Every finding on record at Good Samaritan Society - St Martin Village

Based on record review, interview, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was reviewed with and a copy offered to the resident or the resident's representative within 48 hours of the resident's admission to the facility for three of four newly admitted residents (3, 9, and 12).Findings include: 1. Review of resident 9's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. There was no documentation that resident 9's baseline care plan was reviewed with him or his representative, and a copy was offered to him or his representative within 48 hours after his admission to the facility. 2. A copy of resident 9's baseline care plan was requested from the facility on 7/29/26. 3. Interview on 7/30/26 at 7:38 a.m. with director of nursing (DON) B revealed that a copy of resident 9's baseline care plan was not available. The facility nurses initiate a care plan after a resident's admission to the facility and then personalized it to fit the resident's care needs. 4. Review of resident 3's EMR revealed he admitted to the facility on [DATE]. There was no documentation that resident 3's baseline care plan was reviewed with him or his representative, and a copy was offered to him or his representative within 48 hours after his admission to the facility. 5. Review of resident 12's EMR revealed she admitted to the facility on [DATE]. There was no documentation that resident 12's baseline care plan was reviewed with her or her representative, and a copy was offered to her or her representative within 48 hours after her admission to the facility. 6. Interview and review of resident 3 and 12's EMR on 7/30/26 at 9:39 a.m. with lead social services coordinator R revealed the resident's baseline care plans were started upon admission to the facility by Minimum Data Set (MDS) nurse S or clinical care leader T. Lead social services coordinator R was responsible for reviewing the resident's baseline care plan with the resident or the resident's representative. She reviewed and offered a copy of the resident's baseline care plan to the resident or the resident's representative during the resident's admission care conference, which usually occurred seven to fourteen days after the resident admitted to the facility. Lead social services coordinator R documented that she reviewed the baseline care plan with the resident or the resident's representative in a progress note in the resident's EMR. She acknowledged there was no documentation that resident 3 or 12 had their baseline care plan reviewed with and offered to them or their representatives within 48 hours after they admitted to the facility. She did not know the regulation required the baseline care plan to be reviewed and offered to the resident or the resident's representative within 48 hours after their admission to the facility. 7. Review of the provider's 12/1/25 Care Plan policy revealed, A baseline care plan will be developed upon admission according to federal and state regulations. The location must provide the resident and resident representative with a written summary of the baseline care plan.

Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices for hand hygiene (HH) (handwashing with soap and water or an alcohol-based hand sanitizer [ABHS]) and glove use were implemented by one of one licensed practical nurse (LPN) (N) during and after one of one sampled resident's (81) dressing change, one of one registered nurse (RN) (I) who did not perform HH before completing one of one sampled resident's (6) wound care treatment, one of one RN (F) who did not perform HH during medication administration for four of five sampled residents (60, 3, 49, and 24), one of one certified nursing assistant (CNA) (G) who did not perform HH during mealtime assistance provided for one of one sampled resident (28), and one of one CNA (H) who did not perform HH after removing her soiled gloves and before putting on a new pair gloves in the dining room during the noon meal service.Findings include: 1. Observation and interview on 7/28/26 at 10:10 a.m. with RN I in resident 6's room revealed RN I informed the resident that she was going to change the bandage on his back. RN I did not perform HH upon entering the room. RN I put on a pair of gloves, assisted the resident to lean forward in his chair, lifted the back of his shirt, removed the bordered gauze bandage from resident 6's back, and disposed of the bandage in the trash can. With the same gloved hands, she opened a new bordered gauze bandage that she had brought to the room, and then placed the new bordered gauze bandage over the skin on resident 6's back. She removed her gloves, disposed the gloves in the trash can, and then used an ABHS. RN I indicated the bandage was being used to prevent skin damage to his back. While still in resident 6's room, RN I acknowledged that she should have performed hand hygiene when she entered the resident's room and removed her gloves after she removed the soiled bordered gauze bandage from the resident's back. She should have performed HH before she applied a new bordered gauze bandage to resident 6's back. 2. Observation on 7/29/26 at 07:55 a.m. with RN F revealed she was administering medications on the south unit. RN F prepared resident 60's medications at the medication cart, walked to the dining area, and administered medications to resident 60. RN F returned to the medication cart, disposed of the used medication cup and water cup in the trash, and did not perform HH. RN F typed on the computer and then prepared resident 3's medication. No HH was performed. RN F walked to the dining room and administered resident 3's medications, returned to the medication cart, disposed of the medication cup and water cup, and then completed HH. 3. Observation on 7/29/26 at 8:24 a.m. with RN F at the medication cart on the south unit revealed she did not perform HH before she prepared resident 49's medications for administration. RN F walked to resident 49's room, set his medications on his bedside table, checked the resident's blood pressure, and administered his medications. RN F then returned to the medication cart and typed on the computer. No HH was performed. 4. Observation and interview on 7/29/26 at 10:51 a.m. with RN F revealed she did not perform HH before she prepared resident 24's medications. RN F put on a pair gloves, picked up resident 24's insulin pen, set the dosage on the pen, prepared the skin site on resident 24's abdomen with an alcohol wipe, and administered the insulin injection into resident 24's abdomen. While wearing the same unclean gloves, RN F opened the medication cart, returned resident 24's insulin pen to the cart, and typed on the computer. She then removed her gloves and did not perform HH. RN F stated she should have completed HH between administering and preparing each resident's medications. 5. Observation on 7/29/26 between 11:28 a.m. until 12:15 p.m. in the south unit dining area during noon meal service revealed CNA G sat at a table with gloves on and assisted resident 28 to eat. CNA G stood up from the table and removed her unclean gloves, did not perform HH, and repositioned herself next to an unidentified resident's wheelchair who was across the table from her. She sat back down at the table, put on clean gloves without performing HH, and continued to assist resident 28 to eat, CNA H stood up from a table with a pair of gloves on, walked to the dining room counter, picked up a box of gloves, and brought the box of gloves back to the table. She removed her unclean gloves, put the unclean gloves in the trash, and then put on clean gloves; no HH was performed. 6. Interview on 7/29/26 at 1:40 p.m. with CNA H revealed she should perform HH before and after providing resident care, before and after wearing gloves, and when going in or out of residents' rooms. 7. Observation and interview on 7/29/26 at 3:25 p.m. with LPN N completing resident 81's right knee dressing change revealed that without first performing HH, LPN N put on a gown and a pair of gloves. She laid a clean barrier on top of the resident's over-the-bed table and placed her dressing supplies on top of that barrier. She removed the medical tape from around the bandage on the resident's knee and removed the soiled bandage. LPN N removed and discarded her gloves in the garbage can and, without performing HH, she put on a clean pair of gloves. She applied a clean bandage to the resident's knee and secured that bandage to the resident's skin with medical tape. LPN N removed and discarded her gloves in the garbage can, then washed her hands in the resident's bathroom sink. She attempted to dry her hands with a paper towel from the automatic paper towel dispenser in the bathroom, but it was not working. LPN N attempted to get a paper towel from the dispenser opening, and then tried to open the dispenser from the top. LPN N then used a hand towel on the counter of the resident's sink to dry her hands. She turned the sink faucet handle off with her dry hand, and discarded the hand towel in a soiled linen container. LPN N applied an ABHS to her hands before she left the resident's room. LPN N stated that she was expected to, but did not, perform HH each time she had put on clean gloves during the above bandage change. She should not have used the hand towel in the resident's bathroom to dry her hands. If that towel was soiled, she had increased the risk of cross-contamination occurring when she turned the faucet handle off with her potentially soiled hand. 8. Interview on 07/30/2026 at 10:28 a.m. with director of nursing (DON) B and Clinical Care Leader C revealed that handwashing should occur before entering a resident's room, after exiting the resident's room, after contact with bodily fluids, and before and after glove use. Hand hygiene should be completed prior to putting on a pair of gloves assist residents with eating. Gloves should be worn when touching the resident's food, and should be removed and hand hygiene performed before assisting a different resident to eat. Gloves should be removed and hand hygiene performed after touching the resident's wheelchair handles or other chair surfaces. Hand hygiene should be performed before and after each resident during a medication pass. 9. Review of the provider's 6/8/26 Hand Hygiene policy revealed: Hand hygiene should be performed by employees: before contact with a resident/patient/client, before performing a clean/aseptic task, after contact with blood or body fluids, after removal of personal protective equipment/gloves, after contact with a resident/patient, after contact with resident/patient/client surroundings. The policy includes: Glove Use: gloves are not a substitute for hand hygiene. If a task requires gloves, perform hand hygiene before donning gloves and touching the resident/patient/client. Perform hand hygiene after removing gloves.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (6) observed to have Cortisone 10 (a medicated steroid cream that is used on the skin to treat inflammation and itching) and a container labeled Hempvona cream (a topical cream with hemp-seed oil) located on his bedside table was evaluated for his ability to safely self-administer those medications.1. Observation and interview on 7/28/26 at 10:15 a.m. with resident 6 in his room revealed a tube of Cortisone 10 and a container labeled Hempvona cream. The resident used the Cortisone 10 for facial itching and the Hempvona cream for discomfort. He did not know if the staff knew he had it.2. Observation on 7/29/26 at 2:20 p.m. in resident 6's room revealed the same Cortisone 10 and Hempvona cream on his bedside table.3. Review of resident 6's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated his cognition was moderately impaired. No medication self-administration assessment was completed to determine whether the resident was able to safely self-administer the above observed medications.His 7/29/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) did not indicate that he self-administered any medications. There was a physician's order dated 11/13/25 for Hempvona cream to be applied topically prn (as needed). There was no physician's order for Cortisone 10 cream. There was no physician's order indicating resident 6 was able to self-administer any of his medications.4. Interview, record review, and observation on 7/30/26 at 9:06 a.m. with licensed practical nurse (LPN) J revealed no creams were ordered for resident 6's face, and there was no order for self-administration of the Hempvona cream. LPN J stated that no medications were to be left in resident 6's room. LPN J entered resident 6's room and confirmed that resident 6 had Hempvona cream in his room.5. Interview on 7/30/26 at 9:15 a.m. with certified nursing assistant (CNA) K revealed that any medicated lotions should not be left in the resident's rooms.6. Interview on 7/30/26 at 9:43 a.m. with Clinical Care Leader C revealed the provider failed to follow their process for self-administering medications by not ensuring resident 6 was assessed to safely self-administer the above creams, securing a physician's order for the resident to self-administer those creams, and ensuring those medications were not stored in his room.7. Interview and EMR review on 7/30/26 at 9:45 a.m. with director of nursing (DON) B revealed that resident 6 did not have a self-administration assessment completed or a physician's order to safely store and administer the Cortisol 10 and Hempvona creams in his room, and he should have. DON B removed the Hempvona cream from resident's room.8. Interview on 7/30/26 at 11:36 a.m. with CNA L revealed that nurses should be notified if medications or medicated creams were found in a resident room.9. Review of the provider's 3/30/26 Medication: Administration policy revealed The resident has the right to self-administer medications if the interdisciplinary team determine that this practice is safe for the individual resident and is documented in the care plan. An order from the provider is required for this activity. Nursing Employees will be aware of medications kept in the room and responsible for recording self-administration doses in the resident's medication record.

Based on record review, interview, and policy review, the provider failed to ensure the care plan (personalized plan that addresses a resident's care needs, goals, and interventions) interventions were attempted and documented, and the indication for administration was documented for an as-needed (PRN) anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability) medication that was administered to one of one sampled resident (11).Findings include:1. Review of resident 11's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. He had a 5/1/26 physician's order for lorazepam (a medication used to treat anxiety) 0.5 milligrams (mg) one to four tablets to be administered every two hours as needed for anxiety and dyspnea (difficulty breathing). There were no parameters to guide which dose of the lorazepam was to be administered.His 5/1/26 psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) consent was for lorazepam. The symptom identified on the consent that the lorazepam was intended to help was drowsiness. There were no non-pharmacological alternatives listed on the consent where it indicated the alternatives attempted were to be listed.His medication administration record (MAR) indicated that on 5/8/26 at 8:26 p.m. resident 11 was administered 0.5 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before he was administered the lorazepam. The 0.5 mg of lorazepam was documented as effective.On 5/9/26 at 12:13 a.m. resident 11 was administered 1 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before he was administered the lorazepam. The 1 mg of lorazepam was documented as effective.On 5/28/26 at 3:54 p.m. resident 11 was administered 0.5 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before he was administered the lorazepam. The 0.5 mg of lorazepam was documented as effective.On 5/29/26 at 8:09 p.m. resident 11 was administered 2 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before he was administered the lorazepam. The 2 mg of lorazepam was documented as effective.On 5/31/26 at 8:00 p.m. resident 11 was administered 1 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before he was administered the lorazepam. The 1 mg of lorazepam was documented as effective.On 6/4/26 at 10:43 a.m. resident 11 was administered 1 mg of lorazepam. There was no documentation what the lorazepam was administered for or non-pharmacological interventions that had been attempted before he was administered the lorazepam. The 1 mg of lorazepam was documented as effective.On 6/27/26 at 9:51 p.m. resident 11 was administered 1 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before he was administered the lorazepam. The 1 mg of lorazepam was documented as effective.On 7/2/26 at 1:50 p.m. resident 11 was administered 1 mg of lorazepam. There was no documentation what the lorazepam was administered for or non-pharmacological interventions that had been attempted before he was administered the lorazepam. The 1 mg of lorazepam was documented as effective.On 7/18/26 at 9:58 p.m. resident 11 was administered 2 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before he was administered the lorazepam. The 2 mg of lorazepam was documented as effective.On 7/19/26 at 6:51 p.m. resident 11 was administered 1 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before he was administered the lorazepam. The 1 mg of lorazepam was documented as effective.On 7/28/26 at 8:35 p.m. resident 11 was administered 0.5 mg of lorazepam. There was no documentation if non-pharmacological interventions were attempted before he was administered the lorazepam. The 0.5 mg of lorazepam was documented as effective. 2. Interview on 7/30/26 at 9:03 a.m. with registered nurse (RN) E revealed resident 11 screamed and became restless in the evening. Non-pharmacological interventions were not always effective in managing his behaviors. 3. Phone interview on 7/30/26 at 1:25 p.m. with RN D revealed she gave resident 11 lorazepam for agitation. He would get ramped up at night, so she gave him the lorazepam to calm him down. She did not document in resident 11's EMR any non-pharmacological interventions attempted or what she was administering the lorazepam for because the order indicated the lorazepam was for anxiety. She felt she administered the lorazepam for his anxiety.She chose the dose of the lorazepam within the range of doses ordered by using her personal judgement. If resident 11 was displaying behaviors before she began her shift, she would choose to administer a larger dose of the lorazepam. She did not think about starting with a lower dose of the lorazepam and increasing the dose of the medication if the lowest dose was not effective. She did not receive any guidance on which dose of lorazepam to give resident 11 for his behaviors. 4. Interview on 7/30/26 at 2:34 p.m. with director of nursing (DON) B revealed she expected non-pharmacological interventions that were attempted for the resident's behavior be documented in the resident's EMR before an as needed anxiety medication was administered.She was not aware resident 11's psychotropic consent stated the indication for use of his lorazepam was drowsiness. She did not expect the psychotropic consent to include the non-pharmacological interventions attempted, but she did expect the non-pharmacological interventions on the resident's care plan to be listed.She expected that if a resident had an as needed anxiety medication with a range of doses that the lowest dose should be tried first to minimize the risk of adverse effects from the medication. 5. Review of the provider's 12/9/25 Psychotropic Medications policy revealed, Before [the] administration of non-emergency psychotropic medications, the following must be completed: Documentation in [the EMR] observations of mood, symptoms, or behaviors that cause the resident distress and/or endanger the resident or others and response to interventions used.

Based on observation, interview, record review, and policy review, the provider failed to implement a physical therapist recommended walk-to-dine program for one of one sampled resident (48). Findings include:1 Observation and interview on 7/28/26 at 10:05 a.m. with resident 48 in his room revealed that he was seated in his recliner. There was a walker near the wall by his dresser. He used the walker to get to and from his bathroom. He was supposed to use the walker to walk to and from the dining room for meals. The staff were to follow behind him with his wheelchair in case he became fatigued and needed to sit down. Resident 48 said he used his wheelchair to get to the dining room that morning for breakfast, because the staff were too busy to follow behind him if he walked to the dining room with his walker. He said the purpose of using the walker to get to and from the dining room was to keep my strength up. There was a dry-erase board on the resident's wall in his room. On it was written, assist x1 [assistance of one staff person] with FWW [a front-wheeled walker] and gait belt [a waist strap gripped as support for safe mobility and transfers] regarding resident 48's mobility needs. 2. Observations and interviews on 7/28/26 at 12:30 p.m. and at 5:45 p.m. during the noon and evening meal services revealed that resident 48 sat in his wheelchair in the dining room for both of those meal services. He used his wheelchair to get to and from the dining room for both of those meal services. The staff did not offer to walk behind him with a wheelchair while he used his walker to walk to and from the dining room for those meals. 3. Observation and interview on 7/29/26 at 12:30 p.m. revealed that resident 48 sat in his wheelchair in the dining room. He used his wheelchair to get to and from the dining room for the noon meal service. The staff did not offer to walk behind him with a wheelchair while he used his walker to walk to and from the dining room for the meal. 4. Observation and interview on 7/30/26 at 8:00 a.m. revealed that resident 48 sat in his wheelchair in the dining room. He used his wheelchair to get to and from the dining room for the noon meal service. The staff did not offer to walk behind him with a wheelchair while he used his walker to walk to and from the dining room for the meal. 5. Review of resident 48's electronic medical record (EMR) revealed his revised 3/31/26 activities of daily living (bathing/hygiene, dressing, eating, transferring/mobility, and continence) care plan indicated, Ambulation: Walk to dine with [the] staff following [the resident] with a wheelchair and [the staff using a] gait belt [around the resident's waist]. 6. Interview and EMR review on 7/30/26 at 9:30 a.m. with occupational therapist (OT) Q revealed that recommendations for a resident to participate in a walk-to-dine program were made by the therapy staff. Those recommendations were communicated to a nurse supervisor to add to a resident's plan of care (POC) for implementation. The therapy staff had recommended a walk-to-dine program for resident 48 after his 6/22/26 discharge from therapy services. The recommendation stated, Walk-to-dine with FWW, W/C [wheelchair] follow _A X1 [assistance from one] staff). 7. Interview on 7/30/26 at 9:35 a.m. with registered nurse (RN) P revealed that walk-to-dine recommendations were discussed in morning interdisciplinary team meetings, then communicated to the nursing staff. The therapy staff also communicated directly with the nursing staff regarding the initiation of walk-to-dine programs. It was the responsibility of the certified nursing assistants (CNAs) to implement and document the walk-to-dine program each day on their ADL task list. RN P did not know if resident 48 was on a walk-to-dine program. 8. Interview on 7/30/26 at 9:45 a.m. with CNA O revealed that she referred to the dry-erase board in a resident's room to know if a resident was on a walk-to-dine program. She was not sure if resident 48 was on a walk-to-dine program. 9. Interview on 7/30/26 at 1:45 p.m. with director of nursing (DON) B revealed that the therapy staff were responsible for communicating to her their walk-to-dine recommendations for a resident. It was her responsibility to ensure that the caregiver's were informed of the recommendation and the recommendation was added to the resident's POC. Adding the program to a resident's POC populated the walk-to-dine program task on the caregiver's task list within the resident's EMR. That enabled the caregiver to document when the walk-to-dine program was implemented. That process had failed for resident 48 because she did not add the walk-to-dine recommendation to his POC. 10. Review of the provider's revised 7/30/25 Restorative-Walk and Dine Program revealed, 2. A resident capable of ambulating to and from the dining room will be placed on the Walk and Dine Program, identified in the approaches in the resident's care plan, indicates the resident is able to walk to and from [the] resident['s] room for meals.

Based on observation, interview, and policy review, the facility failed to ensure drugs and biologicals were labeled, securely stored, and discarded regarding one of one medication cart on the south unit that was left unattended by one of one registered nurse (RN) (F) with pre-poured medications observed on top of the medication cart in a hallway where residents, unauthorized staff, and visitors could access it, one of one sampled resident's (63) medication with a shortened expiration date (medication that expires in a time frame after opening that is before the manufacturer's expiration date) that was not labeled with an open date, and for one of one medication storage room and one of one medication cart on the north unit that had expired medications and supplies.Findings include:1. Observation and interview on 7/28/26 at 5:44 p.m. with Clinical Care Leader C in the medication storage room revealed four Universal Viral Transport for Viruses (a specialized liquid solution used to safely collect and preserve clinical samples for transport) with an expiration date of 2/28/26 and approximately half a box of 75 count of Banatrol Plus powder (to manage diarrhea) packets with an expiration date of 5/21/26. Clinical Care Leader C confirmed above medications and supplies were expired and that they should be removed from the medication room.2. Observation and interview on 7/28/26 at 5:54 p.m. with licensed practical nurse (LPN) N at the north unit medication cart revealed there was a Trelegy Ellipta (treats chronic obstructive pulmonary disease and asthma) 200 microgram (mcg) /62.5mcg/25mcg inhaler opened and not dated, and one box of Bisacodyl (laxative) 10 milligram (mg) suppository with an expiration date of 6/30/26. LPN N confirmed the expiration date of the Bisacodyl and stated that the nurse that opened the Trelegy was responsible for labeling it with the opened date. LPN N removed the above medications from the cart.3. Observation on 7/29/26 at 7:55 a.m. revealed the south unit medication cart in the hallway near the dining room had 2 medication cups sitting on top of it. One medication cup had an orange gummy medication and a red gummy medication, and the other medication cup had 3 white pills. No nurse or staff member was present at the cart at the time of observation. Clinical Care Leader C approached the medication cart and put the medication cups in the top drawer of the cart. 4. Interview on 7/26/26 at 8:00 a.m. with registered nurse (RN) F revealed that she had previously prepared the medications and left them sitting unsecured on top of the medication cart. RN F states she left the medications there while she went to another room.5. Interview on 7/30/26 at 2:56 p.m. with director of nursing (DON) B revealed she expected medications to not be pre-poured and left unattended on top of medication carts, expired medications and supplies were to be removed from the medication carts and medication storage rooms by clinical coordinators and nurses, medications were to be checked for expiration dates before being administered to the residents and as needed, medications are to be labeled by the nurse that opens the medication, and medication carts were to be checked quarterly by pharmacists.6. Review of the providers 3/30/26 Medications: Acquisition Receiving Dispensing and Storage policy revealed: Medications will be stored in a locked medication, cart, drawer or cupboard, the location will routinely check for expired medication and necessary disposal with be done in accordance with state/pharmacy regulations, all medications (including samples or other medication dispensed by the physician) are packaged in accordance with the location dispensing system and state pharmacy regulations. Cautionary and accessory instructions, as well as the expiration date will be included. New labels may be applied by the pharmacist or the pharmacists' agent as needed.7. Review of the provider's 3/30/26 Medication: Administration Including Scheduling and Medication Aides policy revealed: Pre-setting medications in not an acceptable practice. For medication designed for multiple administrations (e.g. inhalers, eye drops, insulin, the employ opening the medication writes the open date on the label to promote correct administration.

Based on interview, observation, record review, and policy review, the facility failed to provide the dietary staff initial and ongoing education regarding a physician-ordered gluten-free diet, ensure menus were developed, and that an early breakfast was provided before a morning medical appointment for one of one sampled resident (48) to enable the resident to make food choices that he preferred and that his nutritional needs were met.Findings include: 1. Interview on 7/28/26 at 10:05 a.m. with resident 48 revealed he was placed on a gluten-free diet after his April 2026 hospitalization. He was provided a menu each day that listed a main menu option for breakfast, lunch, and dinner. Beneath each of those main menu options, there was an alternate meal option.Resident 48 stated that for breakfast that morning, pancakes were on the main breakfast menu that he had selected, but he was not able to choose the pancakes because they were not gluten-free. He had yogurt, eggs, and toast instead. 2. Observation, interview, review of resident 48's menu on 7/28/26 at 12:10 p.m. with resident 48 in the dining room revealed that sweet potatoes were on the main lunch menu, which he had selected. He was not served the sweet potatoes he had ordered. The resident's meal consisted of a turkey sandwich, peas and carrots, and a dessert. Resident 48's 7/28/26 menu was labeled Gluten Restricted and listed his allergies as peanuts, watermelon, and wheat.There was a line through the pancakes option for breakfast, and beside it the word, ALLERGY. There was no gluten-free option listed on the menu to replace the pancakes that the resident could not have. Resident 48 did not understand the reason for the pancake restriction because he had made and eaten pancakes during a recent occupational therapy session. Resident 48 had selected a turkey sandwich, baked sweet potato fries, and peas and carrots for the lunch menu option. There was a line through the baked sweet potato fries option, and beside it the word, ALLERGY. There was no gluten-free option listed on the menu to replace the sweet potato fries that the resident could not have.3. Interview and resident 48's menu review on 7/28/26 at 5:45 p.m. with resident 48 in the dining room revealed he was served a piece of baked cod and wild rice pilaf for the evening meal. His 7/28/26 dinner menu indicated that the alternate meal that the resident selected for that evening included baked cod, wild rice pilaf, and breaded cauliflower. There was a line through the breaded cauliflower option, and beside it the word, ALLERGY. There was no gluten-free option listed on the menu to replace the breaded cauliflower that the resident could not have. 4. Review of resident 48's electronic medical record (EMR) revealed a 4/8/26 physician's Nursing Home Progress Note that indicated the resident was hospitalized from [DATE] to 4/6/26 for treatment of a small bowel obstruction likely due to dietary indiscretion. Registered dietician (RD) U's 4/7/26 and 5/19/26 RD progress notes indicated that resident 48's diet order was changed to gluten-free after the resident's 4/7/26 hospital discharge. The note indicated that the resident was eating and drinking well since his hospital return. There was no indication that RD U had met with the resident to discuss the resident's April 2026 diet order change. Former dietary manager (DM) V's post-hospitalization 4/15/26 Food and Nutrition Data Collection assessment for resident 48 revealed that section 3 of that assessment identified the resident's meal and snack preferences. There was space to indicate resident-specific dietary information such as food likes, dislikes, and preferences. The space was left blank. Section 9 of that assessment was Education. There was no indication that DM V had provided resident 48 with instructions or education related to his new diet order. No follow-up Food and Nutrition Data Collection assessments were completed by former DM V after 4/15/26. 5. Interview on 7/29/26 at 1:30 p.m. with occupational therapist (OT) Q revealed she confirmed that the resident used a gluten-free pancake mix provided by the therapy department to make gluten-free pancakes during a therapy session after the resident's discharge from the hospital in April 2026. 6. Interview on 7/29/26 at 5:45 p.m. with former DM V revealed that as of 7/29/26, he was no longer the DM. He was still employed by the facility, providing training to the new DM.Former DM V stated that he was expected to have interviewed resident 48 when he completed the resident's post-hospital Food and Nutrition Data Collection assessment to ensure that changes in the resident's food likes, dislikes, and preferences were documented, communicated to, and followed by the dietary staff. Former DM V was not aware of how much or if resident 48 understood his new gluten-free diet, but he agreed that interviewing the resident for his 4/15/26 post-hospital assessment may have addressed some of the above uncertainties that the resident had about foods he was no longer being served. Former DM V indicated that the facility did not have a gluten-free pancake mix or the necessary ingredients to make gluten-free pancakes from scratch if that was on the menu and the resident wanted to have them. That food choice was not, but should have been accommodated for the resident.Former DM V thought that the reason resident 48 was not served sweet potato fries and the breaded cauliflower was because of the coating that was on both of them. He agreed that the resident's menu should have reflected gluten-free alternatives for both of those vegetables. Not offering gluten-free substitutions on the menu for the resident to choose from increased the resident's risk of not having a nutritionally balanced diet. 7. Review of the revised 7/30/26 DM job description revealed that the responsibilities of that position included communicating with the food preparation and service department to ensure that therapeutic menus were fully understood and executed. In addition, the DM was expected to employ sound methods of planning, introducing, and following through on change, and monitoring progress, providing feedback, support, and course correction as necessary. Providing resident care was also expected.8. Review of the provider's revised 11/13/25 Dignity in Dining policy revealed that staff were expected to offer residents a choice of food and beverages that respect their preferences . and monitor [food service] to ensure that residents receive their identified preferences. 9. Observation and interview on 7/29/26 at 7:45 a.m. with resident 48 revealed he was in his wheelchair and moving it towards the front lobby. He had a medical appointment that he was going to. Neither the kitchen staff nor a caregiver had offered him the option to eat his breakfast early that morning, or provided him with a ready-to-eat breakfast food item to take with him before he left the building and was transported to his appointment.10. Interview on 7/29/26 at 8:15 a.m. with food service assistant W revealed that she relied on former DM V or the receptionist to let her know the residents' appointment schedules so that she could arrange for early meal trays for the residents when they had early morning medical appointments. Food service assistant W was not aware of resident 48's 7/29/26 appointment, so he was not offered or provided breakfast before he left for his appointment that morning. 11. Interview on 7/30/26 at 2:30 p.m. with senior director A revealed that upcoming resident appointments were discussed daily during the morning interdisciplinary team meetings. Department leaders were expected to communicate resident appointment information with their staff. Signs were also placed outside of the residents' rooms with appointment information. It was expected that all staff had used that information to ensure residents' nutritional needs were met on appointment days. She expected the staff to have offered and provided resident 48 with something to eat before he left for his appointment on 7/29/26.12. Review of the provider's revised 12/18/25 Dining Service Standards policy revealed that the staff will, provide assistance in dining in a way that promotes independence, maintains dignity and focuses on quality of life.

Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to follow their policy for reporting to the SD DOH and one of one sampled resident's (1) representative of the resident's injury of bruising to her left arm and hand with unknown cause (origin).Findings include:1 Review of a 7/16/25 SD DOH complaint intake revealed that during the weekend of 7/4/25, resident 1 was visited by her family. The resident's left hand and arm had shown no signs of injury at that time. The resident's family had returned a few days later to visit and noticed extreme bruising and swelling of her [the resident's] left hand and forearm. Digital photographs of resident 1's hand taken by the family during that visit showed the underside of the resident's hand had purple and black bruising of her fingers and palm that extended upwards to her forearm. The entire top of the resident's left hand was similarly bruised. The resident's family had not been notified that resident 1 had been injured.Interview on 9/4/25 at 9:00 a.m. and review of resident 1's electronic medical record (EMR) with infection preventionist (IP)/clinical care leader (CCL) B revealed the progress note she entered in resident 1's chart on 7/1/25 stated received and returned her [the resident's daughter] call to discuss the bruise noted on the resident's arm. Explained that according to PCC [EMR] notes, the mark was most likely caused by a recent lab draw on 7/7/25. IP/CCL B confirmed resident 1's 7/7/25 blood draw was taken from the resident's right arm. She confirmed the cause of resident 1's left hand and arm injury was not the result of a lab draw.IP/CCL B confirmed that resident 1's left hand and arm injury was first documented in her medical provider's 7/11/25 Nursing Home Attending Physician Visit note, which indicated there was no definitive cause that was found for resident 1's left hand and arm injury. A 7/11/25 nurse progress note completed by licensed practical nurse (LPN) E after the above visit: indicated [Medical provider's name] visited. The medical provider and a nurse wrapped resident 1's L [left] forearm, which is bruised and has a large hematoma [a raised bruised area] on the top of [her] L hand.IP/CCL B stated it was LPN E's responsibility to have notified resident 1's family of the left hand and arm injury. Because the cause of that injury was unknown, LPN E should also have notified a nurse supervisor or administrator A. Injuries of unknown origins were expected to have been documented, investigated, and reported to the SD DOH, but that had not occurred. Interview on 9/4/25 at 10:15 a.m. with administrator A confirmed the staff had not followed the provider's procedure for notifying families, and the SD DOH regarding resident injuries of unknown cause.Review of the provider's revised 4/7/25 Abuse and Neglect policy revealed:Procedure: 4.c. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency [SD DOH].4.g. Notify the physician and family regarding the facts of the situation. If there is alleged or suspected abuse/neglect or in an injury of unknown origin, inform them that an investigation is in progress. That notification was expected to have been recorded.

Based on South Dakota Department of Health (SD DOH) complaint review, observation, record review, interview, and policy review, the provider failed to ensure an investigation was completed and documented for one of one sampled resident (1) with an injury of bruising to the resident's left arm and hand with unknown cause (origin).Findings include:1 Review of a 7/16/25 SD DOH complaint intake revealed that during the weekend of 7/4/25, resident 1 was visited by her family. The resident's left hand and arm had shown no signs of injury at that time. The resident's family had returned a few days later to visit and noticed extreme bruising and swelling of her [the resident's] left hand and forearm. Digital photographs of resident 1's hand taken during that visit showed the underside of the resident's hand had purple and black bruising of her fingers and palm that extended upwards to her forearm. The entire top of the resident's left hand was similarly bruised. Observations 9/3/25 at 10:10 a.m. of resident 1's room revealed there were bilateral 1/4 siderails on her bed, and it was positioned low towards the floor. She had a cylindrical-shaped call light with a red button at one end to alert staff for assistance.Continued observation on 9/3/25 at 10:15 a.m. of resident 1 in an activity room revealed she was participating in a game of Jeopardy with other residents. She sat in a wheelchair that tilted slightly back and had been customized with things like a left arm trough (a device attached to the wheelchair armrest for positioning comfort and posture support) that accommodated her left-sided weakness. Her hands had no visible bruising. Review of resident 1's electronic medical record (EMR) revealed that her admission date was 5/9/25. Her diagnoses included hemiplegia (muscle weakness or partial paralysis on one side of the body) due to a stroke affecting her left side, dysphagia (difficulty swallowing), congestive heart failure, anxiety, and insomnia. She had fallen multiple times after she had been admitted , but she had no documented falling incidents since the beginning of July 2025.Resident 1 had episodes of restlessness, anxiousness, and calling out. At times when staff had responded to her calling out, resident 1 was not able to identify what she had needed. Her ability to functionally use her call light was infrequent. Redirecting the resident was not always successful. Changes to her anti-depressant and anti-anxiety medications had been made by her medical provider in May 2025 and June 2025.Interview on 9/3/25 at 2:20 p.m. with physical therapist (PT) F revealed that resident 1 was receiving therapy services. PT F had seen resident 1's left hand and arm injury after the 4th of July weekend. It was black and blue and puffy. She stated that resident 1 was unable to provide any insight into the cause of her injury. PT F stated there was no known cause for the injury that she remembered, but she thought the resident's hand could have been injured when she was transferred. Staff had used an Easy Stand lift (a type of mechanical lift used for transferring from one position to another) for transferring her. PT F also stated that resident 1's previous wheelchair did not have a left arm trough that kept her weakened left arm stable and safely positioned, like her current customized wheelchair had. Resident 1 had started using that wheelchair in early August 2025.Resident 1's left hand and arm injury was first documented by the resident's medical provider in her 7/11/25 Nursing Home Attending Physician Visit note. This patient [resident] developed swelling and bruising of her left hand on July 7 or 8. Her family had visited on the weekend, and the [resident's] hand appeared normal, although she has left arm weakness because of a stroke. Yesterday they visited and found the left hand very swollen with bruising extending from the fingertips to up the forearm. [Resident 1] thinks she might have rolled out of bed (staff says that has not happened this week) or bumped it on a door [she] but does not really know how it happened. Staff thought it might have been related to a blood draw on July 7 but [resident 1] says the blood draw was from the other arm. [resident 1] is on aspirin and apixaban [anticoagulant] for history of stroke and DVT [deep vein thrombosis] with PE [pulmonary embolism].A 7/11/25 progress note completed by licensed practical nurse (LPN) E after the above medical provider's visit indicated [Medical provider] visited. We wrapped the L [left] forearm which is bruised and has a large hematoma [a raised bruised area] on the top of [her] L hand. There was no documentation to support that an investigation had been initiated to identify a cause for resident 1's injury, any factors that might have contributed to that injury occurring, or what actions had been implemented to decrease the likelihood of that injury reoccurring. Interview on 9/4/25 at 10:10 a.m. with LPN E revealed she stated, I don't recall knowing it [resident 1's left hand and arm injury] was there earlier that day [on 7/11/25 before the medical provider's visit]. LPN E stated the cause of that injury might have been related to the resident's 7/7/25 blood draw. LPN E had not known that a blood draw was taken from resident 1's right hand and not her left hand, so it could not have caused that injury.LPN E confirmed that after the left hand and arm bruise was identified on 7/11/25, she had not reported that injury of unknown cause to a nurse supervisor. As a result, an investigation was not initiated to identify the cause or possible cause for that injury. Without having identified a cause for resident 1's left arm and hand bruising, LPN E agreed that nothing different had been done to prevent a similar injury from recurring. Interview on 9/4/25 at 9:00 a.m. with infection preventionist (IP)/Clinical Care Leader (CCL) B revealed it was LPN E's responsibility to have notified a nurse supervisor or administrator A of resident 1's injury of unknown origin. Injuries of unknown origin were expected to have a thorough investigation completed and documented, but that had not occurred. Interview on 9/4/25 at 10:15 a.m. with administrator A confirmed that the staff had not followed the provider's procedure for documenting and investigating resident injuries of unknown cause. Review of the provider's revised 4/7/25 Abuse and Neglect policy revealed:Purpose: To ensure that all identified events of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated. To ensure a complete review by the investigation team to identify events, such as suspicious bruising of residents/clients, occurrences, patterns and trends that may constitute abuse to determine the direction of the investigation.

Based on interview, record review, and policy review, the provider failed to follow nursing professional standards of practice for implementing and documenting neurological checks according to the provider's policy for one of one sampled resident (2) who had fallen and sustained a head injury. Findings include:1. Record review of resident 2's electronic health record (EHR) revealed:*She was admitted to the facility on [DATE].*Her diagnoses included blindness, cerebral infarction (stroke), hearing loss, rheumatoid arthritis (an auto-immune disease affecting small joints in the hands and feet, and can damage other body systems), repeated falls, major depressive disorder, dementia (a group of symptoms affecting memory, thinking, and social abilities) without behavioral, psychotic, and mood disturbance, anxiety disorder, and traumatic subdural hemorrhage (fall with head injury that caused bleeding inside the skull).*She had been taking Aspirin (an anticoagulant or blood thinner medication) since 2021.*Her fall risk assessments (an assessment of a resident's risk for falling) indicated her risk for falling was:-High (score of 20) after she fell on 2/21/25.-Low (score of 11) after she fell on 3/4/25 and 3/20/25.-Medium (score of 14) after she fell on 5/21/25 and 6/15/25.-High (score of 20) after she fell and sustained an injury on 7/22/25.*She had seven falls in the last six months (between April 2025 and September 2025).*She had a fall in her room on 7/22/25 and sustained a head injury with bleeding.-She was found lying on the floor, next to her bed at 6:52 a.m. in a pool of blood under her left face/head.-The pool of blood was partially coagulated (thickened) and was approximately 10 by 14 inches in diameter. *Resident 2 was talking and stated, I fell and hit my head and my hips hurt and Get me up.*A head-to-toe assessment had been completed and her vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were checked by registered nurse (RN) G.-RN G did not perform a neurological assessment (an evaluation of mental status, cranial nerve function, motor strength, reflexes, sensation, and coordination) of resident 2.*Resident 2 was transferred to the emergency room and admitted to the hospital for treatment of a subdural hemorrhage (a collection of blood between the brain and the inner layer of the skull).-Neurological assessments were not performed of resident 2 upon her return to the facility from the hospital. 2. Interview with administrator A on 9/4/25 at 1:50 p.m. revealed:*Nurses were expected to follow the fall prevention policy and protocols.*She verified that neurological exams should be completed for all residents who fell and hit their head during that fall.-She agreed that no neurological exam had been completed for resident 2 after she fell and hit her head on 7/22/25. 3. Review of the facility's 2/17/25 Neurological Evaluation Policy revealed:*The policy is used following:- a witnessed fall when a resident has hit his/her head.-an unwitnessed fall.-a resident event that results in known or suspected head injury.*The policy procedure includes:- After the completion of initial neurological evaluation with vital signs, continue with evaluations every 30 min [minutes] x4 [times four], then every eight hours [times three] days or as directed by the provider.-Notify responsible party of event, resident condition, and findings and document.-If after completing one or more Neurological Evaluations the resident goes to the hospital for a few hours or is admitted to the hospital and returns to the center, documentation should resume using the existing schedule. 4. Review of the provider's 4/8/25 Fall Prevention and Management Policy revealed:*The purpose of the policy is to give prompt treatment after a fall occurs and to provide guidance for documentation.*Procedure:-1. Do not move resident.-2. Remain calm and reassure and comfort the resident.-3. Stay with the resident and summon the licensed nurse or other help. If able, observe the fall scene.-5. For a fall WITH injury, do the following:--a. If the resident is bleeding, locate the injured area and apply continuous, form pressure to the area.--b. Do not remove any blood-soaked dressings or clothing but instead add more layers to absorb the blood.-6. A 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.--b. If the fall was not witnessed, neurological checks are required and must be documented in the medical record.

51816 Based on interview, record review, and policy review, the provider failed to support residents' right to choose and receive the frequency and type of shower or bath consistent with their preferences for 7 of 17 sampled residents (20, 13, 38, 18, 15, 42, and 306). Findings include: 1. Interview on 3/24/25 at 3:30 p.m. with resident 20's daughter/power of attorney (POA) revealed: *Resident 20 was scheduled for a bath weekly. *She previously was bathed twice weekly but resident 20's daughter/POA was told she no longer received twice weekly baths because there was not enough staff to accommodate that. Review of resident 20's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 2/17/25 Brief Interview of Mental Status (BIMS) assessment score was 6, which indicated she had severe cognitive impairment. *She was documented to have been bathed weekly. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred two or more baths per week. *Resident 20's 3/26/25 care plan did not address her preference to receive two or more baths per week. 2. Interview on 3/24/25 at 5:04 p.m. with resident 13 revealed: *She was bathed once weekly. *She had notified facility management that she would like to bathe more than once weekly but was told she could not because there was not enough staff. Review of resident 13's EMR revealed: *She was admitted on [DATE]. *Her 2/4/25 BIMS assessment score was 15, which indicated she was cognitively intact. *She was documented to have been bathed weekly. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred two or more baths per week. *Resident 13's 3/26/25 care plan did not address her preference to receive two or more baths per week. 3. Interview on 3/25/25 at 11:32 a.m. with resident 38 revealed: *She usually received her bath weekly. *She had not received a bath in the past week. *She had not refused her bath for a long time. Review of resident 38's EMR revealed: *She was admitted on [DATE]. *Her 2/20/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *There was no documentation that indicated she had been bathed since 3/15/25. -She had not received a bath within the last 10 days. 4. Interview on 3/24/24 at 2:28 p.m. with resident 306 and his daughter in his room revealed: *Resident 306 stated he always had to ask for a bath. *He was told by staff, I'll be right back to give you a shower and three hours later he still hadn't had one. *He stated, They always say we're short-staffed. *He stated he wanted a shower but they talked me into a bath. *His daughter stated she would like for him to get on a bath schedule. Review of resident 306's EMR revealed: *He was admitted on [DATE]. *His 2/12/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated he was cognitively intact. *His 2/11/25 Sit-Stand-Walk Data Collection Tool assessment indicated he preferred two or more baths per week. *His 2/11/25 care plan did not address his preferences for type or frequency of bathing. *From 2/23/25 to 3/25/25 he had documented bathing on 3/3/25, 3/5/25, 3/10/25, and 3/20/25. A follow-up interview on 3/26/25 at 4:13 p.m. with resident 306 and his wife in his room revealed: *His wife stated, One bath a week is not enough. *He stated he had previously shared his concerns about not getting a shower with the social worker. 5. Interview on 3/24/25 at 3:02 p.m. with resident 15 in her room revealed: *She stated, I didn't get a bath last week, and they're working on getting one for this week. *She stated, It does not feel like there's enough help here. Review of resident 15's EMR revealed: *She was admitted on [DATE]. *Her 1/21/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her 1/20/25 Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *From 2/23/25 to 3/25/25 she had a bed bath documented on 2/27/25, 3/6/25, and 3/13/25. *It was documented that she refused a bath on 3/20/25. *There was no documentation that indicated she had been bathed since 3/13/25, 12 days prior. A follow-up interview on 3/26/25 at 4:36 p.m. with resident 15 in her room revealed: *She did not refuse a bath last week. *She would prefer two or three baths per week. 6. Interview on 3/24/25 at 3:26 p.m. with resident 18 in her room revealed: *She was supposed to get a bath that day but did not. *She was told by staff that they would try to get her a bath tonight. Review of resident 18's EMR revealed: *She was admitted on [DATE]. *Her 9/13/24 BIMS assessment score was 12, which indicated she was moderately cognitively impaired. *Her 2/27/25 Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *She had documented baths on 3/3/25, 3/10/25, 3/19/25, and 3/24/25, all at 2:14 p.m. -The bath that was documented on 3/24/25 at 2:14 p.m. was the same day she said that she was supposed to get a bath but did not and was told by staff that they would try to get her a bath that night. A follow-up interview on 3/26/25 at 4:42 p.m. with resident 18 regarding her preferences revealed she would like to have a bath every day if possible. 7. Interview on 3/24/25 at 4:14 p.m. with resident 42 in her room revealed: *She stated, We only get a bath once a week because they're short on help. *She would prefer more frequent baths. Review of resident 42's EMR revealed: *She was admitted on [DATE]. *Her 2/18/25 BIMS assessment score was 12, which indicated she was moderately cognitively impaired. *Her 2/17/25 Sit-Stand-Walk Data Collection Tool assessment indicated she would like two or more baths per week. *She had a 2/24/25 physician order for two baths per week. *From 2/23/25 to 3/25/25 she had baths documented on 3/4/25, 3/10/25, and 3/17/25. 8. Review of the provider's grievances from 1/16/24 through 2/26/25 revealed: *There were five grievances filed on behalf of four separate residents related to not receiving baths consistent with their preferences. *Documented resolutions to those grievances included the provider: -Indicated what days baths were scheduled. -Educated staff on following the bath schedule. -Followed up with the resident in writing that they would try to accommodate a preference for two baths per week but did not schedule the resident for two baths. -Followed up with family and indicated the resident is getting baths. -Followed up with family and indicated the resident remains on a bathing schedule. 9. Interview on 3/26/25 at 1:45 p.m. with Clinical care leader (CCL)/infection preventionist (IP) D regarding resident bathing revealed if no bath aide was available the certified nursing assistant (CNA) that was working on the floor providing resident cares would be responsible to provide the resident's bathing according to the bath schedule. 10. Interview on 3/26/25 at 2:25 p.m. with Minimum Data Set (MDS) nurse C revealed: *The resident preferences related to bathing was documented in the Sit-Stand-Walk Data Collection Tool assessment in the EMR. -MDS nurse C completed this assessment quarterly. *CCL/IP D maintained the resident bath schedule and MDS nurse C believed she went by the preferences documented on the Sit-Stand-Walk Data Collection Tool assessment to make the bath schedule. *It was her expectation that the preferences documented in the Sit-Stand-Walk Data Collection Tool assessment be followed when scheduling the resident's bathing. 11. Interview on 3/27/25 at 8:01 a.m. with CNA M revealed: *She was usually scheduled as a bath aide when she worked. *If a resident refused a bath, the bath aide was to ask again later that day. If the resident refused again, the bath aide was to ask another staff member to approach the resident for a bath or the evening staff was to attempt to give that resident a bath. *She rarely had a resident refuse their scheduled bathing. *Residents usually received one bath per week. *There were times the bath aide was reassigned to work as a CNA on the floor to provide resident cares. *If the bath aide was reassigned to the floor each CNA would be responsible to complete the resident's bathing according to the bathing schedule. *She thought the bath aide was reassigned to work the floor at least one day per week. *If a resident requested more than one bath per week, staff were to attempt to accommodate the request, and the bathing schedule and the resident's care plan were to be updated to reflect the request. 12. Interview on 3/27/25 at 8:22 a.m. with CNA P regarding resident bathing revealed: *There was a resident bathing schedule located in the nurses' station. *The residents' baths were to be completed by the CNA assigned to provide resident bathing for that shift. *There were times when a bath aide was not scheduled to work. *There were times the bath aide was reassigned to work on the floor to provide resident care. *If there was no bath aide scheduled the float CNA would usually complete the resident baths. *If there was no float or a bath aide the CNAs assigned to work on the floor were to complete the baths scheduled for that day. *In the last three weeks, on the days he had worked, there had been three or four times when no bath aide was available to complete the assigned residents' baths and the CNA that was providing direct care was responsible to provide the resident on their assignment with their bath. 13. Interview on 3/27/25 at 10:16 a.m. with CCL/IP D regarding resident bathing revealed: *She maintained the resident bathing schedule. *The resident baths were scheduled on the treatment administration record (TAR) and in the tasks in the EMR. *The bathing schedule may change according to resident requests. *She indicated the residents were interviewed regarding their bath preferences. *She was not aware who completed the interview, when the interviews were to be completed, or where to locate the information obtained during the interview. *Residents could discuss their concerns and preferences with staff or during care conferences. 14. Interview on 3/27/25 at 10:37 a.m. with administrator A regarding resident choices revealed it was her expectation that staff do their best to accommodate resident choices. 15. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B regarding resident bathing revealed she expected staff to follow the bathing schedule. 16. Review of the provider's 2016 Resident's Rights for Skilled Nursing Facilities revealed: *The resident has the right to be informed of, and participate in, the development and implementation of his or her person-centered plan of care, including, but not limited to: -The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency and duration of care and any other factors related to the effectiveness of the plan of care. *The resident has the right to be treated with dignity including: -The right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. *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 choose activities, schedules (including sleeping and waking times), healthcare and providers of healthcare services consistent with his or her interests, assessments and plans of care. -The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. *Services included in Medicare or Medicaid payment. -Routine personal hygiene items and services as required to meet the needs of residents, including, but not limited to, .hair and nail hygiene services, bathing assistance, . 17. Review of the provider's 12/02/2024 Grievances, Suggestions, or Concerns- Rehab/Skilled policy revealed: *Purpose -To document concerns, investigative findings and plans of correction. -To develop a systematic approach in resolving grievances as a tool to ensure continuous quality of care. *Policy -A resident has the right to voice grievances orally, in writing and anonymously without discrimination or reprisal. Such grievances, complaints or concerns include those with respect to treatment that has been furnished, as well as those that have not been furnished. -Grievances, suggestions and concerns are to be deemed high priority customer satisfaction issues. Facility staff will make prompt efforts to resolve a grievance and keep the resident/resident representative apprised of progress toward resolution.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of eight sampled residents' (1 and 51) care plans were revised to reflect their current status and care needs. Findings include: 1. Observation and interview on 3/24/25 at 3:13 p.m. with resident 51 and his spouse revealed: *The resident's room was without any personal items from home. *He was admitted to the facility after back surgery. He had a complicated and extensive hospitalization . *His goal was to return home with his spouse after his rehabilitation stay at the facility. *His pain had improved since he was admitted to the facility. *The resident's affect was flat. *In early March 2025, the resident's medical provider had recommended he see a counselor for his worsening depression. -The resident's spouse had asked that a male counselor see the resident. She was told there were no male counselors available to have met with the resident. No other counseling alternatives had been discussed with her or the resident. Interviews on 3/25/25 at 2:00 p.m. and on 3/26/25 at 4:45 p.m. with resident 51 in his room revealed: *He had a history of depression and was taking an anti-depressant medication. He had increased depressive symptoms since he was admitted to the facility. -He had lost weight because nothing tasted good. He had feelings of imprisonment, and a sense of loss of control of his body. He was a loner and remained in his room most of the time. *His spouse had visited him regularly and a few friends had also visited him. -It had felt good to unload how he was feeling with his friends. *At home, the resident had enjoyed sitting in his own recliner and using his home computer. Having personal items that surrounded him at home brought him joy. Review of resident 51's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 3/26/25 Brief Interview for Mental Status assessment score was 13 which indicated he had little or no cognitive impairment. *His 2/11/25 PHQ-9 (Patient Health Questionnaire - a self-report tool used to assess depression symptom severity) assessment score was 8 which indicated he had mild depression. *His anti-depressant medication was increased on 2/19/25. Review of resident 51's care plan revealed: *Interventions related to the resident's risk for an alteration in his mood and psychosocial well-being were initiated on 2/10/25 and included: -Adjust environment to promote comfort i.e. room temperature, furniture arrangement, lighting, personal belongings. -CSW [certified social worker] to initiate referrals as needed/indicated. -Depressive symptoms: Encourage positive conversation during cares and interactions, offer praise and encouragement, empathize with feelings and concerns. -Provide opportunities for resident to engage in meaningful conversation and activities with others. -Staff to monitor and provide ongoing conversation regarding routine and preferences. *No revisions were made to those interventions since they were initiated. *Interventions related to the resident's depression diagnosis initiated on 2/25/25 and revised on 3/3/25 included: -Consult with pharmacy, healthcare provider, etc. to consider dosage reduction when clinically appropriate. -Depression: attempt non-pharmacological interventions such as one-one [one on one] visits, offer counseling if agrees, monitor for adverse effects of medications and effectiveness of medications. *Interventions related to the resident's use of anti-depressant medication were initiated on 2/10/25 and included Monitor resident condition based on clinical practice guidelines or clinical standards of practice r/t [related to] use of Sertraline [anti-depressant medication]. Interview on 3/28/25 at 9:10 a.m. with social service directors (SSD)/CSW I and J revealed: *SSD/CSW J had documented the above care plan interventions related to resident 51's risk for a decline in his mood and psychosocial well-being. *She stated those interventions were generic. -She was expected to have revised the interventions to ensure they had been person-centered and individualized to have reflected the current and ongoing needs of resident 51 during his nursing home stay. *Her care plan had not reflected: -What individualized accommodations were to have been offered or made to improve the resident's environmental comfort. -If any counseling service referrals had been made or services provided. -How staff were to attempt to engage the resident in meaningful conversation and activities. -SSD/CSW J stated the one-on-one visits with the resident would have been her responsibility to have implemented and documented. She had not known about that intervention so there had been no follow-up. *Care plan interventions related to resident 51's anti-depressant medication monitoring and depression diagnosis had been documented by minimum data set (MDS) nurse C. Interview on 3/28/25 at 1:10 p.m. with MDS nurse C regarding resident 51's care plan revealed she: *Had documented the interventions on his care plan related to depression and anti-depressant medication use monitoring. *No monitoring tool had been implemented to measure the type and frequency of resident 51's depression symptoms. -Should have identified the staff person responsible for implementing that intervention on the care plan and communicated that responsibility to them. *Agreed the intervention related to a medication dose reduction should have been updated to reflect the resident had an increase in his anti-depressant medication. A dose reduction was currently contra-indicated. *Had not known if the one-on-one visits she had referred to in her interventions were implemented. -Should have identified the staff person responsible for implementing that intervention on the care plan and communicated that responsibility to them. 51472 2. Observation and interview on 3/24/25 at 4:04 p.m. with resident 6 in her room revealed: *There was a cushion in her wheelchair. *She reported she had a sore on her buttocks that staff was applying cream to. *There was no PPE in her room or outside the door to her room. Interview on 3/24/25 at 5:19 p.m. with registered nurse (RN) F regarding resident 6's skin revealed: *She previously had a pressure ulcer to her right heel that was healed. *She had some excoriation (skin was scraped off) on her buttocks that the CNAs were applying a cream to. Review of resident 6's 3/26/25 care plan revealed: *A focus area of The resident has respiratory infection: Covid 19. -A intervention for the focus area was, DROPLET and CONTACT PRECAUTIONS: Wear gowns, gloves, N95 masks (if available), and eye protection when changing contaminated linens. Bag linens and close bag tightly before taking to laundry. Isolation x10 days dx [diagnosis]. *A focus area of The resident requires Enhanced Barrier Precautions R/T [related to] wounds. -An intervention for the focus area was, [NAME] [put on] gown and gloves when performing high contact care activities including: dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care, and/or use, and wound care. 3. Interview on 3/26/25 at 10:37 a.m. with RN S regarding resident 6 revealed: *Her right heel wound had resolved almost three weeks ago, and she was no longer on EBP for this. *She had COVID over a month ago and was no longer on transmission-based precautions. 4. Interview on 3/36/25 at 8:22 a.m. with Minimum Data Set (MDS) nurse C regarding care plans revealed: *She was responsible for updating resident care plans with each resident's MDS assessment. *Anyone on the interdisciplinary team could update resident care plans. *Clinical care leader (CCL)/infection preventionist (IP) D was responsible for updating resident care plans that addressed resident wounds or infections. *It was her expectation that care plan updating be an ongoing process and occur any time there was a change in resident condition or care. *Resident 6's care plan had not been updated after the resolution of her right heel wound and after she was taken off transmission-based precautions for COVID. 5. Interview on 3/26/25 at 1:58 p.m. with CNA O revealed: *She was a travel CNA and had recently been assigned to this facility. *She indicated she referenced a resident's care plan or Kardex (a report of residents' care needs and interventions) to determine what cares were to be provided for a resident and how to provide the cares. 6. Interview on 3/27/25 at 10:16 a.m. with CCL/IP D regarding care plans revealed: *She was responsible for updating residents' care plans related to infections, wounds, transmission and enhanced barrier precautions. *Care plan updating was a working interdisciplinary team collaboration. *Care plans should be updated anytime there was a change in resident condition or care needs in addition to quarterly. *She agreed resident 6's care plan was not up to date and should have been. 7. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B regarding care plans revealed: *It was the responsibility of the nurses, clinical team, and herself to update resident care plans. *She expected resident care plans to be updated anytime there was a change in the residents' plan of care. Review of the provider's 12/2/24 Care Plan policy revealed: *Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders. *The plan of care will be modified to reflect the care currently required/provided for the resident. Review of the provider's 4/2/24 standard and transmission based precautions policy and procedure revealed that the use of EBPs was indicated for residents with: *Chronic wounds (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous statis ulcers) and residents with indwelling medical devices,)central lines, hemodialysis catheters, indwelling urinary catheters, feeding tubes, and tracheostomies). *EBP are also needed for residents with centers for disease control and prevention (CDC) targeted and epidemiologically important (facility discretion) MDRO infection and colonization, when contact precautions do not apply. multi-drug-resistant organisms (MDRO) when contact precautions do not otherwise apply. *High contact resident care activities include transfers, dressings, assisting during bathing, providing hygiene, changing briefs or assisting with toileting, working with resident in therapy gym, specifically when anticipating close physician contact while assisting with transfers and mobility, changing linens, device care or use. Review of the provider's 10/30/24 infection, prevention and control program policy and procedure 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. *Infection prevention and control program is 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.

Based on observation, interview, record review, grievance review, and facility assessment review, the provider failed to have enough sufficient staff available to promote resident's rights, physical, mental, and psychosocial well-being for: *Eleven of fifteen sampled residents (7, 13, 14, 15, 18, 20, 26, 33, 38, 42, and 306) who were dependent on the staff to assist them with grooming, bathing, and toileting. *Five of five additional residents (22, 36, 45, 54, and 55) who had filed grievances on bathing and extended call light response time. Findings include: 1. Observation and interview on 3/24/25 at 2:14 p.m. with resident 33's in her room revealed, she: *Had multiple long gray facial hairs extending from her chin. *Reported that there were times when it took staff a long time to answer her call light. *Had waited longer to have her call light answered at night. Review of resident 33's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated she had moderate cognitive impairment. *Her care plan indicated she required assist of one staff member for dressing, grooming, and bathing. 2. Interview on 3/24/25 at 3:21 p.m. with resident 7 revealed, she: *Was told her physician ordered her two baths per week, but she had been receiving one bath weekly. *Had expressed her desire for more than one bath weekly with the CNAs, but no one else had come to talk to her about it and nothing had changed. *Expressed concerns about her call light not being answered promptly. -Staff told her that her call light was not working but it was now. Review of resident 7's EMR revealed, she: *Was admitted on [DATE]. *Had a BIMS assessment score of 15, which indicated she was cognitively intact. *She required assistance of for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of resident 7's 2/2/25 grievance revealed: *She indicated she was placed on a bedpan at 3:00 a.m. and the staff member told her, I will be back. -The staff member had not returned, she fell asleep, woke up feeling the bed pain, and started to feel pain. -She turned on her call light and thought she felt someone touch her shoulder and leave. -She again turned on her call light and thought someone came in and left again. -She then started yelling, but nobody came. -She knew it was about the time of a staff shift change because she looked at her cell phone and it was morning. -Someone entered her room, removed the bedpan from under her, and assisted her with her care needs. -She indicated by that time her bedding was soaked [with urine]. *The CNA that placed resident 7 on the bedpan stated she did so sometime between 3:30 a.m. and 4:30 a.m. -She indicated she had forgotten to remove the bedpan and forgot to tell the oncoming shift. 3. Interview on 3/24/25 at 3:30 p.m. with resident 20's daughter/power of attorney (POA) revealed: *She indicated she visited her mother daily. *Her mother was hard of hearing and legally blind. *She indicated she felt the facility was short-staffed. *She felt the staff rushed the residents when providing their care. *There were times when staff did not apply her mother's compression socks or put in her hearing aids before taking her to breakfast. *When resident 20 was in the dining room, staff often did not take the time to explain to her where her food was on her plate or assist her with eating meals. *Her mother has had multiple falls. *Resident 20 was scheduled for a bath weekly. *She previously was bathed twice weekly but resident 20's daughter/POA was told she no longer received twice weekly baths because there was not enough staff to accommodate that. Review of resident 20's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 2/17/25 Brief Interview of Mental Status (BIMS) assessment score was 6, which indicated she had severe cognitive impairment. *She was scheduled to have been bathed weekly. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred two or more baths per week. *Her care plan revealed she required assist of one staff member for bathing, dressing, personal hygiene, and toilet use. *She required set up assistance and cueing for eating. 4. Interview on 3/24/25 at 5:04 p.m. with resident 13 revealed: *She had at times waited for her bathroom call light to be answered for a half hour. *She thought she had waited as long as an hour and ten minutes for her bathroom call light to be answered. *She was bathed once weekly. *She had notified facility management that she would like to bathe more than once weekly but was told she could not because there was not enough staff to accommodate that. Review of resident 13's EMR revealed: *She was admitted on [DATE]. *Her 2/4/25 BIMS assessment score was 15, which indicated she was cognitively intact. *She was documented to have been bathed weekly. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred two or more baths per week. *Her care plan revealed she required assistance from one staff for toilet use, and transfers. -She required set up assistance for dressing, grooming, eating, wheelchair mobility, and oral care. Review of resident 13's 2/20/25 grievance revealed: *During 2/19/25 care conferences resident 13 and her daughter expressed concerns regarding: -Her bathroom her call light response time was often 30 to 60 minutes. -She did not know week to week if she was going to receive a bath. -She had gone 15 days between baths previously. -Her preference for bathing was twice weekly and always on Fridays. -She would have liked to receive more assistance from staff with clothing mgt [management]. *Investigation stated, Unable to view call light response time. *Response to resident 13's grievance included: -Staff was educated on call light response time; review Call light Policy at daily huddles. -Whirlpool completed on 01/31; 02/07; 02/14; 02/21 and 02/28. Preference is twice a week and will strive to accommodate twice weekly. Care plan updated regarding clothing management. 5. Interview on 3/25/25 at 8:53 a.m. with resident 26 in her room revealed: *She indicated she was assisted to bed last night by a male staff member and he did not put her into her pajamas. *When she woke up in the morning, she was in the same clothes she had worn the day before and the morning staff member helped her change her clothing. *She felt staff took a long time to answer her call light. -It often took between 10 to 15 minutes but was longer at times when she was in the bathroom. *She indicated she usually got a bath on Sundays but recently she has had to fuss in order to get a bath. *She stated she felt, they don't have time for me. Review of resident 26's EMR revealed: *She was admitted on [DATE]. *Her 2/17/25 BIMS assessment score was 12, which indicated she had moderate cognitive impairment. *Her care plan revealed she required assistance of one staff member for bating bed mobility, dressing, toilet use, and transfers. -She required set up assistance by a staff member for eating, oral care, and personal hygiene. 6. Interview on 3/25/25 at 11:32 a.m. with resident 38 revealed: *She usually received her bath weekly. *She had not received a bath in the past week. *She thought the facility was short-staffed but felt the staff was doing the best they could. *Staff had told her they were short-staffed. *She did not feel there was a specific time of day that the call light response times were longer than other times. Review of resident 38's EMR revealed: *She was admitted on [DATE]. *Her 2/20/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *There was no documentation to support she had been bathed since 3/15/25, 10 days prior. 7. Resident group interview on 3/25/25 at 1:59 p.m. revealed: *One resident stated she would like more baths, especially when it was hot out. *Another resident stated she had gone 12 days without a bath, she began to cry and then stated they [staff] told her they were too busy to give her a bath and that made her upset. She then stated, I have to suffer because the staff are too busy to give me a bath. *Another resident stated she didn't receive help soon enough. She expanded to state she waited an hour and ten minutes last week for staff to respond to her call light. Usually, the call light response time was 20 minutes, and she then stated the wait time kills me. *Another resident stated that call light response wait times varied from a few minutes to an hour. 51816 8. Interview on 3/24/24 at 2:28 p.m. with resident 306 and his daughter in his room revealed: *Resident 306 was admitted for rehabilitation after a hospitalization *He stated he hadn't been able to regain his strength after his cancer diagnosis and treatment *He stated he always had to ask for a bath and never knew when or if he was going to get one. *He was told by staff, I'll be right back to give you a shower, and three hours later, he still hadn't had one. *He stated, They always say we're short-staffed. *He stated he wanted a shower but they talked me into a bath. *His daughter stated she would like for him to get on a bath schedule. Review of resident 306's EMR revealed: *He was admitted on [DATE]. *His 2/12/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated he was cognitively intact. *His diagnoses included personal history of malignant neoplasm of prostate (prostate cancer), weakness, difficulty in walking, not elsewhere classified, and unsteadiness on feet. *His 2/11/25 Sit-Stand-Walk Data Collection Tool assessment indicated he preferred two or more baths per week. *His 2/11/25 care plan contained an intervention that indicated he needed staff assistance for transfers. *From 2/23/25 to 3/25/25 he had documented bathing on 3/3/25, 3/5/25, 3/10/25, and 3/20/25. A follow-up interview on 3/26/25 at 4:13 p.m. with resident 306 and his wife in his room revealed: *His wife stated, One bath a week is not enough. *He stated he had previously shared his concerns about not getting a shower with the social worker. 9. Interview on 3/24/25 at 3:02 p.m. with resident 15 in her room revealed: *She stated, I didn't get a bath last week, and they're working on getting one for this week. *She stated, It does not feel like there's enough help here. Review of resident 15's EMR revealed: *She was admitted on [DATE]. *Her 1/21/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her 1/20/25 Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *From 2/23/25 to 3/25/25 she had a bed bath documented on 2/27/25, 3/6/25, and 3/13/25. *It was documented that she refused a bath on 3/20/25. *There was no documentation that indicated she had been bathed since 3/13/25, 12 days prior. A follow-up interview on 3/26/25 at 4:36 p.m. with resident 15 in her room revealed: *She did not refuse a bath last week. *She would prefer two or three baths per week. 10. Interview on 3/24/25 at 3:26 p.m. with resident 18 in her room revealed: *She was supposed to get a bath that day but did not. *She was told by staff that they would try to get her a bath tonight. Review of resident 18's EMR revealed: *She was admitted on [DATE]. *Her 9/13/24 BIMS assessment score was 12, which indicated she was moderately cognitively impaired. *Her diagnoses included difficulty in walking, unsteadiness on feet, repeated falls, and muscle wasting and atrophy (decrease in size). *Her 2/27/25 Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *She had documented baths on 3/3/25, 3/10/25, 3/19/25, and 3/24/25, all at 2:14 p.m. -The bath that was documented on 3/24/25 at 2:14 p.m. was the same day she said that she was supposed to get a bath but did not and was told by staff that they would try to get her a bath that night. A follow-up interview on 3/26/25 at 4:42 p.m. with resident 18 regarding her preferences revealed she would like to have a bath every day if possible. 11. Interview on 3/24/25 at 4:14 p.m. with resident 42 in her room revealed: *She stated, We only get a bath once a week because they're short on help. *She would prefer more frequent baths. Review of resident 42's EMR revealed: *She was admitted on [DATE]. *Her 2/18/25 BIMS assessment score was 12, which indicated she was moderately cognitively impaired. *Her diagnoses included weakness, muscle wasting and atrophy, difficulty in walking, not elsewhere classified, and unsteadiness on feet. *Her 2/17/25 Sit-Stand-Walk Data Collection Tool assessment indicated she would like two or more baths per week. *She had a 2/24/25 physician order for two baths per week. *From 2/23/25 to 3/25/25 she had baths documented on 3/4/25, 3/10/25, and 3/17/25. 12. Interview on 3/24/25 at 5:05 p.m. with resident 14 in her room revealed: *She no longer waited for the staff to answer her call light when she needed to use the bathroom. *She used to wait for assistance to the bathroom but had incontinent episodes because she had to wait too long. *She stated, Sometimes I don't see anyone from 8:00 in the morning until 8:00 at night, except the person who brings in my room [meal] tray. They don't have enough help. Review of resident 14's EMR revealed: *She was admitted on [DATE]. *Her 1/29/25 BIMS assessment score was 15, which indicated she was cognitively intact. Review of the 2/6/25 grievance filed by resident 14 revealed: *She had concerns about not getting her bedtime medications on time. *She did not get her medications until midnight. *She had concerns about medications being left at her bedside. *The provider's investigation documentation of medication pass times included nothing [no medications] administered after midnight. *The provider's resolution included: -Reassured res [resident] that meds [were] to be passed per schedule. 13. Review of the provider's grievances from the previous year revealed: A 1/16/24 grievance filed on behalf of resident 54 by family indicated: *Resident 54 was not getting a bath since he was admitted . *Extended call light staff response times. *The provider's investigation documentation included: -When [the] resident was admitted , bathing was added but not finalized to show on tasks. Completed on 1/18/24. -Call light audit from 1/11/14 through 1/16/24 revealed: --Three call light response times over 10 minutes. --One call light response time over 15 minutes. --Two call light response times over 20 minutes. --Two call light response times over 30 minutes. *The provider's follow-up included: Will educate nurses about call light response time. A 7/30/24 grievance filed by resident 55 for her call light being on for an hour indicated: *A call light audit confirmed the resident's call light was on for 56 minutes. *Resolution documentation included: Education provided to CNA/nurse that all call lights are to be answered promptly. An 8/13/24 grievance filed on behalf of resident 22 for not getting a bath indicated: *The provider's audit of Tasks documentation revealed resident 22 had a: -Bed bath on 8/2/24 at 9:59 p.m. -Whirlpool bath on 8/5/24 at 12:01 p.m. -Bed bath on 8/9/24 at 10:14 p.m. -Bath documented as refused on 8/12/24 at 1:22 p.m. A 2/6/25 grievance filed on behalf of resident 45 with concerns about her bathing schedule indicated: *The provider's investigation documentation included: bathing schedule reviewed and resident is getting her bathing completed. -No audit was included. A 2/18/25 grievance filed by resident 36 regarding extended call light response time indicated: *Resident 36 reported that the shampoo machine was so loud that nobody heard anything. *A call light audit revealed a response time of 29 minutes and 26 seconds. *T provider's follow-up comments included: Education to staff: be extremely cognizant of loud equipment used, i.e.; shampoo machine; conduct an additional and intention rounding to ensure residents needs are addressed. An additional 2/26/25 grievance filed on behalf of resident 45 regarding bathing and call light response time indicated: *A family member reported that resident 45 had only received three baths since arriving at the facility. *The resident's call light was on for an hour. *The provider's follow-up comments included: -Education to staff on following bathing schedule. -Call light response time; strive for timely manner to answer. *No audits were included. Interview on 3/26/25 at 1:45 p.m. with Clinical care leader (CCL)/infection preventionist (IP) D regarding resident bathing revealed if no bath aide was available the certified nursing assistant (CNA) that was working on the floor providing resident cares would be responsible to provide the resident's bathing according to the bath schedule. Interview on 3/26/25 at 2:25 p.m. with Minimum Data Set (MDS) nurse C revealed: *The resident preferences related to bathing was documented in the Sit-Stand-Walk Data Collection Tool assessment in the EMR. -MDS nurse C completed this assessment quarterly. *CCL/IP D maintained the resident bath schedule and MDS nurse C believed she went by the preferences documented on the Sit-Stand-Walk Data Collection Tool assessment to make the bath schedule. *It was her expectation that the preferences documented in the Sit-Stand-Walk Data Collection Tool assessment be followed when scheduling the resident's bathing. Interview on 3/27/25 at 8:01 a.m. with CNA M revealed: *Residents usually received one bath per week. *There were times the bath aide was reassigned to work as a CNA on the floor to provide resident cares. *If the bath aide was reassigned to the floor each CNA would be responsible to complete the resident's bathing according to the bathing schedule. *She thought the bath aide was reassigned to work the floor at least one day per week. Interview on 3/27/25 at 8:22 a.m. with CNA P revealed: *There was a resident bathing schedule located in the nurses' station. *The residents' baths were to be completed by the CNA assigned to provide resident bathing for that shift. *There were times when a bath aide was not scheduled to work. *There were times the bath aide was reassigned to work on the floor to provide resident care. *If there was no bath aide scheduled the float CNA would usually complete the resident baths. *If there was no float or a bath aide the CNAs assigned to work on the floor were to complete the baths scheduled for that day. *In the last three weeks, on the days he had worked, there had been three or four times when no bath aide was available to complete the assigned residents' baths. *It was his expectation that call lights be answered as soon as possible. *He answered the bathroom call lights first. *He indicated that nurses and CNAs were responsible for answering the call lights. Interview on 3/27/25 at 8:45 a.m. with licensed practical nurse (LPN) K revealed: *He expected residents' call lights to be answered by around five minutes. *He indicated it was everyone's responsibility to respond to call lights. Interview on 3/27/25 at 10:16 a.m. with CCL/IP D revealed: *She indicated the residents were interviewed regarding their bath preferences. *She was not aware who completed the interview, when the interviews were to be completed, or where to locate the information obtained during the interview. *Residents could discuss their concerns and preferences with staff or during care conferences. *It was her expectation that anyone could answer a call light. Interview on 3/27/25 at 10:37 a.m. with administrator A revealed: *That she expected staff do their best to accommodate resident choices. *Regarding grievances, she expected staff to follow policy, complete a thorough investigation, and complete periodic reevaluations after the initial grievance resolution. *She stated that anyone could answer a resident's call light. *She referred to the facility assessment when the staffing policy was requested. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed: *She expected staff to follow the bathing schedule. *She indicated it was everyone's responsibility to answer call lights. *She expected call light response times would be what the policy stated. *Call light response audits were periodically completed on a case-by-case basis. -The north call lights were able to be audited through the call light system. -The south call lights were audited by a leadership member by activating a call light and then waiting in the room and timing the response of the staff member to respond to the call light. Interview on 3/27/25 at 1:04 p.m. with CCL E regarding call light response times revealed: *She was responsible for the coordination of QAPI (quality assurance and performance improvement) for the facility. *The facility had identified call light response times as an area that needed improvement. -A performance improvement plan (PIP) was initiated regarding staff response times to resident call lights. --A trend was identified during this PIP of call light response times being the longest between 7:00 a.m. and 9:00 a.m. --The PIP was completed on 12/9/24. Review of the provider's 8/12/24 Facility Assessment revealed: *The assessment indicated: -The provider had appropriate staffing to meet the needs of the residents. -The acquity [acuity] & [and] needs of [the] residents were met by [The provider] monitors the acuity level and the PPDs [per patient day hours] of the facility. We ensure we have the appropriate staffing levels based on national and state averages. We ensure that if we have a high acuity level[,] we adjust staffing to meet the needs of the residents. -[Provider] utilizes an interdisciplinary approach to meet the needs of our population and its individuals across all shift[s] including nights and weekends, using data from MDS, case mix index, and considering care planned interventions . As the needs of the population change as indicated by the number of residents served, acuity levels, MDS results and care plans the staffing pattern is adjusted to meet those needs. We consider variability in care needs across day, evening and night shifts, including weekends and holidays, and adjust as necessary. We confirm needs are met by engaging in frequent communication with residents, their families and representatives with regular care conferences, rounding, quality assurance audits, resident group meetings, availability of suggestion/concern forms and email surveys. -The following is measured and monitored to ensure proper ongoing care and service meet resident needs. --Care plans, Care conferences/Family conversations, Medicare Meeting, continuous staff meetings, QAPI meetings, Quarterly and annual MDS assessments, resident council meetings, concern forms, and quality of life meeting. -Coordination and continuity of care is measured and monitored by Scheduling will be done. We will monitor through resident council and other means as well to ensure coordination and continuity of care is being done. Refer to F561.

Based on observation, interview, record review and policy review, the provider failed to ensure: *Two nurses had signed for the receipt of controlled medications (medications at risk for abuse and addiction) on the controlled drug record for five of five residents (6, 15, 21, 24, and 31) who were prescribed controlled medications *One prescribed controlled liquid medication concentration was documented on the Controlled Drug Record for one of one resident (31). *The destruction of fentanyl patches for one of one sampled resident (6) was accurately documented appropriately by individuals authorized to destroy controlled medications. Findings include: 1. Observation on 3/24/25 at 2:30 p.m. of the controlled substance binders on the south medication carts revealed: *A handwritten Controlled Drug Record identified as resident 15's for 24 lorazepam (a controlled anti-anxiety medication) 0.5 milligrams (mg) tablets did not indicate when the medication was received or who verified the receipt of the medication. *A Controlled Drug Record identified as resident 6's for 60 pregabalin (a controlled medication for nerve pain) 75 mg tablets delivered on 3/8/25 did not contain a pharmacy representative signature that documented the delivery of the controlled medication nor a nurse's signature that verified the receipt of the medication. 2. Observation on 3/26/25 at 11:30 a.m. of the controlled substance binders on the north medication carts revealed: *A handwritten Controlled Drug Record identified as resident 31's for 15 ml (milliliters) of morphine sulfate (a controlled pain medication) with no identified medication concentration, did not indicate when the medication was received or a signature of who verified the receipt of the medication. *A Controlled Drug Record identified as resident 24's for 60 tramadol (a controlled pain medication) 50 mg (milligrams) tablets delivered on 3/7/25 did not contain the signature of the nurse who verified the receipt of the medication. *A handwritten Controlled Drug Record identified as resident 24's for 4 patches of buprenorphine (a controlled medication to treat pain and opioid use disorder) 7.5 mcg (micrograms)/hr (hour) that did not indicate when the medication was received or a signature of who verified the receipt of the medication. *A Controlled Drug Record identified as resident 21's for 15 ml of morphine sulfate 100 mg/ml that did not contain the signature of the nurse to document the receipt of the medication. 3. Interview and review of the above controlled drug records on 3/24/25 at 2:48 p.m. with registered nurse (RN) G revealed she confirmed there were areas of documentation that had not been completed including signatures of receipt, dates of receipt, and a medication concentration. 4. Interview on 3/26/25 at 11:03 a.m. with RN S revealed: *Medications arrived from the pharmacy at about 6:00 p.m. *The night nurse was responsible for checking the medications in when received from the pharmacy transport person. *When the nurse received the medication from pharmacy transport person the nurse was to sign a form that was retained by the pharmacy and the Controlled Drug Record for that medication was then to be placed in the controlled substance binders on the medication carts. 5. Observation on 3/24/25 at 2:30 p.m. of the controlled substance binders on the south medication carts revealed: *Resident 6's Controlled Drug Record indicated she was to receive fentanyl 25 mcg/hr (controlled pain medication) topical patches every three days. *There was no documentation in the Controlled Substance Binder of the disposal of the fentanyl patches that were removed from the resident when another patch was applied. 6. Interview on 3/26/25 at 10:33 a.m. with RN S and unlicensed medication aide (UMA) L regarding used fentanyl patch destruction revealed: *Resident 6's fentanyl patch was scheduled for removal every three days on her medication administration record (MAR). *When the fentanyl patch was removed from the resident, it was to be destroyed by two people and documented in a nurse's note within the scheduled removal area in the MAR. *RN S stated resident 6's fentanyl patch had been removed that morning and she had witnessed its disposal in the medication destroyer product container in the medication cart. *RN S reviewed resident 6's nurse's notes and confirmed there was no documentation the fentanyl patch was destroyed. *RN S stated the process she had described was her practice to cover myself from suspicion of drug diversion. *She clarified two nurses did not sign the removal and destruction of the fentanyl patch, but rather the nurse that was charting in the MAR would indicate who witnessed the destruction. 7. Review of resident 6's electronic medical record (EMR) revealed: *She had a physician's order for fentanyl Transdermal [through the skin] Patch 72 Hour 25 MCG/HR (Fentanyl) Apply 1 patch transdermally one time a day every 3 day(s) related to OTHER LOW BACK PAIN. *Resident 6's MAR included and area for documentation of the application and removal of the fentanyl patch at 10:00 a.m. every third day. *Review of resident 6's March 2025 nurses notes revealed: -On 3/17/25 a nurse's note included, removed patch from RUQ [right upper quadrant] [of the abdomen], lead social service coordinator T in SWS [social work services] witnessed waste [destruction]of patch. -On 3/23/25 a nurse's note included, CMA UMA L witnessed this nurse placing previous [fentanyl]patch in liquid waste container, --Per Administrative Rules of South Dakota (ARSD) the destruction or disposal of controlled medications were witnessed by two persons, both of whom must be a nurse or pharmacist. -There was no documentation to support the fentanyl patch was destroyed or there was a witness to the destruction on 3/2, 3/5, 3/8, 3/11, 3/14, or 3/20. 8. Interview on 3/27/25 at 8:45 a.m. with licensed practical nurse (LPN) K revealed: *A fentanyl patch should be destroyed by two nurses. *He was unable to identify where the destruction by two nurses was to be documented. 9. Interview on 3/27/25 at 9:41 a.m. with social service director (SSD)/certified social worker (CSW) I and SSD/CSW J revealed that lead social service coordinator T was not a licensed nurse. 10. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed: *She expected when a controlled substance arrived from the pharmacy, the pharmacy form and the Controlled Drug Record were to be signed by the pharmacy courier and the nurse that received the medication after the medication and count were verified as accurate. *She expected the fentanyl patches to be destroyed according to the provider's policy. 11. Review of the provider's 3/4/25 Medications: Acquisition and Receiving Dispensing and Storage policy revealed: *An employee will be responsible for signing for receipt of medication and obtaining the signature of the delivery person. It is preferred that a licensed nurse receive and verify the medications . Licensed nurses and medications aides (when allowed by state law) are responsible for reconciling medications received. *These medications must be labeled according to state pharmacy regulations. Cautionary and accessory instructions, as well as the expiration date, will be included. New labels will be applied by the pharmacist or the pharmacist's agent as needed. Review of the provider's 6/27/24 Medications: Controlled policy revealed: *Reconciliation: refers to a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, administered and/or, including the process for disposition. *The location will along with their consultant pharmacist will establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation that determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled and meets all state and federal requirements for controlled medications. *When a new controlled medication is delivered, the nurse in the skilled nursing facility will be responsible for counting the medication, Schedule II medications require an Individual Resident's Narcotic Record . or in the Controlled Substance Bound Book. *Disposal of any medication will be carried out under local, state and federal guidelines or in consultation of the pharmacist for the appropriate disposal procedure. Documentation of medication disposal will be made using the [providers' form] or Controlled Substance Bound Book and will include the resident's name, medication name, prescription number (as applicable), quantity disposed, date and method of disposition and the involved nurse (s), consultant or other applicable individuals per state regulations. Review of the provider's 9/3/24 Medication: Disposition (Disposal) policy revealed: *Disposal of any medication will be carried out under local, state and federal guidelines or in consultation of the pharmacist in the appropriate disposal procedure. Documentation will include the resident's name, medication name, prescription number (as applicable), quantity, date of disposition and the involved staff member, consultant or other applicable individuals. *For Controlled substances, two nurses or a nurse and a med [medication] aide must witness the destruction, document on the Individual Resident's Narcotic Record [provider's form number], or in the Controlled Substance Bound Book, to ensure accuracy of the count. Document in [the] medical record the reason for the destruction.

Based on observation, interview, record review, policy review, and manufacturer's recommendations review, the provider failed to ensure a medication error rate of less than 5 percent related to: *A topical pain medication was not applied according to the manufacturer's recommendations for two of two sampled residents (18 and 42) by one of one observed registered nurse (RN) (S). *An oral medication was given to one of one sampled resident (42) without a physician's order by one of one observed RN (S). Those observations created a medication error rate of 10.71%. Findings include: 1. Observation and interview on 3/26/25 from 7:42 a.m. through 8:28 a.m. of registered nurse (RN) S during medication (med) administration revealed: *She dispensed an unknown amount of diclofenac sodium external gel 1% (for arthritis pain and inflammation) into a med cup and administered the gel to resident 18's right lower chest. -The order on resident 18's medication administration record (MAR) indicated she was to receive two grams of the gel. *She dispensed an unknown amount of diclofenac sodium external gel 1% into a med cup and administered the gel to resident 42's left elbow, right knee, and both wrists. -The order on resident 42's MAR indicated she was to receive two grams of the gel to her hands and knees two times a day. *When asked how she knew she was administering the correct dose she stated she thought two grams was about 2.5 cc's [cubic centimeters]. -She read the box for the diclofenac sodium gel and said, Maybe that's just a guess. *She administered vitamin C 1,000 milligrams by mouth to resident 42. -There was no order on resident 42's MAR for the vitamin C. -She indicated the administration of the vitamin C without an order was a medication error. 2. Interview on 3/27/25 at 8:44 a.m. with licensed practical nurse (LPN) K revealed: *The measuring device that was included in the box with the diclofenac sodium 1% gel was to be used to determine the dose of the gel to be administered. *He agreed the measurement device remained secured to the diclofenac sodium 1% gel box that was stored in the medication cart. *He agreed the tube in that box was partially empty. *He indicated that some staff members do not use the device when they administered the medication. 3. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed it was her expectation: *That the measurement device in the diclofenac sodium 1% gel be used to determine the dose of the medication prior to administration to a resident. *That the correct dose of medication was to be administered. *That staff follow the Six Rights of medication administration and follow their policy. 4. Review of the manufacturers' 10/22 recommendations for the diclofenac sodium 1% gel revealed: *User Guide -Remove the dosing card from the inside of the carton. You should always use the dosing card to measure out the correct dose of diclofenac sodium topical gel. 5. Review of the provider's 3/4/25 Medication: Administration Including Scheduling and Medication Aides policy revealed: *Procedure -Review the MAR 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.

Based on observation, interview, and record review, the provider failed to ensure: *Medications for two of two residents (28 and 12) were properly labeled. *Medications for four of four residents (28, 50, 6, 12) were dated when opened. *Temperatures for two of two medication rooms (north and south) were monitored for acceptable medication storage temperatures according to the provider's policy. *Expired nutritional supplements and supplies were removed from two of two medication rooms (north and south). Findings include: 1. Observation and interview on 3/24/25 at 2:40 p.m. of a south medication cart with registered nurse (RN) G revealed: *There was a plastic bag with resident 28's identifying information on the outside of the plastic bag. -In the plastic bag was a Levemir (long-acting) insulin pen. --The Levemir pen did not have a resident's name on the label. --It was marked as opened on 2/11/24. *RN G verified the date the Levemir was opened was marked 2/11/24 and there was no resident name on the insulin pen. *She indicated a medication should be labeled with a resident's name to determine who the medication belonged to. *She indicated resident 28 no longer received Levemir. *Resident 28's Latanoprost eye drops (medicated eye drops for glaucoma) had a label on the box that instructed to discard 42 days after opening. -There was no date documented to indicate when the Latanoprost was opened. *Resident 50's Latanoprost eye drops did not indicate a date when it was opened. *Resident 6's Breo Ellipta inhaler (used to treat asthma and chronic breathing issues) had a label on the box that instructed to discard 42 days after opening. -The location on the label for the date the medication did not indicate a date when it was opened. *Resident 12's Breo Ellipta inhaler did not indicate a date when it was opened. *RN G verified resident 28's and 50's Latanoprost eye drops did not contain documentation to indicate when the eye drops were opened. *RN G verified resident 6's and 12's Breo Ellipta inhalers did not indicate when the inhalers were opened. *RN G stated she was aware of some medications that had shortened expiration dates after the medication was opened or removed from the refrigerator. *She verified she would not be able to determine when the expiration on the medications with the shortened expiration dates expired if there was no date documented on the medications. 2. Observation on 3/26/25 at 10:47 a.m. of the South medication room with RN S revealed: *Temperature logs for two refrigerators that were complete. *There was no thermometer in the South medication room. -There was no temperature log to record the temperatures of the medication room. *A lock box for controlled substances in a refrigerator where food was stored. *Five bottles of Pro-Stat (a protein supplement drink) with an expiration date of 11/14/24. *A bottle of hydrogen peroxide labeled as opened on 4/24/24 with an expiration date of 10/24. *Two bottles of Prosource (a protein supplement drink) with an expiration date of 12/5/24. *Two 14 Fr (French) (measurement of the diameter of catheters and other medical tubes) urinary catheter (a flexible tube inserted into the bladder to drain urine) with an expiration date of 1/31/25. *A partial box of 10cc syringes with an expiration date of 12/1/24. 3. Observation and interview on 3/26/25 at 11:17 a.m. of a South medication cart with unlicensed medication aide (UMA) L revealed: *A Voltaren gel (a topical medication for arthritis pain and inflammation) box that had [a resident's first name] #1 handwritten on it. -There was no pharmacy label with the medication's dosage, instructions, or the resident's identification. -There was no date documented on the medication to indicate when it was opened. *UMA L stated that the Voltaren gel belonged to resident 12. -She stated the resident's family provided the medication. 4. Observation and interview on 3/26/25 at 11:38 a.m. with clinical care leader (CCL)/infection preventionist (IP) D in the north medication room revealed: *Temperature logs for two refrigerators that were complete. -There was no temperature log to record the temperatures of the medication room. *A bin of 60cc syringes with an expiration date of 12/2014. *Nurses and medication aides were assigned to check for outdated supplies and medications in the medication rooms and the medication carts once a month. *There was no formal process for the staff assignment or completion of that task. *She verified the temperatures were not monitored or documented in the north or south medication rooms. 5. Interview on 3/27/25 at 8:45 a.m. with licensed practical nurse (LPN) K revealed: *If a medication was brought from home by a resident or a resident's family, staff would encourage the medication to be taken back home with the resident's family. *When he administered medications, he expected the medication to have a pharmacy label that contained the medication name, administration information, and the dispensing pharmacy. *He verified that he would not be able to compare the administration information on the medication with the medication administration record (MAR) on resident 12's unlabeled Voltaren gel. 6. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed: *Medications brought in by residents' families was generally discouraged but is addressed on a case-by-case basis. *If a medication was brought in by a resident's family and the medication must be used by the facility the pharmacist would work with the facility to reconcile the medication. *It was her expectation that those medications be labeled with resident and medication information in order to complete the six rights of medication administration and the three checks during administration. *It was her expectation that medications be dated when opened. *She had not been aware the temperatures of the medication rooms needed to be monitored for safe storage conditions per the facility policy. 7. Review of the provider's 3/4/25 Medications: Acquisition Receiving Dispensing and Storage policy revealed: *The resident may secure prescriptions from the pharmacy of his/her choice when not receiving Medicare A services. *Licensed nursing employees are responsible for ordering from the pharmacy (except Schedule II medications) and checking all new orders of medications from the physician's orders. *An employee will be responsible for signing for receipt of medication and obtaining the signature of the delivery person. It is preferred that a licensed nurse receive and verify the medications . Licensed nurses and medications aides (when allowed by state law) are responsible for reconciling medications received. *The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations. *Refrigerators holding medications (such as insulin, etc) will be kept between 36 [degrees] F [Fahrenheit] and 46 [degrees] F. Medication rooms will be kept between 59 [degrees] F and 86 [degrees] F. Check refrigerator temperatures once in the morning and once in the evening. *Although it is not recommended to store medications with food, if this is done, medications should be kept in closed, labeled containers or compartments with internal and external medication separated; and separate from fruit juices, applesauce and other foods. *Controlled drugs (Schedule II) and other drugs subject to possible abuse will be stored in separate, locked, permanently fixed compartments, except when a single unit package drug distribution is used. If the medication requires a refrigerator, these need to be locked in a separate container. These drugs will be reconciled at least daily through an appropriate system of records of receipt and disposition established by the licensed pharmacist. *These medications must be labeled according to state pharmacy regulations. Cautionary and accessory instructions, as well as the expiration date, will be included. New labels will be applied by the pharmacist or the pharmacist's agent as needed. *If a medication is not available, please document discussion per #6 of the Local Pharmacy Medication Ordering - R/S, LTC procedure with the physician in the PN-Communication/Visit with Physician/EMR. If a medication is not available from the pharmacy when the order is received, contact the prescriber to determine if a different medication is needed or to determine the time frame acceptable to wait for the medication. 8. Review of the provider's 3/4/25 Medication: Administration Including Scheduling and Medication Aides policy revealed: *Procedure -Review the MAR 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. 51816

Based on record review, observation, interview, and policy review, the provider failed to ensure: *The physician was notified of medications not administered due to unavailability as directed in the provider's policy for one of one sampled resident (20). *A physician's order to take vital signs every six hours was followed for one of one sampled resident (38) for an infection. Findings include: 1. Review of resident 20's medication administration record (MAR) revealed: *She had physician's order for Benefiber Oral Tablet Chewable (Wheat Dextrin) [fiber supplement] 1 tablet by mouth in the morning for constipation related to DRUG INDUCED CONSTIPATION. -In March 2025 resident 20's Benefiber was documented not available 13 times. --Unlicensed medication aide (UMA) L had documented all the medication not available in March 2025 for the Benefiber. *She had a physician's order for Citracal Plus Tablet (Multiple Minerals-Vitamins) [calcium with vitamin D supplement] 1 tablet by mouth one time a day related to VITAMIN D DEFICIENCY. -Resident 20's Citracal was documented as not available on 3/24/25 and 3/25/25 by two different UMAs. 2. Observation on 3/26/25 at 10:15 a.m. of the medication cart revealed: *There was a bubble-pack medication card with one Citracal tablet in a bubble, and one empty bubble. -The dispensed date on the Citracal card was 3/25/25. *There was a bottle of Benefiber powder with a dispensed date of 1/10/24 and was labeled with #4. -The bottle was unopened. *There was no medication card that contained Benefiber tablets. 3. Interview on 3/26/25 at 10:25 a.m. with UMA L revealed: *The monthly medication delivery for all medication carts was scheduled for 3/27/25. *The Citracal had been received from the pharmacy with 28 tablets in February, which left the facility two tablets short for the month. *UMA L had requested the Citracal from pharmacy on 3/23/25 and 3/25/25 and both times she had indicated on the medication request that the facility had no remaining tablets for administration. *UMA L stated that she had documented the Benefiber as unavailable because the medication order was for a tablet and the medication available in the medication cart was the powder. *She explained that resident 20 had previously been on the Benefiber tablets but per her daughter's request the order had been changed to the Benefiber powder. *When resident 20 was returned from a hospital admission the order was changed back to a tablet. *UMA L indicated she had alerted Minimum Data Set (MDS) nurse C and registered nurse (RN) F of the Benefiber order being for a tablet instead of the powder when resident 20 was readmitted to the facility from the hospital. 4. Review of pharmacy Medication Reorder Sheet revealed: *A 3/23/25 Medication Reorder Sheet which indicated Resident 20's Citracal had been reordered from the pharmacy by fax at 1:36 p.m. -The reorder form also indicated there were no tablets that remained for administration. *A 3/25/25 Medication Reorder Sheet which indicated Resident 20's Citracal had been reordered from the pharmacy by fax at 12:14 p.m. 5. Review of resident 20's electronic medical record (EMR) revealed: *Resident 20's 2/12/25 readmission orders indicated the Benefiber order as, wheat dextrin 3 gram/3.5 gram powder 1 dose by mouth daily. -The order was entered as Benefiber Oral Tablet Chewable (Wheat Dextrin) [fiber supplement] 1 tablet by mouth in the morning for constipation related to DRUG INDUCED CONSTIPATION. -The order was entered and cosigned by MDS C and RN S. *A 3/24/25 progress note indicated the Citracal Plus tablet was currently unavailable, pharmacy contacted and awaiting delivery. *There was no documentation that indicated the physician was notified regarding the Citracal or the Benefiber not having been given related to the medication not having been available. 6. Interview on 3/26/25 at 5:04 p.m. with MDS nurse C regarding medication orders revealed: *If a staff came to her with a medication question, she would help the staff figure out the order. *She would look at the original order and compare it to the MAR and the pharmacy label. *She was not previously aware of the Benefiber order being a tablet and the medication available in the medication cart was a powder. *She indicated that if the medication order was for a tablet and the facility had the medication as a powder, she would agree that the medication was not available for administration. *She expected the pharmacy to have been notified of the medication not being available and to request the form of the medication that was indicated on the order. -The pharmacy typically was able to provide the medications requested the same day the medication was ordered. *It was her expectation that the physician would have been notified the medication was not administered due to the medication not being available for administration. *She thought someone had entered the Benefiber order incorrectly when resident 20 was readmitted from the hospital. *The admission and readmission orders for residents were typically entered and verified by the nursing office staff. 7. Review of resident 38's EMR revealed: *She had a urine sample sent to her physician's office to be tested for an infection. *The physician was waiting for the urine culture and sensitivity [results to determine treatment]. *On 3/22/25 a physician's order to Monitor VS [vital signs] every 6 hours and notify on call [physician] of HR [heart rate] >[greater than]110 [beats per minute], SBP [systolic blood pressure] < [less than] 90, RR [respiratory rate] > 22 [breaths per minute], or Temp [temperature] >100.4 [degrees Fahrenheit] every 6 hours with an end date of -Resident 38's vital signs were being monitored to determine if there was a change in her vital signs which could indicate a worsening infection. --A variation from the indicated margins would require the facility to notify the resident's physician for immediate interventions. -The order entered into the EMR did not include the link to enter the vital signs within the order to have them documented into the EMR vital signs tab. *Review of resident 38's vital signs documentation revealed: -On 3/22/25 her vital signs were documented at midnight, 5:07 a.m., 11:42 a.m., 5:00 p.m., and 9:09 p.m. -On 3/23/25 her vital signs were documented at 3:09 p.m. and 9:41 p.m. -On 3/24/25 her vitals signs were documented at 5:56 a.m. and 12:52 a.m. -On 3/25/25 her vital signs were documented at 2:25 a.m., 6:03 a.m., 12:25 p.m., and 5:33 p.m. -On 3/26/25 her vital signs were documented at 5:15 a.m. and 9:13 p.m. 8. Interview on 3/27/25 at 8:45 a.m. with licensed practical nurse (LPN) K revealed: *He indicated the physician orders often were received by fax. *Once an order was received, he would enter the order into the resident's EMR, fax the order to the pharmacy, and if there was a medication that needed to be administered immediately, he would obtain it from the emergency medication supply, otherwise he would wait for the medication to arrive from the pharmacy. *If a medication was not available for administration or was not given, he would notify the pharmacy immediately. *If the medication was unable to be obtained from the pharmacy or the facilities emergency medication supply, he would notify the physician. *He stated the nurses and CMAs completed and documented residents' vital signing the EMR. *Vital signs were charted into the EMR. *He verified there was no documentation that indicated resident 38's vital signs had been taken as ordered by the physician. *He was not aware there was a physician order for resident 38 to have her vital signs taken every 6 hours until he was told in shift report that morning (3/27/25) that the order was completed. 9. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed: *She expected that physician orders be followed. *The pharmacy delivered medications to the facility daily and medications typically arrived at the facility the same day it was ordered. *The process for new physician orders was for the nurse to read, sign, and enter the order into the resident's EMR. *The order process was to be completed by the nurse that was in charge of that resident's care and the order should be double-checked and cosigned that the order was entered into the EMR correctly. *She expected the physician to be notified if a medication was held or not administered for any reason. *She was aware the physician had not been notified for the medications that were documented as not administered due to medication not being available. Review of the provider's 3/4/25 Medications: Acquisition Receiving Dispensing and Storage policy revealed Licensed nursing employees are responsible for ordering from the pharmacy and checking all new orders of medications from the physician's orders. Review of the provider's 3/4/25 Medication: Administration Including Scheduling and Medication Aides policy revealed: *A provider's order for any medication is required and must include: diagnosis, name of medication, dose, route, frequency, and STOP order if indicated. *If a medication is not available for 24 hours, the provider must be notified that the medication is not available and must be given direction for how to proceed. *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.

Based on observation, record review, interview and policy review, the provider failed to ensure residents who used assist/grab bars (bed rails) had: *A routine assessment, when a assist/grab bar was initiated and quarterly, was completed for four of eight sampled residents (6, 8, 33, and 38). *A signed consent for the use for the assist/grab bars for one of six sampled resident (6), with cognitive impairment, and a power of attorney (POA). *Received education on the risks of use versus benefits of the use of assist/grab bars for five of six sampled residents (6, 23, 26, 33, and 38). *Other attempted interventions were documented on five of eight sampled residents (6, 13, 23, 33, and 38). Findings include: 1. Observation on 3/24/25 at 2:14 p.m. of resident 33's room revealed she had bilateral (on both sides) assist/grab bars in the upright position near the head of her bed. Review of resident 33's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated she had moderate cognitive impairment. *Her 11/9/24 Physical Device and/or Restraint Evaluation and Review assessment revealed: -She consented for her own assist/grab bars with known cognitive impairment and a POA. -No barriers were documented related to Learning barriers related to education/educational material provided. -There were no documented attempted alternatives identified. *Her care plan revealed: -She has a focus area of has impaired cognitive function relating to vascular dementia e/b [evidence by] cognitive impairment, forgetfulness, decision making impairments. -Her POA had given prior consents via phone for resident 33 to receive liquor and to be photographed. 2. Observation on 3/24/25 at 2:24 p.m. of resident 26's room revealed she had bilateral assist/grab bars in the upright position near the head of her bed. Review of resident 26's EMR revealed: *She was admitted on [DATE]. *Her 2/17/25 BIMS assessment score was 12, which indicated she had moderate cognitive impairment. *Her 2/23/25 Physical Device and/or Restraint Evaluation and Review assessment revealed there was no documentation to reflect education had been provided related to the risk vs benefit of the use of resident 12's assist/grab bar. 3. Observation on 3/24/25 at 4:04 p.m. of resident 6's room revealed she had bilateral assist/grab bars in the upright position near the head of her bed. Review of resident 6's EMR revealed: *She was admitted on [DATE]. *Her 2/21/25 BIMS assessment score was 15, which indicated she was cognitively intact. *There was no Physical Device and/or Restraint Evaluation and Review assessment completed. 4. Observation on 3/24/25 at 5:04 p.m. of resident 13's room revealed she had an assist/grab bar in the upright position near the head of her bed on the right side. Review of resident 13's EMR revealed: *She was admitted on [DATE]. *Her 2/4/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her 2/10/25 Physical Device and/or Restraint Evaluation and Review assessment revealed: *There was no attempted alternative to the assist/grab bars documented. *Review of resident 13's 3/26/25 care plan did not identify that she had an assist/grab bar on her bed. 5. Observation on 3/25/25 at 11:29 a.m. of resident 8's room revealed she had bilateral assist/grab bars in the upright position near the head of her bed. Review of resident 8's EMR revealed: *She was admitted on [DATE]. *Her 2/12/25 BIMS assessment score was 8, which indicated she was moderately cognitively impaired. *Her 8/23/24 Physical Device and/or Restraint Evaluation and Review assessment indicated, Resident does not have grab bars on her bed since moving rooms. Resident has no difficulty without [the] use of them. 6. Observation on 3/25/25 at 11:30 a.m. of resident 23's room revealed she had an assist/grab bars in the upright position near the head of her bed on the left side. Review of resident 23's EMR revealed: *She was admitted on [DATE]. *Her 2/11/25 BIMS assessment score was 12, which indicated he had moderate cognitive impairment. *Her 2/18/25 Physical Device and/or Restraint Evaluation and Review assessment revealed: -There was no attempted alternative to the assist/grab bars documented. -There was no education documented related to risk versus benefit of use, the resident's ability to use the assist/grab bars or the resident's understanding of use. 7. Observation on 3/25/25 at 11:32 p.m. of resident 38's room revealed she had bilateral assist/grab bars in the upright position near the head of her bed. Review of resident 38's EMR revealed: *She was admitted on [DATE]. *Her 2/20/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her 8/19/24 Physical Device and/or Restraint Evaluation and Review assessment revealed: -There was no attempted alternative to the assist/grab bars documented. -There was no education documented related to risk versus benefit of use, the resident's ability to use the assist/grab bars or the resident's understanding of use. 8. Interview on 3/26/25 at 2:25 p.m. with Minimum Data Set (MDS) nurse C revealed: *She expected the Physical Device and/or Restraint Evaluation and Review assessments to be completed prior to the implementation of a resident's assist/grab bars. *She completed the Physical Device and/or Restraint Evaluation assessment for residents with assist/grab bars with the quarterly MDS. *She was unaware there was missing documentation within the assessments and there were assessments not completed upon initiation of the assist/grab bars and quarterly. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed: *It was her expectation the completion of the Physical Device and/or Restraint Evaluation assessments be completed by a licensed nurse prior to the application of assist/grab bars. *The Physical Device and/or Restraint Evaluation assessment would determine if an assist/grab bar was appropriate to be initiated for the evaluated resident. *Once the assist/grab bar was placed on the bed others would know that the assessment was completed. *It was the licensed nurse's responsibility to assess for the resident's risk for entrapment. *She indicated it was MDS nurse C's responsibility to complete the Physical Device and/or Restraint Evaluation and Review assessment with the quarterly MDS. Review of the provider's 10/29/24 Restraint policy revealed: *Anytime a device, material or equipment is attached or placed adjacent to the resident's body, a determination will be made by a licensed nurse as to whether it is or could be a restraint for the individual resident and a Physical Device and/or Restraint Evaluation and Review UDA is completed by a Licensed Nurse. *If the device, material or equipment is not a restraint, it must be reviewed quarterly and with significant change in condition in conjunction with the care plan to ensure that it continues to not be a restraint for the resident.

Based on observation, interview, record review, and job description review, the provider failed to assess, document, and implement interventions for one of one sampled resident (51) with a mood disorder. Findings include: 1. Observation and interview on 3/24/25 at 3:13 p.m. with resident 51 and his spouse revealed: *The resident's room was without any personal items from home. *He enjoyed music but had no way to listen to it. He was Lutheran and would not have objected to having clergy from that faith visit him. His spouse was working with a visually impaired service provider so the resident had access to books on tape. *He was admitted to the facility after back surgery after a complicated and extensive hospitalization . -His goal was to return home with his spouse after his rehabilitation stay at the facility. *His pain had improved since he was admitted to the facility. *The resident's affect was flat. *In early March 2025, the resident's physician had recommended he see a counselor for worsening depression. -The resident's spouse had asked that a male counselor see the resident. She was told there were no male counselors available to have met with the resident. No other counseling alternatives had been discussed or provided for the resident. Interviews on 3/25/25 at 2:00 p.m. and on 3/26/25 at 4:45 p.m. with resident 51 in his room revealed: *He had a history of depression and was taking anti-depressant medication. His depression had worsened his admission to the facility. -He felt he had lost weight because nothing tasted good. He had feelings of imprisonment, and a sense of loss of control of his body. He was a loner and remained in his room most of the time. *His spouse had visited him regularly and he had a few friends who had stopped by to see him occasionally. -It had felt good to unload how he was feeling with his friends. *Caregivers had been good about engaging with him during routine care. He would have liked to have someone who could sit down to talk with him each week about his loss of control. *At home the resident had enjoyed sitting in his own recliner and using his home computer. Having personal items that surrounded him at home brought him joy. Review of resident 51's electronic medical record (EMR) revealed: *His admitted was 2/10/25. *His 3/26/25 Brief Interview for Mental Status assessment score was 13 which indicated he had little or no cognitive impairment. *His 2/11/25 PHQ-9 (Patient Health Questionnaire - a self-report tool used to assess depression symptom severity) assessment score was 8 which indicated he had mild depression. *A 2/11/25 physician's history and physical progress note (PN): Psychiatric/Behavioral: Positive for confusion (now improved) and sleep disturbance. The patient is nervous/anxious (He is concerned about what the future may hold). *A 2/18/25 physician's PN: Staff and his [resident 51's] wife note that he is depressed. His wife would like his sertraline (anti-depressant medication) increased. A physician's order was written on that same date changing the sertraline dose from 50 mg (milligrams) daily to 100 mg daily. *A 2/20/25 interdisciplinary care conference PN had discussed the resident's weight loss, his improved pain management, and his current medications. -Social Services: [resident's spouse] would like home health at discharge and plan is to discharge home with wife. [Resident 51] is a full code, no concerns from social services at this time. *A 3/4/25 physician's 30-day post admission PN revealed resident 51's chief complaints had been a poor appetite and depression. -He [resident 51] admits to feeling depressed. He feels down at times and wishes his life were over. He has thought about suicide but did not verbalize a method. He feels worthless and not any good to his children or grandchildren. His energy level was poor and his concentration was decreased. -The resident had agreed that counseling was not a bad idea. A physician's order was written on that same date: [Counseling agency] may see for psychological counseling. *There was no nurse PN documented on 3/4/25 after the physician's visit that acknowledged any communication had occurred between the nursing staff and the physician. *SSD/CSW I's PN documentation between 2/20/25 and 3/20/25 regarding resident 51's mood state revealed: -On 3/5/25 the resident's spouse had asked SSD/CSW I if a male counselor was available to visit with resident 51. -On 3/6/25 SSD/CSW I had documented the counseling agency resident 51 had been referred to for counseling had no male counselor available to have met with the resident. -There was no documentation to support what other counseling alternatives had been investigated or offered to resident 51. *On 3/18/25 registered dietician (RD) R's PN: Resident has not been eating and has noted to state 'I'm going to starve myself' per IDT [interdisciplinary team] at QOL [quality of life] meeting - this was stated a few weeks ago. Review of the 2/11/25 through 3/25/25 weekly QOL/Nutrition meeting minutes revealed: *Resident 51's weight loss was discussed during those meetings. -There was no documentation in those minutes related to RD R's above documentation regarding resident 51's statement about starving himself. Interviews on 3/25/25 at 1:00 p.m. and again on 3/26/25 at 4:00 p.m. with SSD/CSW I and SSD/CSW J regarding resident 51's mood state revealed: *One of SSD/CSW I's responsibilities was monitoring and responding to the psychosocial well-being of the residents. *She was aware resident 51's depression symptoms had worsened since his admission and his anti-depressant medication was increased on 2/19/25. In response, she had not but could have: -Initiated one-to-one visits with the resident and identified, and implemented other interventions to have addressed his mood state. -Collaborated with the activities department to have followed-up on those things above that the resident had identified that had enhanced his quality of life. -Confirmed a daily mood symptom monitoring task had been initiated to assess if the resident's mood state continued to worsen or had improved. -Readministered a PHQ-9 assessment for comparison with the last completed PHQ-9. *SSD/CSW I had only spoken with resident 51's wife and not the resident regarding the above physician-ordered counseling services so she had not known the resident's preference for a male versus a female counselor. She had not informed the resident of her inability to find a male counselor or discussed with him any other alternatives to assist him with the management of his depression. *SSD/CSW I had not known about the above statements made by resident 51 to his physician during their 3/4/25 visit. Interview on 3/27/25 at 8:00 a.m. with administrator A regarding resident 51's mood state decline revealed: *Psychological services could have been arranged for resident 51 through a telehealth service provider the facility had access to. *The QOL/Nutrition meeting was an interdisciplinary team whose focus was discussing residents who had weight loss and were at risk for or had factors that affected their well-being. -She stated weight loss had mostly been discussed during those meetings, but her goal was for the inclusion of residents' QOL issues. It just hasn't happened yet. Interview on 3/28/25 at 9:45 a.m. with administrator A and director of nursing (DON) B regarding the physician's on-site resident visits revealed: *The physicians had a list of residents they were expected see during their on-site resident visits. -Nursing staff had discussed with the physician pertinent non-emergent changes or developments related to the residents on the physician's visit list as well as residents not on the list. *Nursing staff received a hand-off report from the physician after the physician's visits had been completed. That report included a review of new physician's orders and resident recommendations. *It was the responsibility of that nursing staff to ensure information from that hand-off communication was relayed to the appropriate interdisciplinary team members -That usually occurred during weekday interdisciplinary stand-up meetings. If the matter was more urgent, a personal conversation or telephone call was expected to have occurred. *The nursing staff who had received hand-off communication from the physician was expected to have made a progress note entry regarding that communication. *Administrator A and DON B had not known: -SSD/CSW I was not notified of the comments made by resident 51 during his 3/4/25 physician visit. -There was no documentation to support if nursing staff had received a physician's hand-off report after resident 51's 3/4/25 physician visit. A Mood/Behavior policy was requested from administrator A on 3/28/25 at 9:00 a.m. A Behavioral Causes and Interventions policy was provided which had not addressed the provider's process for managing resident's mood disorders. Review of the revised 3/19/25 Social Services job description revealed: *It was SSD/CSW I's responsibility to: -Provide leadership for the delivery of medical Social Services, expertise and/or consultation and acts as a liaison by representing at the local, regional, and state levels. -Develop and review service plans in consultation with clients and perform follow-ups assessing the quantity and quality of services provided.

Based on observation, interview, record review and policy review, the provider failed to Follow proper infection control practices and precaution interventions related to: *The use of personal protective equipment (PPE) to help prevent the transmission of infections for three of three sampled residents (1, 31, and 24). *Maintaining the cleanliness of four of four handwashing sinks used by staff (Charting Station 1, Charting Station 2, Charting Area 151, and Charting Area 174) in two of two residential living units (North and South). Findings include: 1. Observation of resident 1's room on 3/24/25 at 3:10 p.m. revealed: *There was a magnet on the door frame of her room that indicated she was on transmission based precautions (TBP). -There were gowns outside of her room for staff to don (put on). Interview on 3/24/25 at 3:12 p.m. with resident 1 revealed: *Resident indicated that she is on EBP because It tells people who are sick to not come into my room. - She verified they wear gloves when caring for her, but they do not wear gowns. Review of resident 1's electronic medical record (EMR) revealed: *Her 1/7/25 Brief Interview for Mental Status (BIMS) assessment score was 15, indicating she had no cognitive impairment. *Her 3/26/25 revised care plan indicated that she was on enhanced contact precautions (CP) requiring the use of gown and gloves on every entry into her room, regardless of the level of care being provided to the resident. -She had extended spectrum beta-lactamase (ESBL) (bacterial infection that is resistant to many antibiotics and highly contagious). -Wear gowns when changing contaminated linens and brief. - Provide private room and use contact precautions. -She required enhanced barrier precautions (EBP) that required staff to wear gowns and gloves during resident care and activities due to her ESBL. -Staff were to [NAME] gowns 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, device care and/or use, and wound care. -Physical therapy (PT) and occupational therapy (OT) are to use EBP in common areas when therapy activities have risk for repeated contact. -Educate resident and /or family regarding the importance of good hand hygiene and the need for and duration of EBP. 2. Observation on 3/24/25 at 3:11 p.m. of resident 31's room revealed: *On the door frame outside of resident 31's room there was a magnet that indicated she was on TBP. -Inside of resident 31's room there were gowns and gloves for staff to don. Interview on 03/24/25 at 3:52 p.m. with resident 31 revealed staff do not wear gowns when doing cares with her, but they do wear gloves. Observation on 3/26/25 at 2:07 p.m. of resident 31's room revealed: *Certified nurse assistant (CNA) N and unlicensed medication assistant (UMA) L had exited resident 31's room after providing care for her, both only wearing gloves. *There now was a magnet on the door frame of her room that indicated resident 31 was on EBP. Interview on 03/26/25 at 2:20 p.m. with CNA N revealed: *She verified that only gloves were worn when she provided cares for resident 31. -She had indicated typically gloves, gown, and a face shield is worn if working with bodily fluids, but stated I have a tendency to forget. Observation and interview on 3/27/25 at 8:27 a.m. with CNA M revealed: *She had provided cares for resident 31 with glove use only. -She had verified that the resident is on EBP because She has something in her urine. -She had indicated that they only transferred the resident out of bed to her chair, they were not doing anything with her urine or changing her brief. Review of resident 31's EMR revealed: *Her most recent care plan indicated that she was on EBP related to MDRO (multidrug-resistant organism) colonization. -Interventions on her care plan had indicated to [NAME] 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, device care and/or use, and wound care. -Doff (remove) gown and gloves inside resident's room. Perform hand hygiene. -Educate resident and /or family regarding the importance of good hand hygiene and the need for and duration of EBP. *Her 9/26/24, BIMS assessment score was 15, indicating she had no cognitive impairment. 3. Observation of resident 24's room on 3/24/25 at 3:12 p.m. revealed: *There was a magnet on the door frame of her room that indicated she was on TBP. -There were gowns outside of her room for staff to don. Interview on 03/25/25 at 10:55 a.m. with resident 24 revealed staff do not wear gowns when doing cares with her, but they do wear gloves. Review of resident 24's EMR revealed: *Her 7/24/24 BIMS assessment score was 15, indicating she had no cognitive impairment. *Her most recent care plan indicated that she requires to be on EBP related leg wound. -Interventions on her care plan had indicated to [NAME] 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, device care and/or use, and wound care. -Educate resident and /or family regarding the importance of good hand hygiene and the need for and duration of EBP. Interview on 3/24/25 at 5:19 p.m. with clinical care leader (CCL)/infection preventionist (IP) D revealed: *While providing cares to a resident who is on EBP she would do the following: -She had indicated that she would apply her PPE before caring for a resident who is on EBP whenever she is having close contact with them such as working with the resident's linen, changing their clothes or assisting them with their activities of daily living (ADL)'s, or repositioning them. -She would finish by doffing her PPE prior to leaving their room and then wash or sanitize her hands. 4. Interview on 3/26/25 at 2:50 p.m. with administrator A revealed: *She stated, she would expect staff to Follow the Policy and do exactly what the sign says on the door. -When asking Administrator A what the facility's policy is for EBP, she had indicated, gloves, gowns, and masks and whatever the signs tell them to be doing. 5. Interview with clinical care leader (CCL) E on 3/27/25 at 1:04 p.m. revealed: *Her expectation of staff would be for them to follow the precautionary measures by wearing the appropriate PPE according to the EBP policy when caring for the residents. *They have done a performance improvement plan (PIP) within the last year over EBP and had provided education for all staff. 40788 6. Observation on 3/24/25 at 2:00 p.m. of the North Unit Charting Station 2 handwashing sink revealed: -There was a white build-up around the perimeter of the handwashing sink that was removed with a fingernail. That white build-up smelled like soap. -The faucet spout had a white lime build-up around it. Additional lime splashes and stains were observed throughout the inside of the sink basin, at the base of both hand controls, and at the base of the faucet spout. -There was an unidentified brown substance around the sink drain perimeter that was removable with a fingernail. *There was a container of disinfectant wipes near that sink. 7. Observations on 3/24/25 at 2:30 p.m. and on 3/26/25 at 1:15 p.m. of the North Unit Charting Station 1 handwashing sink revealed the same observed findings described above for the Charting Station 2 handwashing sink. Observation and interview on 3/26/25 at 8:32 a.m. with RN G revealed: *After exiting an unidentified resident's room, RN G had used the Charting Station 2 handwashing sink to wash her hands. -The handwashing sink remained in the same uncleaned condition that it was observed to have been in on 3/24/25. *RN G did not know who was responsible for cleaning that sink or how frequently that sink was cleaned. She agreed the sink was unclean. 8. Observation on 3/26/25 at 1:15 p.m. of the South Unit Charting Area 151 handwashing sink revealed: *The faucet was dripping. -The faucet spout had white lime build-up around it. Additional lime splashes and stains were observed throughout the inside of the sink basin, at the base of the hand controls, and at the base of the faucet spout. -There was an unidentified brown substance around the sink drain perimeter that was removable with a fingernail. *There was no container of disinfectant wipes near that sink. 9. Continued observation of the South Unit Charting Area 174 handwashing sink and interview with certified nurse aide (CNA) M revealed: -The faucet spout had white lime build-up around it. Additional lime splashes and stains were observed throughout the inside of the sink basin, at the base of the hand controls, and at the base of the faucet spout. -There was an unidentified brown substance around the sink drain perimeter that was removed with a fingernail. *There was a container of disinfectant wipes near that sink. *CNA M had thought the handwashing sink was cleaned daily by a housekeeper. She agreed that sink was unclean. 10. Interview on 3/27/25 at 8:05 a.m. with administrator A and environmental services supervisor Q regarding the cleaning of the above four handwashing sinks revealed: *Those handwashing sinks were expected to have been cleaned daily by housekeeping staff. -Disinfecting and cleaning those sinks and countertops was included on a daily cleaning checklist that housekeeping staff was expected to have followed. Review of the provider's undated SNF [skilled nursing facility] Checklist for Cleaning Public Areas checklist revealed disinfecting and cleaning the above handwashing sinks was listed as a task to have been completed daily.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of one sampled resident (1) had assessments and monitoring completed for safe warm pack administration and use. *Care plan was updated to reflect current status and needs for one of one sampled resident (1). *Appropriate nurses delegation of tasks to certified nurse assistants (CNA) for one of one sampled resident (1) for application of warm pack . *Appropriate training and monitoring for task delegation to CNAs for appropriate application of warm pack. *Timely and accurate documentation of a burn incident for one of one sampled resident (1) by one of one licensed practical nurse (LPN) (E).*The facility Incident Report Procedure had been followed for the safe administration and use of warm packs for one of one sampled resident (1). Findings include: Review of resident 1's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He had a Brief Interview for Mental Status (BIMS) assessment score of ten indicating he was moderately impaired. *He required extensive assistance of staff with his bed mobility, transfers, dressing, toilet use, and personal care. *an order for [REDACTED]. *A 3/24/19 a physician order [REDACTED].>-Okay to provide WARM pack to BLE (Bilateral lower extremities) as needed. -Do NOT apply directly to skin. -USE a BARRIER at bedtime for feet warmth. *An 11/18/19 computer generated Order Details revealed: *Communication Method: Prescriber written. -Ordered by (physicians name). -Monitor blister to lt. (Left) upper thigh until healed two times a day. -Created by: (Name), RN (registered nurse) (RN A). -Created Date: 11/18/2019 20:07 (8:07 p.m.). Review of resident 1's 11/22/19 South Dakota Department of Health (SD DOH) event reporting form revealed: *The date of the event was listed as 11/22/19. -According to the notes it was unclear if the date of the event was 11/16/19, 11/18/19, or 11/22/19. *The brief explanation was: Staff nurse, while performing assessment on resident found a red area to the left inner thigh. Red area measures 6 x (by) 9 cm (centimeters). Located in the middle of the reddened area is an intact fluid filled blister 2.5 x 2 cm. *The conclusionary statement was: Investigation to be completed with all staff in contact with resident. (Resident name) is an [AGE] year old resident, current BIMS is 10/15, meaning he has moderately impaired cognition. Resident has chronic pain in the left leg with [MEDICAL CONDITION] and neuralgia. Resident is able to voice needs and wants, and able to request pain medication when appropriate. Resident receives [MEDICATION NAME], Tylenol, [MEDICATION NAME], and [MEDICATION NAME] for pain. On (MONTH) 31, (YEAR) resident received an order for [REDACTED]. On Friday, (MONTH) 22, 2019 (name) LPN (licensed practical nurse) (LPN B) on her examination of the resident discovered a red area to the left inner thigh. Red area measures 6 x 9 cm. Located in the middle of the reddened area is an intact fluid filed blister 2.5 x 2 cm. It was immediately reported to Medical Director, DNS (director of nursing services) and resident refused a call to family. (name), wound care specialist (with an outside service AMT) was here making rounds, and looked at residents leg, he believes it to be consistent with a burn with no interventions needed at this time. Follow up with resident on 11/23/19, and resident denies pain in the thigh area, Naw, it doesn't even hurt. Dr. (name) is aware of blister and no new orders were received at this time. Nursing staff continues to monitor. Investigation was completed by the staff development coordinator and director of nursing services. Upon interviews with nursing staff, it was discovered to be reported by a CNA (certified nursing assistant) on Saturday 11/16/19, to the night nurse. She reported it to the oncoming day staff. No report was created, DNS and MD (medical director) were not notified. On 11/19/19 the same night nurse created a wound assessment documentation note, without reporting it to MD or nursing leadership. Upon all staff interviews, nurses had been delegating the task to the CNA (certified nursing assistant) staff, to warm and place the pack on the resident. The pack was often placed directly on the skin according to the resident. Beginning 11/22, all CNAs were educated the placement of warm packs is outside their scope of practice (name) (resident 1) was also educated on the discontinuation of the placement of warm packs at this time until proper equipment can be obtained by the facility. Interview on 12/10/19 at 12:25 p.m. with the staff development coordinator revealed: *She was also the wound care nurse. *She had helped with the investigation of resident 1's left upper thigh burn. *He had told her: -He asked for a warm to hot wet towel; she believed that had been the evening of 11/21/19. *She believed the next morning, on 11/22/19; it was reported and the investigation into the residents left thigh burn began. *She was unaware if he specifically asked for the wet towel and the plastic bag to be microwaved. *He had a wet towel in a bag that was kept in his nightstand. -He asked for it to be warmed up. -The wet towel with the plastic bag was being put into the microwave and being warmed up. --That was what had been considered a warm pack. *She stated there was not a policy for warming towels in a plastic bag in the microwave for a warm pack. -She had been unaware of the amount of time the warm packs were being microwaved. -She had been unaware that was what CNAs had been giving to the resident. -She had been unaware the nurses had been delegating that task to the CNAs. *They should have been using an Aqua K-thermia machine (electrical heat therapy machine with temperature control), but it had been on order since (MONTH) 2019. -It had not yet been received by the facility. -She did not know what they were supposed to be using for a warm pack in the mean time. Interview on 12/10/19 at 12:30 p.m. with the DNS revealed: *She had helped with the 11/22/19 investigation of resident 1's left upper thigh burn. *Prior to the investigation she had not known that warm packs had been made using a wet towel in a plastic bag and heated in the microwave. -That was not their policy and should have not been done. -She had tried to rent a Aqua K-thermia machine on 11/22/19, the day she was aware of warm packs being made that way. But none had been available. *She was unaware nurses had been delegating the heating and placement of warm packs to the CNAs. -That had not been in the CNAs scope of practice. *The nurses should have been assessing the resident's skin before and after they placed a cold or warm pack on a resident. -Especially for this resident due to his cold legs and being at a higher risk for an incident due to his having less feeling in his lower extremities. *She had been unaware that physician (name) had ordered a warm pack for that resident. *She stated she had a discussion with physician (name) in late spring or early summer about warm packs for another resident. -She told her they did not have the right equipment, so an order for [REDACTED]. --Physician (name) did not place the order for that resident due to not having the proper equipment. *The staff had not been educated to inform the DNS if the physician placed an order for [REDACTED].>*The DNS placed an order in (MONTH) 2019 for a Aqua K-thermia machine and pads. -Resident 1's warm pack had been ordered on [DATE] approximately four months before the order of the Aqua K-thermia equipment. -There had been a re-order of the same equipment in (MONTH) 2019. --She has received the pads but not the Aqua K-thermia machine. *The assisted living center (ALC) director had been the one who had placed the orders. Continued interview with the DNS regarding resident 1 revealed: *CNA D had stated he reported the redness and blister to LPN [NAME] on 11/16/19 during the evening shift. *LPN [NAME] stated to CNA D to place the warm pack below his reddened, blistered, area on the left leg. *There had been no documentation from LPN [NAME] that she had: -Assessed the resident. -Completed an investigation. -Completed an incident report. -Informed the MD, administrator, or DNS. *CNA F stated he had also reported the redness and blister to LPN [NAME] on 11/16/19 during the night shift. *LPN [NAME] stated to CNA F to place the the warm pack below his reddened, blistered, area on the left leg. *There had been no documentation from LPN [NAME] that she had: -Assessed the resident. -Completed an investigation. -Completed an incident report. -Informed the MD, administrator, or DNS. *The DNS stated during the investigation on 11/22/19 into the incident LPN [NAME] had stated to her: -She knew CNAs were heating wet towels in plastic bags in the microwave for warm packs. -She knew resident 1 had a reddened area with a blister on his left leg. -She had told the CNAs to continue to place the warm packs. -They were to place them below the burn area. Continued interview with the DNS revealed: *During her interview with LPN [NAME] she stated: -On 11/18/19 she had discussed the burn on resident 1's leg with RN (registered nurse) [NAME] -RN A whose shift had ended was still in the facility completing documentation in the computer. -It was approximately 8:00 p.m., and her shift had ended at 6:00 p.m. -RN A had handed the Risk Management Incident Reporting form to her, told her to fill it out, and document in PCC. *LPN [NAME] had used that Risk Management Incident Reporting form for a resident who fell later in the evening. -She did not fill one out for resident 1. -She had not entered any documentation into the nursing progress notes. -She had not informed management. Observation, interview, and record review on 12/10/19 at 4:55 p.m. of resident 1 with the DNS, staff development coordinator, and CNA G revealed: *He stated a white male nurse had brought in the warm pack that had burned him. -He had went to place the warm pack on his leg when the bag fell off the towel. -The bag landed on his upper left thigh, it had been hot, and burned him. -He had not been in pain at that time and had no pain now. *They used a sit-to-stand to raise him from a sitting position. *CNA G pulled down his sweat pants to reveal the upper left thigh. *There was a slightly brown area approximately 6 x 9 cm. to the inside of the left upper thigh that looked slightly dry. -On 12/1/19 the weekly Skin Observation documentation noted no skin conditions observed. -On 12/2/19 the Wound RN Assessment noted wound to left inner thigh was healed. -There was nothing noted about the burn to the left upper thigh on 11/18/19 on the Wound Data Collection and Skin Observations document. Interview and record review on 12/10/19 at 5:30 p.m. with LPN [NAME] regarding resident 1 revealed: *She had been working the night shift on 11/18/19. -That was when she had been notified of the blister. *She stated she went to the resident's room and assessed it. *She returned and spoke with RN [NAME] *RN A told her to put a note into PCC under Skin Assessment. -That had been all she did. *Skin Observation record dated 11/19/19 at 2:59 a.m. revealed: -Site: Left thigh front -Description: Blister on left inner thigh. -Medications and Conditions: Left blank. -Treatments: Monitor area. -Follow up: Left blank. *She, Did not know to notify anyone else or do anything more because that was all (name) (RN A) told her to do. *She stated she believed an incident report was only needed when they did not know what the cause of an incident was. -She knew the cause of the burn was from the warm pack, so she had not followed the Incident Report Procedure.*Review of the Incident Reporting and Medication training for (MONTH) 2019 revealed: -She had completed training on 11/7/19.--That had been eleven days before her notification of the blister on resident 1.*She signed an Incidents Reporting form that stated:-I (her handwritten name) acknowledge I have received education and policies related to incident reporting and had the opportunity to ask questions. I will be responsible and abide by the GSS (Good Sam Society)/Sanford way.-She signed and dated it 11/17/19.*Interview with the DNS revealed she nor anyone else had completed any additional training with LPN [NAME] since that burn investigation for resident 1 on 11/22/19. Interview on 12/10/19 at 5:20 p.m. with RN C revealed he believed placement and removal of warm packs was within the scope of practice of a CN[NAME] However he would make sure by asking someone first. Interview and record review on 12/10/19 at 6:00 p.m. with the MDS coordinator regarding resident 1's care plan revealed: *She and the case managers updated the resident car plans. -Because the staff development nurse was also the wound nurse she updated care plans when it involved skin or wound care. *She updated care plans quarterly, when new physician orders [REDACTED]. *She had heard about resident 1's burn but was unsure who had told her. -She believed it may have been the staff development nurse. *Because it was a skin/wound issue, the staff development nurse would have been responsible to update resident 1's care plan. *She would have been responsible for entering the 3/24/19 physician's orders [REDACTED]. Do NOT apply directly to skin. USE a BARRIER at bedtime for feet warmth. -She thought she had entered that order into the care plan. --It was not on the care plan. *She agreed that the burn incident that should have been entered by the staff development nurse was not on the care plan. Continued interview and record review with the MDS coordinator, staff development nurse, and the DNS revealed: *The staff development nurse had started working at the facility 6/24/19. *She was being trained by the MDS coordinator and the ADON. *She had not completed work on care plans before. *The staff development nurse had entered information about resident 1's burn. -Manipulation of printing configurations revealed a care plan had been updated but the information was not available to the staff providing care to resident 1. Interview on 12/10/19 at 7:05 p.m. with RN A about the 11/18/19 physician's orders [REDACTED]. *Since her 3/14/19 hire date she had been entering nursing orders under Prescription written with a physicians name. -She stated she was unable to enter a nursing order in the Point Click Care (PCC) program. *She had not notified, spoke to, or received a physician's orders [REDACTED]. -She had entered the order as a nursing order. Interview on 12/11/19 at 12:30 p.m. with RN H revealed: *She was not aware of what was being used for warm packs. -They had been used on night shift, and she did not work nights. *She believed placement and removal of warm packs was within the scope of practice of a CN[NAME] Interview on 12/11/19 at 12:41 p.m. with the assistant director of nursing revealed: *They needed to use an Aqua K-thermia pad for warm packs. -One had been ordered in (MONTH) 2019, but they had trouble with the distributor. *She was unaware resident 1 had a physician's orders [REDACTED]. *The long term care (LTC) side of the building had been open for approximately two years, and they had not had warm packs in the facility since they opened. *They should not have been using a wet towel in a bag that had been microwaved as a warm pack. Interview on 12/11/19 at 12:48 p.m. with LPN B regarding resident 1 revealed: *She had been called into the resident's room on the morning of 11/22/19 by CNA I. *She saw the burn on his upper left thigh. -She had reported it to the MD and DNS. *She was going to do a report but found out from RN A and an unnamed CNA that the burn had been there since the prior weekend. *It had been the responsibility of the nurse that found it who had been LPN [NAME] to complete the report. *She stated she was unaware they had been placing wet towels into a plastic bag and microwaved them to use as warm packs. -The last time she knew they had been doing that had been six to eight months ago. *She stated, You should not put hot stuff on the elderly because they were not fully aware. Interview on 12/11/19 at 1:00 p.m. with CNA I regarding resident 1 revealed: *On the morning of 11/22/19 she was getting him ready for breakfast. *She noticed a warm pack on his left, upper thigh. -It was a towel in a bag with the word Caution on it.--She believed it had been left from the night before. *She removed the bag and saw a reddened area with a blister. *She called LPN B to the room right away. *She stated she had only seen a warm pack once, that one; and she had never made one.Review of treatment records for September, October, (MONTH) and (MONTH) 2019 regarding resident 1 revealed:*Okay to provide WARM pack to BLE as needed. Do NOT apply directly to skin. USE a Barrier at bedtime for feet warmth.-It was marked all thirty days of (MONTH) as having been performed.-It was marked thirty out of thirty-one days in (MONTH) as having been performed.-It was marked twenty-five out of thirty days in (MONTH) as having been performed.-It was marked seven out of nine days in (MONTH) as having been performed. Review of the providers 9/9/19 through 12/10/19 Incidents By Incident Type reports revealed no incident documentation had been submitted for the blister to resident 1's left, upper thigh.Review of the revised (MONTH) 2019 Incident Report Procedure revealed:*Purpose:-To document resident and visitor incidents.-To conduct an investigation of each incident-To gather objective information and identify root causes to prevent similar occurrences from happening in the future.Definition:-Incident-An event with or without injury (fall, elopement, etc.) or a deviation from the standard of care that includes, but is not limited to a physical injury, verbal, physical, mental or sexual abuse, failure to provide treatment, misappropriation of resident property, a crime against a resident, etc.Review of the revised (MONTH) (YEAR) Abuse and Neglect Policy and Procedure revealed:*Purpose:-To assure that employees are knowledgeable regarding the reporting and investigative process -To ensure that all identified incidents of alleged or suspected abuse/neglect are promptly investigated and reported. -To ensure that all identified incidents involving injuries of unknown origin are promptly investigated to determine probable cause of unknown origin injuries.-To prevent future injuries.Review of the revised (MONTH) (YEAR) Heat Applications Procedure revealed:*Purpose:-To reduce pain, inflammation and swelling.-To promote healing. -To improve circulation to a body area.-To apply heat treatments in a safe manner.*Responsible Employees: -Rehabilitation/Skilled Care.-Therapist.-Licensed nurse.-Rehabilitation nurse.-Restorative nursing assistants with documented training.*A physician's orders [REDACTED].*Equipment:-Hot packs.-Towels or covers.-K-pad or other electrical heat therapy machine with temperature control.*Note: Time for heat treatment is usually 15 to 20 minutes or as identified in plan of treatment, care plan and/or service plan.*Procedure for Microwave heating Packs (Rice, Grain or Commercial Packs).-Equipment:--Microwave packs with covers.--Microwave.*Procedure:3. Place pack in the microwave and follow manufacturer's recommendations for setting and length of heating time.4. Remove from microwave and follow manufacturer's recommendations for setting and length of heating time.5. Test the pack on employee's inner forearm prior to applying to the resident.6. Cover pack with towel and place on treatment area of resident.7. Check area in one minute for any redness of skin.8. Check area again every five minutes for any redness of skin or discomfort.9. After 15-20 minutes, remove pack. Remove sooner and check skin area if resident complains of any discomfort, pain or itching and report to licensed nurse.The DNS was asked on 12/10/19 at 12:13 p.m. for an Accident/Safety Policy. A policy was not provided prior to exit on 12/11/19. Phone interview on 12/12/19 at 12:30 p.m. with the DNS after exit confirmed:*They did not have rice or grain heat pads in the facility.-Heat devices had been unavailable to carry-out physician ordered warm packs.*She had not completed education to the staff to avoid entering orders for warm packs and to inform her of such orders.*It had been her expectation that the physician would not have ordered warm packs unless they spoke first.