Every finding on record at Good Samaritan Society Tyndall

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, and record review, the provider failed to ensure the staff prepared and administered medications according to professional standards of practice for two of two residents (1 and 2) when licensed practical nurse (LPN) (C) prepared both residents' medications at the same time, mistakenly gave resident 1 the wrong medication, and tried to place resident 2's medication back into the wrong medication bubble pack using a piece of tape. LPN C did not inform the nursing home leadership team, the resident's representatives, or the resident's primary care providers about the medication error. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.Findings include:1. Review of the provider's 7/30/26 submitted SD DOH FRI report revealed that on 7/30/26, certified nursing assistant (CNA)/certified medication aide (CMA) G was preparing to administer resident 2's PRN (as needed) hydrocodone medication, a controlled narcotic medication that controls pain and is potentially addicting. CNA/CMA G noticed that the pill in the #9 slot of the medication bubble pack looked different from the others and notified registered nurse (RN) B and LPN E at that time. The provider immediately secured the medication cart, counted all controlled medications, and found no other discrepancies.An investigation determined that on 7/26/26, LPN C mistakenly mixed-up medications while preparing medications for two residents at the same time. She accidentally gave resident 2's PRN hydrocodone to resident 1 instead of resident 1's scheduled tramadol (a synthetic opioid pain reliever), and then placed resident 1's tramadol into resident 2's hydrocodone bubble pack. Resident 1 experienced no adverse effects from receiving resident 2's hydrocodone.LPN C, along with all staff licensed to administer medications, was counseled and educated on safe medication practices, including preparing medications for one resident at a time, verifying medications with the resident's medication administration record (MAR), and never returning medications to bubble packs once they were removed. Additional training and competencies were completed on medication destruction procedures. A facility wide audit showed no further issues.Follow up monitoring included weekly medication pass observations for four weeks, then monthly for two months, plus ongoing controlled substance audits. The provider planned on reviewing the results of their audits through their Quality Assurance and Performance Improvement (QAPI) committee.2. Observation on 8/26/26 from 9:03 a.m. to 11:04 a.m. of LPN E, RN F, and LPN H during medication administration revealed no concerns related to the control and accountability of controlled medications. There were no discrepancies noted.Interviews with those nurses at the time of the observations revealed that LPNs E and H were aware of the incident and confirmed they received retraining and competencies regarding medication administration. RN F was a new employee and that day was her third shift at the facility. She confirmed she received orientation and training on the provider's policies and procedures, including medication administration, and their process for tracking controlled medications.3. Interview on 8/26/26 at 3:13 p.m. with administrator A revealed that education coordinator I provided the staff with the education and checked the staff's competencies related to medication administration, control and accountability of drugs, and medication destruction. At the beginning of their investigation, they did not know who taped the wrong medication back into resident 2's medication card. They interviewed all their nurses and medication aides, and LPN C confirmed what happened. Administrator A confirmed that resident 1's representative and their primary care provider were notified of the medication error.4. Review of LPN C's employee file revealed she was hired at the facility on 3/17/25. She completed the annual medication administration retraining on 7/24/26. On 8/4/26, she received formal re-education and competency training on medication administration. 5. Review of the provider's investigation file from the above incident revealed that the issue was identified on 7/30/26. On 8/1/26 and 8/4/26, licensed nurses and medication aides were re-educated on Managing Interruptions and Distractions During Medication Administration, Medication Bubble Pack Reminders, and Narcotic Reminder[s]. The provider initiated audits during medication administration starting on 8/6/26. Audits were completed on 8/6/26, 8/13/26, and 8/23/26. Areas reviewed included, Did [the] nurse perform medication rights during medication administration? Yes/No; Was hand hygiene performed during medication administration? Yes/No; and Was narcotic count correct during audit? Yes/No. There were no discrepancies found during their audits.6. The provider's implemented actions to mitigate the likelihood of the deficient practice from reoccurring were verified from 8/26/26 through 8/27/26 after record review, and interview with administrator A revealed that the facility had followed its QAPI process regarding medication administration. They monitored and documented the staff's performance during medication administration and verified that the narcotic count was correct. In addition, three of three licensed nurses (LPNs E and H, and RN F) were observed during medication administration on 8/26/26 and no issues were identified. LPN C was counseled and reeducated on the provider's medication administration policies and procedures on 8/4/26. All licensed nurses and medication aides were educated from 8/1/26 to 8/4/26. Audits to ensure sustained compliance were initiated on 8/6/26 and were ongoing at the time of the survey. Based on the above information, noncompliance at F755 occurred on 7/26/26, and based on the provider's corrective action plans that were initiated on 7/30/26 and implemented for the deficient practice confirmed on 8/27/26, the noncompliance is considered past noncompliance.

Based on observation, interview, record review, and policy review, the provider failed to implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (11) who was identified as having a mild risk for developing a pressure ulcer and developed a stage IV (4; open wound with full-thickness skin and tissue loss. Bone, tendon, or muscle may be visible) pressure ulcer to her right antecubital space (the shallow triangular depression directly in front of the elbow joint).Findings include: 1. Observation on 7/15/26 at 2:19 p.m. revealed resident 11 was sitting in her recliner in her room. She wore an arm brace that started just above her right wrist and stopped at her elbow, and there were no visible wounds on her right arm.2. Interview on 7/15/26 at 3:25 p.m. with resident 11 revealed that she did not have any current wounds, but had an open wound on her right arm a month ago; that wound had healed. She was unable to move her right arm and had worn an arm brace that had caused the wound on her right arm a month ago. She now wore a different arm brace on her right arm that provided more padding.3. Review of resident 11's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact.Her diagnoses included spastic hemiplegia (a neuromuscular condition causing muscle stiffness on one side of the body) affecting her right dominant side, peripheral vascular disease, contracture (the permanent tightening or shortening of muscles, tendons, ligaments, or skin that prevents normal joint movement) on her right side, and a non-pressure chronic ulcer on the right upper arm with the fat layer exposed.Her 3/3/26 Braden scale (a tool used to assess the risk of developing pressure ulcers) assessment score was 15, which indicated she had a mild risk of developing a pressure ulcer.Resident 11's 4/28/26 weekly skin assessment revealed that she had developed a moisture-associated skin damage (MASD) open area in the right antecubital space of her right arm. The wound measurements were 1.2 centimeters (cm) in length x 0.8 cm in width x 0.2 cm in depth. A non-stick Telfa dressing (a sterile, non-adherent wound dressing designed to protect wounds without sticking to the healing tissue) was placed over the area for protection. The CCL E requested a physician's order to continue with the Telfa dressing at that time.Resident 11's medication administration record (MAR) included a 4/29/26 physician's order for a Brace to be ordered for extension and contracture, and a 5/5/26 physician's order for Resident brace to right elbow to be placed on in the AM and removed at HS. There was no documentation on resident 11's treatment MAR to support when her old brace was placed or when it was removed.On 5/12/26, resident 11 was referred to and seen in the wound clinic, and her initial wound measurements on her right arm were 0.5 cm in length x 0.7 cm in width x 0.2 cm in depth. The fat connective tissue was exposed, and there was a moderate amount of serosanguineous (a thin, watery wound drainage that is light pink or pale red in color) drainage.The wound clinic staff indicated the wound was a stage III (3; open wound with full-thickness skin loss. Fatty tissue may be visible) pressure injury. The wound clinic physician's orders were to change the dressing on resident 11's right arm every other and to have her arm brace on during the day and off at night.A 5/19/26 wound clinic note indicated that her right arm wound measured 0.4 cm in length x 0.5 cm in width x 0.2 cm in depth. A 5/26/26 wound clinic note indicated that her right arm wound measured 0.4 cm in length x 0.4 cm in width x 0.1 cm in depth. Wound clinic staff indicated the wound was a stage IV pressure injury.A 6/9/26 wound clinic note indicated that resident 11's right arm wound was completely healed and resident 11 would be discharged from wound clinic care.Review of resident 11's 7/15/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated she had an actual and potential risk for pressure ulcer development due to increased need for assistance and a right arm contracture. The goal was to maintain her intact skin without redness or discoloration. The interventions included providing a right arm brace, which was initiated on 6/8/26, and a goal for the staff to immediately notify the nursing department of any new skin issues such as redness, blisters, bruising, or discoloration during bathing or daily care that was initiated 7/1/24. The care plan contained no evidence of implemented interventions to prevent resident 11's antecubital stage III pressure injury at the right arm brace site before was identified on 4/28/26.4. Interview on 7/15/26 at 4:11 p.m. with licensed practical nurse (LPN) F revealed that the resident's dressing changes were completed based on the physician's order in the resident's medication administration record (MAR). The nurses tried to change the residents' dressings in the morning when the staff members were helping the residents get up and dressed for the day.5. Phone interview on 7/16/26 at 2:34 p.m. with clinical care leader (CCL) E regarding the process to prevent and monitor the resident's skin for breakdown revealed that the weekly skin assessments were completed on the residents to monitor for skin breakdown. Resident 11's pressure ulcer to her antecubital space on her right arm was found during a weekly skin assessment. CCL E stated she had called resident 11's primary care provider (PCP) to provide an update and request an order for wound care. Initially, resident 11's wound was identified as a moisture-associated skin damage (MASD) wound. Resident 11 received a physician's order on for a foam dressing to be placed on the antecubital space of her right arm daily and for continued monitoring of the pressure ulcer.CCL E discussed with the care team the possibility of a different arm brace for resident 11 to help manage her contracture and to prevent further skin breakdown in that area. CCL E had contacted the physical therapy department, who suggested obtaining an order from resident 11's physician for what brace to use, and a new brace was purchased for resident 11's right arm. When resident 11's right arm wound did not improve, she was referred to the wound clinic for further treatment.6. Interview on 7/16/26 at 6:00 p.m. with certified nursing assistant (CNA) G regarding resident 11's right arm wound revealed that she did not notice a wound on resident 11 while providing her care. CNA G stated that if she were to notice a skin issue, she would report it to the nurse on duty.7. Interview on 7/16/26 at 6:07 p.m., with the director of nursing (DON) B and administrator A revealed the facility utilized the Braden Scale as its standardized skin risk assessment tool. DON B explained that the Braden Scale assessments were documented in the resident's EMR and that the nursing staff members were expected to complete an additional nursing note. DON B stated that CNAs were trained to report any skin concerns such as redness or bruising to a nurse on duty at that time. The staff members were educated on care plan interventions for residents identified as having a high risk of developing pressure ulcers, including specialized mattresses, heel floating, repositioning, and other preventive strategies.DON B expected the nursing staff to notify the resident's primary care provider of any skin changes and follow the provider's recommendations and orders. Regarding resident 11's right arm wound and brace, DON B reported that the new arm brace was ordered after consulting with resident 11's physician, and the physical therapy (PT) department educated the nursing staff on how to apply the brace. The nurses were responsible for applying the brace and were to document its removal.DON B was unaware of any documentation that resident 11's old right arm brace was put on and removed during April or May 2026 and was unsure who was responsible for putting on and removing the brace. Resident 11 received restorative services, as listed in her care-plan. DON B did not recall any differences between the two arm braces that resident 11 used. DON B was unsure whether the nurses had received any education regarding brace management.DON B stated there was no documented education provided by the PT department specific to resident 11's old arm brace, and they were not involved in establishing a schedule for when to put on and remove resident 11's brace. There was no documented education that any staff members were trained in putting on and removing resident 11's old arm brace.DON B stated CCL E initially identified resident 11's pressure ulcer during a weekly skin assessment on 4/28/26. Resident 11 was referred promptly to the wound care clinic, and the clinic routinely sent their visit notes back to the facility. The resident's antecubital area on her right arm was initially treated at the facility for MASD. DON B stated there was no documentation indicating resident 11's old arm brace caused her right arm wound.DON B was unsure what interventions were in place for resident 11's old right arm brace to prevent her from acquiring a pressure ulcer. DON B believed the old brace was intended to prevent further contracture of the resident's right arm.8. Review of the provider's 3/2/26 Pressure Ulcer policy revealed the facility was required to provide appropriate assessment and prevention of pressure ulcers, as well as treatment when necessary.9. Review of the provider's updated 6/30/26 Wound and Pressure Ulcer Management policy revealed the facility was to provide current and consistent standards of practice in wound care management. Wound care management may include the management and treatment of surgical wounds, pressure ulcers, diabetic ulcers, skin conditions, as well as arterial and venous ulcers. These are the most common types of wounds that occur. [Redacted provider's name] wound care programs, pressure ulcer guidelines, and protocols have been developed and implemented to provide quality service to residents. Promotion of healing, pain management, and prevention of complications is extremely important, as well as accurate assessment and documentation.

Based on interview, record review, and policy reviews, the provider failed to ensure staff members responded to call lights promptly for two of two sampled residents (2 and 4) who reported concerns regarding extended call light wait times. Findings include:1. Interview on 7/14/26 at 3:41 p.m. with resident 4 revealed she felt her call lights were often answered slowly, especially due to her room being located at the far end of the hallway. She had two instances of incontinence due to a delayed response from the staff. 2. Review of resident 4's electronic medical record (EMR) revealed she was admitted on [DATE]. Her 6/5/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. Her 6/3/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated she required one staff member to assist her and a front wheeled walker and gait belt (a waist strap gripped as support for safe mobility and transfers) to be transferred to the toilet. 3. Review of resident 4's 6/17/26 through 7/16/26 call light report (a data report that measures how long it takes nursing home staff to answer a patient's call button) revealed 15 call-light response times exceeded 20 minutes, and the longest call-light response time was 44 minutes. 4. Interview on 7/15/26 at 9:46 a.m. with resident 2 revealed that he experienced delays when he requested the staff assistance, which included requesting medication for pain. He stated the facility often appeared short staffed to him. 5. Review of resident 2's EMR revealed he was admitted on [DATE]. His 5/22/26 BIMS assessment score was 14, which indicated his cognition was intact. His 5/18/26 care plan indicated that he required one staff member to assist him with a non mechanical stand aid (a caregiver-assisted transfer device that relies on the resident's own strength to move from a seated to a standing position) and a gait belt for toilet transfers and assistance with dressing and bathing. 6. Review of resident 2's 6/17/26 through 7/16/26 call-light report revealed 10 call-light response times that exceeded 20 minutes, and the longest call-light response time was 27 minutes. 7. Interview on 7/16/26 at 2:22 p.m. with certified nursing assistant (CNA) I revealed that resident call lights were expected to be answered as soon as they can, but acknowledged the staff were delayed when caring for other residents. 8. Interview on 7/16/26 at 3:54 p.m. with resident 4 revealed that her longest wait time for the staff to respond to her call light during the past month was approximately one hour. She stated that was embarrassing for her. 9. Interview on 7/16/26 at 4:06 p.m. with director of nursing (DON) B revealed all staff were responsible for answering the residents' call lights and should notify specific staff members depending on the residents' needs. 10. Interview on 7/16/26 at 5:36 p.m. with administrator A revealed that she expected resident call lights to be answered as soon as possible, depending on the resident's needs. She reviewed the call-light reports weekly and conducted random audits of call light response times. 11. Review of the provider's revised 7/8/25 Call Light policy revealed the facility was required to ensure residents always had a method to call for assistance and that call lights were to be answered promptly.

Based on observation, interview, record review, and policy review, the provider failed to ensure a homelike environment was maintained for two of fourteen sampled residents (18 and 32) who did not have a bathroom door and four of fourteen sampled residents (10, 24, 35, and 44) whose walls in their rooms had exposed drywall and peeling paint. Findings include:1. Observation on 7/14/26 at 9:28 a.m. in resident 24's room revealed an approximately ten-inch area between her end table and stationary chair with peeling paint, more than five gouges in the drywall, and two three-to-four-inch areas where the drywall was exposed. 2. Observation and interview on 7/14/26 at 11:19 a.m. with residents 18 and 32 in their shared room revealed that they did not have a bathroom door. The bathroom was directly across from where resident 18 sat in her recliner and resident 32 sat in her wheelchair.Resident 18 stated that the door was removed a few days ago to be repaired. She was unsure if the door was removed before or after the weekend. She went across the hallway into the empty resident room's bathroom to use the bathroom if she wanted to close the door. She felt that going across the hall to use the bathroom gave her the privacy that she needed but wondered when their bathroom door would be repaired. She often got up one to two times during the night to use the bathroom and hoped that their bathroom door would be repaired soon so she could use their bathroom.Resident 32 stated that when she used the bathroom, if resident 18 was in their room, the staff members would try to remember to pull the curtain around resident 18 and her bed, and the staff members closed the bedroom door to the hallway. 3. Observation and interview on 7/14/26 at 12:51 p.m. with resident 10 in her room that she shared with resident 35 revealed there was a large area behind her recliner between her bed and resident 35's bed where there were more than five three-to-four-inch gouges in the wall with exposed drywall and peeling paint. She pointed at the area behind the recliner and stated it was like that when she moved from another room in the facility into that room a couple of weeks ago. She thought that the staff members were aware of the area because it was visible from anywhere in the room. 4. Observation and interview on 7/15/26 at 8:28 a.m. with resident 44 in her room revealed that she sat in a chair between her bed and the window, and she did not share the room with another resident. There were several areas behind resident 44's recliner where the paint was peeling, and the drywall was exposed. On the side of the room closest to the window, there were more than five eight-inch-long areas on the heat register where the paint was peeling, and the metal was exposed. There were more than ten scratches on the wall by the window, with deep scratches, peeling paint, and exposed drywall.Resident 44 did not know how long the areas on her wall or on the heat register were damaged. 5. Observation and interview on 7/15/26 at 8:30 a.m. with maintenance mechanic J regarding residents 10, 18, 24, 32, 35, and 44's rooms revealed that he was unaware of the areas of exposed drywall and peeling paint. He stated that the facility's management team conducted angel rounds (a process of going room to room to observe for resident and environmental concerns). He expected that when the staff members observed environmental concerns like peeling paint or exposed drywall, they would document the need for repairs on the Maintenance Request Sheets.Maintenance mechanic J reviewed the Maintenance Request Sheets on the maintenance clipboard and stated that there were no requests made for those areas to be repaired. If those areas were reported to him, he would fix them. He thought that there were several resident rooms with damaged sheetrock and peeling paint. He thought the damaged areas on the walls were caused by the resident recliners being pushed up against the wall, and when he fixed those areas, they just happened again. He confirmed that the area of drywall damage and peeling paint in resident 24's room was not behind a recliner and thought that there was once a recliner in that spot in her room. He thought that the peeling paint and drywall damage in resident 44's room was caused by a resident's bed being placed too close to the heat register and the wall. He stated there was not a current plan in to repair those areas.Maintenance mechanic J was aware that residents 18 and 32 did not have a bathroom door because he removed it so that he could repair it. The repair was not finished, and he was unsure when the door would be rehung. 6. Observation and interview on 7/16/26 at 9:19 a.m. with certified nursing assistant (CNA) H revealed that when the surveyor knocked on the bedroom door to resident 18 and 32's shared bedroom, CNA H informed them that resident 32 was seated on the toilet and then entered that room. Resident 32 was seen seated on the toilet in the shared bathroom from the doorway when CNA H entered the room.CNA H thought that it was a few days since residents 18 and 32 had a bathroom door. CNA H tried to make sure to pull the curtain around resident 18's bed and close the bedroom door to the hallway when residents 18 and 32 were both in the room. The curtain was not pulled because resident 18 was not in the room at that time. CNA H stated that resident 32 preferred to use the bathroom in the empty resident room across the hall from her room, because she wanted to use a bathroom with a door. There was a clipboard located in an office near the nurses' station where she would document when there was a problem that maintenance needed to fix.She was aware of the areas of exposed drywall and peeling paint in residents 10, 24, 35, and 44's bedrooms but did not report them to the maintenance department because she thought that administrator A and maintenance mechanic J already knew about those areas, as the management staff members took turns checking the rooms each week. She did not document when she noticed that residents 18 and 32 did not have a bathroom door because the residents told her that maintenance mechanic J removed the door. 7. Observation and interview on 7/16/26 at 4:13 p.m. with administrator A revealed she was aware of the damaged drywall and peeling paint in residents 10, 24, 35, and 44's rooms and that residents 18 and 32 did not have a bathroom door.Management level staff members completed Angel Rounds weekly to look at the residents' rooms and the environment for damage or other concerns. She expected the staff members who completed those rounds to document environmental areas of concern on the Maintenance Request Sheet.She thought that an external contractor would need to complete the repairs to the walls in residents 10, 24, 35, and 44's rooms due to the extent of the damage and felt that it was difficult to schedule those repairs due to time constraints and the contractor's schedule. Those repairs were not scheduled to occur.Administrator A expected the staff members to pull the curtain around residents 18 and 32's beds and to shut residents 18 and 32's hallway door when they needed to use the bathroom in their shared room. Administrator A acknowledged that pulling the curtain did not provide privacy if someone entered the room from the hallway while resident 18 or 32 were seated on the toilet, as the curtain extended around the residents' beds and did not provide privacy from the hallway door.Administrator A confirmed that a new resident moved into the previously empty resident room across the hall from residents 18 and 32 on 7/16/26 and was unsure which bathroom resident 32 would have to use if she wanted to use a bathroom with a door. She stated that the repair to residents 18 and 32's bathroom door was scheduled to take several days, was not completed, and that it was a challenge. 8. Review of the provider's 3/26/26 through 7/15/26 Maintenance Request Sheet revealed that no documentation indicated that there was drywall damage in residents 10, 24, 35, and 44's rooms. On 7/7/26, it was reported that residents 18 and 32's Bathroom door is really bad [and] falling apart. Safety Hazard. The Maintenance Comments indicated Have [a] new one coming. 9. Review of the provider's 5/22/26 through 6/26/26 Angel Room Rounds documentation revealed that on 5/22/26 the walls in residents 10, 35, and 44's rooms contained damage. On 6/26/26, the walls in residents 10, 35, and 44's rooms did not contain damage. There was no documentation of the condition of resident 24's bedroom walls. 10. Review of the provider's revised 12/29/25 Resident Environment policy revealed the center will provide a safe, clean, comfortable homelike environment.

Based on interview, observation, record review, policy review, and manufacturer user guide review, the provider failed to ensure respiratory care was provided one of one sampled resident (18) who had a physician's order for Continuous Positive Airway Pressure (CPAP) therapy (a treatment for obstructive sleep apnea by delivering a steady, gentle stream of pressurized air through a tube and mask) when she slept, and could not use it due to the mask unsnapping during the night. Findings include:1. Interview and observation on 7/14/26 at 11:19 a.m. with resident 18 in her room revealed that she was supposed to wear a CPAP mask at night when she slept. For the past couple of months, she was unable to wear that CPAP mask because the strap that held the CPAP mask on came unsnapped at night while she tried to sleep, and she could not tolerate wearing it. She felt that the mask coming unhooked and having to sleep without her CPAP therapy disrupted her sleep. She did not have a good night's sleep for the past couple of months. She could not remember which nurse she had informed that her CPAP mask came unsnapped and fell off when she slept. She had told them that she needed a new CPAP mask, but they said, it's not time yet. 2. Review of resident 18's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 6/30/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. Her diagnoses included sleep apnea (a common, potentially serious disorder where breathing repeatedly stops and starts during sleep), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), and coronary artery disease (CAD) (narrowing of the blood vessels of the heart that causes inadequate oxygen flow to the heart). She had a 7/23/25 physician's order to wear her CPAP mask, on at HS [bedtime], off in AM, for her sleep apnea.A 5/11/26 nurse's progress note indicated .resident's CPAP nasal mask has a tear in it and we are needing a replacement mask/head piece. Resident has a ResMed AirFit nasal mask (N20) size small. The head piece [headpiece] is attached to the nasal mask. Got the after hours answering service. They will message the office tomorrow and someone will be calling us back. Her CPAP mask was unable to be worn as ordered by the physician.A 6/18/26 nurse's progress note indicated that resident 18 was refusing to wear her CPAP mask. Mask and tubing [were] hanging in [the] bathroom. Resident [18]'s roommate is [on] contact precautions [infection control measures used to prevent the spread of diseases that transmit through direct or indirect contact with an infected person or contaminated surfaces] and resident [18] states that [her] mask should not be hanging in [the] bathroom due to cross contamination. Resident verbally upset and wants to know which staff placed [her] mask and tubing in the bathroom. Mask removed from resident's room at this time. DON [director of nursing B was] updated on [the]incident.A 7/11/26 nurse's progress note indicated Resident [18] states that her CPAP mask is not staying connected by the clips and velcro. It got stuck to her neck when staff put tape on it to keep it together and left a mark on her neck. Resident does have 2 [two] visible purplish marks to [the] left side of neck behind [her] ear. Resident [18] states that she cannot wear it, if it will continue to not stay on with the hardware. Writer addressed concern with Admin [administrator], DON via text to make aware of equipment.Resident 18's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated she had a goal to be free from signs and symptoms of complications of cardiac problems and wore a CPAP at night while she slept due to her altered cardiovascular status. She has enhanced psychosocial well-being R/T [related to] individualized daily routine and honoring personal preferences: stating they had a good night's sleep, improved mood, expression of contentment, comfort and/or satisfaction, positive facial expressions, maintains activity interests, maintains positive relationships. 3. Interview and review of resident 18's progress notes on 7/16/26 at 12:13 p.m. with DON B revealed that she thought that resident 18's CPAP mask was replaced. She was not aware of the 5/11/26 documentation that indicated resident 18's CPAP mask was torn, and asked for time to follow up to find out what transpired after 5/11/26. 4. Interview on 7/16/26 at 4:13 p.m. with administrator A revealed that she thought clinical care leader (CCL) E had provided resident 18 with a new CPAP mask but was unable to find documentation of that. She expected that resident 18 would have been provided with a new CPAP mask when her CPAP mask was torn or would not stay on, so that she could wear her CPAP at night when she slept. Administrator A expected that when resident 18's mask was replaced, it would have been documented in her EMR. 5. Interview on 7/16/26 at 5:04 p.m. with DON B, registered nurse (RN)/Minimum Data Set (MDS) D and CCL E who participated by phone revealed CCL E was aware that resident 18 was having issues with her CPAP mask. She could not recall when she was first told about the CPAP mask being torn and coming unsnapped.RN/MDS D stated she had documented that she contacted the oxygen supply company regarding resident 18's CPAP. She recalled the oxygen supply company sent nose pieces for the CPAP, and that she replaced the nose piece, but was unaware that the mask was coming unsnapped and that resident 18 was refusing to wear her CPAP at night because it disrupted her sleep.CCL E stated that she contacted the oxygen supply company on 7/13/26 about resident 18's CPAP but was unable to locate documentation of that call and did not receive confirmation that the replacement parts were ordered. 6. Review of the provider's reviewed 10/31/25 Non-Invasive Respiratory Support policy revealed Inspect the device and be sure the enclosure is not broken, and all components are secure. 7. Review of the ResMed Air Sense 11 manufacturers undated user guide revealed that it referred to the mask's user guide for detailed information. That user guide was not provided before the survey exit.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to assess for potential accident hazards and safety related to the usage of a lift chair for one of one sampled resident (1) and was transferred to the emergency department (ED) for evaluation and treatment of injuries acquired from the fall.Findings included:1. 1. Review of the providers 7/8/25 SD DOH FRI revealed:*On 7/8/25 at 10:45 a.m., resident 1 was found lying face down on the floor in front of his lift chair.*His lift chair was raised all the way up in the air.*He had a laceration (a cut or tear in the skin) to the left side of his forehead.*A registered nurse (RN) completed neurologic assessment (evaluation of nerve function, reflexes, coordination, motor skills, sensation, and mental status) with slight delayed response, which was normal for resident 1.*Resident 1's vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were within normal limits (WNL).*The local ambulance was notified and resident 1 was transferred to the ED.*His family was notified of the fall.*His primary care provider (PCP) was notified of the fall.*Resident 1 returned from the ED on 7/8/25 with a diagnoses of a fall, contusion (bruise) to the face, laceration of an eyebrow that was repaired with tissue glue, and subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain).*Orders: cold pack to left cheek TID (three times a day) x15 minutes until swelling resolves.Glue to left eyebrow laceration to remain in place until starts falling off on its own. 2. 2. Review of resident 1's electronic medical record revealed:*He admitted to the facility on [DATE].*His diagnoses included hypertension (high blood pressure), paranoid schizophrenia (symptoms of paranoia including delusions and hallucinations), peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), hypoxemia (low level of oxygen), heart failure, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), dysphagia (difficulty swallowing), and major depressive disorder.*His Brief Interview for Mental Status (BIMS) assessment score on 5/13/25 was 14, which indicated he was cognitively intact.*A 7/8/25 progress note: [Resident 1 was] Laying in prone position with [his] nose touching [the] floor with [a] pool of blood noted and gurgling breathing sounds noted, grabbed a towel and raised [resident 1's] head just enough to get my hand between [his] forhead [forehead] and floor so he could breathe, his eyes were open, and [he] responded to [the] 2nd [second] nurse whom rolled him onto his left side and then ambulance [was] called for emergent [emergency] transfer to nearest hospital via T.O.R.B. [telephone order read back]. [Local doctor] for evaluation. 2nd nurse checked his pupils and the O.D. [right eye] is 4mm [millimeters] and reactive, unable to open O.S. [left eye] d/t [due to] swelling around eye and left cheek bone. He did squeeze CNA's [certified nursing assistant] hands [he was] not strong but [he was] able to follow command and he did slightly move his right leg and his left leg just a little. Ambulance crew of 2 arrived and [a] cervical collar made from rolled towels were applied to neck and he was slid onto transfer board and then 4-5 people [assisted] to lift him onto the gurney. VS [vital signs] WNL @ [at] 134/66, [blood pressure] 73, [pulse] 18, [respirations] 98.2. [temperature]*A 7/9/25 progress note: FALL F/U [follow up] VS [vital signs] and Neuro's [neurological assessment] WNL, only able to check [NAME]] pupil as O.S. is swollen shut. [Resident 1 was] Able to move all extremities on command, hand grasps weak, per baseline. Purplish black and red ecchymosis pbruising] to O.S and cheek bone. C/O [complains of] 10/10 [ten out of ten]pain in my back what part lower, he just received his scheduled 650 mg [milligrams] of Tylenol. Will continue to monitor.*A 7/10/25 progress note: Fall f/up: [Resident 1] Continues to have bruising and swelling to left eye. No bleeding or drainage noted to [left] eye brow. Neuro's intact. Complains of pain, Tylenol given per MAR [medication administration record] Moves all extremities per self.*He had lift chair safety assessments completed on 2/4/2024, 7/9/25 and 7/11/25.-The 7/9/25 and 7/11/25 indicated the lift chair would be used for repositioning and would not be a restraint for resident 1.-No documentation identified that resident 1 would be safe to use the lift chair. 3. Observation and interview on 7/16/25 at 4:15 p.m. with resident 1 revealed he:*Was lying in bed, with his legs elevated on a pillow. He had a bruise above his left eye and bruising on his neck.*Was unsure how he fell out of his lift chair on 7/8/25.*Since that fall on 7/8/25, he has not used his lift chair. 4. Interview on 7/17/25 at 8:33 a.m. with CNA E regarding the 7/8/25 FRI involving resident 1 revealed:*She had found resident 1 face down on the floor and immediately called for the nurse on duty.*She put on gloves and supported his head to ensure he could breathe.*The emergency department was called promptly.*It took five staff members to roll resident 1 onto his back.*A cold compress was applied to resident 1's head while an RN assessed him and checked his vital signs.*Paramedics arrived and were assisted by staff in transferring resident 1 onto the gurney.*She reported that the facility conducted a huddle (staff meeting) the same day to discuss lift chair safety.*She stated that the appropriate height for the lift chair would depend on the individual of each resident. 5. Interview on 7/17/25 at 8:59 a.m. with CNA D revealed:*She explained that the height she raised the lift chair would depend on the individual resident's needs.*Some residents had their chairs unplugged due to safety concerns related to their cognition status and required assistance when transferring out of the chair.*some residents, families preferred that the lift chair remote be kept in the drawer behind the resident. That preference was to be documented in the resident's care plan.*She stated that if there was any uncertainty about how a resident should be assisted, CNAs could refer to the resident's mini care plan (a document that identifies the resident's care needs and interventions) for guidance. 6. Interview on 7/17/25 at 9:35 a.m. with Minimum Data Set (MDS) nurse C revealed:*She stated she completed the residents' physical device and/or restraint evaluation review form quarterly.*She was unsure how long resident 1 had had his lift chair.*She was unaware that a lift chair safety assessment was completed on 2/4/24 for resident 1.*She was aware that resident 1 had assistive grab bars on his bed, which she stated was the reason for the safety assessment.*She explained that when resident 1 physical device and restraint evaluation review form was carried forward in the computer, it was empty, and she was unaware he had a lift chair that needed to be completed at the same time as the assistive grab bars. 7. Interview on 7/17/25 at 10:53 a.m. with director of nursing (DON) B revealed:*She was unsure how long resident 1 had had his lift chair.*They were to follow the guidelines outlined in the physical device and/or restraint evaluation review form, which indicated the form should be completed upon the device's arrival, quarterly, and then after any significant change in the resident's condition.-The RN would assess the lift chair when the lift chair arrived, and then the lift chair would be assessed quarterly.*She stated that through their Quality Assurance and Performance Improvement [QAPI] process, they have identified that some of their residents have not had the physical device and/or restraint evaluation review form completed as directed. 8. Interview on 7/17/25 at 11:00 with administrator A revealed:*She was unsure how long resident 1 had had his lift chair.*She stated staff were to follow the physical device and/or restraint evaluation form as directed in their provider's restraint policy. Review of the provider's undated Physical Device and/or Restraint Evaluation and Review Form revealed:Purpose: 1. To evaluate if [a] physical device is appropriate and beneficial. 3. To conduct [a] quarterly review to ensure physical devices continue to be appropriate and beneficial.Use: 1. Required upon [a resident's]admission/re-admission if [the] resident is currently using a device and/or restraint, and quarterly thereafter. 2. Required with implementation of a new device and/or a restraint, and quarterly thereafter. Review of the provider's reviewed 10/29/24 Restraints policy revealed:Procedure: Non-Emergency Restraint Use 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.

Based on South Dakota Department of Health (SD DOH) complaint report review, interview, document review, and policy review the provider failed to ensure full investigations had been completed to rule out potential misappropriation of controlled medications (high risk for addiction, dependence, abuse, and theft) found to be missing during the controlled medication count between nursing shifts for four of six sampled residents (5, 6, 7, and 8) with physician-ordered controlled medications. Findings include: 1. A review of the 3/12/25 SD DOH complaint report involving resident 8 revealed: *Licensed practical nurse (LPN) H had gone to resident 8's room to change her Fentanyl patch and give her nasal drops. *The nasal drops were in the manufacturer's box and LPN H placed the old patch for destruction inside of the box with the bottle of nasal drops. *LPN H had placed the box with the old Fentanyl patch inside the medication (med) cart before destroying it. *The patch was missing when she went to destroy the patch an hour later. *LPN H and other staff members looked for the patch and were unable to find it. *Administrator B and the director of nursing (DON) A were contacted, an incident report was completed, and the police department was notified. *DON A educated LPN H on the importance of destroying meds immediately. *All nurses were educated on the [NAME] Policy for Transdermal Patch Application and Disposal. -When removing the patch from a resident, the nurse is to fold it in two with the medicated side together, place it in a plastic bag, and destroy it immediately. -Plastic bags were placed on all three med carts. *DON A was to complete random audits three times to ensure the policy had been followed. *No internal malice (intent to do wrong) was suspected. 2. A review of the 4/4/25 SD DOH complaint report involving resident 5 revealed: *During controlled medication count between registered nurse (RN) J and certified med aide (CMA) I found that resident 5's med card of Tramadol (a controlled pain med) 50 milligram (mg) was short one pill. -They had counted 76 pills and there should have been 77. *Both RN J and CMA I searched around the cart and in the trash. -The missing Tramadol was not found. *CMA I had been in the process of getting the resident's Tramadol pill out for administration when another resident needed assistance to prevent a fall. *When she went back to the med cart, she took out another Tramadol pill from the med card and had not realized she had already done that. -She assumed she had given the resident two Tramadol pills. -She thought being distracted by the high fall-risk resident contributed to the med error. *The nurses and CMAs were educated to double-check the med cards with the medication administration record (MAR) and the narcotic signature sheet before popping the pill out of the med card. *DON A was to: -Complete a med pass skills validation for CMA I. -Complete random audits of med passes on all the nurses and CMAs. No documentation indicated how often DON A should have completed the med pass audits. *No malice was suspected, and the provider had determined resident 5 had received two Tramadol pills. 3. A review of the 4/15/25 SD DOH complaint report regarding resident 6 revealed: *During the narcotic medication count between LPN O and RN J, they found that resident 6's narcotic med card of Tramadol 50 mg was short one pill. -They had counted 64 pills and there should have been 65. *LPN O and RN J immediately searched the med cart for the missing narcotic, but it was not found. *DON A was notified, and she talked with LPN O to try to determine what had happened. -LPN O indicated that she could have given resident 5 two doses of Tramadol during her noon med pass. *DON A: -Educated LPN O to double-check the med cards with the MAR and with the narcotic signature sheet before popping the pill out of the card. -Assessed LPN O's med pass competency skills on 4/16/25 with no identified concerns. -Was to have conducted random med pass audits once a week for two months to ensure compliance. *No malice was suspected. 4. A review of the 5/6/25 SD DOH complaint report regarding resident 7 revealed: *During the narcotic medication count between LPN H and RN G, they found that resident 7's narcotic med card counts for Tramadol 50 mg and Xanax (a controlled anxiety med) 0.25 mg had not been accurate. -The Tramadol 50 mg narcotic card had 74 pills in it and should have had 72 pills. -The Xanax 0.25 mg narcotic card had 17 pills in it and should have had 18. *LPN H was re-educated on double-checking the narcotic count book before popping the narcotic med out of the med card and after administration to the resident. *RN G stated that the med cart, and trash had been searched for the missing narcotic. *LPN H stated: -She felt like there were many distractions during the med pass that may have caused the narcotic count to have been off. -There had been distractions from residents with behaviors and from needing to assist other staff. *Nurses were to be educated on establishing clear communication boundaries with other staff members for urgent or non-urgent issues to limit distractions while passing meds. *DON A: -Had been completing random med pass audits on the nurses and CMAs. -Was to complete a skills validation for the med pass with LPN H *No malice was suspected. 5. Observation and interview on 6/10/25 at 9:20 a.m. and again on 6/11/25 at 9:17 a.m. with RN C during morning med pass revealed: *She reviewed the process of administering a narcotic med to a resident, which had included the application and destruction of a Fentanyl patch. *She stated the process had always been the same except for the narcotic med count verification sheet. -They had not been using that sheet for some time, and she was not sure why. -It had been re-implemented in April or May for the staff to use during the narcotic med counts at the change of shift. -After the narcotic med count was completed, both the nurses and CMAs should have signed off on the med count verification narcotic sheet to support that the narcotic med counts had been accurate. -The Fentanyl patches were to be placed and sealed inside a small plastic baggie, and sealed after placing inside, and then destroyed immediately with the C wing nurse. *She stated that using the small baggies was the only change in that process. They should have destroyed the patches immediately anyway. *She: -Was unsure if DON A had been completing med pass competencies. -Stated the DON had been completing multiple insulin administration audits on all of the nurses but she was unaware if the DON had been auditing anything else. *The nurses and CMAs received med pass, insulin administration, and narcotic med administration education in April or May. Observation and interview on 6/10/25 at 10:05 a.m. and again at 3:30 p.m. with LPN D revealed: *She had been assigned to work the 300 wing and one of her duties had included med administration. *She could not recall any recent education on med administration, specifically the Fentanyl patch application and destruction process, missing narcotics, and security of controlled meds. *She was not aware of any changes to the process for med administration. *The nurses' meetings were mandatory and she had rarely missed any. *They had med administration competencies completed once a year. -The only med administration competency that she was aware of was for insulin administration. *A narcotic med count for the med cart she was assigned to was then completed. *The med counts were accurate, but the narcotic verification form had only been signed-off by the night nurse. -LPN D had not signed the form with the night nurse that verified the narcotic count was completed and accurate at the change of shift. *LPN D stated: -We are supposed to sign that sheet off together after the count is done. -Not sure why I didn't. *She then signed the narcotic medication count verification form. 6. Interview on 6/10/25 at 10:35 a.m. with LPN E revealed: *She reviewed the process of administering a narcotic to a resident which had included the application and destruction of a Fentanyl patch. *She stated: -The process had always been the same, except for the narcotic medication count verification form. -That form had been implemented at least a year ago. *She confirmed the Fentanyl patches were to be placed and sealed inside a small plastic baggie, and then destroyed immediately with the C wing nurse. *She stated that using the small baggies was the only change in that process. *The only med administration competency or audit that she was aware of was for insulin administration. *They were reminded of the med administration process, signing of the narcotic medication count verification form between the two shifts, and the destruction of the Fentanyl patches in the last nurses' meeting. *Otherwise, any process changes or re-education was placed in a binder at the nurses' station for the staff to review, sign, and date. Interview on 6/10/25 at 2:00 p.m. with RN G revealed: *She confirmed the process for counting narcotics between shift change with either the nurse or CMAs. *The narcotic counting process was not new nor was the narcotic verification form. *She: -Had been involved when the narcotic count with another nurse was off in April. -Had been coming on duty for the night shift and the other nurse was going off duty and leaving the facility. *There had been two meds in the cart that looked similar. *It appeared as if the other nurse had given an extra Xanax to the resident, but they were not sure. Interview on 6/10/25 at 2:45 p.m. with LPN H revealed: *She reviewed the controlled medication reconciliation process like the other nurses had described above. *She had been involved when a Tramadol count had been short for a resident during the shift change controlled med count verification process. *She could not recall all the details of that incident. *She stated: -The nurses are responsible for med pass, treatments, and assisting residents. -The provider did not want them passing residents their meds in the dining room ,and they were required to remain in the wing. -Because of that, it was quite hectic during med pass. -You can have a lot of distractions and the residents and CNAs are asking for help. -I feel really rushed. *She had been involved with a missing Fentanyl patch. -She had placed the old patch on the outside of a box and could not find it when she went to destroy it. -She thought she might have wadded it up in her glove when she had taken it off. -She and the other nurse looked all over and were never able to find it. *She had: -Been reminded to be more mindful about her process for signing off meds, verifying meds, and destroying meds right way. -Not recalled a lot of education related to those incidents, but she had to go through a competency process. Interview on 6/10/25 at 3:12 p.m. with CMA I revealed: *She worked the afternoon shift and only passed the meds for the 200 wing until after supper. *She had been required to complete a controlled medication verification count with that nurse. -The night nurse completed a controlled medication verification count on the 100 and 300 wings for shift change. -She completed a count on all the med carts at the end of her shift with the night nurse. *To her knowledge, nothing had changed with that process, except they had to sign the controlled medication verification signature form when count was completed and they had not had to before. -They used to sign each controlled medication count sheet before that sheet was added to the narcotic binders on the med carts. *She confirmed she had given two narcotic meds to a resident in error. -The resident should have only received one. *She had: -Been interrupted during the administration process and accidentally gave the resident an extra dose. -Been educated recently on med administration. -A competency completed on med administration and her knowledge on the correct process for administering meds. Interview on 6/10/25 at 3:35 p.m. with LPN O revealed: *She had worked for the facility for two years and they had recently received education on: -Med administration and making sure they had checked the seven rights of med administration during med pass. -The verification signature form had been added back into all three med cart controlled medication count binders. -The destruction process for the old Fentanyl patch. The patches should have been placed and sealed inside a small baggie and then destroyed immediately with another nurse. *She had received her yearly med pass competency and thought that competency had been nothing new. *She had been involved with a wrong controlled med count during a shift change. -She had looked all over and never found the missing med. *She stated, I could have given her [a resident] two during the noon med pass, but I'm not sure. Interview on 6/10/25 at 4:04 p.m. with RN J revealed: *She had received education on med administration and making sure they followed the seven rights for med administration. *The only new process she had been aware of was the Fentanyl patches now had to be placed in a baggie before they were destroyed. -The destruction process had to be completed immediately. *There had been med pass competencies completed by DON A on insulin administration. *She was not aware of any additional: -Competencies for med administration. -Competencies that had been completed on the process of narcotic counts. 7. Review the nursing staff education dated 3/6/25, 4/2/25, and 4/11/25 revealed: *All the education had been typed on a plain sheet of paper. *The 3/6/25 education sheet had the transdermal patch application and removal process attached to it. *The staff were to have signed the education after they had read the document. -There was no documentation that supported when the staff had read the education. *The nursing staff had been educated on: -The policy for the removal and destruction process for a transdermal patch. -The process for administering a narcotic. -The seven rights of medication administration. *There was no documentation that indicated the staff had received education on drug diversion and misappropriation of meds. 8. Review of the med administration audits revealed: *On 5/20/25 and on 6/6/25 med administration audits had been completed. *Both audits had: -Been completed by DON A. -Been completed for med administration to make sure to check if staff had followed the seven rights of med administration. -Had no issues or concerns identified. -Not included to review the narcotic med count sheet to make sure it was double checked before and after administration. *There was no documentation on the audit forms that supported: -Who the staff was that the competency had been completed on. - Who the resident was and the time of day when the med pass was observed. *Those were the only audits the provided for the survey team to review. *There was no documentation that supported the following audits had been completed per their correction process for the above four facility reported incidents (FRI): -The 3/12/25 FRI indicated DON A was to have completed random audits three times to ensure the policy had been followed for the destruction process of Fentanyl patches. There were no audits to support the competencies had been completed. -The 4/4/25 FRI indicated DON A was to complete random med administration audits on all the nurses and CMAs. No documentation indicated how often DON A should have completed the med administration audits. -The 4/14/25 FRI indicated DON A was to have conducted random med administration audits x 1 a week for 2 months to ensure compliance. -The 5/6/25 FRI indicated DON A had been doing random med administration audits on the nurses and CMAs. *The provider had no documentation to support: -All of those audits had been completed before the initial 5/20/25 audit. -DON A had completed audits on the education provided to the staff on transdermal patch application and destruction, the verification process with the change of shift narcotic med count, and the seven rights of med administration were followed for controlled substances. -The DON had completed audits of the staff administering controlled meds to ensure no misappropriation of controlled meds had occurred. Review of the validation signature forms from 3/1/25 through 6/10/25 for all three med carts revealed: *The forms on the med cart located on the 100 wing had 14 days where two staff members had not signed between that they had completed the controlled med count together at the change of shift with no missing meds. *The forms on the med cart located on the 200 wing had 23 days where two staff members had not signed that they had completed the controlled med count together to support with no missing meds. *The forms on the med cart located on the 300 wing had 28 days where two staff members had not signed that they completed the controlled med count together with no missing meds. *The med room controlled med narcotic box count record they had completed the controlled med count together with no missing meds. Interview on 6/10/25 at 3:50 p.m. and again on 6/12/25 at 9:46 a.m. with DON A revealed: *She confirmed they were not able to locate the Fentanyl transdermal patch, the missing Xanax, and the missing Tramadol pills. *She had no documentation of her investigations into the missing meds other than what was included in the FRIs. *She had interviewed the nurses and the CMA involved directly with the missing meds, looked at what they had done, and took their word on how the meds were not accounted for. -She had no documentation that indicated there was no concern for misappropriation of those meds. *She agreed that missing meds was a form of drug diversion or misappropriation of meds but she had not thought of that when investigating the incidents. *She confirmed: -She had not followed her plan of correction for each of those submitted FRIs and had not completed those audits as stated in those reports. -She had only completed the two audits that were started late on 5/20/25. -She had not educated the staff on their drug diversion policy and should have. *She had not completed any audits of: -The application and removal of the transdermal patches, specifically Fentanyl patches to ensure the change in the destruction process had occurred. -The verification signature forms to ensure the staff were following their policy for a two-signature verification at the change of shift. -The individual residents' controlled medication sign-out sheets to support accurate med counts and reporting to her and the administrator when the count was not accurate. -The staff administering the residents their controlled medications and should have. *The pharmacy had not been included to help with the process of missing controlled substances per their policy. Review of the provider's 4/8/25 Medication: Missing/Diversion of Medications policy revealed: *Purpose: To provide guidance to nursing employees when medications are missing/diverted. *Procedure: -An investigation of the situation is performed by the investigation team. -During this investigation, there is potential for other issues or missing medications to be discovered. -The location will work closely with the pharmacy staff to prove when and what amount of medication was sent to the location or review past records related to the issue. -This is viewed as misappropriation of resident property - a type of abuse and neglect. -At the conclusion of the investigation, it may be appropriate to put a plan of correction in place to discourage this from happening again. Review of the provider's Medication: Transdermal Patch Application and Disposal policy revealed: *When removing a previously placed patch, use caution to protect skin. Fold the patch in two with the medicated sides together. Place [the] old patch in [a] plastic bag for transport to [the] medication room. *Narcotic patches should be destroyed by two licensed nurses, or a nurse and a pharmacist. *Medication destruction process for both controlled and non-controlled medications should be reviewed annually and approved by your state-licensed consultant pharmacist. Review of the provider's Medications: Controlled policy revealed: *Purpose: -To provide verification and reconciliation of all controlled medications. -To provide safe storage for all controlled medications. -To provide guidance on [the] destruction of controlled substances. *Each time the keys that secure controlled medications change from one nurse/medication aide to another, the oncoming and off-going nurse/medication aide will work together to reconcile all controlled medications, including all discontinued controlled medications and document the same. *The verification signature form was attached to the policy

Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure suicide risks evaluation had been completed for one of one sampled resident (1) by two of two nurses (E and G) who had documented the resident's comments of not wanting to live anymore to address his observed and expressed changes in his mental health. Findings include: 1. Review of the SD DOH FRI regarding resident 1 revealed: *On 5/9/25 licensed practical nurse (LPN) E had walked by resident 1's room and noticed blood on the floor in his room. *Resident 1 had a push pin in his hand and had cut himself in the antecubital (the area of the arm at the elbow crease) areas of both of his arms. *Administrator B had visited with the resident while LPN E notified the resident's physician. *Resident 1 was transferred to the emergency room for evaluation on 5/9/25. 2. Interview on 6/10/25 at 10:40 a.m. with certified nursing assistant (CNA) K regarding resident 1's behaviors revealed: *She had overheard resident 1 stating he had felt depressed and informed registered nurse (RN) J of the resident's voiced feelings. *It was not normal for resident 1 to have said that. 3. Interview on 6/10/25 at 11:15 a.m. with CNA L regarding resident 1's behaviors revealed: *She had assisted him and had noticed he had changed his shirt frequently that day. *CNA L informed the charge nurse of resident 1's behavior. *It was not normal for resident 1 to have changed his shirt so frequently. 4. Interview on 6/10/25 at 11:30 a.m. with environmental service M regarding resident 1's behavior revealed: *She had noticed he had become irritable and informed the charge nurse of the noticed change. *She had also noticed his bathroom had become dirtier than usual with smeared areas of bowel movement (BM). *That was not resident 1's normal behavior. 5. Interview on 6/10/25 at 12:10 p.m. with CNA N regarding resident 1's behaviors revealed: *He had participated in restorative therapy and informed her he needed to get a job. *That was not a normal comment he would have made. *She informed the charge nurse of his comment. 6. Interview on 6/10/25 at 1:35 p.m. with LPN E regarding resident 1's behaviors revealed: *She had been working the day resident 1 had injured himself. *Resident 1 had increased behaviors after his clozapine (an anti-psychotic medication used to treat schizophrenia, a serious mental health condition that affects the way a person thinks, acts, and feels, and to lower the risk of suicidal behaviors in patients with schizophrenia) had been out of his system. *While resident 1 was not taking his clozapine he had been administered olanzapine (an antipsychotic medication that can be used to treat schizophrenia). *On 5/4/25, resident 1 tried giving some of his personal belongings to LPN E. *Resident 1 had made comments to her that he was unable to get an erection and was receiving lethal injections. *He informed her that he was not feeling the same. *LPN E stated resident 1 had not voiced any suicidal ideas to her. *Resident 1 was receiving mental health services weekly. *CNAs had reported the behaviors they had observed exhibited by resident 1 to LPN E. 7. Interview on 6/10/25 at 2:00 p.m. RN G regarding resident 1's behaviors revealed: *She had provided care for him before he attempted to harm himself. *Resident 1 complained of pain, had removed his shirt and had his hands down the front of his pants. *He had at one time asked her to assess his genitals. Resident 1 had been observed masturbating. *She did not provide care for resident 1 without a chaperone. *Resident 1's clozapine had been slowly restarted, but it did not help with his behaviors. -She was unsure of when the medication was restarted. --The above behaviors were not normal for resident 1. 8. Interview on 6/10/25 at 3:12 p.m. certified medication aide (CMA) I regarding resident 1's behaviors revealed: *She had noticed that he had acted more inappropriately with staff once his clozapine medication was stopped. *Resident 1 became more paranoid and withdrawn since the medication had been stopped. 9. Record of resident 1's electronic medical record (EMR) revealed: *Resident 1 was diagnosed with: -Paranoid schizophrenia (a mental health condition where people can experience a disconnection from reality), chronic obstructive pulmonary disease (COPD) (a lung disease that causes airflow obstruction and breathing problems) diabetes type two, congestive heart failure (CHF) (a chronic condition where the heart muscle is weakened), chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood effectively). *On 11/21/24 resident 1 had a clinic appointment with his cardiologist (heart doctor). *At that clinic appointment, it had been recommended to taper resident 1 off his clozapine to help reduce his cardiomyopathy (a disease when the heart does not pump effectively because it is enlarged). *Resident 1's cardiologist had spoken to resident 1's psychiatrist (a medical doctor who is specialized in mental health) regarding tapering off the clozapine. Resident 1's psychiatrist agreed to the tapering off of the medication. *On 2/25/25 at 4:07 p.m., a progress note entered by LPN E revealed resident 1 had informed her that he wants to die. *On 3/11/25 at 5:11 a.m. a progress note entered by RN G revealed resident 1 had informed a CMA I want to die; I can't take this anymore. *On 3/22/25 at 3:15 a.m., a progress note entered by RN G revealed resident 1 had informed her What am I going to do, I will have to commit suicide. *Resident 1 had weekly visits with behavioral health services. *Resident 1 had one completed suicide risk evaluation on 5/9/25. -No suicide risk evaluation was completed for resident's comments on 2/25/25, 3/11/25, and 3/22/25. *Resident 1's care plan had not been revised to include resident's comments on 2/25/25, 3/11/25, and 3/22/25. -The care plan had been revised on 5/9/25 following his self-harming incident to include the following interventions: --Listen carefully for any suicide [suicidal] statements (i.e. I'm going to kill myself, the world will be better off without me, I've had enough, I'm a burden) and observe for non-verbal indications of suicidal intent (i.e. giving away possessions) and report to charge nurse. --Remove items from residents [resident's] room that could cause harm, (i.e. sharp objects, cords, belts, neckties, etc.) 10. Further interview on 6/11/25 at 12:05 p.m. with LPN E regarding resident 1's suicidal ideation and attempt to give away personal property revealed: *She had known resident 1 was being seen by behavioral health services. *She would have assessed resident 1 for other clues, but she did not believe he was serious with his comments and actions. *She had recently received education regarding the provider's suicide precautions policy. *She had not been aware that there was a specific assessment for suicide risk, she did complete the evaluation on 5/9/25 when resident 1 injured himself. *She did not admit that she would complete a suicide risk evaluation if a similar situation were to arise after her education. 11. Further interview on 6/11/25 at 12:41 p.m. with RN G regarding her documented comments made by resident 1 revealed: *She did not recall resident 1 using the words that she had documented in the progress notes in resident 1's EMR. *She had assessed resident 1 after the comments he had made to her. She did not believe he was serious, and did not complete a suicide risk evaluation or document her assessment in the resident's EMR. *Since the education she had received, she would complete a suicide risk assessment on any resident who had made suicidal comments and follow the provider's policy. *She did not think resident 1 was incompetent when he had made his comments above. 12. Interview on 6/12/25 at 9:46 a.m. with administrator B and director of nursing (DON) A regarding resident 1's comments that had been documented revealed: *DON A agreed that a suicide risk evaluation should have been completed with each comment that was documented or any other negative statements. *Both agreed that staff should have assessed resident 1 on his perception of how he had been feeling and not the staff's perception of his expressed feelings. *Both agreed resident 1's care plan should have been revised with his first comment of wanting to die. -Nurses and the interdisciplinary team were able to update care plans. *DON A had not completed any chart audits since suicide risk education had been provided to all staff. 13. Review of staff education for behavioral health revealed: *RN G had completed her training on 10/14/24. *LPN E had completed her training on 10/31/24. 14. Review of the provider's 7/29/24 Facility Assessment revealed they had been able to care for residents with behavioral symptoms. 15. Review of the provider's April 2025 Suicide Precaution policy revealed: *Purpose: -To provide for the safety of residents at risk for suicide. -To identify/recognize possible signs of intent to commit suicide. -To increase employee awareness regarding suicide. *Possible clues and warning signs that a person might be suicidal include the following: -Talks of or threatens to hurt or kill him or herself. -Experiences drastic changes in routine or behavior. -Gives away prized possessions. *Procedure: -When the resident has verbalized suicidal ideation or intent, the social worker or registered nurse must assess the resident to determine the risk for self-harm and the ability of the center to keep the resident safe. -To assess the resident, complete the Suicide Risk Evaluation UDA. -Document any interventions in the care plan.

Based on observation, interview, record review, and policy review, the provider failed to identify and implement interventions to prevent falls for two of two sampled residents (22 and 55) who fell and sustained injuries. Findings include: 1. Observation and interview on 1/22/25 at 9:16 a.m. with resident 55 while in the 200-hallway revealed: *She had a large bruise around her left eye. -The bruise was above her eyebrow and extended to her cheekbone. -The bruise was brown with yellowing edges. *When asked about the bruise, she could not remember. Observation on 1/22/25 at 2:09 p.m. revealed that resident 55 was resting in bed with the bed in the lowest position to the floor. There was an air mattress overlay on the bed and a fall mat on the floor next to her bed. Review of resident 55's electronic medical record (EMR) revealed: *She admitted to the facility on [DATE] for rehabilitation after surgical repair from a previous fall with fractures at the assisted living facility where she previously resided. *She was hard of hearing and wore hearing aids in both ears. *Her 12/27/24 Brief Interview for Mental Status (BIMS) assessment score was 9, which indicated she had moderate cognitive impairment. *Her 12/27/24 falls tool assessment indicated she was at medium risk for falls. No interventions were selected in the Action Plan section. *Her 12/27/24 nursing admit data collection tool indicated the following: -She was not able to ambulate independently. -Grab bars had been installed on her bed. -She had received education about the following: --Resident orientated to room and call light use. --Resident orientated to facility routines, activities, accommodations. --Therapy evaluations. --Meal times and routine. --Immunizations. --Safety and fall prevention. --Her impaired hearing was a barrier to education. --She had verbalized understanding. Review of her baseline care plan initiated on 12/27/24 in relation to falls, fall risks, and fall prevention revealed: *Educate resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. *Ensure that Resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. *The Safe Resident Handling Program (SRHP) intervention for ambulation safety was initiated on 12/30/24. *SRHP - TRANSFER - Transfer Between Surfaces: non-mechanical stand aide and 1 staff assist [assistance]. *She required the assistance of one staff member for other activities like bed mobility, dressing, and personal hygiene. Incident note 12/28/24: At 0815 [8:15 a.m.], resident was found on the floor at the foot of her bed. Resident was alert. Yelling out, 'I want to go to bed.' Gripper socks were on. Call light was attached to grab bar on side of bed. w/c [wheelchair] was not within reach. No walker. When resident asked [what] happened or what she was trying to do she stated, 'I don't remember.' VS [vital signs] with neuro's taken. Laceration noted on forehead at the hairline. Moderate amount of bleeding. Total lift used to set resident in chair. Shower provided d/t [due to] bleeding on hands, hair and face. Laceration cleansed and dry telfa [Telfa, a brand of wound dressing] dressing applied. Ice offered, refused. 2cm [centimeters] superficial wound. Bruising noted across bridge of nose and on left hand. ROM [range of motion] was WNL [within normal limits]. Physician notified by fax and son contacted. Will care plan to put bed in lowest position at night with mat beside bed. *She continued to have increased pain, potentially from her multiple healing fractures, head laceration, and bruising from the fall. Interview on 1/24/25 at 10:42 a.m. with director of nursing (DON) B revealed: *After resident 55's fall, fall interventions were initiated that included having the bed in the lowest position while she was in bed and having a cushioned fall mat in place next to her bed. *The care team held a fall huddle to determine what could have contributed to the fall, and brainstormed new interventions to prevent further falls. *Surveyor requested documentation of fall prevention interventions that had been implemented for resident 55 prior to her fall. Interview on 1/24/25 at 11:11 a.m. with social worker D revealed: *If a resident had a fall, she and the care team would have filled out a fall scene huddle worksheet to determine the fall details and recreate the fall scene. *At the time of resident 55's fall on 12/28/24, she had a different bed than the one she had at the time of the survey. -Her initial bed had a grab bar attached to it. -Resident 55 had not been assessed for the safe use of a grab bar. -Someone was supposed to have switched out her bed at supper time on 12/27/24, but that had not happened. *She remembered that resident 55 may have been confused after she admitted because she was in a new facility, she was incontinent, and she most likely tried to get out of bed on her own or rolled out of bed which resulted in the fall. -At the time of resident 55's fall, the call light cord was wrapped around the grab bar. Review of the Fall Scene Huddle Worksheet completed on 12/28/24 after resident 55 fell revealed: *Resident 55 said, I don't remember when asked what she was trying to do just before the fall. *The night staff was noted to have last interacted with her and assisted her to the toilet at 5:59 a.m. on 12/28/24. *Under item #4 for Description of fall scene -Resident 55 had not been wearing her glasses. -The bed was noted to be in a high position. -She was wearing socks. -Her wheelchair was not near her bed. -In the environmental section it was noted that she was a new admit and the lighting was inadequate. -She was incontinent of urine. *Under item #6 for Prior to fall, resident seemed: and After fall, resident seemed: the following items were checked for both: -She was alert and oriented to person and place only. -She was confused and forgetful. *The staff narrative under item #7 read, Call light [was wrapped] around grab bar. She may not have been able to reach it. New [admit.] Confused. Remote under her bed, could've been trying to grab it. *Under item #10 for Resident Injuries/ROM (range of motion): -Her ROM was noted to have been within her normal limits. -She had a laceration to her head and bruising to her left hand and bridge of nose. *There was a handwritten note on the first page that read, ? Need to remove grab bar from bed. Not in [care plan] . Review of the handwritten list of fall prevention interventions that were implemented prior to the resident's fall on 12/28/24 provided by DON B on 1/24/25 at approximately 12:00 p.m. revealed: *Staff provided call light education. *They monitored the resident every hour for safety whereabouts. *Education was provided not to bend over. *They provided proper footwear education. -There was no documentation in her EMR that indicated the hourly safety checks had occurred. -There was documentation that indicated the provider had educated her about the call light, not to bend over, and proper footwear, however there was documentation that she was confused and moderately cognitively impaired at the time of admission. 51370 2. Observation and interview on 1/22/25 at 9:06 a.m. of resident 22 while seated in her wheelchair in her room revealed: *Her right eye and cheek were bruised from the eyelid to an inch below her eye. *Her forehead was bruised from her eyebrow into her hairline. *She had what appeared to be a lump or area of swelling just below her hairline. -The lump was approximately one inch by one inch. *She said she had fallen on her head. *She thought she had fallen from her bed when reaching for something on the floor. Interview on 1/24/25 at 10:02 a.m. with clinical care leader C revealed: *Certified nursing assistants (CNAs) were trained that residents could have been left with the lift sling straps connected to lift equipment while using the toilet. -Some residents may have the lift sling straps loosened, and the lift equipment could have been left in front of them to supplement their upper body strength while they sat on the toilet. *Resident 22 had poor torso strength due to her diagnosis of multiple sclerosis. -She could be left with the straps loosened but remaining attached to the lift. -It was not documented in the resident's care plan to leave her on the toilet with the lift equipment still attached and in the bathroom with her. -Her care plan did not include that she required staff supervision was required while she used the bathroom. *She expected CNAs to know which residents could have been left alone and which were not safe to have been left alone. -The default was that residents could have been left alone in the bathroom while still attached to the lift equipment until they saw reasons that they resident should not have been left alone. *Resident 22 was not required to have been supervised while on the toilet at the time of her fall on 1/17/25. *CNAs learned of updated residents care information by: -Verbal communication between staff. -The wing binder, which included the daily nursing huddle report sheet and other relevant care notes for CNA use. -The bulletin board in the employee break room. -The resident's care plan/Kardex (a brief overview of the resident that was generated directly from care plan). However, she stated that the CNAs don't really use the Kardex. *Care plans were updated by nurses, the MDS coordinator, and herself. Interview on 1/24/25 at 10:28 a.m. with DON B revealed: *Staff were educated that residents could be left connected to the total body lift while using the bathroom. The lift sling straps were loosened to ensure the resident was not suspended. -Staff would need to know if the resident was cognitive to be left alone in the bathroom. *Information would be available on the Kardex. -Nursing staff including CNAs have access to the Kardex. Review of resident 22's EMR progress notes revealed she had a history of unhooking the lift sling straps or threatening to unhook lift straps: *A 4/4/24 social services note Res [resident] unhooked lift strap on one occasion when she was talking with her. *A 4/5/24 nursing services note removes sling from lift before staff can start to lift her. *A 5/18/24 nursing services note she was grabbing the loop and trying to take if off the hook when staff were assisting her from the toilet with the total body lift. *A 6/23/24 nursing services note would attempt to unhook self and pull on [the] sling, making sling placement difficult. This could be a safety issue if behaviors continue. *A 6/24/24 social services note trying to remove straps from lift. *A 7/15/24 nursing services note needed redirection and distraction to keep her from attempting to unhook sling. *A 7/22/24 social services note res [resident] was removing straps to lift. *A 7/23/24 nursing services note Other observations: Agitation, Delusions. Impaired decision making. Safety concerns. *An 8/25/24 note indicated the resident was put on the toilet, when they returned she had unhooked the sling from the lift and had it off. *A 9/4/24 care plan review note Resident continues to think that she can walk so she tried to stand up and fell on the floor, Cna [CNA] found her on the floor by her bed. *A 9/25/24 nursing services note Nurse notice CNA going in the room with stand aid [a lifting device for those who have difficulty rising from a seated to standing position], Nurse [went] running down the hall and stated that resident was a Hoyer lift [total body lift]. Resident tried to tell CNA to ignore her [the nurse] and do what she was going to do, nurse stated No, the CNA needs to know so she doesn't lose her license and or drop you because you do not stand. *A 10/22/24 nursing services note regarding behaviors, staff unable to safely transfer resident to toilet without the use of the lift. *A 11/3/24 nursing note she was trying to take the Hoyer sling off the Hoyer lift. Review of resident 22's 1/9/25 BIMS assessment revealed a score of 8, which indicated she had moderate cognitive impairment. Review of resident 22's EMR regarding her fall on 1/17/25 revealed: *She was found on the floor of her bathroom by a CNA. *The bar from the left side of the total body lift was removed. *The rest of the straps were not hooked to the other bar of the lift. *She had a large bump on the right side of her forehead, and she voiced discomfort. *Neurological checks were initiated. *Her physician was notified by fax on 1/17/25 at 3:29 p.m. -A response from her physician was not found. *The 1/17/25 falls tool assessment noted the following: -She was receiving more than two risk factor medications. -She appeared moderately affected by one or more of the following factors: anxiety, depression, decreased cooperation, decreased insight, or decreased judgment especially related to mobility. -Her cognition was mildly impaired. -The risk factor checklist and intervention plan noted cognitive status, poor memory, and difficulty following instructions. -She was observed using the equipment in an unsafe manner. Review of the provider's internal Fall Scene Huddle Worksheet regarding resident 22 revealed: *The incident date was 1/17/25 at 2:18 p.m. *She had an unwitnessed fall. -Under Equipment/Safety, the box under Assistive Device was checked none. -Her time last toileted was reported as 2:10 p.m. and 2:15 p.m. *She had taken the following medications in the last eight hours: antidepressant, antipsychotic, and a blood thinner. *She unhooked the straps and bar of the total body lift. *She was experiencing pain with movement. *It was also marked that she had a head injury, and abrasion, skin discoloration with bruising, and swelling. -There was a handwritten note that stated, right side hematoma. Review of resident 22's current care plan revealed: *It was noted that she had impaired cognitive function or impaired thought process relating to her diagnoses of multiple sclerosis, Alzheimer's disease, dementia, and other cognitive deficits. *Intervention for toilet use and transfers revealed: -She required two staff for toilet use. -She required the total body lift to transfer between surfaces, with the assist of two staff. *Her care plan was last revised on 1/20/24 and included that she was at risk for falls related to: Heart failure, Multiple sclerosis, Alzheimer's disease, Dementia, history of falls, poor safety awareness, and a history of removing the lift sling straps from the lift. *Her care plan did not include if staff were required to stay with her while she used the bathroom. -There was no documentation regarding need for supervision while toileting. 3. Review of the provider's 7/29/24 Fall Prevention and Management policy revealed: *Purpose -To promote resident well-being by developing and implementing a fall prevention and management program. -To identify risk factors and implement interventions before a fall occurs. -To give prompt treatment after a fall occurs. -To provide guidance for documentation. *Proactive Approach before a Fall Occurs (e.g., New Admit) Procedure -1. On admission or readmission, review the applicable documents (i.e., discharge summary from transferring agency, transfer record, history and physical, lab values, nursing admit/readmit data collection) and any additional admit information documentation for fall risk factors. -2. Complete the Falls Tool UDA [user-defined assessment] for fall screening and identifying fall risk factors. -3. Care Plan the appropriate interventions, including personalizing all '(SPECIFY)' areas. -4. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-Hour Report, care plan and Kardex, daily stand-up meeting, and/or Fall Committee meetings.

Based on observation, interview, record review, and policy review, the provider failed to follow infection prevention practices by not having ensured: *Shared resident lift equipment (at least six different stand aids) was maintained in a clean and sanitary manner per the manufacturer's recommendations. *One of one registered nurse (RN) (G) used a clean utensil to open a packet of powdered nutrition supplement and performed appropriate hand hygiene during an observed medication administration. Findings include: 1. Observation on 1/22/25 at 4:52 p.m. in the 100-hallway revealed: *There was a buildup of an unidentified brown substance in the footwell of the non-motorized stand aid. The black anti-slip covering in the foot plate was loose and rolling upwards from the edges, that exposed more of an unidentified brown substance. *There were food crumbs and unidentified white flakes in the footwell of the motorized stand aid. The black anti-slip strips were torn and peeling away. Additional random observations throughout the survey from 1/21/25 through 1/24/25 revealed: *The stand aids in the 100-hallway remained in the same unclean condition. *Three non-motorized stand aids in the 200-hallway had an unidentified brownish-orange and black buildup in the border of the footwells. -The black anti-slip covering in one of those stand aids appeared to have been loose and stretched out, and exposed more buildup underneath. *One of the non-motorized stand aids in the 300-hallway had an unidentified brownish-orange and black buildup in the border of the footwells. Interview on 1/24/25 at 10:26 a.m. with activities director F revealed: *She was cleaning one of the non-motorized stand aids in the 300-hallway at the time of the interview. *To her knowledge, all shared resident lift equipment was cleaned with sanitizing wipes after each resident use. *She did not know if the resident lift equipment was deep cleaned. Interview on 1/24/25 at 10:30 a.m. with licensed practical nurse (LPN) I revealed that she did not know if the resident lift equipment was deep cleaned or how often deep cleaning was supposed to have occurred. Interview on 1/24/25 at 10:40 a.m. with director of nursing (DON) B revealed: *The shared resident lift equipment was to be cleaned after each use with sanitizing wipes. *She was not aware of the buildup of the unidentified substances in the footwells. *She did not know if the lift equipment was on a deep-cleaning schedule. Review of the 2/25/21 manufacturer's EZ Way Equipment Cleaning Guide revealed: *To keep your EZ Way equipment clean and in good condition, we recommend that you use a standard germicidal spray, Sani-Wipe, or similar product and that you follow these guidelines: -DO NOT SPRAY PRODUCT DIRECTLY ON THE MACHINE. -Spray the cleaner onto a cloth or paper towel then wipe the unit to clean it. -The germicidal spray, Sani-Wipe, or similar product can be used on the control panel and front panel graphics. If not using a wipe, make sure to spray the cleaner onto a cloth or paper towel then wipe the unit to clean it. -Be careful not to wipe off the model and serial number sticker (located on the side of the mast, on floor lifts and sit-to-stands). 2. Observation on 1/23/25 from 9:31 a.m. to 10:12 a.m. of RN G during medication administration revealed: *RN G did not perform hand hygiene prior to putting on a clean pair of gloves. He then checked resident 33's blood sugar level which involved pricking the resident's finger for a blood sample. *RN G then gathered those used supplies and went back to the medication cart. -With those gloved hands, he cleaned the glucometer, then removed those gloves and performed hand hygiene. *RN G prepared resident 33's insulin and brought the insulin pens into her room. -He set the insulin pens down onto a barrier on her overbed table. -He did not perform hand hygiene and put on a clean pair of gloves. -After he administered the resident's insulin, he removed those gloves, did not perform hand hygiene, and went back to the medication cart to prepare the rest of resident 33's medications. *While RN G was preparing resident 33's powdered nutrition supplement: -He pulled a pair of scissors out of his shirt pocket. Without cleaning or sanitizing the scissors, he cut open the pouch of powdered nutrition supplement and poured the contents into a plastic cup. *He prepared the rest of resident 33's medications and brought them to her room. -He did not perform hand hygiene and put on a pair of clean gloves. -He assisted the resident with taking her medications, including administering her eye drops. -After the resident finished taking her medications, RN G removed his gloves and discarded them into the trash. He did not perform hand hygiene. He went back to the medication cart to prepare the next resident's medications. Interview at that time with RN G about the above observations revealed: *He stated he was nervous about the survey process. *He agreed he missed several opportunities for hand hygiene throughout the medication administration observation. *He was not aware that the scissors should have been cleaned and sanitized prior to using them to open the pouch of powdered nutrition supplement. Interview on 1/23/25 at 1:13 p.m. with DON B revealed: *She expected staff to perform hand hygiene before putting gloves on, and after taking gloves off. *Staff should not use scissors to open packages of powdered nutrition supplement, medicated patches, or other packages used for medication administration. Review of the provider's 3/29/22 Hand Hygiene policy revealed: *Policy: - .All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. -All employees in patient care areas .will adhere to the 4 Moments of Hand Hygiene and 2 Zones of Hand Hygiene. --1. Entering Room. --2. Before Clean Task. --3. After Bodily Fluid/Glove Removal. --4. Exiting Room. --5. Zones: Patient zone and Health-care zone. - .Gloves are a protective barrier for the HCW [healthcare worker] according to standard precautions. --1. Gloves are never to be reused or sanitized. --2. Hand hygiene should be performed after glove removal. *Procedure: HCW will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: -When entering patient room. -Before preparing or administering medications. -Before donning sterile gloves. -If gloves are used to perform a clean/aseptic procedure, hand hygiene must be completed before donning gloves. -After removing gloves regardless of task completed. - .When moving from contaminated body site to a clean body site during patient care. -When entering healthcare zone (supply drawers, linen drawers or cupboards). -When exiting patient room.

Based on observation, interview, record review, and policy review the provider failed to ensure one of one sampled diabetic resident (33) was free from a potential insulin medication error. Findings include: 1. Observation on 1/23/25 from 9:31 a.m. to 9:47 a.m. with registered nurse (RN) G during medication administration revealed: *RN G was preparing resident 33's insulin pen. *Resident 33 was scheduled to receive 10 units of Admelog insulin and 40 units of Tresiba insulin. *RN G primed both pens and dialed each pen to the correct ordered dose. -He then walked over to licensed practical nurse (LPN) J to verify the correct dosage. LPN J verified that each insulin pen was dialed at the correct dose. *While the surveyor walked with RN G back to resident 33's room, the surveyor heard a noise that sounded like the insulin pen was clicking as if the dose was changed. *RN G brought the insulin pens to resident 33's room and set the pens down on resident 33's bedside table. *The Tresiba insulin pen was then observed to be dialed at 32 units instead of 40 units. *RN G lifted the resident's shirt and prepared an area on her abdomen to inject the Tresiba. -Just as RN G was about to administer the incorrect insulin dose, the surveyor stopped RN G and requested that he verify the units again. -RN G was surprised that the Tresiba insulin was at 32 units rather than 40 units. -He did not know how the insulin pen was dialed back to 32 as he had verified with LPN J that the pen was dialed to correct dosage. *Had the surveyor not intervened, resident 33 would have received the wrong dose of insulin. *RN G then dialed the Tresiba insulin pen up to 40 units and administered the insulin to resident 33. *After leaving resident 33's room, RN G again indicated that he did not know how the insulin pen was dialed back to 32 units rather than 40 units. 2. Interview on 1/23/25 at 12:53 p.m. with LPN J revealed: *The facility's policy was to have two licensed nurses verify a resident's insulin dosage prior to administering the insulin. *She confirmed that she verified resident 33's Tresiba insulin pen was dialed to 40 units when RN G showed it to her. *She did not know how the insulin pen was dialed back to 32 units in the time RN G walked to resident 33's room. *She would have considered that situation a medication error if RN G would not have noticed the insulin pen was at the incorrect dosage. -Had resident 33 received 32 units of insulin rather that 40 units, her blood sugar level may have been higher than normal due to the reduced amount of insulin administered. 3. Interview on 1/23/25 at 1:13 p.m. with director of nursing (DON) B revealed: *She would have considered the above observation a medication error. *She said, The resident would have been at risk. 4. Review of resident 33's electronic medical record revealed she had a physician's order for Tresiba FlexTouch Subcutaneous Solution Pen injector 200 UNIT/ML [milliliter] (Insulin Degludec) Inject 40 [units] subcutaneously one time a day . 5. Review of the manufacturer's instructions for the Tresiba FlexTouch insulin pen revealed: * .3. Prime your pen: Turn the dose selector to 2 units, press and hold the dose button until the dose counter shows '0,' and ensure a drop of insulin appears. *4. Select your dose: Turn the dose selector to the number of units you need to inject. 6. Review of the provider's 9/5/24 Medication: Insulin Administration, Insulin Pens, Insulin Pumps policy revealed: *Insulin Pen .Procedure - .2. Verify provider order . - .11. Dial in the ordered dose on units.

Based on observation, record review, and interview, the provider failed to revise and update a care plan for one of fifteen sampled residents (22) to reflect her care needs for supervision while using the bathroom. Findings include: 1. Observation and interview on 1/22/25 at 9:06 a.m. of resident 22 while seated in her wheelchair in her room revealed: *Her right eye and cheek were bruised from the eyelid to an inch below her eye. *Her forehead was bruised from her eyebrow into her hairline. *She had what appeared to be a lump or area of swelling just below her hairline. -The lump was approximately one inch by one inch. *She said she had fallen on her head. *She thought she had fallen from her bed when reaching for something on the floor. *She said she was embarrassed by the bruising to her face. *Her makeup was not covering the bruising as much as she would have liked. 2. Refer to the fourth and sixth paragraphs in F689 finding 2 for information related to her history of unhooking the lift sling straps and her fall on 1/17/25. 3. Review of resident 22's current care plan revealed: *Her care plan did not include if staff were required to stay with her while she used the bathroom. *There was no documentation regarding need for supervision while toileting. *It was noted that she had impaired cognitive function or impaired thought process relating to her diagnoses of multiple sclerosis, Alzheimer's disease, dementia, and other cognitive deficits. *Intervention for toilet use and transfers revealed: -She required two staff for toilet use. -She required the total body lift to transfer between surfaces, with the assist of two staff. *Her care plan was last revised on 1/20/24 and included that she was at risk for falls related to: Heart failure, Multiple sclerosis, Alzheimer's disease, Dementia, history of falls, poor safety awareness, and a history of removing the lift sling straps from the lift. 4. Interview on 1/24/25 at 10:02 a.m. with clinical care leader C revealed that: *As a result of resident 22's fall on 1/17/25, she expected staff to supervise the resident while she was using the bathroom. *She confirmed that resident 22's care plan had not been updated to reflect that change. *When asked how nursing staff were supposed to know which residents required supervision in the bathroom, she said that there are a certain few that they [the staff] know they [the resident] will stay upright, they [the staff] know the ones [the residents] who they [the staff] can leave alone, and those [residents] who cannot. *CNAs learned of updated residents care information by: -Verbal communication between staff. -The wing binder, which included the daily nursing huddle report sheet and other relevant care notes for CNA use. -The bulletin board in the employee break room. -The resident's care plan/Kardex (a brief overview of the resident that was generated directly from care plan). However, she stated that the CNAs don't really use the Kardex. *Care plans were updated by nurses, the MDS coordinator, and herself. 5. Interview on 1/24/25 at 10:28 a.m. with DON B revealed: *Staff would be educated that residents can be left connected to the total body lift while toileting with the tension removed to ensure they were not suspended. -Staff would need to know if the resident was cognitive to be left alone in the bathroom. *Information would be available on the Kardex, which came directly from the care plan. -Nursing staff, including CNAs, have access to the Kardex. 6. Review of the provider's 7/29/24 Fall Prevention and Management policy revealed: *Purpose -To promote resident well-being by developing and implementing a fall prevention and management program. -To identify risk factors and implement interventions before a fall occurs. -To give prompt treatment after a fall occurs. -To provide guidance for documentation. *Proactive Approach before a Fall Occurs (e.g., New Admit) Procedure -1. On admission or readmission, review the applicable documents (i.e., discharge summary from transferring agency, transfer record, history and physical, lab values, nursing admit/readmit data collection) and any additional admit information documentation for fall risk factors. -2. Complete the Falls Tool UDA [user-defined assessment] for fall screening and identifying fall risk factors. -3. Care Plan the appropriate interventions, including personalizing all '(SPECIFY)' areas. -4. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-Hour Report, care plan and Kardex, daily stand-up meeting, and/or Fall Committee meetings.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (23 and 42) who were identified as at risk for developing pressure ulcers indicated by the Braden Scale for Prediction Pressure Ulcer scores had interventions in place to prevent those residents acquiring a pressure ulcer. Findings include: 1. Observation on 9/25/23 at 4:00 p.m. of resident 42 revealed he was seated in his recliner with his feet elevated. -Continued observation at 4:30 p.m. revealed he was seated in his wheelchair and was alert. -Continued observation at 6:00 p.m. revealed he was seated in his wheelchair and was in the dining room. *Observation on 9/26/23 at 8:00 a.m. he was not in his room. Registered nurse (RN) H stated he was at a telemedicine appointment with his daughter. Continued observations revealed: -He returned to his room from the appointment at 10:00 a.m. and was seated in his wheelchair. -At 11:30 a.m. he was seated in his wheelchair in his room. -At 11:36 a.m. interview with RN H revealed he had a facility acquired stage II pressure ulcer to his left buttock. It looked much better than when she had last observed it two weeks ago. -At 2:40 p.m. he was seated in his wheelchair in his room. Observation of his recliner at that time revealed a flat gel filled cushion placed in the recliner. -At 4:30 p.m. he was seated in his wheelchair in his room. *On 9/27/23 at 9:00 am. he was seated in his wheelchair in the dining room. -Continued observation at 10:44 a.m. certified nursing assistant (CNA) I and RN G transferred resident 42 from his wheelchair to the toilet with the E-Z stand. Noted to have a flat gel filled cushion in his wheelchair. He was assisted to sit in his wheelchair after he used the toilet. -At 11:40 a.m. observation of RN H during the wound care treatment to his left inner buttock pressure ulcer revealed the following: *An area to his left inner buttock with red tissue in the middle and gray/white edges. *The wound was measured and had a depth of 0.2 centimeters (cm), width of 0.7 cm, and a length of 1.0 cm. -At 12:30 p.m. he was seated in his wheelchair in the dining room. *At 2:30 p.m. resident 42 was seated in his wheelchair in his room. *On 9/28/23 at 9:00 a.m., 11:30 a.m., and 2:45 p.m. resident 42 was seated in his wheelchair in his room. -At 9:00 a.m. the bed had no bedding but a flat gel-filled cushion that covered the mattress half-way from the top and bottom and approximately three-quarters from side-to-side. Interview on 9/25/23 at 4:54 p.m. with RN H revealed resident 42 had a stage III pressure sore (Full-thickness skin loss, in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present) to his left inner buttock. He had acquired it in August 2023 of this year. His wound care orders were managed by the wound care clinic at the hospital. Interview on 9/27/23 at 10:44 a.m. with CNA I revealed resident 42 was usually in either sitting in his wheelchair or recliner when she arrived for the day shift in the morning. He could not tolerate lying in bed very much. He had pain in both of his shoulders. She was not aware he was to have lay down after lunch. She had only ever put him in his recliner. Interview on 9/28/23 at 4:53 p.m. with director of nursing (DON) B revealed: *Resident 42 had a decline in April 2023 after he had gotten COVID-19. *He was more at risk to develop a pressure ulcer as he could not ambulate anymore. *His cognition had also changed and he had more resistive behaviors to lying down in bed. *She agreed his care plan stated he was to have laid down in bed after lunch each day. *He was not laid down as he would not tolerate it. He had pain in both of his shoulders and was not able to lie on his sides. Most of the time he slept in his recliner. His family had informed them he had usually slept on the couch when he lived at home. *They used the T-Gel pads as a preventative measure in wheelchairs, recliners, and in beds. These were the products they used most often. *Review of the T-Gel pads in the product catalog with DON B revealed it was to reduce shearing. She thought those pads were pressure relieving. Review of the manufacturer's website revealed the T-Gel pads the provider had been using were to reduce shearing. Review of resident 42's medical record revealed: *He was admitted on [DATE]. *He had diagnoses that included: diabetes, dementia with agitation, previous stroke, and pain in bilateral shoulders. *His Braden Scale for Predicting Pressure Sore Risk on: -9/27/22 was 17 which indicated he was at mild risk. -9/11/23 was 14 which indicated he was at moderate risk. *No new interventions had been put in place when his risk score changed. *He acquired the left buttock pressure ulcer on 8/13/23. *The pressure ulcer measured 0.2 cm depth, 1.7 cm width, and 2.0 cm length. *A gel cushion was placed on his bed and recliner at that time after the pressure ulcer had developed. *The intervention to have him lie down in bed on his side after the noon meal was initiated at that time. There were no other turning and repositioning interventions prior to the 8/13/23 identification of the stage III pressure ulcer. *He first attended the wound care clinic starting on 8/22/23. -The wound care clinic managed the type of dressing or other treatments. Review of resident 42's care plan revealed: *Focus: The resident has potential/actual pressure ulcer development R/T [related to] increased need for assistance with ADLs [activities of daily living], frequent incontinence. Revised on 9/21/23. *Goal: The resident will have intact skin free of redness, blisters, or discoloration by the review date. Revised on 8/9/23. *Interventions included Provide t gel in recliner. and t gel on bed. lay down in afternoon and lay on side. Revised on 8/13/23. 41088 2. Observations of resident 23 in her room at the following times revealed: *On 9/26/23 at 4:16 p.m.: -She was in her bed covered with a blanket with her eyes closed. -She was lying half-way on her right side with her knees together and bent in a fetal position. -Her wheelchair was next to her bed with a cushion in the seat. *On 9/27/23 at 9:19 a.m.: -She had been seated in her wheelchair watching TV. -She was not able to have been interviewed. -There had been a pressure relieving pad on her bed. -Both of her feet had protective boots on that rested on the wheelchair foot pedals. -The right protective boot had a sheepskin lining. *On 9/28/23 at 9:40 a.m.: -She was in her bed with her eyes closed. -A pillow was positioned between her knees. -Her bilateral protective boots were on with her legs resting on a pillow to protect her heels. -Her wheelchair was located next to her bed with a cushion in the seat. Review of resident 23's medical record revealed: *She had been admitted on [DATE]. *She had no pressure injuries at the time of her admission. *Her Brief Interview for Mental Status (BIMS) assessment score was four which indicated she had severe cognitive impairment. *She had a history of skin integrity issues and was frequently incontinent of bowel and bladder. *Staff used a mechanical full-body lift to transfer her. *Her diagnoses included the following: -Mild intellectual disability. -Retention of urine. -Osteoarthritis. -Anemia. -Generalized anxiety disorder. -Chronic kidney disease stage 3. -Dementia -History of methicillin-resistant staphylococcus aureus (MRSA). -A pressure ulcer to her right lateral ankle that was identified on 10/10/22. -It measured 0.7 length centimeters (cm) by 1.2 cm width by 0.1 cm depth. -It currently measured 0.6 cm length by 0.7 cm width by 0.1 cm depth. -A second unstageable pressure ulcer was identified on her left heel on 5/16/23 and was healed on 7/11/23. -MRSA was found in the wound on her left heel on 5/30/23. Review of resident 23's 7/19/22, 10/19/22, 1/10/23, 4/6/23, and 6/29/23 Minimum Data Set (MDS) assessments revealed: *She had been dependent on staff to assist her with: -Toileting. -Rolling from side to side. -Lying to sitting. -Sitting to standing. *Interventions included pressure-reducing devices in her chair and her bed. *There had been no intervention for turning or repositioning. *A nutrition and hydration intervention had not been added until the 1/10/23 MDS assessment. Review of resident 23's Braden Scale for Predicting Pressure Sore Risk assessments revealed: *On 7/16/22, she scored a 16, which placed her at mild risk for developing pressure ulcers. *On 10/9/22, 1/9/23, 4/6/23, she scored a 15 which placed her at mild risk of developing pressure ulcers. *On 6/28/23, and 9/18/23, she scored a 14 which placed her at moderate risk of developing pressure ulcers. Review of resident 23's 6/29/23 revised care plan revealed: *Focus area: The resident has actual impairment to skin integrity R/T [related to] pressure EB [evidenced by] soft tissue injury to right outer ankle. Date initiated: 10/30/22. *Goal: -Resident will be free from skin injury through the review date. Date initiated: 10/30/22. Revision on 1/20/23. -Resident will have no complications R/T soft tissue injury of the right out [sic] ankle through the review date. Date initiated: 10/30/22. Revision on 1/20/23. *Interventions: -Elevate heels and ankle off bed. Date initiated: 10/30/22. -Resident needs protection for the right foot, sheepskin boot. Date initiated: 10/30/22. *Focus area: The resident has potential for/actual pressure ulcer development R/T needing extensive assistance with ADL's and being frequently incontinent, history of pressure areas to bilateral heels post COVID illness, open area to right lateral ankle. History of left heel wound. Date initiated: 2/17/20. Revision on 8/28/23. *Goal: -Resident will have intact skin, free of redness, blisters or discoloration by the review date. Date initiated: 2/17/20. Revision on: 1/20/23. *Interventions: -Inform resident/family of any new area of skin breakdown. Date initiated: 2/17/20. -Provide t-gel on chair. Cushion in wheelchair. Date initiated: 10/11/22. Revision on: 8/28/23. -Provide pressure relieving boots to bilateral lower extremities. U-pillow to float heels when in bed. Soft spacer between knees to reduce internal rotation of left leg onto right leg. Date initiated: 8/28/23. Revision on 8/28/23. -Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. Date initiated: 02/17/20. -Treatment/medication as ordered for skin issues. Treatment at wound clinic as ordered. Date initiated: 12/22/21. Revision on 9/18/23. *Her care plan had not included re-positioning. Interview on 9/28/23 at 3:22 p.m. with nutrition and food services manager C regarding resident 23 revealed: *The registered dietician followed up with her monthly. *They met to discuss any residents that had been at risk for weight concerns or skin issues. *Changes were made as needed for her nutrition. *She had usually eaten well. *Her weight had remained stable. *She had good health otherwise, so they were not sure why her skin had not healed. Interview on 9/28/23 at 2:48 p.m. with RN H regarding resident 23 revealed: *The resident had COVID on 7/1/21 and again on 4/28/23 and has had issues with her skin since then. *The wound had been facility acquired and discovered on 10/10/23 on the right lateral ankle bone. *The physician was notified for the treatment options. *She tended to place her knees together and bent over to the right side. *The nursing staff had floated her legs and had placed a cushion between her knees to prevent friction. *Bath aides watched for any new skin concerns and would notify the RN. *The RN completed weekly skin assessments but also completed a daily in-depth UDA (user defined assessment) of the wound. *The wound started to heal and then would open up again. *She had been up and down with progress since it was discovered. *The wound clinic had seen her for the first time on 11/1/22 and she was scheduled every week to two weeks for treatment. Interview on 9/28/23 at 4:35 p.m. with medication aide/CNA and administrative assistant K revealed: *She had often worked the floor to help out with open shifts. *The residents were well-known to her. *Residents that had skin issues were to have been repositioned and that would have been included in the care plan. *She confirmed an intervention for repositioning resident 23 had not been her in the care plan and should have been. *The care plan was what had driven the tasks for the CNAs. *Information flowed from the care plan into the Kardex and that was how the tasks for residents were assigned to the CNAs for what needed to have been done for the resident's care. *There should have been interventions in place prior to the development of the pressure ulcer. Interview on 9/28/23 at 4:43 PM with CNA L regarding care for resident 23 revealed: *The CNAs checked the assigned tasks in the Kardex for what care was to have been provided for the residents. *She wore bilateral protective boots, and the right heal was floated. *When asked if resident 23 was repositioned she stated no, but she would have to check. *She pulled up resident 23's assigned tasks and confirmed there had not been a repositioning task. *Some of the residents had been repositioned but resident 23 had not been one of those residents. Interview on 9/28/23 at 5:30 p.m. with DON B regarding resident 23 developing a pressure ulcer revealed: *Resident 23 was seen bi-weekly at a wound clinic for treatment. *She believed nursing staff repositioned resident 23 throughout the day. *She confirmed the care plan had not included an intervention for repositioning resident 23. *They had no documentation to support that repositioning resident 23 had taken place. *Her care plan should have been updated to reflect resident 23's current needs. *If an intervention had not been listed on the care plan, a task for the CNAs would not have been created in the Kardex system. *She agreed interventions should have been in place prior in order to prevent pressure ulcers from developing in the residents. Review of the provider's revised 4/26/23 Skin Assessment Pressure Ulcer Prevention and Documentation Requirements policy revealed: *Residents who are unable to reposition themselves independently, should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnoses, mobility and observation of the resident's skin over a period of time. The Positioning Assessment and Evaluation UDA [user defined assessment] is a required tool that is used to determine an individualized repositioning plan. *The interdisciplinary team should determine any modifications that are necessary to the resident's plan of care. Interventions should focus on physical, mental and psychosocial aspects that may be impacted.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of seven residents (16 and 35) who were at nutritional risk received ongoing monitoring of nutrition and revisions in care as their nutritional intake, dining assistance, and revisions in care as their nutritional status changed. Findings include: 1. Observation on 9/26/23 at 12:00 p.m. of resident 16 in the dining room revealed: *She was seated at an assist table with four other residents. *Her meal was served to her at 12:11 p.m. *The meal consisted of: -A Philly steak sandwich. -Mashed potatoes. -Green beans. -A glass of cranberry juice. -A cup of cocoa. *She made no attempt to eat her meal. *At 12:24 p.m. certified nursing assistant (CNA) D came over to the table and tried to cue resident 16 to eat something. *She picked up her cup of cocoa took a drink and sat it back on the table. *CNA D then returned to the table she was assisting. *At 12:35 p.m. CNA D came back to the table and asked resident 16 to try her lunch. *She picked up part of her sandwich took a bite and sat it back on her plate. *At 12:42 p.m. CNA D went back to resident 16 table, picked up her spoon and assisted her in eating two bites of mashed potatoes. *At 12:45 p.m. CNA E came into the dining room and assisted resident 16 with her meal. *She ate two more bites of mashed potatoes and was finished eating. *The resident sat in the dining room for over 45 minutes without consistent meal assistance from staff. Interview on 9/26/23 at 12:52 p.m. with CNA D revealed: *Staff were assigned to assist tables during meals. *CNA E was called to help a resident in his room during lunch which took her away from an assist table. *She agreed it was not an ideal situation for residents needing assistance. Interview on 9/26/23 at 2:07 p.m. with CNA E revealed: *She was in the dining room to help assist residents with the noon meal. *Another staff member needed assistance helping a resident, who was an assist of two, in his room. *She stated it was a high priority to get all residents to meals. *She agreed it was an issue if assisted residents were not helped with their meals in a timely manner. Interview on 9/26/23 at 3:35 p.m. with nutrition and food services supervisor C revealed: *Resident 16 had been hospitalized at the end of July with a urinary tract infection (UTI) and received intravenous (IV) fluids. *She knew the resident was not eating well since returning from the hospital. *She was aware resident 16 was at risk for weight loss. *She was receiving supplements the contracted dietitian had recommended to address her weight loss issue. Observation on 9/27/23 at 12:00 p.m. of resident 16 in the dining room revealed: *The menu consisted of: -Barbecued chicken. -Mashed potatoes. -Mixed vegetables. -Apple cobbler. *At 12:24 p.m. she received her food. *An unidentified CNA was sitting across the table assisting another resident. *The CNA had not prompted or cued any other residents at the table. *At 12:31 p.m. CNA D came to the table and offered resident 16 her first drink of juice. That was 31 minutes after the resident came to the dining room, *CNA D picked up the spoon and assisted her with two bites of mashed potatoes. *CNA D left the table to get another resident a cup. *At 12:38 p.m. CNA D sat back down and cued resident 16 to drink her juice. *She picked up a cup of cocoa and took a drink. *She then stated she was done eating. Review of resident 16's medical record revealed: *An admitted [DATE]. *Her diagnosis included: chronic kidney disease, stage 3, anemia, mild cognitive impairment of unknown etiology, hypokalemia, vascular dementia, and dysphagia. *Her weights were recorded as follows: -8/4/23 was159 pounds. -8/11/23 was 147 pounds. -8/18/23 was 147 pounds. -8/25/ 23 was 146 pounds. -9/1/23 was 146 pounds. -9/8/23 was 146.3 pounds. -9/15/23 was 145 pounds. -9/22/23 was 142.8 pounds She had lost 16.2 pounds which was 10.1% of her body weight in two months which was a significant weight loss. Review of resident 16's interdisciplinary progress notes revealed she: *Had been admitted to the hospital on 7/27/23. *Was diagnosed with a urinary tract infection (UTI). *Returned to the provider on 7/30/23. *Refused to eat at meals after returning from the hospital. *Would only consume cocoa and her supplement. Review of resident 16's 8/18/23 care plan revealed: *The goals were: -To not have weight loss or complications related to refusing food. -To maintain weight at 155 pounds +-10 or more. *Interventions included: -Praise any efforts made towards reaching goal. -Explain importance of prescribed diet to resident and the need for adequate nutritional intake. -Monitor for poor intake of meals/fluids/supplements, food dislikes, meal refusal. -Monitor for weight loss or gain. -Weigh weekly. -Trial ground meats, soft fruits, no raw vegetables unless processed fine as recommended by speech until the next visit. -House supplement three times a day (TID) by nursing restarted after the hospital return. -Offer cranberry juice at noon and evening meal 4 oz. -Cut up meats in the kitchen and prepare food. -Offer food highest in calories in added fats, sugars, fortified potatoes, and whole milk. Interview on 9/28/23 at 10:59 a.m. with registered dietitian (RD) F and nutrition and food services supervisor C regarding resident 16's meal intake revealed: *Resident 16 had recently been moved to an assist table. *RD F had recommended supplements as needed instead of three times a day (TID) to try to get her to consume more calories. *Initially the physician had not agreed with decreasing the supplements to as needed. *Nutrition and food services supervisor E had the charge nurse resend the order to the physician. *The provider had a card system to organize resident dining. *The CNAs pulled the cards from the rack to notify kitchen staff who they could serve. *The CNAs were responsible for ensuring the residents were supervised accordingly. *They agreed the resident should not have waited that long for staff assistance once she was served her meal. Interview on 9/28/23 at 11:22 a.m. director of nursing (DON) B regarding resident 16's meal intake revealed: *She knew she had been moved to an assist table. *RD F had recommended an increase in supplements to increase her caloric intake. *Nursing staff were encouraging her to eat snacks and cookies between meals. *Nursing staff could get called away from the dining room to help other staff with resident care. *Staff should communicate with each other to ensure assist tables were supervised if a staff member needed to leave the dining room to assist other residents. *It was her expectation that the CNAs assist the residents who need assistance in the dining room once they were served their meal. 26632 2. Observations of resident 35 on: *9/26/23 at 12:22 p.m. received her lunch. *9/26/23 at 12:26 p.m. unidentified CNA came over from another table, stood over the resident to get her started with eating and then went back to sit down by another resident. The resident never started eating. *9/26/23 at 12:34 p.m. the unidentified CNA came over again and stood over the resident and the resident next to her and then left. Another unidentified CNA came over and stated Grandma aren't you going to eat? Assisted to reposition the resident to a more upright position in the wheelchair. The resident had not eaten or drank anything. -No staff person attempted to give her any food on her fork or spoon or a drink. *9/27/23 at 8:32 AM assisted in dining room for breakfast by an unidentified CNA there was one CNA assisting two residents. The resident had drank all of her resource drink. Review of resident 35's Bedside Kardex report revealed on 7/14/23 she required extensive assistive of one staff person with eating. Review of resident 35's weight record revealed: *On 8/23/2023 she weighed 138.5 lbs. and on 9/26/2023 she weighed 128.7 pounds which was a 7.08 % loss in one month. *On 5/30/2023 she weighed 152.5 lbs. and on 9/26/2023 she weighed 128.7 pounds which was a 15.61 % loss in six months. Review of the provider's 4/26/23 Resident-Assisted Dining policy revealed: *Purpose -To help resident to maintain or regain independence in eating skills. -To encourage independence with dining, providing assistance as needed. 10. Encourage residents in feeding self, assisting as needed, following care plan approaches. If the specific state has an approved paid feeding assistant program, then the resident's individual care plan must state if a feeding assistant is appropriate. 11. When assisting the resident, employees are to sit next to the resident; do not stand and feed the resident. Employees can assist two residents and offer assistance if needed. 12. Do not rush. You can start with liquids by having resident try to use a straw or hold a half-filled glass and drink. With solid foods, have resident start with foods that are easy to get on spoon or fork. Note care plan approaches, which are individualized to the resident. Offer alternatives for items not consumed.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (14) had a diagnosis for the continued use of an indwelling urinary catheter after her wounds had healed. Findings include: t 1. Observation and interview on 9/25/23 at 3:55 p.m. with resident 14 revealed she was in her room and was seated in a wheelchair. There was a urinary catheter bag that was inside a cloth bag. It was attached to the lower side of her wheelchair. She stated she had been in the hospital for sores on her legs and a bladder infection earlier in the year. That was when they put in the Foley catheter. She had bladder infections since then and was hospitalized . She was unsure of the exact dates. Observation of resident 14 on 9/26/23 at 8:30 a.m. she was asked if the surveyor could be present during personal cares, she declined th request. Review of resident 14's hospital discharge summaries revealed: *She had been admitted to the hospital on 1/27/23 and discharged back to the nursing home on 2/1/23. Her hospital admission diagnoses included: -Sepsis from a urinary tract infection (UTI). -Yeast dermatitis in her lower abdominal folds, below her breasts, and behind her right knee. -Cellulitis of her right lower leg. -Her discharge instructions included: Foley (urinary catheter) indication - skin integrity compromise. Foley removal instructions - Until follow-up with (physician name) for wound evaluation. *She had been admitted on [DATE] and discharged on [DATE]. Her admission diagnoses included: Sepsis secondary to left lower extremity cellulitis, pneumonia, and possible UTI in the setting of a chronic indwelling Foley catheter. -Her discharge summary indicated a CT [computerized tomography] scan showed no obstructive uropathy [when urine cannot drain through the urinary tract]. Her urinary incontinence will need to be addressed by her primary care physician and urology as this is a constant source of infection. Review of an infectious disease progress note for resident 14 on 5/12/23 revealed a discussion regarding asymptomatic bacteriuria frequency in elderly patients. The factors that complicate included the high-rate of indwelling catheter use. Review of resident 14's primary care provider's (PCP) nursing home recertifications revealed a diagnosis of neurogenic bladder on the 2/13/23, 4/28/23, and 9/8/23 visits. That diagnosis was not associated with her use of a urinary catheter. Review of resident 14's Wound Registered Nurse (RN) Assessment documentation revealed on 8/29/23 the last wound she had was documented as healed. That wound was to her left buttock and was a healed stage II pressure ulcer. Weekly RN assessments were discontinued on that date. Interview on 9/27/23 at 10:04 a.m. with director of nursing B revealed: *She was not aware resident 14's PCP had added the diagnosis of neurogenic bladder. *The diagnosis of neurogenic bladder was not on her nursing home's current list of diagnoses. *The catheter was used due to her skin breakdown and recurrent UTIs. *She agreed the resident had UTIs after the catheter was placed. It had not reduced her UTIs. *Her skin was presently healed. *Due to her previous incontinence, impaired skin integrity, and frequent UTIs it had not been discussed to remove her catheter. Review of the provider's 2/10/23 Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, Specimen policy revealed: *To provide short-term skin and wound protection in cases where incontinence is delaying healing. *Catheter Removal: -Indication for usage has been resolved (e.g., pressure ulcer healed). -To prevent potential complications (such as urinary tract infections and kidney stones) associated with the long-term use of indwelling catheters.

Based on observation, interview, policy review, and manufacturer's recommendations review, the provider failed to follow infection control procedures for: *Cleaning and disinfecting residents rooms. *Hand hygiene and glove use for three of four observed housekeeping staff (D, E, and G). *Proper use and contact time for facility chemical disinfectants. *Disinfection time for one of one facility whirlpool tub. Findings include: 1. Observation and interview on 3/16/21 at 10:54 a.m. with housekeeper F cleaning a resident's room revealed: *She had worked in the facility for sixteen years. *Two weeks ago she had started working in the housekeeping department. *Her training had consisted of shadowing another employee, but she did not recall how many times. *She had a green caddy that contained various chemicals. -She placed the green caddy on the resident's bathroom floor. *She used an Ecolab pink chemical and sprayed: -The sink and sink fixtures. -The toilet. *She stated that it sits for four minutes. *She grabbed a Swiffer duster and dusted the vents in the room, top of doors, and windows. -When she was finished she put the Swiffer back in the caddy. *She grabbed a towel and used the sink to wet it with water. -She then sprayed the towel with Mufti-surface Peroxide chemical. *With that rag she wiped items in the following order: -The door knobs. -The light switches. -The bedside tables. -Bathroom door knobs. -The resident's dresser. *She then cleaned the mirrors with Windex. *She wet another towel and sprayed it with 66 Alkaline Heavy Duty Bathroom Cleaner. *She cleaned out the sink. *Cleaned off the top of the toilet tank. *Cleaned the toilet assist grab bars. *Cleaned the inside of the toilet seat and rim of toilet. *She then flipped her rag over to turn her rag inside out *She stated that her rag was soiled so she turned it inside out. *Cleaned underneath the toilet and then the floor. *After cleaning the room she brought the caddy and put it on the housekeeping cart to get ready to clean another room. *The caddy was not wiped down in between resident rooms. *She had not used the appropriate ten minute contact time for the chemical. 2. Observation and interview on 3/18/21 at 8:28 a.m. of housekeeping staff/CNA/bath aide F in the facility's tub room revealed: *She stated she followed the posted manufacturer's instructions for cleaning the tub. *That was the only tub *She put the lift in the tub and closed the door. *She pressed the disinfectant button on the tub, let the disinfectant rise to the lowest jet on the tub. *Took a brush and scrubbed the surfaces with the disinfectant. *Rinsed off the brush with water. *Said they set the timer for ten minutes. *At 8:36 a.m., which was eight minutes after the chemical was applied: -Began rinsing the sides of tub, and removed the drain plug. *After the tub drained she turned on the jets until it ran clear. *She turned on the air jets for 30 seconds. *She sprayed off the sides with water, and used a towel to dry the tub. 3. Observation and interview on 3/18/21 at 10:16 a.m. with housekeeping staff E revealed she: *Went into a resident's room, with her cleaning caddy, and a pair of gloves on. *Set the caddy on the bathroom floor. *Sprayed the toilet and sink with the 66 Alkaline Heavy Duty Bathroom Cleaner and disinfectant. *Waited one minute before wiping the chemical off. *Wet a rag with water. *Wiped the sink and toilet with a wet rag in one hand and dried with a dry rag in the other hand. *Cleaned the toilet seat and rim of toilet and then cleaned the tank of the toilet. *Had left that room. *Had not cleaned: -The mirrors. -Any high touch surfaces, such as door handles, light switches or remote controls. -Or clean any other surfaces. -Did not use the 66 Alkaline toilet in the toilet bowl bottle to clean the toilet. *Stated she was done cleaning the resident's room. *Had left the room with the same gloves that she had on when she entered the room. *Once outside the room with the same soiled gloves on she: -Placed her caddy on top of the housekeeping cart, without disinfecting it. -Reached in her pocket to get keys for the storage room. -Put some items away in the storage closet. *She then removed her soiled gloves and performed hand hygiene. *She had not cleaned the inside of the toilet with the chemical. *She had not changed her gloves. *She had not used the appropriate ten minute contact time for the chemical. -The chemical was on the surfaces for one minute. Further observation on 3/18/21 at 10:25 a.m. with housekeeping staff E revealed: *She put on new gloves and went into another resident's room. *She sprayed the toilet, lifted the lid and sprayed inside the toilet, and sink. -She sprayed them with the 66 Alkaline bathroom cleaner. *With the same gloves she reached in her bag and grabbed a clean rag. *She then wet a cloth with water and wiped off: -The bedside tables, moving the resident's masks and papers. -Wiped off the mirror. *After four minutes she went back in the bathroom and she: -Used a wet rag with water and dry rag and cleaned and dried the sink. -Cleaned and dried the toilet. -Cleaned the shelf above the toilet. --Touched the resident's comb and toiletries items with her soiled gloves. *She then wiped off the toilet seat and rim of toilet. *Took a toilet brush out of her caddy that was located underneath a Swiffer duster. -Wiped the toilet bowl and put the brush back under the Swiffer duster. *She then wiped underneath the toilet seat, then bottom of toilet, then back to toilet seat. *She then went to the resident's trash can and took out the trash, placing a clean bag in the receptacle. *She grabbed the caddy off the floor, left the room and placed the caddy on top of the housekeeping cart. *With the same pair of gloves, she entered the room then she reached in her pocket to grab a set of keys. *Opened the storage closet door. *Put items back in the closet. *She took off her gloves, the same ones she put on when she started cleaning the room, and performed hand hygiene. *She had not used the appropriate ten minute contact time for the chemical. -The chemical was left on the surfaces for four minutes. 4. Observation and interview on 3/18/21 at 10:40 a.m. with housekeeping staff G revealed: *She had worked here about two years. *With gloves on she lifted up the toilet seat lid and sprayed the surfaces with an 66 Alkaline Heavy Duty Bathroom cleaner and disinfectant. *She had: -Used a squirt bottle to spread the chemical disinfectant inside the toilet bowl. -Sprayed a wet rag with Multi-surface Peroxide chemical. -Used the same rag to clean both residents' bedside tables and items in the shared rooms. -Then used that rag to clean the bathroom shelves and toilet. -Did not change gloves at all. -She did not use the appropriate ten minute contact time for the chemical. --The chemical was applied for six minutes 5. Observation and interview on 3/18/21 at 11:02 a.m. with housekeeping supervisor D revealed: *She sprayed the resident's toilet and sink with 66 Alkaline Heavy Duty bathroom cleaner. *She stated it had to sit for three minutes. *Grabbed a rag, wet it with water, and sprayed it with Multi-surface Peroxide chemical. *She used that rag to clean the surfaces in the room. *She cleaned the: -Sink. -Handrail. -Top of toilet tank, toilet rim, and inside of toilet. -Riser on toilet. -Underneath and sides of toilet. *She then changed out the trash in the resident's room. *She had not changed her gloves or perform hand hygiene until she left the room. *She had not used the appropriate contact time for the chemical. Review of the manufacturer's cleaning instructions for the facility whirlpool tub after every use revealed: *These had been the instructions to clean the bath after every use, which included: -Press the tub fill button #4 and turn the Temperature control knob #9 all the way to the left to its warmest level to heat the disinfectant solution and maximize its effectiveness. *The facility had been using these instructions to disinfect their tub. Interview on 3/18/21 at 11:11 a.m. with housekeeping staff/bath aide/CNA F revealed: *This surveyor asked if she turned the temperature knob all the way to the left when cleaning the tub. *She stated that she never turned the temperature knob during the tub cleaner. *She stated with their tub cleaner they did not have to. *She stated the knob was hard to turn so they left it in the set resident temperature position. Review of the provider's September 2016 Standard or Light Cleaning policy revealed: *Dwell time was defined as: -The amount of time necessary for a disinfectant to obtain maximum effective disinfection of the contacted area. *5. Address any clutter/trash in the room prior to beginning the cleaning process. *6. Enter the bathroom and spray all surfaces of sink and toilet (including the tank if present, top and bottom of lid, top and bottom of seat, and inside and outside of bowl) with the appropriate EPA (environmental protective agency) listed product. This/these product(s) typically have a dwell time of at least 10 minutes. Add toilet bowl cleaner in the toilet bowl. *10.Scrub and wipe down the toilet ensuring that the disinfectant used has reached its proper dwell time. It is recommended that separate rags be used for sleeping areas and bathrooms. Review of the chemical manufacturer's cleaning instructions for rooms revealed: *Spray Peroxide Multi Surface Cleaner and Disinfectant on to cloth. Wipe mirrors top to bottom until there are no streaks. *Wipe down vanity and sink. *Spray 66 Heavy Duty Alkaline Bathroom Cleaner and Disinfectant inside and outside of the toilet. Swab bowl completely using toilet brush, making sure to get under rim. *Allow product to work by leaving it to dwell on surfaces for contact time indicated on product label. Flush toilet. *High-touch points, Spray Peroxide Multi Surface Cleaner and Disinfectant onto cloth. Wipe all high-touch points including fixtures and light switches. 6. Interview on 3/18/21 at 12:49 p.m. with housekeeping supervisor D revealed: *She has been working in the facility for almost [AGE] years. -She has been the housekeeping supervisor for about [AGE] years. *They currently use the 66 Heavy Duty Alkaline disinfectant for bathrooms and use the peroxide for other surfaces. *She stated that it had a contact time of three minutes. *The surveyor asked her why they wet the rag before they spray the peroxide on the rag. *She stated that a representative from the company had told them to wet the rag first. *She acknowledged that would further dilute the product. *They did not have staff orientations or competencies done for housekeeping staff. *When asked about glove usage and hand hygiene she stated: -If staff touched something that was not clean then they should have removed their gloves, performed hand hygiene, and put on a new pair of gloves. -After cleaning the toilet or bathroom they should sanitize and change their gloves prior to touching any items in the resident's room. On 3/18/21 at 2:06 p.m. housekeeping supervisor D stated she contacted to the chemical manufacturer and the contact time was ten minutes for the 66 Heavy Duty Alkaline bathroom cleaner and disinfectant. Interview on 3/18/21 at 2:28 p.m. with registered nurse (RN) C revealed: *She helped out with infection control. *She had received certification with infection control practices. *She had completed an audit in August of 2020 of housekeeping practices. *The audit had not addressed contact time or dwell time of chemicals. *Order in which to clean items. *There was an area for strict handwashing procedures (ex: (i.e.) between resident areas) are followed. but it was not marked whether staff had met it or not. Review of the manufacturer's product specification document for chemical 66 Heavy-Duty Alkaline Bathroom Cleaner and Disinfectant revealed: * .Allow a 10-minute contact with the surface. *Swab bowl with brush to remove heavy soil prior to cleaning or disinfecting. Clean by applying 8 to 12 oz of product per 1 gallon solution around the bowl and up under the rim. Stubborn stains may require brushing. To disinfect, first remove or expel over the residual bowl water. Pour in three ounces of the use-solution. Swab the bowl completely using a scrub brush, making sure to get under the rim. Let stand for 10 minutes or overnight, then flush.

Based on observation, interview, record review and policy review, the provider failed to: *Follow their protocol for verifying liquid narcotic medication dosage with another nurse prior to administering the medication for one of one sampled resident (2) who received two liquid narcotic medications. *Maintain the security of four narcotic medications awaiting destruction in one of one medication room. *Ensure four of four narcotic medications awaiting destruction had been counted by two nurses at the end of each shift. Findings include: 1. Review of a 3/26/20 Healthcare Online Self-Report event sent to the South Dakota Department of Health (SD DOH) by the provider revealed: *On 3/26/20 at 3:54 p.m. registered nurse (RN) H had attempted to remove a dose of liquid [MEDICATION NAME] from resident 42's multi-dose medication bottle. *Resident 42's liquid [MEDICATION NAME] record had indicated there were 3.75 milliliters (ml) remaining in the multi-dose bottle. *RN H had found only 0.75 ml remaining in the bottle. *A narcotic count had been performed on 3/26/20 at 6:00 a.m. that morning. Review of director of nursing (DON) B's 3/29/20 final investigation report to the SD DOH revealed: *Unlicensed assistive personnel (UAP) I confirmed she had given the liquid narcotics without verification of dose by another nurse prior to administering it. *The nursing staff had reported difficulty seeing the amount left in the [MEDICATION NAME] bottles during the shift count of narcotics. *DON B had reported the provider was unable to determine if the missing liquid narcotic had been a dosage error or a drug diversion. *DON B's plan going forward was: - All liquid narcotic/scheduled medications need to be double checked by another nurse or (UAP) prior to each administration of the medication when there is one available. This is and had been our policy and we need to make sure we are doing this. -The night shift only had one nurse, so would not be able to verify a dose during the night shift. -When the nurse entered orders for liquid narcotics/scheduled medications the nurse would provide an area on the Medication Administration Record [REDACTED]. Interview on 3/18/21 at 9:00 a.m. with RN/assistant director of nursing (ADON) C regarding the provider's procedure for verifying liquid narcotic medication dosages revealed: *The provider had a process in place for double-checking the narcotic dosage with another nurse before giving it to the resident. *She was not sure the above process was being done. *A UAP had to ask for permission from a nurse before giving an as needed narcotic, but not double-checking the dose. *She didn't think the provider currently had any residents with orders for narcotic medications to be given as needed (PRN). Review of Resident 2's March 2021 Medication Administration Record [REDACTED] *[MEDICATION NAME] (HCL) solution, a schedule II narcotic, five milligrams (mg)/5 ml, give 0.5 mg by mouth every four hours PRN. *[MEDICATION NAME] Solution 2 mg/1 ml give 0.5 ml orally every two hours PRN. Interview on 3/18/21 at 1:30 p.m. with ADON C regarding resident 2's PRN narcotic medications revealed: *Resident 2 was given: -Twenty-two PRN administrations of [MEDICATION NAME] HCL between 3/1/21 and 3/18/21. -Fifteen PRN administrations of [MEDICATION NAME] between 3/1/21 and 3/18/21. *The MAR indicated [REDACTED]. *Extra spots used to verify the narcotic doses had not been added to the MAR. *The narcotic should have been double-checked to verify the correct dosage. 2. Observation and interview on 3/18/21 at 11:15 a.m. during a review of the medication room with ADON C revealed: *A metal lock box that required a key to open it was attached to cabinet. *This surveyor lifted the lid and opened the box without a key. The box had not been locked. *A three-ring binder lay beside the box containing four individual residents' narcotic records. -The oncoming nurse had not signed that she had counted the narcotics on 3/18/21. Review of the metal box revealed three medication cards and one clear bag containing: *A card of 24 [MEDICATION NAME] tablets. -Those tablets had been moved to the lock box on 3/1/21. -The medication had been counted and signed by only one nurse on four occasions: 3/5/21 two times (morning and evening shifts), 3/10/21, and 3/18/21. *Another card contained 14 [MEDICATION NAME] tablets. -The narcotic record for that card had not indicated when the medication had been moved to the lock box. -The 3/18/21 oncoming nurse had not signed that she had counted the medications. *A card containing 15 [MEDICATION NAME] 5/325 mg tablets. -The narcotic record for that card had not indicated when the medication had been moved to the lock box. -The medication had been counted and signed by only one nurse three times: 3/5/21, 3/5/21, and 3/18/21. *A plastic bag containing nine [MEDICATION NAME] 12 micrograms/hour patches. -The narcotic record for the patches had not indicated when the medication had been moved to the lock box. -The medication had been counted and signed by only one nurse on three occasions: 3/9/21, 3/12/21, and 3/18/21. Interview with ADON C at the above time regarding the unlocked box containing narcotics confirmed: *The box contained discontinued narcotic medication awaiting destruction by two nurses. *Narcotics awaiting destruction were not destroyed daily because it required two nurses to destroy medication together. *The lock box should have remained locked at all times. *She did not know why the box had not been locked. *A key was required to lock and unlock the box. *The provider had two keys that opened the box. -DON B had one key. -The second key was normally carried by the 300 nurse, but there was not a 300 nurse because of the low census. -The 100 and 200 units shared the key. -All nurses who worked in the building had access to that key. -An oncoming nurse was suppose to count narcotics with the outgoing nurse at each shift change. *The narcotics in the metal box had not been secured. Interview on 3/18/21 at 3:30 p.m. with DON B regarding not verifying narcotic liquid doses, unsecured narcotics, and missing nursing signatures for counting narcotics confirmed: *All narcotic liquid dosages were to have been verified by another nurse for correct doses prior to giving the medication to the resident. -That was a verbal protocol specific to the provider. *All narcotic medications including those awaiting destruction were to have been locked and secured. *Nurses were to have counted all narcotics at each shift change. Review of the provider's December 2020 Controlled Medications policy revealed: *Medication reconciliation referred to accurate keeping that ensured an accurate inventory of medications by accounting for controlled medications that had been received, dispensed, administered and had included the process of disposition. *Each time the keys that secured controlled narcotic medications changed from one nurse/UAP to another, the oncoming and off-going nurses worked together to reconcile all controlled medications, including all discontinued controlled medications and document the same. *Having liquid narcotic medication dosages verified by another nurse or UAP had not been part of the written policy.

Based on observation, interview, staff training review, off-site document review, off-site telephone interview, and policy review, the provider failed to ensure a comprehensive infection control plan and process had been implemented for the current COVID-19 pandemic related to: *Staff had not been fit-tested for the N95 respirators. *Resident room doors had not been closed on the two of two dedicated COVID-19 units (Iris Place and Tulip Lane). Findings include: 1. Interview on 11/12/20 at 9:00 a.m. with administrator A regarding N95 respirators revealed: *All staff were expected to wear N95 respirators. *Not all of the staff had been fit-tested to wear a N95 respirators. *Staff working on the dedicated COVID-19 units wore N95 respirators. -Not all of those staff had been fit-tested for the N95 respirators. *They had received the fit-test kit for N95 respirators from the state of South Dakota (state) on 11/6/20. *She: -Had watched the video on fit-testing. -Was in the process of having the director of nursing (DON), the assistant DON, and the infection control preventionist trained to do the fit-testing. -Was not sure if she could do the training since she was not a nurse. -Had some questions on the training from the state webinar on 11/11/20. *The video webinar had said it was better to wear an N95 respirator even if one had not been fit-tested . -It would provide more protection for the individual but to be fit-tested when available. *Her goal was to get all the staff fit-tested with the N95 respirator in the next two weeks. *The corporate regional vice-president had instructed them to have all staff wear N95 respirators and to do a seal check. Observation on 11/12/20 at 10:40 a.m. on the non-COVID-19 unit (Daffodil) revealed all staff had on N95 respirators and face shields. Observation and interview on 11/12/20 at 11:40 a.m. with certified nursing assistant (CNA) B in the dedicated COVID-19 units (Iris Place and Tulip Lane) revealed: *The above units had plastic barriers with zippered walls leading into and out of them. *CNA B had an N95 respirator on with a face shield. -The mask fit loosely on her face. -She had not been fit-tested to wear the N95 respirator. -She always wore an N95 respirator at work. *The resident room doors on both above units leading into the hallways had been open. Telephone interview on 11/13/20 at 8:40 a.m. with administrator A regarding the above observation revealed: *She confirmed sometimes the resident room doors had been closed and sometimes they had been left opened. *They had tried to keep the room doors closed. *There were three residents on those two dedicated Covid-19 units that had been in quarantine. -They either had been moved to another room or their roommates had been moved. -They had not tested positive for COVID-19 but had a direct exposure from a positive roommate. Review of off-site resident roster flow sheet and staff training documents revealed: *There were twelve residents that were confirmed COVID-19 positive and three residents who had not tested positive on the dedicated COVID-19 units. *There were twelve staff who had been fit-tested to wear the N95 respirators in May 2020. Phone interview on 11/16/20 at 3:00 p.m. with administrator A and DON C regarding opened residents' room doors on the dedicated COVID-19 units and N95 respirator fit-testing revealed: *The three residents on the dedicated COVID-19 units had not tested positive for COVID-19, but were there due to direct exposure from their roommates. *There were twelve residents who were currently active with COVID-19 on the dedicated COVID-19 units. *The remainder of those residents on the dedicated units had recovered. *They considered the Decision Tree for Closed Door Isolation a part of their COVID-19 policy. *That policy had been developed earlier, and the tools were developed later as things changed. *Residents 1, 2, and 3: -Were considered being in the light red zone on one of the dedicated Covid-19 units. -Had not tested positive for COVID-19. -Wanted their room doors left opened. *Resident room doors that had been left opened on the dedicated COVID-19 units were done on a case-by-case basis. *They had fit-tested twelve staff in May 2020. -They had anticipated a small number of residents to get COVID-19 and thought a small amount of staff would be adequate. -They had not expected all staff to be required to wear an N95 respirator. -Corporate office had instructed them to have all staff wear an N95 respirators. -Staff were instructed to do a seal check after donning (putting on) an N95 respirator. -They had not had the resources to get everyone fit-tested . --The local emergency management system and hospital were not doing fit-test training. --They had to reach out to other facilities in order to get the twelve fit-tested . *DON C could not verify if CNA B had on the proper N95 respirator since she had not seen it. -It would depend if CNA B had done a seal check. -CNA B wore glasses and would be able to verify if the N95 respirator fit correctly with the seal check, because her glasses would have fogged up. *They wanted to protect their staff. *In hindsight they should have had all their staff fit-tested . Off-site record review for residents 1, 2, and 3 revealed: *They were all on the same COVID-19 unit. *There were seven residents positive for COVID-19 on their unit. *There were four residents recovered from COVID-19 on their unit. *Resident 2: -Had been educated on 3/27/20 on COVID-19 and explained facility lockdown to outside visitors, resident states that she understands and has no questions at this time. -The undated care plan revealed she was at risk for infection related to COVID-19 pandemic and congregate living situation. --In an outbreak, resident is encouraged to keep door closed to room but will honor resident's rights and wishes also. -There was no further documentation in her medical record regarding education of closing her room door during an outbreak or her wanting her door closed during an outbreak. *Residents 1 and 3 did not have any documentation regarding education of closing their room doors during an outbreak or wanting their room doors closed during an outbreak. Review of the provider's 11/2/20 Infection Prevention: Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID)-Enterprise policy revealed: *Purpose: -To prevent the transmission from person to person of respiratory pathogens. *Long Term Care of Skilled Nursing Facility: -Infection Prevention and Control Recommendations Individual rooms: --Upon identification of any resident with suspected or positive COVID-19, a Droplet Precautions sign will be posted on the outside of the residents room. --The resident will be isolated in their room with the door closed (include roommate if applicable). -Cohort Units: --Multiple residents with COVID-19 will be housed (cohort) on a COVID unit/wing as the building allows. Separation units or barriers may also be used to cohort positive residents.*The policy had not included if resident room doors were to be closed when cohorting positive residents with non positive residents. Review of Center for Disease Control (CDC) 4/30/20 guidance for Responding to Coronavirus (COVID-19) in Nursing Homes for considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 revealed: .Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19, depending on facility capacity (e.g.(for example),staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms .

Based on observation, interview, record review, and policy review, the provider failed to adequately manage pain for one of one sampled resident (64) who had pain. Findings include: 1. Review of resident 64's medical record revealed: *She had been admitted on [DATE]. *Her Brief Interview for Mental Status assessment score was fourteen indicating her cognition was intact. *Her [DIAGNOSES REDACTED].>-[MEDICATION NAME] with other complications. -Neuralgia and neuritis, unspecified. -Gastro-[MEDICAL CONDITION] reflux disease without esophagitis. -[MEDICAL CONDITION]. -Abnormal weight loss. -Presence of left artificial hip joint. -Primary generalized arthritis. -Presence of right artificial shoulder joint. -Presence of left artificial shoulder joint. Observation and interview on 8/15/19 at 10:45 a.m. with resident 64 revealed: *She was sitting in her recliner reading the newspaper. *She said she was having a good day and liked living in the facility. *When she was asked about her pain, she said it makes her life miserable. *The medications used to help but did not anymore. *She had shingles to her torso on the left side and at times had a stabbing pain. *She had told nurses the medications did not help, and sometimes they brought her another medication. *She stated she did not always get the [MEDICATION NAME]-[MEDICATION NAME] and Tylenol extra strength together. -She had not noticed if when given together if it had helped more or not. *She did not think the nurses could have done more for her. *She said the doctor had been on vacation last week, and she did not know when she would see him again. Review of resident 64's (MONTH) 2019 Medication Administration Record [REDACTED] *[MEDICATION NAME] 50 milligrams (mg) two tablets by mouth three times a day. *[MEDICATION NAME]-[MEDICATION NAME] 5/325 mg one tablet three times a day as needed. To be administered with extra strength (ES) Tylenol for break through pain. -[MEDICATION NAME]-[MEDICATION NAME] had been administered thirteen times. -The last administration date had been on 8/11/19. *Tylenol ES 500 mg one tablet three times a day as needed. To be administered with [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg for break through pain. -Tylenol ES had been administered four times. -The last administration date had been on 8/7/19. Review of resident 64's revised 7/25/19 care plan revealed: *The resident had a potential for pain and/or discomfort related to [MEDICAL CONDITION] and arthritis as evidenced by resident stating she had pain. *Resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. *To notify health care provider if interventions were unsuccessful or if complaint was a significant change from resident's past experience of pain. *To attempt non-pharmacological interventions such as ice, heat, repositioning, therapy, reminisce, or distraction. *Resident's pain was rated using Pritchett & Hull 0 to 10 face scale. Review of Communication/Visit with Physician notes regarding resident 64 revealed: *On 7/29/19, resident had been seen by her physician. -Her pain had been discussed. -Her physician did not want to change medication, as he was going to be out of town. -He would review past pain medications and possible change in medications when he returned in about ten days. -She had agreed with that plan. *On 8/15/19 at 11:11 a.m., the physician's office had been contacted regarding pain management, and the physician was out of the office. -His nurse would get back to the provider when he was back in the office. Interview on 8/15/19 at 11:03 a.m. regarding resident 64 with licensed practical nurse (LPN) A revealed: *The resident had rated her pain high on the pain scale at times. *She had not known if the physician had been notified of her pain. *She had been told that nurses had been trying to utilize the [MEDICATION NAME]-[MEDICATION NAME] and Tylenol ES more between meals. *She had known the [MEDICATION NAME]-[MEDICATION NAME] should have been given with Tylenol ES, and then each medication should have been signed out separately on the MAR. Interview on 08/15/19 at 3:14 p.m. with the director of nursing regarding resident 64 and the above revealed: *She agreed the physician should have been called and pain medications should have been changed. *She had been admitted because of the pain management. *She had rounded with the physician on 7/29/19, and he had talked about trying a [MEDICATION NAME] but non had been ordered at that time. *She had agreed the physicain orders for [MEDICATION NAME]-[MEDICATION NAME] and Tylenol ES had not been followed correctly. Review of the provider's revised (MONTH) (YEAR) Pain Management, Data Collection and Assessment, and Non-pharmacological Pain Interventions policy and procedure revealed: *The purpose of the policy was to: -Provide residents assistance in pain management. -Promote well-being by ensuring that residents are as comfortable as possible. -Consistently collect data related to pain. -Determine what pain relief interventions specific to the resident can be used to aid in maintaining a comfortable level of function and quality of life. *The registered nurse will assess current pain levels and develop with the physician and inter disciplinary team interventions that may be non-pharmacological, as well as pharmacological. The registered nurse will review response to medication intervention and work closely with the physician to assist in the individualized pain management plan. *Follow prescribed orders for pain, documenting results as needed. Residents with a history of pain or a [DIAGNOSES REDACTED].

Based on observation, interview, record review, policy review, and manufacturer's review, the provider failed to ensure professional standards were followed for: *The physician notification in a timely manner for one of one sampled resident (27) who had increased pain. *One of one registered nurse (RN) B had followed manufacturer's instructions for the administration of [MEDICATION NAME] R insulin by an insulin pen for one of one sampled resident (51). Findings include: 1. Review of resident 27's medical record revealed: *He had been admitted on [DATE]. *His 6/4/19 Brief Interview for Mental Status assessment score was seven indicating severely impaired cognition. *His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Acute chronic diastolic (congestive) heart failure. -Unspecified dementia without behavioral disturbance. -Essential (primary) hypertension. -Gastrointestinal hemorrhage. -Gastro-[MEDICAL CONDITION] reflux disease without esophagitis. -[MEDICAL CONDITION] ulcer, unspecified as acute or chronic, without hemorrhage or perforation. -Primary generalized arthritis. Observation and interview on 8/15/19 at 10:53 a.m. with resident 27 revealed: *He was sitting in his wheelchair in his room. *He was clean and well dressed. *He was pleasant and answered questions appropriately. *He did not remember having rectal bleeding or having been in the hospital. Review of 6/7/19 nurses progress notes regarding resident 27 revealed: *At 4:41 a.m. he had a gross amount of rectal bleeding with quarter size blood clots in pull-up, toilet, and on the floor. (Resident name) denies rectal pain, but on palpitation he stated that he had discomfort on left upper and lower quadrate of abdomen. (Resident name) stated that he had a BM on 6-6-19 and that the BM was soft, he didn't have to push hard. States that he feels weak. Resident assisted back to bed. Call light placed within reach. (Resident name) was encouraged to call for assists if he needs to get up. Will continue to observe condition and report any changes as needed to primary physician. *At 5:21 a.m. a fax communication was sent to physician concerning the rectal bleeding. *At 2:52 p.m. had rectal bleeding on the morning shift. -A physician order [REDACTED]. *Resident had been admitted to the hospital for a gastro-intestinal (GI) bleeding from 6/7/19 until 6/10/19. Interview on 8/15/19 at 3:14 p.m. with the director of nursing (DON) regarding resident 27 revealed: *The nurse should not have sent the physician a fax to notify him of bleeding. *The nurse should have called the emergency room for the physician on call or used the eLTC program at the time the bleeding was observed. Review of resident 27's undated care plan revealed: *No mention of his history of GI bleed. *He had a history of [REDACTED]. *He would remain free of signs and symptoms or complications related to [MEDICAL CONDITION]. *Report to the health care provider signs and symptoms of [MEDICAL CONDITION]. Review of the provider's (MONTH) (YEAR) Notification of Change policy revealed: *A facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there is: -An accident involving the resident which results in injury and has the potential for requiring physician intervention. -A significant change in the resident's physical, mental or psychosocial status. -A need to alter treatment significantly - a need to discontinue or change an existing form of treatment or to commence a new form of treatment. 2. Observation and interview on 8/15/19 at 11:29 a.m. with RN B during the preparation and administration of [MEDICATION NAME] R insulin by an insulin pen revealed she: *Removed the pen from the medication cart drawer, uncapped it, sanitized the port, and placed a new needle on it. *Went to resident 51's room, cleansed the resident's abdomen, and injected the insulin. *Had not primed the pen with five units of insulin prior to the administration. *Had not held the insulin pen needle in the resident's abdomen for at least five seconds. *Stated the insulin pen only had to be primed when it had first been opened. *Did not have to hold the needle in abdomen for any amount of time. Interview on 8/15/19 at 4:00 p.m. with the DON agreed RN B had not administered the insulin according to manufacturer's instructions. Review of the [MEDICATION NAME] R manufacturer's instructions revealed: *The [MEDICATION NAME] R insulin pen should have been primed with five units of insulin to fill the needle. *That would have ensured the resident received the full amount of insulin ordered. *The needle was to have been held in the injection site for five seconds to ensure all the insulin had been delivered. Review of the provider's (MONTH) (YEAR) Insulin Pens policy revealed: *Turn the dosage knob to '2' units to prime the pen. *Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. *Dial in the ordered dose of units. Be sure to wait about 10 seconds to ensure that the full dose has been delivered.

Based on observation, interview, record review, policy review, and manufacturer's instructions review, the provider failed to: *Ensure one of three sampled residents (1) who used Broda chairs were properly monitored when the chair was left in the upright position. *Ensure staff members were trained on the use and safety precautions of Broda chairs according to the manufacturer's instructions. *Have care plans that contained resident specific instructions for the use of the Broda chair for three of three sampled residents (1, 6, and 8) as called for in the manufacturer's instruction manual. Findings include: 1. Review of the required nursing facility event reports submitted to the South Dakota Department of Health on 11/10/12, 11/16/12, and 12/14/12 regarding resident 1's 11/9/12 fall revealed: *Her Broda chair had been in the upright position while at the supper table. *Staff had not directly been supervising her. *She had fallen face first from her Broda chair in the dining room while waiting for supper to be served. *The fall had resulted in facial trauma that had included fractures of the sinuses and septum. *The provider had documented the resident's plan of care had been followed for her Broda chair. Review of the provider's Broda chair operating manual revealed: *No one should had operated or maintained a Broda chair including a family member unless they had read the operation manual. *"A copy of the instruction manual must always be available." *The resident's primary caregiver was responsible to ensure no one who was unfamiliar with, unwilling, or unable to adhere to the safety and operating instructions, was not permitted to operate or move the chair. *"The primary caregiver must maintain a list of caregivers who have read this manual and who they have authorized to operate and move the chair." *Section 2.5 (Hazards) of the manual reviewed falling, tipping, skin injury, clamping, and collision. *Section 2.5.1 stated the manufacturer recommended the chair's seat be tilted sufficiently immediately after the resident was placed in the chair to prevent sliding and falling. *Each person using the Broda chair was to have resident specific instructions to ensure safe and effective use of the chair. Those specific instructions were to have been based on the provider's professional experience and knowledge of the caregivers as well as the resident's specific conditions and requirements. The manufacturer stated "These instructions form an essential part of the Safety Requirements for using the chair and must be made available to all caregivers." A form was provided by the manufacturer in section 2.9 of the manual to document the resident specific instructions. Observations, interviews, and Broda chair operating manual review on 1/3/13 from 7:30 a.m. through 10:30 a.m. revealed: *Residents 6 and 8 were currently using Broda chairs. *They had signs taped to the back of their chairs that directed staff not to leave residents unattended when the seat was in the upright position. *Certified nursing assistant (CNA) G who was assigned to the hallway where residents 6 and 8 were stated: -She did not remember ever reading the Broda chair manual. -She did not know where the Broda chair manual was kept. -The only training she remembered receiving specific to the Broda chair was when another CNA had showed her how to use it (on-the-job training). -Residents were to never have been left unattended when the chair was in the upright position. -She was not aware of any specific instructions for the use; such as degree of incline or position for meals for either resident 6 or 8. -She had never seen the resident specific instruction sheet located on page 10 of the operator's manual. -She was not sure what the care plan was for the use of the Broda chair for residents 6 and 8. *Licensed practical nurse (LPN) B who was assigned to the hallway where residents 6 and 8 were had the same answers as CNA G. *Certified nursing assistant (CNA) H who was assigned to the hallway where residents 6 and 8 were had the same answers as CNA G and LPN B. Interview, record review, and Broda chair operating manual review on 1/3/13 at 10:30 a.m. with the director of nursing (DON) and the administrator regarding the provider's current Broda chair procedures and practices revealed: *The provider had no policies and procedures in place for Broda chairs. *No formal staff training had been conducted related to the proper use and maintenance of the Broda chairs. *No list of authorized users of the Broda chair was kept. *No physician's orders or therapy orders were present for the use of the Broda chairs as nursing staff made the decision to use that piece of equipment. *No nursing assessments were present for residents 6 and 8's specific needs for and specific uses of the Broda chair. *The signs currently on the back of resident 6 and 8's Broda chairs had been placed there after resident 1's 11/9/12 fall from the Broda chair. *They both confirmed the manufacturer's Broda chair operating manual had not been followed currently and in the past. *They agreed resident 6's and 8's care plans were not reflective of each of the residents' individual care needs as outlined in the Broda chair manual. Interview, record review, and Broda chair operating manual review on 1/3/13 at 2:20 p.m. with the DON and the administrator regarding the fall of resident 1 from her Broda chair on 11/9/12 revealed: *Based on the provider's internal investigation resident 1 had her Broda chair in the upright position while she was at the dining room table on 11/9/12 and was not directly monitored by staff members when she had fallen from her chair face first resulting in significant facial trauma. After multiple staff interviews the provider had been unable to find out who had put the resident's Broda chair in the upright position. *Both confirmed the resident should not have been left in her Broda chair in the upright position on 11/9/12 without having been directly monitored. *The resident's care plan interventions dated 8/2/12 related to the use of her Broda chair were: -"Assist of 1 staff. Broda chair." -"Monitor when in Broda chair between meals. If restless may be in recliner or bed with legs elevated." -"Uses 4 inch cushion in Broda chair." *No evaluation of the use of the four inch cushion placed in the resident's Broda chair was in place. Both the administrator and the DON confirmed that cushion elevated the resident in the chair making the side arms of the Broda chair shorter and hence making the chair easier to fall out of. The DON stated those cushions had now been removed from all of the other Broda chairs as a result of the resident's 11/9/12 fall. *No nursing assessments were present for residents 1's specific needs for and specific uses of the Broda chair. *They agreed the resident's care plan was not reflective of her individual care needs and outlined in the Broda chair manual. *They again confirmed the manufacturer's Broda chair operating manual had not been followed. *No formal quality assurance process had been implemented as a result of the resident's Broda chair fall.

Based on record review, interview, and policy review, the provider failed to appropriately assess, monitor, intervene, transport, and document on one of two sampled residents (1) who had fallen and sustained an injury. Findings include: 1. Review of the required nursing facility event reports submitted to the South Dakota Department of Health on 11/10/12, 11/16/12, and 12/14/12 regarding resident 1's 11/9/12 fall revealed: *Her Broda chair was in the upright position while at the supper table. *Staff were not directly supervising her. *She had fallen face first from her Broda chair in the dining room while waiting for supper to be served. *The fall had resulted in facial trauma that included fractures of the sinuses and septum. *At the time of the incident she had significant bleeding that staff could not stop resulting in the transfer of the resident to the hospital. Review of the 11/9/12 nursing documentation for resident 1 revealed: *There had been no nursing documentation related to the circumstances, condition, transfer, or care of her after the above fall. *One set of vitals from 6:00 p.m. on 11/9/12 was present. The vitals taken were: pulse 90, respirations 20, and blood pressure 127/75. *One neurological check had been documented at 6:00 p.m. It stated the resident's: -Level of consciousness was "Persistent vegetative state, opens eyes/wakeful but no evidence of purposeful behavior of cognition." -Pupils were 2 millimeters in size and reacted to light. -All four extremities were "strong" and spontaneous movement to command was present. Review of all of the provider's investigation documents requested from the administrator related to resident 1's 11/9/12 fall revealed an internal fall report had been filled out. However no nursing documentation was present related to assessments, condition of the resident post fall, or how the resident had been transported to the hospital. Interview, record review, and policy review on 1/3/13 at 2:00 p.m. with the director of nursing (DON) and the administrator regarding resident 1's 11/9/12 fall revealed: *The administrator believed she had fallen around 5:30 p.m. and had been transported to the hospital per the facility van around 6:30 p.m. after nursing staff could not control the bleeding from her nose. She further stated she was the person who had transported her to the local hospital without any medically trained personnel in the van. When asked why the resident had been transported in the van without medical personnel assistance instead of calling the ambulance she stated "The nurses thought it was okay." *No documentation was present related to the resident's condition at the time of her transfer or during her transfer. The administrator confirmed she had not documented anything related to the resident's transfer in the facility van or the decision to not transport her via ambulance. *According to the provider's internal investigation the following had occurred on 11/9/12: -The resident had fallen face first from her Broda chair sustaining injury to her face with significant bleeding coming from her nose. -Nursing personnel had removed the resident from the floor minutes after the fall with a lift and had placed her back in her Broda chair. The resident was taken to her room until around 6:30 p.m. when it was decided to transport her to the local hospital as noted above. *No nursing documentation related to the care she had received post fall was available other than the information noted above. *The DON agreed with the following: -Basic first aid principles had not been followed related to a fall with face and potential head/neck injury; such as stabilizing the persons neck in case of neck fracture, calling 911 for assistance due to potential fracture, and not moving the resident until properly immobilized. -The basic tenants of nursing documentation had not been followed for the post fall care of the resident. -The resident should have been transported per ambulance. However after the decision had been made to transport the resident a nurse should have accompanied the administrator to ensure the safety and well being of the resident. *They had not evaluated or interviewed any staff related to the post fall emergency care she had received after her 11/9/12 fall. *They confirmed the provider's revised October 2012 fallen and injured resident policy had not been followed. *No formal quality assurance processes had been started as a result of the resident's 11/9/12 fall from the Broda chair. Interview on 1/3/13 at 2:49 p.m. with licensed practical nurse (LPN) B regarding resident 1's 11/9/12 fall revealed: *She had not performed any nursing assessments or vital signs on the resident. *She had not observed any other nursing staff performing vitals or assessments prior to moving the resident. *She had not been involved in moving/transferring the resident. *She stated "I mainly was involved in the clean-up of all the blood." *LPN C and registered nurse (RN) D had been taking care of her after the fall. *She agreed basic first aid principles had not been followed after the resident's 11/9/12 fall. Interview on 1/3/13 at 2:30 p.m. with LPN C regarding resident 1's 11/9/12 fall revealed: *She was one of the nurses who had cared for the resident that night. *She had been left in charge of the resident the majority of the time the resident was in her room while RN D made phone calls to family and doctors. *A staff member who she could not remember came to her and stated an ambulance was needed as resident 1 had fallen. She had not called the ambulance as she had wanted to see what the problem was first. After arriving at the scene of the fall she and RN D decided an ambulance was not needed. *She and RN D had decided to move the resident off the dining room floor to her Broda chair and then to her room, so the other residents' supper was not disturbed further. When asked what clinical data had been gathered to ensure the resident was stable prior to moving the resident she stated she was unsure. *She and RN D had cared for the resident for an hour or so prior to deciding to transfer the resident to the hospital due to being unable to control the bleeding from her nose. *When asked how she and RN D cared for the resident after the fall she stated they had applied ice to the back of her neck and face initially and then packed the resident's nose with tissue to help slow the bleeding. *When asked how she and RN D had assessed the resident's oxygen saturations and breathing as the resident's nostrils were occluded and she was still actively bleeding she stated she could not remember listening to her lung sounds or whether or not oxygen saturations had been taken. *When asked why no documentation was present regarding the care and interventions she had provided after the resident's fall she was unable to explain, and then stated "I should have." *When asked how frequently the resident's vital signs had been checked she stated she could not remember. *When asked if she had felt the basic principles of first aid had been followed after the resident's 11/9/12 fall she stated no and could not explain why they had not been. *When asked why the resident had been transported to the local hospital in the facility van per the administrator without nursing personnel LPN C stated the administrator had stated she was not needed. When asked if nurses should turn the care of a significantly injured resident over to non-medically trained personnel she stated "No." Phone interview on 1/4/13 at 11:00 a.m. with RN D regarding resident 1's 11/9/12 fall revealed: *She was a part-time nurse at the facility *She was the first nurse at the scene of the resident's fall on 11/9/12 and had been her primary nurse that day. *She had initially asked for the ambulance to be called. However she had changed her mind after LPN C had arrived and told her "We don't need to call an ambulance for a bloody nose." *She had confirmed and had agreed with all of the above comments of LPN C except she stated she had not packed the resident's nostrils with tissue. *She confirmed as the RN on duty she had responsibility for supervision and documentation of the care administered after the resident's fall. *No physician's orders had been written as a result of the 11/9/12 fall that she could remember. That included the order to transfer to the hospital without using an ambulance. Review of Medline Plus Encyclopedia, "Head Injury and Neck Injury", Service of the National Institute of Health, http://www.nlm.nih.gov/medlineplus/ency/article/ 8.htm, (June 27, 2011) revealed: *In the case of a serious head or neck injury 911 should be contacted immediately. *Signs of head and neck trauma can include: agitation, confusion, restlessness, fluid draining from the nose mouth and ears, changes in the size of the pupils, behavioral changes, and lack of coordination. *Persons with suspected significant head and neck injuries should not be moved. All attempts should be made to immobilize the injured persons neck and back to prevent further injury. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO, pg. 477, revealed: *Complete and appropriate documentation was a vital aspect of nursing practice. *"Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice." Review of the South Dakota Board of Nursing's Administrative Rules, Chapter 20:48, revealed: *"A licensee is personally responsible for the actions that the licensee performs relating to the nursing care furnished to clients and cannot avoid this responsibility by accepting the orders or directions of another person." *"The registered nurse is responsible for the nature and quality of nursing care that a client receives under the nurse's direction." *"The registered nurse shall recognize and understand the legal implications of delegation and supervision. The nurse may delegate to another only those nursing interventions which that person is prepared or qualified to perform and shall provide minimal or direct supervision to others to whom nursing interventions are delegated. The registered nurse may only delegate nursing tasks to unlicensed assistive personnel in accordance with the standards in chapter 20:48:04.01." *The licensed practical nurse may practice in two general settings: with at least minimal supervision when providing nursing care in a stable nursing situation; and with direct supervision when providing nursing care in a complex nursing situation; *"The licensed practical nurse shall consult with a registered nurse or other health team members and seek guidance as necessary and shall obtain instruction and supervision as necessary."

Based on observation, interview, record review, policy review, and manufacturer's manual review, the provider failed to: *Report one of one incident related to improper equipment usage resulting in injury to resident 1. *Appropriately assess, monitor, intervene, transport, and document for one of two sampled residents (1) who had fallen and sustained an injury. *Ensure one of three sampled residents (1) who used Broda chairs were properly monitored when the chair was left in the upright position. *Ensure staff members were trained on the use and safety precautions of Broda chairs according to the manufacturer's instructions. *Have care plans that contained resident specific instructions for the use of the Broda chair for three of three sampled residents (1, 6,and 8) as called for in the manufacturer's instruction manual. *Follow isolation protocols for one of one sampled resident (6) in contact isolation. *Develop formal quality assurance processes related to improper use of equipment after incidences of injury have occurred. Findings include: 1. All of the above findings are addressed in the following deficiencies. Refer to F226, F281, F323, and F441.