing interventions involved, medication administration, encouraged and assisted with ADLs, safe transfers. Effectiveness noted, resident continues to be a high fall risk with frequent checks required. *On 5/28/24 nursing interventions involved, assist with all cares, able to feed self after set up, assisted as needed, therapy as needed. Effectiveness noted, continue to assist as needed, more responsive. *On 6/1/24 the nursing interventions involved, assist with all dressing, hygiene, transfers, bed mobility, locomotion, and toileting. More restless this evening after supper, attempting to verbalize more, Continues poor safety awareness, able to feed self after set up, appetite good, therapy as able. Effectiveness noted, continue to anticipate needs. *On 6/2/24 the nursing interventions involved, assist with dressing, hygiene, transfers, bed mobility, locomotion and toileting. More restless this eve after supper. Attempting to verbalize more. Continues poor safety awareness. Able to feed self after set up. Appetite good. Neuros WNL after unwitnessed fall. Therapy as able. *On 6/3/24 The incident progress note read, After resident was done eating breakfast, resident was put in her room to watch television, while the resident was watching television she attempted to stand up and fell on the floor and hit her head which resulted in a knot to the back of her head and a laceration to the right side of her head that didn't stop bleeding even with pressure. *On 6/3/24 the nurse progress note read, resident returned from emergency room visit following fall this a.m. During her hospitalization the resident received 6 staples to the laceration noted on the right side of her head. 19. Review of the provider's 11/1/23 Rehab/Skilled and Long Term Care Therapy Rehab policy revealed: *Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. *The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. It will address the relationship of items or services required and the facility responsibility for providing these services. 20. Review of the provider's 8/1/23 call light policy revealed staff were to:: *Ensure the resident always had a method of calling for assistance. *Promptly answer the residents' call lights.

Based on interview, observation, record review, and policy review, the provider failed to ensure interventions were consistently implemented for two of two sampled resident (38 and 83) who developed a pressure ulcer. Finding include: 1. Telephone interview on 12/05/23 at 3:23 p.m. with resident 83's family member revealed: *The family member was concerned that the resident smelled of urine when they would visit and felt that he was not being checked and changed when he was incontinent. *The family member stated that they had voiced their concerns regarding that at the residents care conferences. Interview on 12/6/23 at 7:30 a.m. with registered nurse (RN) manager I and RN J revealed: *Resident had an unstageable pressure ulcer on his left (L) heel that was originally identified in December 2022 during a routine skin check. *Resident had peripheral vascular disease that had made the healing of the pressure ulcer on the heel more difficult. *The resident had a stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed or may appear as an intact or open/ruptured blister) pressure ulcer to his buttock that was identified on May 2, 2023, that had since healed. *Interventions were put in place for the resident to wear heel boots and to have been repositioned every 2 hours before the development of the pressure ulcer to his right (R) buttock. *The certified nursing assistants (CNAs) were responsible for charting when interventions such as repositioning was completed. *Nursing staff were responsible for ensuring interventions were implemented and followed through by the CNAs. Review of resident 83's 4/16/2023 Braden scale for predicting pressure ulcer risk form revealed: *The resident had a score of 14 indicating a moderate risk for skin breakdown. *Interventions documented on the Braden scale included the following: -Frequent turning with a planned schedule. -Use foam wedges for 30-degree lateral positioning. -Pressure reduction support surfaces. -Maximal remobilization. -Protect heels. -Manage moisture. -Manage Nutrition. -Manage friction and shear. Review of resident 83's most recent care plan revealed: *He had the potential for pressure ulcer development related to incontinence of bowel and bladder and right-sided weakness evidenced by a history of vascular and pressure ulcers. *Interventions initiated on 1/14/2020 and revised on 8/7/2023 had included assisting with turning and repositioning and offering the toilet at least every 2 hours. Review of the April 2023 repositioning documentation for resident 83 revealed multiple missing documentation that the resident was not repositioned that went from 4 to 20 hours in between documentation by the CNAs for repositioning every 2 hours. Interview on 12/7/23 at 8:15 a.m. with RN manager I revealed: *The documentation for repositioning had been a challenge to ensure interventions were completed. *Nurse managers had recently identified the issue of lack of repositioning documentation by the CNAs and were auditing charts to ensure that repositioning was being documented. *CNAs were made aware of interventions through group huddles and interventions were entered into the provider's Point Click Care system under the CNA tasks. *Documentation that the pressure ulcers were unavoidable was requested but the surveyor had received no documentation before exiting the facility. 2. Interview on 12/4/23 at 3:11 p.m. with resident 38 revealed: *She was not able to use her arms and legs and spent most of her time in bed. *She was not able to operate the call light system provided, used her cell phone to call the facility and contact the nursing staff. -She had called the facility around 1:00 p.m. that day, but her phone call went unanswered. -She called a little later but again her phone call was not answered. -At 1:30 p.m. a CNA came by her room and she was able to get her needs addressed. --She had needed her fan moved, the window shades pulled down, and a blanket placed over her. *She felt there was not enough staff during the evening shift, night shift, and on the weekends. -She dreaded the weekends. -She had difficulty getting her teeth brushed at night [bedtime]. --She stated four out of seven days her teeth were not brushed at bedtime. --She had brushed her teeth every morning and bedtime when she lived at home. Observations and interviews on 12/5/23 included: *From 8:11 a.m. through 8:22 a.m. she was lying on her back in bed until registered nurse (RN)/clinical care leader R and agency licensed practical nurse (LPN) S came in and repositioned her. This surveyor stepped out and then returned to resume the interview. Observation and interview on 12/5/23 at 8:22 a.m. with resident 38 revealed: *She was laying tilted to her left side with a pillow under her right side on an alternating airflow mattress. *She was to have been turned and repositioned every couple of hours, including throughout the night. *She stated that she had not been repositioned at all last night and had laid flat on her back all night. Observation and interview on 12/5/23 at 11:15 a.m. with resident 38 revealed she remained laying tilted to her left side with a pillow underneath her right side. Resident 38 stated she was supposed to have been turned and repositioned every two hours but now it had been three hours later and she had not been repositioned. Review of resident 38's electronic medical record revealed: *She was a quadriplegic. *Her current care plan included: -An intervention I have natural teeth along with an upper partial, I need total assistance with my oral cares. --An intervention to Turn/reposition approx. [approximately] every 2 hours; try to avoid right side due to ulcer. I do refuse to reposition at times. Interview on 12/7/23 at 9:58 a.m. with RN/clinical care leader R regarding resident 38 revealed: *She had the stage four pressure ulcer on her right ischium for almost two years. -The pressure ulcer was categorized as a chronic pressure ulcer. *Their electronic health record was having problems with the task of turning and repositioning every two hours not pulling into the system [not recording the task]. *She was not surprised to learn resident 38 had experienced difficulties with getting her teeth brushed at bedtime. Review of the provider's 2/10/2023 Pressure Ulcer policy revealed that the provider would use prevention and assessment interventions to ensure that a resident entering a location without pressure ulcers would not develop pressure ulcers unless the individual's clinical condition demonstrated that the pressure ulcer was unavoidable.

Based on observation, interview, record review, and policy review, the provider failed to ensure ongoing monitoring, assessments, resident education, and interventions were implemented for one of two sampled residents (83) who acquired an in-house pressure ulcer. Findings include: 1. Observation on 6/14/21 at 8:52 a.m. of resident 83 revealed he had: *Been sitting in his wheelchair in his room. *A pressure relieving boot on his right foot and a tennis shoe on his left foot with both feet placed on the wheelchair pedals. *A pressure relieving air mattress on his bed with another boot laying on that bed. *A mechanical lift sling laying on the second bed in the room. Observation and Interview on 6/14/21 at 1:49 p.m. with resident 83 revealed he: *Had been in bed. -Was laying on his back. -Had a pressure relieving boot on his right foot and a tennis shoe on his left foot. -Had a pillow underneath his knees. --Both knees were bent, and he was unable to straighten them. *Stated he: -Had a boil, what I call my sores from his wheelchair. -Had one on his heel and one on his buttock. -Wore a padded boot and thought his foot had a wrapping under the boot. -Had a sore bottom that hurt from sitting in his wheelchair ten to twelve hours each day. -Had pain in his right foot and it was aggravating. -Had a towel between his knees at night due to knee problems. -Had not received any restorative exercises and he would have participated if he had been offered. -Thought the provider was terribly understaffed, many people just don't come to work. -Thought his boil/sores were improving. Review of resident 83's medical record revealed: *He had been admitted on [DATE]. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)]. -Peripheral vascular disease, unspecified. -Bilateral primary [CONDITION(S)] of knee. -Raynaud's syndrome without gangrene (a disorder that can cause decreased blood flow to areas of the body including the toes and knees). -[CONDITION(S)] [CONDITION(S)], unspecified. -Unspecified protein-calorie malnutrition. -Other multiple and varied diagnosis. Review of resident 83's 1/29/21 Minimum Data Set (MDS) assessment revealed: *His Brief Interview for Mental Status (BIMS) assessment score was fifteen indicating his cognition was intact. *He: -Did not have a pressure ulcer or injury. -Had been at risk for developing pressure ulcers or injury. -Had used a pressure reducing device for chair and bed. -Had not been on a turning/repositioning program. -Required two staff members and extensive assistance to: --Turn in bed from one side to the other. --Position body while in bed. --Transfer to and from bed to chair or wheelchair. -Required one staff member and extensive assistance for personal hygiene. -Had impairment in his range of motion to both sides of his lower extremities. Review of resident 83's 1/25/21 nursing admission assessment revealed he: *Had no contractures to his lower extremities. -This was not correct per documentation by physical therapy. *Had no pressure ulcers. -Had a focus of the potential for pressure ulcer development related to his decreased mobility. -Had a goal of having intact skin, free from redness, blisters, or discoloration. -Did not have specific interventions to prevent pressure ulcers on this assessment. *Was not able to move up in his bed from a lying position on his own. *Required an assistive device or employee assistance to turn from side to side while in bed. *Was not able to move from a lying or reclining position to sitting on the edge of the bed on his own. *Required guided maneuvering of limbs by an assistive device or employee assistance. *Required a repositioning sling or device. *Was unable to bear weight on at least one leg. Review of resident 83's 1/26/21 physical therapy evaluation revealed he had: *Been unable to ambulate and transfer independently. *Significant lower extremity instability. *Bilateral knee contractures. Review of resident 83's 1/25/21 Braden Scale for Predicting Pressure Sore Risk assessment revealed he had a score of 17 which indicated a mild risk for developing pressure ulcers. Review of resident 83's 1/25/21 initial care plan revealed he had: *A focus of The resident has potential for pressure ulcer development R/T [related to] decreased mobility. *A goal of Resident will have intact skin, free of redness, blisters or discoloration by/through review date. *Interventions of -Monitor/remind/assist to turn/reposition at least every two hours. -Pressure reducing mattress, cushion in w/c [wheelchair]. -Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. *A revision to this care plan was made on 5/18/21 to include an additional intervention of: -Air mattress, Roho cushion in wheelchair. Review of resident 83's current care plan revealed: *Focus: -On 2/23/21 for a right heel pressure ulcer. -On 3/11/21 to include the right heel pressure ulcer and a right lower buttock pressure ulcer. *Goal: -Initiated on 2/23/21 of: Resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. -Initiated on 5/2/21 of: Resident's pressure ulcer will show signs of healing and remain free from infection through review date. *Interventions included: -On 2/23/21: --Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. --Assess/record/monitor wound healing daily. Report improvements and declines to the health care provider. --Heel boot to right foot when up in chair; bilateral boots on when in bed. -On 3/11/21: --Educate resident/family as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. --Assist to turn/reposition at least every 2 hours. Prefers going from wheelchair to bed or recliner. --Inform resident/family of any new area of skin breakdown. *An intervention of Transfer resident to (SPECIFY) bed/chair to rest (SPECIFY) after meals. had been removed. *On 4/21/21: -Air mattress applied to bed, cushion to wheelchair or recliner. *Revised on 5/12/21 to: Air mattress applied to bed, cushion to wheelchair and recliner. Currently trying a Roho cushion in his wheelchair. *Revised on 6/15/21 to: Air mattress applied to bed, cushion to wheelchair and recliner. Roho cushion in his wheelchair. Review of resident 83's medical progress notes revealed: *On 2/4/21 a care plan review had been completed. -He had met goal of no pressure injury. -He had benefited from a repositioning schedule, pressure reducing mattress, and a cushion on his wheelchair. *On 2/6/21 he had complained of pain to his right foot. *On 2/20/21 at 3:30 a.m. a pressure ulcer measuring 6 centimeters (cm) by 3.5 cm was identified on his right heel. -It had looked black and had been blanchable, with pus oozing from it. *On 2/21/21 his daughter had been informed of his right heel pressure ulcer. *On 2/23/21 a fax was sent to the physician requesting treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . *On 3/11/21 his daughter had been informed of a wound to his bottom right buttock area. *On 4/8/21 a voice message was left with his daughter to update that his bottom was not improving and that he needs to lay down in order to get his bottom healed. Resident was willing but was definitely not thrilled about the idea. Writer also updated that we will be changing the treatment as well and to call if she had any questions. *There had been no documented education regarding pressure injuries to resident 83 prior to 4/8/21. Review of Resident 83's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *Received 650 milligrams (mg) of Tylenol 8 hour tablet extended release 56 times. -Forty-nine times for unspecified pain. -On 2/11/21, 2/12/21 for right leg pain -On 2/12/21, 2/13/21, 2/24/21 for leg pain. -On 2/25/21 for right leg and heel pain. -On 2/26/21 for right heel pain. *On 2/15/21 he had a prescription order added for Tylenol extra strength 500 mg three times per day for pain and had received it 34 times from 2/15/21 through 2/26/21. Review of resident 83's 1/25/21 through 4/7/21 progress notes revealed there had been no documentation of him refusing to be repositioned. Review of resident 83's 2/19/21 skin assessment revealed he: *Had a pressure sore on his right heel. -It measured 6 cm by 3.5 cm. -It was black, blanchable, sore to touch and had pus oozing from it. Review of resident 83's 2/21/21 wound assessment revealed he: *Had a pressure ulcer on his right heel: -It measured 5.5 cm x 3.5 cm. -It had red edges surrounded by black edges and had a slight foul odor. -There had been a presence of possible complications, including increasing area of ulceration, or soft tissue infection. *Had pain related to the wound and described it as tender. *Had a heel lift boot applied. Review of resident 83's 3/11/21 wound assessment revealed he: *Had a pressure ulcer to his right buttock. -It measured 3.5 cm x 3 cm. *Had pain related to the wound and described it as sore. *Had been repositioned to a recliner. Interview on 6/15/21 at 4:32 at p.m. with registered nurse I regarding resident 83 revealed: *His wounds had started on his right heel. *He had not been evaluated or assessed for positioning until after the pressure ulcer had been identified in February 2021. *She had been the person to assess him for positioning after the pressure ulcers developed. *His foot pedals on his wheelchair had not been positioned properly when he was up in his chair which pushed his legs upward, putting pressure on his heels, which caused the pressure ulcer. *Staff then noticed redness on his buttock several days later. -It appeared to correlate to his right heel and how he had been repositioned to relieve pressure from his foot which caused more pressure to be put on his buttocks. *He would allow staff to reposition him but would not lay down. *He had been more compliant with lying down since they had educated him why it was important to offload for pressure relief. -Education provided to him had been documented on 4/8/21. Interview on 6/15/21 at 4:44 p.m. with certified nursing assistant (CNA) G regarding resident 83's wounds revealed: *She checked with the nurse for direction in caring for anyone with a pressure ulcer. *He wore a pressure relieving heel boot on his right foot due to a pressure ulcer. *He should have been repositioned once every two hours. Interview on 6/15/21 at 4:47 p.m. with CNA H regarding resident 83's wounds revealed: *She usually came to work after 4:00 p.m. *He was in bed when she came to work. -He laid down after lunch to relieve pressure from his bottom. *When he was in bed there was a pillow under his heels and pressure relieving boots on both feet. *He got up at 5:30 p.m. for supper and went to bed at 9:00 p.m. *His wound dressings were changed at 9:30 p.m. each night. Interview on 6/16/21 at 7:04 a.m. with director of nursing D regarding resident 83 revealed she was not sure if a wheelchair positioning assessment had been completed, as he had contractures when admitted . She stated she would provide the assessments if she found them. There were no wheelchair positioning assessments provided. Interview on 6/16/21 at 8:52 a.m. with administrator E regarding resident 83's pressure ulcers revealed: *They could have benefited from a wound nurse. -Had two applicants for the wound nurse position. *The resident was cognitive and staff would not have known he had pain in his heel unless he informed them of his pain with his positioning. Review of provider's 2/10/21 Pressure Ulcers policy revealed: *Purpose: to provide appropriate assessment and prevention of pressure ulcers, as well as treatment when necessary. *Policy: -Based on the resident's comprehensive assessment, the location will use prevention and assessment interventions to ensure that a resident entering the location without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable. -A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. -Residents will receive appropriate assessments and services to promote and maintain skin integrity. If a resident's clinical condition makes compromise of skin integrity clinically unavoidable, this information will be documented in the medical record. Review of provider's 4/21/21 Skin Assessment Pressure Ulcer Prevention and Documentation policy revealed: *Purpose: -To systematically assess residents with regard to risk of skin breakdown. -To accurately document observations and assessments of residents. -To appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. *Procedure: -1. All residents will 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 [User-Defined Assessment]. Those residents determined to be at risk will have the Braden Scale completed weekly for the first four weeks following admission. 6. Residents who are unable to reposition themselves independently, as indicated on the Sit-Stand-Walk Data Collection Tool UDA, should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnoses, mobility and observation of the resident's skin over a period of time. The Positioning Assessment and Evaluation UDA is a required tool that is used to determine an individualized repositioning schedule. The positioning schedule should be communicated to the nursing assistants using the Kardex in PCC-POC. Any resident at risk will be placed on a pressure redistribution surface as determined appropriate. *11. The interdisciplinary teams should determine any modifications that are necessary to the resident's plan of care. Interventions should focus on physical, mental and psychosocial aspects that may be impacted. Treatments and interventions should be consistent with the resident's goals. Education should be provided to the resident and or family.

Based on observation, record review, interview, and policy review, the provider failed to ensure: *One of three sampled residents (12) with a facility acquired pressure ulcer had received preventative care and treatment. *Two of three sampled residents (42 and 75) whose care for pressure ulcers had not followed the provider's policy and procedures. Findings include: 1. Interview and observation on 2/14/18 at 10:00 a.m. of resident 12 revealed he: *Was seated in his wheelchair (w/c) in his room. *Was leaning to the right in his w/c. *Stated the sore on his bottom hurt. Refer to F657 finding 1. Review of resident 12's following Braden Scale for Predicting Pressure Sore Risk assessments revealed: *On 9/18/17 his score was a twelve indicating a high risk for the development of a pressure ulcer. *On 9/25/17 his score was a fourteen indicating a moderate risk for the development of a pressure ulcer. *On 2/5/18 his score was a fifteen indicating a mild risk for the development of a pressure ulcer. Review of resident 12's pressure ulcer healing record (PUSH) tool for his left buttock pressure ulcer revealed: *It had been acquired on 12/27/17. *The initial measurements were 3 centimeters (cm) in length (L), 5 cm in width (W), and zero cm depth. *Measurements taken on 2/14/18 were 3.5 cm L, 3.5 cm W, and zero cm depth. *Progress notes by MDS coordinator T recorded on the PUSH tool included: -1/4/18 measurements are slightly larger. Continue to monitor weekly. Will contact ATM (contracted pressure ulcer product and consultant) as well for suggestions for treatment. -1/9/18: Skin is now eschar, some drainage present on dressing. Wound specialist out today requesting dressing orders for hydrogel saturated gauze and foam Q (every) daily and PRN (as needed). Fax sent to primary physician requesting orders. -1/17/18: Area bigger in size, slough present in wound bed. Continue new dressing order at this time. Temporary catheter was placed to help with moisture. Will continue to monitor weekly. -1/25/18: Area larger this week, 90% granulation/10% slough. Will continue with current dressing and monitor weekly. -1/31/18: Area slightly smaller this week. Some slough still present. Will change dressing to meet needs and monitor weekly. -2/8/18: Area same size, more slough present in wound bed, continue with same dressing and weekly monitoring. -2/14/18 Area measuring smaller today, 10% slough, 90% epi ([MEDICATION NAME]) tissue. Will ask to d/c (discontinue) hydrogel and continue with rest of dressing order. Review of a 1/24/18 wound care skin integrity evaluation by the contracted wound specialist revealed: *It was located on the left ischial tuberosity. *Had been acquired on 1/2/18. *Was a full thickness pressure ulcer and was a stage three. *Measured 3 cm L, 5 cm W, and 0.3 cm in depth. *Had wound pain of a seven on a scale of zero to ten with ten being the worst pain and zero being none. Review of the Minimum Data Set (MDS) nursing care plan review revealed on: *5/24/17 The resident benefits from pressure relieving mattress on bed for pressure injury prevention. *8/21/17 The resident benefits from foam cushion on wheelchair for pressure injury prevention. *11/14/17 The resident did not meet pressure injury goal of no pressure injury: unstageable to right heel. The resident did not meet pain goal of no pain: c/o (complaints of) pain d/t (due to) bol (boil) on lower left buttock. The benefits from pressure relieving mattress on bed and roho cushion on wheelchair for pressure injury prevention. Interview on 2/14/18 at 3:40 p.m. with MDS coordinator T revealed she: *Had previously been a unit manager and had completed the PUSH tool on a weekly basis regarding residents with impaired skin integrity. *Had taken over as one of the MDS coordinators, and those PUSH tools had not been completed on a regular basis. *Agreed it was difficult to determine when his left buttock boil had healed and when he had acquired his left buttock pressure ulcer. *Confirmed his care plan did not reflect his current condition including his pain and acquired pressure ulcer. *His care plan had never been updated with his ongoing skin integrity problems. *Agreed interventions had not been put in place for the prevention of impaired skin integrity. 2. Observation on 2/12/18 at 4:45 p.m. and at 6:22 p.m. of resident 42 in her room revealed: *She had a small thin body build and did not verbally respond to the surveyor.*She was sitting in a Broda specialty w/c in the reclining position. *She had positioners on both sides of her upper body to help keep her sitting up straight. *There was a pillow placed between her left leg and the side of the w/c. *She was wearing slipper socks and had no heel protection on her feet. -Heel protectors were laying on her bed. *She had a mechanical lift sling left in place under her. Observation on 2/12/18 at 6:32 p.m. of resident 42 revealed: *She was wheeled into the dining room by staff in her Broda w/c. -No heel protectors were on her feet. *She required staff assistance with eating, drinking, and moving the wheelchair. Observation, interview, and record review on 2/13/18 at 10:02 a.m. with licensed practical nurse (LPN) R during resident 42's left shin dressing change revealed: *The resident was sitting in her Broda wheelchair in her room. -She had the lift sling underneath her and was not wearing any heel protection.*She stated the resident had thin, fragile skin. *The left shin wound had no: -physician's orders [REDACTED]. -Documentation to indicate what had happened or when it had been found. *Following the shin dressing change she put heel protectors on the resident. *During the review of the resident's physician's orders [REDACTED]. -She stated she had an area to her coccyx that was opened at times, and she had a history of [REDACTED]. *The dressing was not ordered to be completed that day, so she would not be looking at it. *The surveyor then requested to observe the residents coccyx area later that day. Observation on 2/13/18 at 2:49 p.m. of resident 42 in her room revealed: *She was laying in her bed. *An air mattress was in place on her bed. *She had a cushion in the seat of her Broda w/c. Observation and interview on 2/13/18 at 3:26 p.m. with CNAs L and M during resident 42's personal care in her room revealed:*They stated the resident had fragile skin and a history of skin tears and opened areas. *They indicated her left shin wound had been there a long time. -Sometimes it had a dressing on it, and sometimes it had not. -They thought it was bruised and were not aware of it being opened. *During private area care an approximately pencil-eraser sized opened area was noted to her coccyx. -That had an approximately quarter-sized area of scarring around it. -They stated the coccyx area was opened at times, and then it would be closed at times. -After applying a barrier type of cream to the area they put a new disposable brief on her. -They were unsure if the nurse did any type of treatment for [REDACTED]. -There had been no dressing in place to that area. *They both indicated if they had noticed something new on a resident's skin they should have reported it to the nurse. -The area on the resident's coccyx was not new. *Prior to leaving the resident's room they put on a different type of heel protector to both of the resident's feet. -They stated she should have had her heel protectors on at all times. Interview on 2/13/18 at 7:00 p.m. with licensed practical nurse (LPN) H regarding resident 42's skin concerns revealed:*She was unsure how long the resident's pressure injury to her coccyx had been there. *She stated the area comes and goes. *She was unsure when the dressing was due to be changed but looked it up and thought it could be done the next day. -It was usually changed every three days when it was a [MEDICATION NAME] dressing. *She thought night shift nurses checked the placement of the dressing during their shift. -She was unable to find an order to do those placement checks on the treatment administration record (TAR). *She stated the unit manager oversaw any wounds the residents had on that unit including resident 42's. *The surveyor requested to observe the resident's skin care the following morning. Interview, observation, and record review on 2/14/18 at 8:05 a.m. with LPNs I and J of resident 42's skin and medical record revealed:*The resident was in her bed laying on her back with her right leg partly crossed over her left leg. -Her right foot was near the left shin wound. *She had no heel protectors or boots on and no pillows placed for positioning. -They stated she should have had her heel protectors on at all times. *Observation of the resident's coccyx area revealed the same opened area and scarring around it as on 2/13/18. -There was no dressing in place to that area. *They were unsure: -If that area had a treatment or a dressing ordered for it. -How long it had been opened. *According to the resident's TAR a [MEDICATION NAME] dressing change to the resident's coccyx pressure injury was documented as completed by the night nurse at 7:14 a.m. that day. -During the observation they confirmed there was no dressing in place. -They could not explain how a dressing would not have still been in place less than one hour after it was done. *CNA M walked by the area and the nurses questioned her if the CNAs had removed the dressing that morning. -The CNA stated no dressing had been there, and nothing was removed by them. *The nurses confirmed there were no placement checks to ensure the dressing had remained in place as ordered. -The dressing was changed on night shift every three days. *The CNAs should have told them if a dressing was not in place, but that had not always happened. -They could not explain why the CNAs had not known the nurses were doing a treatment for [REDACTED]. Interview and record review on 2/14/18 at 11:13 a.m. with registered nurse (RN)/unit manager K regarding resident 42's skin concerns revealed:*She was not aware of a current pressure injury to the resident's coccyx. -She thought the Mepliex dressing change every three days was just for protection from a previously healed pressure injury. *The last time time a wound data collection tool had been done by the nurses had been on 11/21/16. *The last wound RN assessment was done on 11/17/16. -That indicated the wound on her coccyx was healed. -At that time they were to continue skin checks and dressing changes due to the risk of skin breakdown. *She stated there was no documentation in the resident's record regarding the coccyx area being opened, and there should have been. *She had become unit manager for that unit about three to four months ago. *She was aware of the resident's dressing change every three days for protection. -She was never told that it was opened. *She agreed the resident was high risk for skin breakdown and should have been monitored closely. -The resident had a history of [REDACTED]. *She confirmed if the dressing was put on at 7:14 a.m. by the night nurse it should have still been on at 8:05 a.m. -The resident was not able to remove the dressing and was totally dependent on staff. -If the staff had not removed the dressing it was most likely not put on that day. *There should have been placement checks to ensure the dressing was still in place every shift. -Those placement checks were not ordered on the resident's TAR. *CNAs should have notified the nurse if a dressing was off or if the area was opened. *She confirmed there was no mention of a current pressure injury to the resident's coccyx since she was not aware of it being opened. *Her care plan had not mentioned: -The coccyx pressure injury. -The heel protectors or when they should have been put on her. Review of resident 42's February 2018 TAR revealed:*The [MEDICATION NAME] dressing to the resident's coccyx skin breakdown should have been changed every three days and when soiled. -From February 1st through the 14th it was not initialed as completed two out of the five times it should have been done. --Those were on the 2nd and the 11th. *The as needed entry for the [MEDICATION NAME] dressing change to her coccyx skin breakdown had no initials to indicate it had been applied. Interview on 2/14/18 at 2:30 p.m. with the DON regarding the above for resident 42 revealed: *She confirmed the above findings. *Treatments should have been documented to prove administration had occurred. *Dressing placement checks should have been done to ensure dressings were intact and not in need of changing. *Staff should have completed the appropriate documentation in the resident's medical record related to skin concerns. 3. Observation and interview on 2/12/18 at 5:27 p.m. with resident 75 in her room revealed:*She stated she had a sore spot on her bottom. *She did not know how she got it. *She was sitting in her recliner with her feet up. -There was no cushion underneath her in that chair. *Her w/c had a thin cushion in the seat that was approximately one to two inches thick. Observation on 2/13/18 at 8:59 a.m. of resident 75 revealed: *She wheeled herself in the hallway back to her room from the dining area. *She was able to transfer herself from her w/c into her recliner independently. Interview with CNA L at the above time regarding resident 75 revealed:*She did most everything by herself. *She just needed staff assistance with her stockings in the morning and at bedtime. Interview on 2/13/18 at 9:08 a.m. with resident 75 in her room revealed:*Someone had looked at the sore on her bottom the day before. -They changed the dressing and put some salve on it that hurt. *The staff said it was healing. *She thought they looked at the area every other day. Interview and record review on 2/13/18 at 9:35 a.m. with RN O regarding resident 75's opened area revealed: *She stated she would have to look up the dressing change since she was unsure when it was scheduled for. -It was not due to be changed during her shift that day. *Review of her February 2018 TAR indicated physician's orders [REDACTED]. *Review of the [MEDICATION NAME] label revealed: -It was for OTC (over the counter) use for management of skin abrasions, minor irritations, lacerations, cuts, exit sites and intact skin. -It was for professional use to be used under the supervision of a healthcare professional in the management of wounds such as stage I-IV (one to four) pressure ulcers, partial & full thickness wounds, first & second degree burns, grafted & donor sites. *The nurse did not know it was a pressure injury until she reviewed the TAR. *She stated the unit manager did the weekly wound assessments for any pressure injuries. *Review of the resident's February 2018 TAR indicated the dressing had not been completed as ordered on the 9th or on the 12th. -She confirmed that finding. Observation on 2/13/18 at 2:53 p.m. of resident 75 revealed: *She was sitting in her recliner in her room. *During lunch time she had been in her wheelchair. *She had not repositioned herself since lunch time. Interview on 2/13/18 at 7:00 p.m. with LPN H regarding resident 75's pressure injury revealed: *The area was on her coccyx, and she was unsure how long it had been opened. *She was unsure when the dressing was due to be changed but looked it up and thought it could be done tomorrow. -Surveyor requested to observe that wound and the dressing change process that following day. *She thought the night shift checked the placement of the dressing every shift. -She was unable to find an order on the TAR for that placement check. *She indicated the unit manager oversaw all the residents' wounds and their care. Observation, interview, and record review on 2/14/18 at 7:51 a.m. with LPN I related to resident 75's coccyx pressure injury revealed:*According to the resident's TAR the dressing should have been changed every three days. -The placement of the dressing was supposed to be checked every shift, but that order had been discontinued on 2/1/18. *She was unsure if the coccyx wound was a pressure injury and stated it looks like a little dimple. *According to the TAR the dressing was not due to be changed until 2/15/18, so she would just ensure it was in place. *Observation of the resident's coccyx area revealed an undated foam dressing was in place. *She confirmed there was no date written on the resident's dressing, and it had not been initialed on the TAR as completed on the 12th. *Nurses usually put dates on the dressings to indicate when it had been changed as well as signing the TAR to confirm it was done. *She stated she knew the nurse had changed the dressing on 2/12/18, but she must not have documented that or dated the dressing. *She stated the charge nurses did the daily wound data collection tool and the unit manager did the weekly RN assessments. *The unit manager oversaw all the wounds and care of them. Interview and record review on 2/14/18 at 10:30 a.m. with RN/unit manager K regarding resident 75 revealed:*The resident was admitted on [DATE] with a pressure injury to her coccyx at that time. *During her weekly wound assessments the week before she had noted the original pressure injury had healed, and a new area was identified. *The new area was a dimple like area that was opened. *The 2/9/18 Wound RN Assessment for the new area indicated: -It was a new stage three pressure injury. -The physician had been notified. *The 2/9/18 Wound Data Collection for the new area indicated:-It was an opened area below where the previous one had been. -It was 1 centimeter (cm) by 0.7 cm and had no depth. -It was 100% granulation tissue. -It had a moderate amount of serous drainage. -The dressing was a wound gel with a foam dressing. *They had a wound consultant that helped them with residents' wounds that usually visited monthly. -That consultant had not been notified of that new area yet but had helped them with the previous one. *After discussing that new area and reviewing her resources for pressure injuries and staging she thought that new area was most likely not a stage three, but it was a stage two pressure injury. *She had some training in pressure injuries, but she thought she could use more. *She confirmed: -The dressing change had not been documented as completed on the 9th or the 12th by nursing. -There were no placement checks for the dressing every shift after they had been discontinued on 2/1/18, and there should have been. *The resident had refused a cushion for her recliner, and that was care planned. *The pressure injury she had been admitted with was healed, but in the mean time she had developed a new facility acquired pressure injury. Interview on 2/14/18 at 2:30 p.m. with the DON regarding resident 75 revealed:*She confirmed the above findings. *Treatments should have been documented to prove administration. *Dressing placement checks should have been done every shift to ensure dressings were intact in- between the every three day changes. 4. Review of the provider's revised April 2016 Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements policy revealed:*The purpose included: -To systematically assess residents with regard to risk of skin breakdown. -To accurately document observations and assessments of residents. -To appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers.*Procedure included to:-1. All residents will 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 . -2. The registered nurse will complete the Braden Scale for Predicting Pressure Sore Risk UDA on all resident quarterly or when the resident has a change in condition that could affect his or her risk of developing an ulcer.-5. A systematic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin breakdown. The nursing assistant responsible for this will report any abnormal findings or signs of skin impairment to the licensed nurse.-11. The interdisciplinary teams should determine any modifications that are necessary to the resident's plan of care . -12. When a pressure ulcer is present, daily monitoring (with accompanying documentation when a complication or change is identified) should include the following: -An evaluation of the ulcer, if no dressing is present. -An evaluation of the status of the dressing; if present (whether it is intact and whether draining, if present, is or is not leaking). -The status of the area surrounding the ulcer (that can be observed without removing the dressing). -The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example, increased redness or swelling around the wound or increased drainage from the wound). -Whether pain, if present, is being adequately controlled. Review of the provider's revised September 2016 Pressure Ulcer Practice Guidelines policy revealed: *Evaluation of an in-house-acquired pressure ulcer included:-Identifying the root cause of pressure ulcer development through evaluation of potential causative factors should be a component of the quality assurance process . -Once the investigation is completed, the information shall be analyzed to determine why the pressure ulcer/sore developed. Determine if the development of the pressure ulcer is isolated or if there is systematic breakdown and other residents have potential to be impacted . Review of the provider's September 2012 Documentation policy revealed:*Documentation of all nursing care and observations, assessments and treatments, and effects will be written by an authorized professional using the PointClickCare Systems and Resident Services System of Forms. All documentation is expected to be legible, accurate, understandable, timely and pertinent and held in confidence. *Documentation is NOT to be altered or falsified. Examples include, but are not limited to, backdating and/or altering data to secure more favorable rates .For any entry in a medical record, the person completing the entry should sign and date the entry.

Based on incident report review, record review, interview, and policy review, the provider failed to: *Thoroughly investigate a fall with major injury for one of one resident (11) with cognitive impairment. *Ensure complete documentation in the medical record for one of one sampled resident (12) with cognitive impairment who had a fall with injury. Findings include: 1. Review of the 8/14/16 incident report sent to the South Dakota Department of Health (SD DOH) regarding resident 11 revealed: *Resident was found lying on her floor. Resident was assessed with [REDACTED]. Portable x-ray reports fracture above elbow, resident sent to ER for further evaluation. *Was allegation of abuse/neglect/misappropriation of funds or property substantiated was marked No. Review of the 8/14/16 internal incident report regarding resident 11 revealed: *She had fallen on 8/14/16 at 12:45 a.m. *Had been found by certified nursing assistant (CNA) D laying with the left side of her head and the left side of her body leaning against the bed with her legs stretched out long ways towards the back of the bed. *She had a golf ball size hematoma on the back of her head that was slightly bleeding and a hematoma on her right elbow. *Had complained of pain in the back of her head. *CNA D found unlicensed assistive personnel (UAP) E on the other hallway and had asked what other nurses were there for us to call. *RN F had been the nurse in charge of resident 11's unit. -She had left the faciity on her lunch break to go to the gas station. *CNA D called registered nurse (RN) G and informed him of resident 11's fall. *RN G had been in the process of assisting a resident on his unit. -Had not come to resident 11's room for 5 to 8 minutes after receiving the phone call. *CNA D and UAP E had transferred resident 11 from the floor into bed without having the resident assessed by a nurse. *CNA D had went to get ice while the other med aid did the vital signs. *The resident kept saying I broke my arm. *CNA D had thought the resident needed to go to the hospital but no one else thought she did. Review of resident 11's medical record revealed: *[DIAGNOSES REDACTED]. *A Brief Interview of Mental Status assessment score of four indicated severe cognition impairment. Review of the 8/1/16 quarterly Minimum Data Set assessment revealed: *A Brief Interview for Mental Status examination score of four indicated severe cognitive impairment. *Coded adequate for ability to express ideas and wants and understanding others. *Required limited assistance with transfer, ambulated with set-up assist and supervision, and had a balance deficit. Review of resident 11's care plan revealed she had: *Impaired cognitive function/dementia or impaired thought process. *Needed cues for recall and safety awareness. *Had a communication problem related to dementia. The progress notes from 8/14/16 through 8/15/16 revealed on: *8/14/16 at 12:45 a.m. per (CNA/UAP): Resident was laying with the left side of her head and left side of her body leaning against the bed. *8/14/16 per RN F: Resident was found on floor laying next to her bed on her back. (nurse was not in the building at the time of the fall. *8/15/16 at 8:19 a.m. per RN: Call placed to Dr. (name) office regarding swelling and pain to right elbow from fall on 8/14/16. *8/15/16 at 1:04 p.m.: Call out again regarding swollen right elbow. *8/15/16 at 2:04 p.m.: Call placed to PPX info given and will be out to x-ray. *8/15/16 at 3:30 p.m.: Left message to nephew regarding resident being sent to Orthopedic Walk in clinic per MD orders. *8/15/16 at 3:33 p.m.: Resident picked up by W/C express. *8/15/16 at 4:20 p.m.: Call from clinic stating the resident can not be seen since she has no one with her and cannot verify birthday. *8/15/16 at 4:30 p.m.: Told clinic resident will need to be seen at the ER. Wheel chair express called. *8/15/16 at 11:44 p.m.: Resident came on unit at 23:15 (11:15) p.m. by wheelchair express. *8/29/16 at 3:15 p.m.: Spoke with (nephews name) about resident's upcoming appointment. Doctor informed facility that she will need someone to accompany her. Review of the neurological (neuro) checks post-fall assessment revealed on: *8/14/16 neuro checks had been done at 3:28 p.m. Neuro checks had not been done until 8/15/16 at 2:52 a.m. which was eleven hours later. *8/14/16 at: -7:33 a.m. Rt elbow swollen and purple bruising, able to move flex and extend joint but it is stiff and painful. -3:28 p.m. continues to c/o (complain of) right arm pain, moves arm freely without limitations. *8/15/16 neuro checks had been done at 7:15 a.m. Resident had left for the clinic at 3:30 p.m. and returned to the facility at 11:15 p.m. No neuro checks had been documented as being done before or after leaving the facility. *8/16/16 next documented neuro checks had been done at 5:07 a.m. *There was no documentation the physician had been contacted from 8/14/16 at 1:09 a.m. until 8/15/16 at 8:19 a.m. A physician's orders [REDACTED]. Physician response okay to go to appointment by herself next week. Review of the 8/15/16 right elbow x-ray revealed a fracture. Review of the August 13, 2016 nursing schedule revealed during the time of resident 11's fall: *The census was 168 residents. *There were three licensed nurses scheduled. *One of the three licensed nurses was not in the building at the time of the fall. Interview on 10/18/16 at 2:15 p.m. with the director of nursing (DON) and the executive director regarding resident 11's fall revealed: *During the post-fall investigation there was a discrepancy between RNs F and G regarding RN F leaving the building and RN G responsible for her unit. *RN G should have stopped what he was doing with the medication pass and immediately went to assess resident 11. *The night nurse could leave the facility during their lunch break. *RN F had been terminated from the facility and reported to the SD BON. *The two CNAs moved the resident after the fall and should have waited for the nurse to do an assessment first. Interview on 10/19/16 at 8:05 a.m. with the DON and executive director regarding resident 11's fall revealed: *Residents with cognitive impairment could be sent to physician appointments without a representative as long as they were not having any behaviors. *The expectations would be for family to meet residents at the appointment or call the clinic with a report. *Confirmed resident 11 did not return to the facility until 11:15 p.m. *Her expectations would have been for one of the facility staff to have gone to her appointment with her. Interview on 10/19/16 at 9:10 a.m. with the registered nurse/assistant director of nursing A and the executive director regarding resident 11's fall revealed: *Since the 8/14/16 incident they had spoken with the nephew regarding having someone present with the resident at physician appointments. *They had given the nephew options of different services to go along with the physician appointments. *The primary physician had given approval for resident 11 to see him without an attendant but the orthopedic clinic had not done the same. *They had been communicating with the nephew about having an in-house physician see resident 11. Review of the provider's August 2015 Abuse and Neglect procedure revealed: *Purpose: -To ensure the location has in place an effective system that regardless of the source, prevents mistreatment, neglect and abuse of residents and misappropriation of their property. Review of the provider's August 2016 Fall Prevention and Management policy revealed: *Procedure: -1. DO NOT MOVE RESIDENT. -5. For a fall WITH injury do the following, --c. Cover the resident and have him or her lay quiet until help arrives. 6. A licensed nurse must observe the resident and perform a full-body exam to determine if there may be suspected injury and direct whether to move the resident. 10. For residents with suspected head injury, physicians should be notified by phone and not fax. Review of the provider's September 2016 Neurological Evaluation Procedure revealed After the completion of initial neurological evaluation with vital signs, continue with evaluations every 30 minutes x 4, then every eight hours x 3 days or as directed by the provider. Review of the provider's February 2013 Transportation policy revealed Purpose: To offer transportation assistance to residents. Review of the provider's August 2015 Meal Breaks and Other Break Periods revealed: *Purpose: -To establish guidance regarding meal breaks and other break periods. -To establish the (company name) position regarding 30-minute meal breaks. -To ensure compliance with applicable laws and regulations. *The policy/procedure had not indicated if an employee could or could not leave the facility on their meal break time. 2. Review of resident 12's undated final investigation report revealed: *It was stamped faxed and 7/26/16 was handwritten next to it. *The investigation addressed: -Her fall on 7/17/16. -Her pupils being non-reactive and unequal during a follow-up neurological check. -Her transfer to (hospital name) emergency room for evaluation. -The question regarding the abuse/neglect/misappropriation of funds being substantiated was marked no. Refer to F514, finding 1.

Based on incident report review, medical record review, interview, and policy review, the provider failed to: *Follow their policies following a fall with a major injury for one of one sampled resident (11). *Ensure a nursing assessment had been completed in a timely manner following a fall with a major injury for one of one sampled resident (11). *Ensure a resident who was cognitively impaired had been supervised during physician appointment for one of one sampled resident (11). Findings include: 1. Review of the 8/14/16 incident report sent to the South Dakota Department of Health (SD DOH) regarding resident 11 revealed: *Resident was found lying on her floor. Resident was assessed with [REDACTED]. Portable x-ray reported a fracture above elbow, resident sent to ER for further evaluation. *Was allegation of abuse/neglect/misappropriation of funds or property substantiated marked No. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., p.488, revealed: *A physical examination is conducted as an initial evaluation in triage for emergency care. *Use physical examination to do the following: -Gather baseline data about the patient's (resident) health status. -Identify and confirm nursing diagnoses. -Make clinical decisions about a patient's changing health status and management -Evaluate the outcome of care. Refer to F226, finding 1.

A. Based on record review, interview, and policy review, the provider failed to implement interventions for one of one sampled resident (3) whose family member had forced her to eat on multiple occasions resulting in hospitalization . Findings include: 1. Interview on 3/9/15 at 1:30 p.m. with the local ombudsman (resident advocate) from the Department of Social Services (DSS) regarding resident 3 revealed: *On 7/9/14 a DSS worker had followed-up on a call made by the facility social worker. *The call had been entered as an adult protection services case. *The facility social worker had concerns of the daughter "force feeding" the resident. *The daughter would "slap" the resident to get her to swallow. *The daughter had not seen that as abuse. *The DSS worker had informed the facility social worker they were responsible for the resident's care. *On 7/11/14 the DSS worker had been informed by the facility the daughter was going on vacation. *The DSS worker requested the facility notify him when the daughter returned. *The facility had not followed through and the DSS adult protection services case was closed in August 2014. Review of resident 3's 11/15/14 Minimum Data Set (MDS) assessment revealed she had short and long term memory problems. She needed total assistance from one staff person for eating. Review of resident 3's 5/29/14 interdisciplinary note revealed: *The daughter had been in the facility feeding her mother. *The daughter had been giving her drinks of fluid and prompting her to drink. *An unidentified nurse witnessed the resident's head "slump" down occasionally, and the daughter had pushed it back. *The resident had spit a few times, and the daughter had stated "Don't spit, that's not nice to spit. Come on take a drink." *The daughter would "nudge" the residents shoulder to reawaken her and to get her attention. *Two other nurses witnessed the daughter feeding the resident. *None of the nurses witnessing the daughter feed her mother in that manner had intervened. *The social worker had met with the daughter prior to the daughter leaving on vacation. *The daughter had asked staff to assist her mother with feeding. *She informed the daughter staff could not force feed the resident. *There was no documentation education had been provided to the daughter regarding the risks of force feeding her mother. Review of resident 3's 6/2/14 interdisciplinary note revealed the staff had noted the physician had provided education to the daughter regarding the resident's decline. Review of resident 3's 6/4/14 interdisciplinary note revealed staff had spoken to the daughter about putting the resident on comfort care. She had refused. She informed the staff she had been out to the facility yesterday and got "some fluids down (the) resident." She wanted staff to "put her head back and tell her to open wide." Staff informed the daughter they could not force feed the resident. There was no documentation that education had been provided to the daughter regarding the risks of force feeding the resident. Review of resident 3's 7/2/14 interdisciplinary note revealed staff had approached the daughter about the resident's pain. The daughter had refused to allow them to put her on any pain medication, but had agreed to starting hospice services as long as they would help feed her. Review of resident 3's 7/7/14 interdisciplinary note revealed the daughter was upset, because the staff were not making her eat. She had been at the facility over the weekend and had gotten her to eat 75-80% of her food. Staff again stated they could not force feed the resident but had not provided any education on the risks of force feeding her. Review of resident 3's medical record revealed her daughter had been in the facility on 2/8/15. She had forced her mother to eat when she had been unresponsive. The resident had been sent to the emergency room later that evening due to respiratory distress. Refer to F226, finding 1. Review of resident 3's 2/18/15 care plan revealed she needed assistance from one staff person with meals. There were no interventions listed that addressed the daughter force feeding the resident or that education to keep the resident safe had been provided to the daughter. Interview on 3/12/15 from 10:00 a.m. through 10:45 a.m. with the executive director, administrator, and the director of nursing (DON) regarding resident 3 revealed: *They were aware the daughter had been force feeding the resident since at least 5/29/14. *They were unaware the facility social worker had contacted the local ombudsman regarding that issue in July 2014. *The facility social worker had resigned her position in September. *Licensed social worker (LSW) O had taken over for her, but they could not provide the exact date of when. *They could not find any documentation regarding the conversations with the local Ombudsman. *They were unaware if the past social worker had followed up on the Ombudsman's requests. *They had not implemented any interventions and had not educated the daughter regarding the risks of force feeding her mother. Interview on 3/12/15 at 10:45 a.m. with the executive director, administrator, DON, and LSW O regarding resident 3 revealed: *LSW O had not contacted the local Ombudsman to advocate for her. *She was unaware of what the past social worker had done for the resident. *The resident had gone into the hospital on [DATE] and returned on 2/13/15 with pneumonia. *She stated the daughter had discussions with a care team at the hospital and was more understanding of the risks of force feeding her mother. *LSW O had not discussed with the daughter the risks of force feeding the resident prior to her going into the hospital. *The notes listed above were the only documentation they had regarding attempted interventions. Review of the provider's June 2014 Comprehensive Care Plan and Care Conferences policy revealed: *The care plan should have been driven by identified resident issues and their unique needs. *Interventions should have been individualized, realistic and understandable. B. Based on observation, record review, and interview, the provider failed to identify the windows in the special care unit and in the 200, 300, and 400 hallways opened at a ninety degree angle and created a potential elopement (when a resident's location is unknown) risk. Findings include: 1. Review of an incident report sent to the South Dakota Department of Health on 2/19/15 revealed resident 4 in the special care unit had climbed out a window and walked two blocks away. Observation on 3/10/15 at 7:45 p.m. in the special care unit in the room at the end of the hall on the left revealed the windows had a screen on the front held in with four plastic tabs. The window cranked out and opened to a 90 degree angle that opening was large enough for a normal sized person to get out of. The window alarm had fallen off the window. Interview on 3/11/15 at 4:00 p.m. with the executive director, administrator, and director of nursing revealed: *The room at the end of the hall to the left was the room resident 4 had climbed out of. *She had taken the screen off the window, opened the window, climbed on a garbage can, and then climbed out the window. *The windows opened to a 90 degree angle. *The windows had not been on a preventative maintenance plan to check for safety. *They felt it was a fire hazard if the the windows did not open that far. *They had put the window alarms on the windows in the special care unit after resident 4 had climbed out the window. *The window alarm in that room had fallen off the window and was inactivated. *They were unsure how long it had been off the window. *They had not checked the window alarms since they had been installed after the elopement of resident 4. *They had not addressed any of the other windows in the 200, 300, or 400 hallways for safety. They also opened to a 90 degree angle.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure: *Appropriate care for pressure ulcer care, hydration, meal supervision, bathing, and fluid restriction had been provided for one of one sampled resident (2) who had a current pressure ulcer, and who had a physician order for [REDACTED]. *Appropriate pressure ulcer care, collaboration of care with a hospice provider, and following physician's order for fluid intake for one of two sampled residents (10) on who had a current pressure ulcer, was on hospice, and had a physician's order to encourage fluids. Findings include: 1. Observation and interview on 6/30/14 at 4:30 p.m. with resident 2 in his room revealed: *He was lying on his back in his bed. *He stated "I am thirsty." *His lips appeared dry, and his tongue looked pale with a whitish coating on it. *He stated he had to ask the nurse for something to drink. *He had a catheter drainage bag that contained red colored urine. Interview on 6/30/14 at 5:30 p.m. with certified nursing assistant (CNA) A regarding resident 2 revealed: *He had some "bladder issues" and did not like to come to the dining room for meals. *He had a Foley catheter (drains urine from the bladder into a collection bag). *He ate very little at meal times. *He usually had a tray brought to his room for meals. *She was unsure as to the reason the resident had no fluids to drink in his room. Observation on 6/30/14 at 6:00 p.m. in the main dining room with resident 2 revealed: *He was in a wheelchair (w/c) and was sitting at a table by himself. *He had a plate of food, a glass of juice, and a cup of hot chocolate. *He had padded silverware to assist him with his grip. *He ate very little and had drank no fluids. *He attempted to eat his dessert, and he dropped the dessert in his lap. *The staff had not stopped to assist the resident or asked him if he needed assistance with his meal. Review of resident 2's complete medical record revealed: *On 5/1/14 he was admitted to the rehabilitation unit. *He had weakness, [MEDICAL CONDITION] (low sodium which regulates the amount of water in and around your cells (an important electrolyte for normal body functions)), and [MEDICAL CONDITION] (not enough healthy red blood cells to carry an adequate oxygen supply to the tissue and making one feel very tired) after a recent hospitalization . *On 5/22/14 there was a physician's order for DuoDerm (dressing) topically (on the skin) to the coccyx (tailbone area) every 72 hours for skin breakdown. *On 5/24/14 he was transferred to the 300 wing for further care. *He was alert, orientated, and able to make his needs known. *He had a small open area on his coccyx area (tailbone area) and received a dressing change every three days. *He had the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] (lack of sensation, tingling, and numbness to parts of the body). -Hypertension (high blood pressure). -[MEDICAL CONDITION]. -[MEDICAL CONDITION] (irregular heart beat). -Malaise (a feeling of discomfort, illness, or lack of well-being). -Fatigue (weakness and feeling tired all the time). -[MEDICAL CONDITION] (low amount of sodium). Review of resident 2's 5/15/14 Minimum Data Set (MDS) revealed he: *Was alert but had trouble recalling words. *Was feeling tired and having very little energy. *Had a poor appetite. *Had trouble concentrating on things. *Needed extensive assistance of two staff for bed mobility, transfers, and toileting. *Needed extensive assistance of one staff person for dressing and personal hygiene. *Was independent with eating after set-up assistance. *Had a weight of 144 pounds (lb) and had no swallowing problems. *Had been at risk for skin breakdown. The treatments were a pressure reducing device for his chair and his bed. *There was no turning or repositioning program documented. Review of resident 2's 5/29/14 MDS revealed he: *Was alert and had some trouble with orientation. *Continued to have little energy and was feeling tired. *Had a poor appetite. *Needed extensive assistance of two staff for bed mobility, transfers, and toileting. *Needed extensive assistance of one staff person for dressing. *Required supervision and set-up assistance for eating. *Had a weight of 141 lb. He had a 5 percent (%) weight loss since his admission. *Was at risk for pressure ulcers. *Currently had a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed). He was on a pressure reducing device for his bed, chair, now was on a turning and repositioning program, and pressure ulcer care. Review of resident 2's 5/1/14 care plan revealed: *He had impaired cognitive (memory) function. *He had diabetes, and staff were to check all of his body for skin breakdown. Staff were to monitor dietary choices and document any problems. The staff were to notify the health care provider for increased thirst and poor wound healing. *He had activity of daily living self care performance deficit related to increased weakness. He required assistance with repositioning and turning in bed, and assistance of one staff person for dressing, bathing, and hygiene. One or two staff assistance with toileting. Extensive assistance of one staff person to empty his catheter bag every shift. *His care plan indicated he was able to feed himself independently. *He had a potential nutritional problem related to diet and fluid restrictions. *The staff were to monitor and record his intake at each meal. *Weigh weekly. "FLUID RESTRICTION: Resident is on a fluid restriction, 1500 milliliters (ml)/day. See charge nurse before giving any fluids between meals. Document all fluids provided." *He had a stage 2 pressure ulcer on his coccyx. *The staff were to assist to turn/reposition at least every 2 hours using two staff. The staff were to assess/record/monitor wound healing, report improvements and declines to the health care provider. *Monitor nutritional status. Serve diet as ordered, monitor intake and record. Review of resident 2's 6/17/14 Braden scale for predicting pressure ulcers revealed: *He scored a 15 that was a mild risk. *The friction and shear area on the Braden scale form revealed he could move freely and required minimal assistance. (The 5/29/14 MDS revealed he was an extensive staff assist with mobility). *The Braden scale form and the MDS documentation were not consistent. Review of resident 2's wound monitoring documentation revealed: *He had a pressure ulcer to his coccyx that had been found on 5/20/14. The coccyx pressure ulcer measured 0.5 centimeter (cm) in length, 0.7 cm in width, and was 0.1 cm depth. *The only other measurement documented was on 6/28/14. The area measured 1.0 cm by 0.75 cm. The documentation was not completed and signed until 6/29/14. The coccyx area had worsened. *There had been no documentation of the assessment, and monitoring of the coccyx pressure ulcer performed weekly by the registered nurse. Review of resident 2's May 2014 repositioning sheet revealed there was no documentation any repositioning had been done. Review of resident 2's total fluid intake record from 6/24/14 through 6/30/14 revealed: *On 6/24/14 he had a total of 480 cubic centimeters (cc). *On 6/25/13 it was 540 cc. *On 6/26/14 it was 600 cc. *On 6/27/14 it was 840 cc. *On 6/28/14 it was 700 cc. *On 6/29/14 it was 240 cc. *On 6/30/14 it was 540 cc. *He had not reached his fluid restriction of 1500 cc per day. Review of resident 2's May and June 2014 electronic Medication Administration Record [REDACTED]. Observation on 7/2/14 at 2:30 p.m. in the 300 wing nurses station revealed there was a typed undated note placed in the nurses station for resident 2 that read: *"Read dietary card -No water with meals. Bkfst (breakfast)- 8 ounce (oz) coffee, 6 oz juice, 4 oz milk for cereal. Lunch-8 oz coffee. Supper -8 oz cocoa. *No water mug in room. *NSG (nursing) give pills with his med (medication) pass nutrition supplement-only use 4 oz water to mix with his fiber medication-He will have 120 cc leftover for NSG discretion or extras like ice cream or soup." Review of resident 2's hygiene record for May and June 2014 revealed he had bathes documented on May 7, June 11, and June 28. Observation on 7/1/14 at 7:25 a.m. of resident 2 revealed: *He was lying in his bed on his back. *His Foley catheter drainage bag was anchored to his bed rail and had bright red blood in the drainage bag. Interview on 7/1/14 at 7:40 a.m. with licensed practical nurse (LPN) C regarding resident 2 revealed his urine had been very bloody for the past week. He had not been eating or taking fluids well. Observation on 7/1/14 between 8:30 a.m. and 9:40 a.m. of resident 2 revealed: *He was sitting in his w/c at the dining room table by himself. *Staff assisted him with buttering his toast. *He was unsupervised during the rest of the meal. *He ate and drank very little. *He was returned to his room and placed beside his bed in his w/c at 9:00 a.m. *He then was assisted by two staff to his bed and was lying on his back in his bed at 9:40 a.m. Interview on 7/1/14 at 9:40 a.m. with registered nurse/MDS care coordinator D regarding resident 2 revealed: *On 5/24/14 he was transferred from the rehabilitation unit to the 300 wing. *She was unsure of the reason he had no fluids to drink in his room but was sure he had gotten fluids in his room. The staff must have been changing drinking mugs at the time of the observation. *The dietary department would have kept track of his oral intake at meals. *She had been unsure if the nursing staff had been keeping track of his oral intake. *The nursing staff would be responsible for updating the care plan when there was a change in a resident's condition. *She agreed the care plan should have been updated to reflect the resident's need for supervision during meals. *He was losing weight, and his current weight was 134.6 lb on 6/27/14 which was an approximate 10 lb weight loss in two months. *She thought he had been receiving a nutritional supplement. *He had a pressure ulcer to his coccyx, but she was unaware if the area had worsened or improved. The nurses changed the dressing every three days. The wound nurse measured the wound weekly. *The residents usually received a weekly bath. *She was unsure why there was no weekly documentation for that resident. The staff must have forgotten to chart the bath. She agreed it looked as though the resident had only three baths since his admission on 5/1/14. Interview on 7/1/14 at 9:45 a.m. with CNA E regarding resident 2 revealed: *She had not offered him any fluids in his room, because he was on a fluid restriction. *The only fluids he was allowed to have were given to him at meal times. *She had never recorded any fluids that he had taken outside of his meals. Observation on 7/1/14 at 12:30 p.m. of resident 2 in the dining room revealed: *He had only ice cream, pudding, and a liquid supplement in front of him. *There were no staff assisting him. Interview on 7/1/14 at 12:40 p.m. with dietitian N following the above observation of resident 2 revealed: *He had not been eating well. *He was refusing to eat his regular lunch menu. *She had asked him what he wanted and thought maybe he would take some nourishment he liked. *She was not aware staff should have been assisting him in the dining room during meals. *He was to have received 1020 cc from the dietary service with his meals. *She agreed he had not been consuming the total allotment for his fluid intake at meals. *She agreed nursing should have been monitoring and supplementing his oral intake to ensure he had received his 1500 cc per day. Interview on 7/1/14 at 2:00 p.m. with licensed practical nurse (LPN) C regarding resident 2's condition revealed: *He had been transferred to the hospital by ambulance at 1:34 p.m. today. *There was a STAT (immediate) order for a hemoglobin (blood test) because of his [MEDICAL CONDITION] and bloody urine. The hemoglobin test result was 8.7 (normal is 13.5 to 17.5). His last noted hemoglobin was 9.1 on 5/1/14. His hemoglobin had not been rechecked in sixty days, and there was no physician order to check his hemoglobin on a regular basis. *She had notified his primary physician after the results of the hemoglobin were obtained and had been instructed to transfer him to the hospital for further care. Interview on 7/2/14 at 9:20 a.m. with the director of nursing (DON) regarding resident 2 revealed: *The care plans were not updated immediately after the change in the resident. The staff would observe for a few days to see if it was a permanent change, and then the care plan would have been updated. The staff would use word-of-mouth to communicate any changes at report time between shift changes. *The care plan should have been updated to reflect the resident's need for supervision and assistance at meals. *The residents were scheduled for baths weekly, and she was unsure as to the reason there was only documentation of three baths in two months. Interview on 7/2/14 at 12:00 noon with the assistant director of nursing (ADON)/wound nurse and RN/MDS care coordinator D regarding resident 2 revealed: *The wound data collection was done by the RN. The data review had not been done since 6/21/14. *The assistant DON was the wound nurse. She was not aware resident 2 had a pressure ulcer. *The nurses should have communicated with her about the pressure ulcer. *The ADON agreed the wound assessment by the RN was eleven days overdue. *They both agreed the wound documentation was inconsistent, and there was a lack of communication between nursing staff and the wound nurse. *They both confirmed the current system for pressure ulcers was not working. *MDS/care coordinator D was unsure as to the reason a hemoglobin laboratory test had not been rechecked on resident 2 since his hemoglobin was low on 5/1/14 at 9.1. She stated that would have been up to the physician to have ordered a recheck of the lab work. Interview on 7/2/14 at 3:00 p.m. with director of dietary services B regarding resident 2 revealed: *He was to receive the following fluid intake with his meals: -540 cc for breakfast. -240 cc for lunch. -240 cc for supper. *The total would be 1020 cc for meals. There was 480 cc left for nursing to use. *He agreed the resident had not reached his 1500 cc fluid restriction amount. *He agreed if the resident had not been consuming all of his fluids at meal times he should have been offered those fluids by the nursing staff in his room. That would have ensured he had been receiving the required oral intake. *The nursing staff had not been reviewing the resident's intake at mealtime and adjusting his fluids as needed. Review of the provider's September 2012 Care Plan policy revealed: *"Residents would receive and be provided the necessary care and services to attain or maintain the highest practible well-being in accordance with the comprehensive assessment. *Each resident would have an individualized comprehensive plan of care that would include measurable goals, and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. *Through the use of departmental assessments, the Resident Assessment Instrument, review of the physician's orders, any problems, needs, and concerns identified would be addressed. *Care plans would be reviewed, evaluation and updated when there was a significant change in the resident's condition and/or in accordance with state guidelines. This plan of care would be modified to reflect the care currently required/provided for the resident." Review of the provider's June 2014 Bathing procedure revealed the purpose of bathing was to: *Promote cleanliness and general hygiene. *Stimulate circulation of the skin. *Promote comfort and relaxation and well-being. *Observe the resident's skin condition. *Assist the resident with personal care. B1. Review of resident 10's 5/28/14 significant change MDS revealed he: *Had a stage 3 pressure ulcer. *Had a [DIAGNOSES REDACTED]. *Weighed 157 pounds. *Had a catheter. *Was on Hospice care. Review of resident 10's June 2014 physician orders revealed: *He was to have fluids encouraged. *An additional order on 6/26/14 requested a deodorant to have been used in his urine/catheter bag. Random observation of resident 10 from 6/30/14 through 7/2/14 revealed there was a strong urine odor around him. Observation of resident 10 at meals on 6/30/14, 7/1/14, and 7/2/14 revealed he: *Was provided with two 6 ounce glasses of fluids. *Received no encouragement to drink those fluids. Interview on 7/1/14 at 5:30 p.m. with RN G regarding resident 10 revealed:*She was unaware the resident had an order to encourage fluids. *He had a history of [REDACTED]. *She confirmed the odor of his urine could have been due to not getting enough fluids. Interview on 7/2/14 at 9:00 a.m. with RN F regarding the urine odor around resident 10 revealed: *She was not sure if the odor was related to his [MEDICAL CONDITION] but agreed there was a strong, lingering urine odor around him. *They had tried different things including the current deodorizer in his catheter bag. *They also cleaned the bag with vinegar. Review of resident 10's diet card revealed it had not addressed the need to encourage fluids. Review of resident 10's June and July 2014 fluid intake records revealed his fluid intake ranged from 360 cubic centimeters (cc) of fluid per day, upwards to 900 ccs. Interview on 7/2/14 at 9:30 a.m. with registered dietitian (RD) N revealed she: *Recommended 30 ccs of fluid per kilogram (kg) of body weight to maintain hydration for all residents. *Was unaware resident 10 had an order to have fluids pushed. *She was not sure the documentation of fluid intake was accurate. *They only monitored the fluids the resident received at meals. Based on the 30 ccs of fluid recommended by RD N and resident 10's current weight he should have received 2140 cc of fluid per day. 2. Interview on 7/1/14 at 8:30 a.m. with registered nurse F regarding resident 10 revealed: *He had a pressure ulcer on his right foot. *That ulcer and dressing change was completed on Fridays by the nurse from Hospice. -They only observed the dressing to the ulcer and the area around the dressing of the ulcer *The assistant director of nursing (ADON) was the wound nurse, and she completed the assessments on all pressure ulcers. Interview on 7/1/14 at 11:00 a.m. with the ADON/wound nurse regarding resident 10 revealed: *She had been unaware the resident had a pressure ulcer on his foot until he went to an appointment at the clinic. -They had debrided it (removal of dead or damaged tissue) during that clinic visit. *She was unsure what had caused the ulcer. *She completed weekly assessments of any resident who had a pressure ulcer. Review of resident 10's 5/27/14 clinic referral documentation revealed: *He had been seen by a podiatrist (a physician who treats problems with feet and ankles) at the clinic. *He was to have several areas evaluated including the right lateral foot and top of his foot, his left index finger, and his right great toe. *It described an area to his lateral right foot that measured 0.9 centimeters (cm) x 1.1 cm x 0.01, red. No drainage noted. *He returned with a physician's order for [MEDICATION NAME] white foam and [MEDICATION NAME] cream to right foot ulcer daily. *He was to return in one week to evaluate shoes and assess wounds in wound clinic. Review of resident 10's 6/3/14 physician's progress note revealed: *The resident had advanced stage [MEDICAL CONDITION]. *He was a new hospice patient. *It had not addressed the pressure ulcer on his right foot. Review of resident 10's wound data collection documentation revealed: *The assessments that had been completed by the ADON/wound nurse on 5/16/14 and 5/23/14 revealed: -During that time the measurements were 1.0 cm (length), the width went from 0.7 cm to 1.0 cm., and depth was 0.2 cm. -There were no other assessments completed by the ADON/wound nurse provided to the surveyor. *Additional wound date collection assessments were provided that had been completed by nurses assigned to care for the resident on specific days. *Those assessments included many unanswered and incomplete data including: -Information identifying the location of the wound. -Measurements. -Daily monitoring for complications. -Wound bed characteristics. Interview on 7/2/14 at 12:05 p.m. with the ADON regarding resident 10 revealed: *There should have been wound data documented every day by the nurse taking care of the resident. *The nurses could not assess a wound if they had not looked at it. *She confirmed she should have done a weekly assessment on the pressure ulcer on his right foot. -That had not been done. -The last assessment she had completed on him was done on 6/13/14. *She confirmed the nursing assessments that had been completed had many unanswered questions on them. -They had not been completed as they were intended to have been done. *She was unable to find documentation the resident's physician had been informed of the pressure ulcer on his right foot. Review of resident 10's 5/28/14 interdisciplinary care plan revealed: *He had a terminal prognosis related to [MEDICAL CONDITION] and received Hospice services. *The approaches for the above terminal illness included: -"Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met." -It listed the frequency that each hospice service would have been provided every month. -Those services included a registered nurse, social worker, clergy, volunteer, and a home health aide. *Another problem included the resident had a potential for a pressure ulcer development related to [MEDICAL CONDITION] and health decline. -Approaches for the prevention of the pressure ulcer included to provide pressure relieving/reducing device on bed, chair, etc. *It addressed the resident having a urinary catheter. -One of the approaches was to monitor and document intake or output. *The care plan had not: -Clearly identified the services hospice would have provided. -Been updated when the resident developed an actual pressure area on his foot. -Specified Hospice was responsible for the care of the pressure ulcer on his foot. -Specified how the provider's nurses would monitor the pressure area on his foot when the dressing changes were completed by hospice. *Addressed encouraging fluids or the problems with the urine odor. Review of the provider's June 2014 Skin Assessment and Pressure Ulcer Prevention policy revealed: *The purpose of the policy was to: -"Systemically assess residents with regard to risk of skin breakdown. -Accurately document observations and assessments of residents. -Appropriately use prevention techniques and pressure redistribution surfaces on those resident at risk for pressure ulcers. *If a pressure ulcer is identified. The registered nurse should record the type of wound and the degree of tissue damage on the Wound Assessment for the pressure ulcer. The licensed nurse records the location of the area, the measurements and the ulcer/wound characteristics. Document the information on the Wound Data Collection sheet. *When a pressure ulcer was present, daily monitoring with accompanying documentation when a complication or change is identified should include the following: -An evaluation of the ulcer, if no dressing was present. -An evaluation of the status of the dressing; if present whether it is intact and whether it was draining, if present, or was not leaking. -The status of the area surrounding the ulcer. *The pressure ulcer should have been assessed/evaluated at least weekly and documented on the Wound RN Assessment sheet. Observations of the ulcer's characteristic may be documented by a licensed nurse and should include the following: -Measurement-length, width, depth. -Characteristics of the ulcer-including wound bed, undermining and tunneling, exudate, surround skin. -Presence of pain. -Current treatments." Review of the provider's February 2013 Residents at Risk for Dehydration/Fluid Maintenance revealed: *Nursing would notify the director of dietary services using a PCC alert, of a new [DIAGNOSES REDACTED]. *The plan of care would include approaches to encourage the resident to achieve and or maintain hydration status if the resident had symptoms which could lead to dehydration such as: -Dependence on staff for the provision of fluid intake. -Limited fluid intake. *If the physician had ordered a specific amount of fluid or a fluid restriction for the resident, the DDS would interview the resident and or family about the resident's fluid preferences and habits. *The fluid allocations would have been added to the resident's care plan. The fluid restriction would contain the details of the fluid allocation. *Staff would document fluid intake with meals and between meals in the PCC-POC (plan of care). Fluids provided at med pass would be documented on the eMAR (electronic medical record). *Nursing would monitor the record to determine if the fluid goals or calculated fluid need were being met consistently and document in the progress notes. *Nursing/dietary would adjust the plan of care as necessary to meet the goals.