Every finding on record at Highmore Health

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, observation, interview, and policy review, the provider failed to ensure the safety of one of one resident (1) identified at risk for elopement (leaving the facility without staff knowledge) who left the building from the east door on 1/17/26 and was found by a citizen. The east door was not alarmed or monitored at the time of the resident's elopement. This citation is considered past noncompliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include:1. Review of the SD DOH FRI received on 1/17/26 revealed that on the evening of 1/17/26 at around 9:00 p.m., registered nurse (RN) G could not locate resident 1. After a preliminary search of the building, RN G contacted director of nursing (DON) B and administrator A. Administrator A came to the facility to help look for resident 1. They searched the facility including all rooms, closets, bathrooms, beds, and ancillary rooms. Staff noted that the east door alarm was turned off. The facility grounds were searched and resident 1 was located at around 9:25 p.m. sitting on the ground across the street. The report did not specify who found resident 1.Resident 1 was assisted back inside the facility and staff helped to warm him up by wrapping him in blankets, sitting him next to the heater, and applying warm socks to his hands. He was assessed from head to toe, and his vital signs were checked. His vital signs were normal; except he was cold with a temperature of 96.4 degrees Fahrenheit. There were no signs or symptoms of frostbite. Resident 1's wife and his primary care provider were notified.Staff reviewed and revised his care plan. Staff were educated to make sure door alarms remain turned on at all times. Hourly checks were initiated to monitor that the door alarms were turned on, and to monitor resident 1's location. A new door was ordered to replace the east door and to change the alarm to a keypad code entry system as the east door experienced higher traffic due to entry/exit through that door by outpatient therapy, deliveries, and visitors.2. Review of publicly available weather data obtained from https://www.wunderground.com/dashboard/pws/KSDHIGHM17/graph/2026-01-17/2026-01-17/daily revealed that there was a personal weather station (weather station ID KSDHIGHM17) located approximately 5.16 miles northeast of the nursing home. The temperature at around 9:00 p.m. on 1/17/26 was 7 degrees Fahrenheit, with wind speeds at 7 miles per hour and wind gusts at 9 miles per hour. There was no precipitation at that time, meaning it was not snowing, raining, or sleeting.According to the Wind Chill Chart, obtained from https://www.weather.gov/safety/cold-wind-chill-chart, the air temperature would feel like negative 5 degrees Fahrenheit when the air temperature is at 7 degrees Fahrenheit, and the wind speed is at 7 miles per hour. Additionally, a person could develop frostbite on exposed skin in about 30 minutes when outside in that temperature.3. Observations throughout the survey from 1/20/26 to 1/21/26 revealed that the exit doors were all alarmed and testing revealed the alarms were functioning.4. Interview on 1/20/26 at 2:17 p.m. with administrator A revealed that a performance improvement project (PIP, a concentrated effort to improve care or services in a facility area that needs improvement) was initiated regarding resident elopements. The Minimum Data Set (MDS) coordinator was in charge of that PIP.5. Interviews with several individuals throughout the survey from 1/20/26 to 1/21/26 (certified nursing assistants (CNA) D, E, F, H, I, K, and M, licensed practical nurses (LPN) J and L, registered nurse (RN) G, visitor 1, resident 1's wife, and citizen 1) revealed that they were aware of resident 1's elopement on 1/17/26.LPN L indicated she had turned off the east door alarm at around 7:10 p.m. to allow a different resident and his family to enter the building without triggering the alarms, and she forgot to turn the door alarm back on. RN G and CNAs D, E, F, and M confirmed the door alarm had not sounded on 1/17/26 when resident 1 eloped.RN G and CNAs D, E, F, and M were unable to determine what time resident 1 left the facility. At around 9:00 p.m., RN G could not find resident 1. She and other staff searched each room in the facility, around the outside of the facility, and around the city block where the facility was located. Visitors 1 and 2 assisted in the search.At around 9:20 p.m., citizen 1 and his dog found resident 1 on the ground in a neighbor's yard. Citizen 1 flagged down the search party and assisted in getting resident 1 into a van.Once back at the facility, the staff assisted resident 1 into clean clothes and assessed his skin. There were no concerning skin issues. Staff warmed him up by wrapping him in blankets, rubbing his feet, and placing him next to a heater. He was agitated when he was brought back in from outside as he was described as resistive to cares, grabbing at staff, and attempting to hit others. CNA E mentioned that was not his normal behavior, but she guessed he was overwhelmed with the amount of people trying to help him at one time. He relaxed as he warmed up. Staff and resident 1's wife reported that his behavior returned to his baseline and there were no lasting negative effects.Staff confirmed there was education regarding the provider's elopement policy, hourly audits were implemented on the exit door alarm status and the locations of all five residents who were identified at risk of eloping and resided at the facility, a new door was ordered to replace the door the resident eloped from, a new style of door alarm was ordered for the other doors, and a performance improvement project was initiated regarding elopements.6. Record review confirmed that staff were educated about the elopement policy, and staff were performing the hourly audits on the five residents at risk for elopement and the door alarms.7. Observation and interview on 1/20/26 at 4:55 p.m. with resident 1 revealed that he was sitting on the edge of his recliner chair in his room. The chair was in the reclined position. He said he needed help standing up. A staff member responded immediately when the call light was triggered and assisted resident 1 with standing. Resident 1 was pleasant and was talking in a clear voice. He thanked the staff member and sat back down in his recliner and readjusted his sitting position. He mentioned that he had a hard time getting his legs to work so he could stand up by himself. He said he did not have any pain at that time.Resident 1 was oriented to himself, but not to time, place, or situation. He spoke fondly of the farm he lived on with his wife and family. He talked about his time spent serving in a war and mentioned that he was drafted when he was [AGE] years old.While the survey team was speaking with resident 1, LPN J came into his room with a clipboard and peeked his head around the privacy curtain. LPN J greeted resident 1, nodded, and wrote something down on the clipboard before exiting the room.8. Review of resident 1's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. He had a primary diagnosis of unspecified dementia, with other behavioral disturbances. This meant that he had a brain disorder that caused memory and communication issues, and changes in his normal behaviors.His 11/18/25 quarterly Brief Interview for Mental Status score was 4, which indicated that his cognition was severely impaired.He was assessed for his risk for elopement on 7/23/25 (admission), 10/23/25 (quarterly), and 1/17/26 (after his elopement event).On 7/23/25, his elopement risk score was 4, indicating a potential for elopement. The elopement analysis and prevention plan included, Ensure all door alarms are on at all times to alert staff should they open. Redirect [resident 1] as needed.On 10/23/25, his elopement score was 5, indicating a potential for elopement. The elopement analysis and prevention plan included, Ensure all door alarms are on at all times to alert staff should they open. Redirect [resident 1] as needed.On 1/17/26, his elopement score was 8, indicating a potential for elopement. The elopement analysis and prevention plan included, Ensure all door alarms are on at all times to alert staff should they open. Redirect [resident 1] as needed. Additional comments were added that read, Actual elopement on 1/17/26 with no injuries noted. Care plan updated.Review of his care plan at the time of his elopement on 1/17/26 revealed that there was a focus area that read, At risk for elopement r/t [related to] dementia. That was initiated on 7/23/25. The goal was, Staff will be aware of [resident 1's] whereabouts and redirect as needed. That was initiated on 7/23/25. Interventions included, All doors will remain alarmed to alert staff to possible elopement, Elopement assessment quarterly and PRN [as needed], and Staff will redirect [resident 1] if/when he is noted to be headed towards an exit. Those interventions were initiated on 7/23/25.Review of his updated care plan after the elopement event on 1/17/26 revealed the focus area was updated to read, At risk for elopement r/t [related to] dementia, impaired safety awareness, exit seeking behavior, and history of elopement. Resident eloped from facility on 1/17/26 via east door. Resident was returned with no apparent injuries. Incident reviewed and elopement risk reassessed [on] 1/17/26. An additional goal was added that read, [Resident 1] will remain within the facility unless signed out by family with no further elopement incidents. Interventions were added that included, Conduct frequent visual checks [every] hour, especially during high-risk times (shift change, evenings, visiting hours). This log will be kept hourly for 72 hours from incident, Monitor for exit-seeking behaviors, restlessness, anxiety, or verbalization of wanting to 'go home,' and Offer structured activities and purposeful engagement to reduce wandering or elopement attempts. Those interventions were initiated on 1/17/26.Further review of his care plan revealed there was another focus area that read, Wandering behavior r/t [related to] dementia. That was initiated on 11/17/25. The goal included, Will wander safely within environment aeb [as evidenced by] no serious injuries from fall and no elopement events through review date. That was initiated on 11/17/25. Interventions included, Assess for pain, hunger, thirst, or discomfort during wandering episodes, Attempt to determine cause of wandering and relieve, if possible ([i.e.,] boredom, looking for someone or something), Ensure that hallways are free from spills, clutter and other hazards, Keep familiar routines intact if possible, [NAME] room door with name or familiar photo, to aid in remembering room location, and Provide a program of activities to minimize potential for wandering while meeting need for social/cognitive stimulation. Those interventions were initiated on 11/17/25.A nursing progress note that was added on 1/18/26 at 2:29 a.m. read, Attempted to locate resident for his medications at 2100 [9:00 p.m.]. Unable to locate. Staff checked all the rooms, closets and beds. [DON B] was notified. [Administrator A] came to the facility and assisted in searching for resident. Resident was found across the street on the ground at 2150 [9:50 p.m.]. Very cold to touch. Was wrapped in blankets and checked vitals. Very combative at the time. Incident was reported online to the State [SD DOH]. An hourly log on location of resident will be kept for 72 hours. Temp at this time is 97.7 [degrees Fahrenheit] temporal. Resting well in recliner by the Nurse's station. Wife was notified. Dr. will be faxed. Will monitor location and make sure the door alarms are set at all times.A late entry nursing progress note was added that read, Edited to correct documentation that resident was actually found at 2125 [9:25 p.m.] (or possibly before), not 2150 [9:50 p.m.]. This RN received a call at home from the nursing home at 2130 [9:30 p.m.] stating that resident had been found several minutes ago and that he was inside already being warmed up with blankets, heating pads, and sitting next to the heater. He was found within 30 minutes of when it was noted that he was missing which was at 2058 [8:58 p.m.], so 911 was not called per policy.Review of his behavior documentation revealed that after the elopement incident on 1/17/26, he was grabbing, hitting, and scratching others. There was no documentation of those behaviors during the previous 30 days. His documented behaviors returned to his baseline after 1/17/26.9. Observation with LPN J on 1/21/26 at 9:55 a.m. of resident 1's skin revealed no signs or symptoms of frostbite.10. Review of the provider's 5/25 Resident Incident Policy and Procedure revealed the purpose read, A resident incident report/unusual occurrence report will be completed following any unusual occurrence involving a resident including.elopement.General Incident Procedures included notification to the primary care provider, resident's representative, and the director of nursing. First aid was to be administered as indicated. The incident report was to be completed in the Risk Management section of the EMR. The policy listed instructions for reporting to the SD DOH as appropriate. The resident's care plan was to be reviewed and revised if needed. Follow through included monitoring vital signs, assessing for pain or discomfort for at least 24 hours, and implementing any new interventions while documenting the effectiveness. The policy included to make any internal changes needed to minimize reoccurrence.Under the elopement section, the policy indicated that residents are assessed for risk of elopement on admission, quarterly, and with significant change of condition including an elopement or attempted elopement. Residents with identified elopement risks were to have elopement-prevention interventions in their care plan. The policy indicated that, a door alarm system is in place on exit doors and must be in the 'on' position at all times. Staff is required to investigate every time the alarm sounds to ensure that residents are accounted for.The elopement section included step-by-step instructions of what the staff were to do in the event of an elopement, including performing a head count on all residents, searching all parts of the building, expanding the search outside block-by-block, calling in off-duty staff to aid in the search, calling emergency services if the resident cannot be located within 30 minutes, notifying the resident's family and physician of the elopement, and assessing the resident after the resident was found.11. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 1/21/26 after record review revealed the facility had followed their quality assurance (QAPI) process regarding elopement and resident safety, education was provided to all staff regarding the resident elopement policy, interviews revealed staff understood the education provided regarding those topics, and audits were implemented regarding the location of the five residents at higher risk of elopement and the status of the door alarms. The audits were to continue until the new security keypads and east door could be installed. Based on the above information, noncompliance at F689 occurred on 1/17/26, and based on the provider's implemented corrective action for the deficient practice confirmed on 1/21/26, the noncompliance is considered past noncompliance.

Based on observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were followed regarding: *The cleaning and storage of nebulizer machines and equipment (a device that converts liquid medication into an inhalable mist) for three of three sampled residents (6, 10, 18) who used a nebulizer machine. *The cleaning and storage of a BiPAP machine (device that pushes pressurized air into your lungs) and equipment for one of one sampled resident (10) who used a BiPAP machine. *The maintenance of one of one whirlpool bath chairs in a safe and cleanable condition. *The cleaning, storage, and use of shared personal care items found in one of one whirlpool room. *The storage of items in two of two designated clean linen closets. *The assessment for the risk of Legionella, the implementation of measures to prevent the growth of Legionella, and the establishment of testing protocols for Legionella. Findings include: 1. Observation on 5/5/25 at 3:41 p.m. in resident 6's room revealed there was an oxygen concentrator in his room with a nasal canula (flexible tubing that delivers oxygen through the nose) attached. The nasal canula was draped over the concentrator and was not covered. There was a nebulizer machine on a table. The tubing and the mask were attached to it, and the medication chamber was wet. The mask was sitting on the table, uncovered. Observation and interview on 5/6/25 at 9:19 a.m. with resident 6 in his room revealed that his nebulizer was in the same condition as observed on 5/5/25. The resident stated he used the nebulizer three times per day. He also stated that the staff changed the tubing every week. Observation and interview on 5/7/25 at 9:16 a.m. with resident 6 in his room revealed the nebulizer was in the same condition as observed on the previous two days. He stated that the staff does not disconnect the medication chamber from the nebulizer, rinse it out, and let it dry between treatments. The nasal cannula remained draped over the oxygen concentrator as observed on 5/5/25. Observation on 5/7/25 at 4:12 p.m. and 5/8/25 at 8:32 a.m. of resident 6's room revealed the nebulizer remained in the same condition as previously observed. Review of resident 6's electronic medical record (EMR) revealed: *He had a diagnosis of chronic obstructive pulmonary disease (COPD) (lung disease that makes breathing difficult). *He received nebulizer medication treatments three times a day. *His breathing was to be assessed by a nurse after each nebulizer treatment was completed. *There was an order to change the nebulizer mask and tubing once per week. *There was no documentation or anything in his care plan that addressed the cleaning and storage of his respiratory devices. 2. Observation and interview on 5/6/25 at 10:16 a.m. with resident 10 in his room revealed he had a nebulizer machine on his bedside table, with the tubing and mask attached. The mask was on the table, uncovered, and the medication chamber was wet. Resident 10 stated he used the nebulizer daily. Observation on 5/7/25 at 9:16 a.m. in resident 10's room revealed the nebulizer was in the same condition as observed on 5/6/25. There was a BiPAP machine with the tubing and mask connected to it. The mask was resting in a pink basin on the floor next to the bed, uncovered. There was also a towel and a plastic grocery bag in the basin. Observation on 5/8/25 at 8:33 a.m. revealed the BiPAP and neb machines were in the same condition as observed on 5/7/25. Review of resident 10's EMR revealed: *He had a diagnosis of COPD and emphysema (a lung condition that causes shortness of breath). *He received nebulizer (neb) treatments twice a day. *His breathing was to be assessed by a nurse after each nebulizer treatment was completed. *There was a physician's order to clean the BiPAP daily with soap and water. *There was a 1/20/25 care plan intervention to Administer nebulizer treatments as ordered. Clean and replace equipment and supplies per protocol/as ordered. *There were 12/27/24 care plan interventions to Change BiPAP and oxygen tubing and supplies as ordered and Clean BiPAP and equipment as ordered. *There was no order or anything written in his care plan that addressed the storage of his respiratory devices. 3. Observation on 5/7/25 at 4:12 p.m. of resident 18's in his room revealed: *A neb machine was on resident 18's bedside table with the mask, reservoir cup, and tubing unassembled lying on a dry washcloth. -The washcloth was folded in half and draped over the neb mask and reservoir cup. *Resident 18 could not verify if he had washed the neb mask, reservoir cup, and neb tubing. Observation on 5/8/25 at 9:15 a.m. of resident 18's room revealed: *The neb machine remained on resident 18's bedside table with the mask, reservoir cup, and tubing all assembled. -There was a small amount of clear liquid that remained in the reservoir cup. Interview on 5/8/25 at 9:21 a.m. with registered nurse (RN) D regarding resident 18's nebulizer equipment revealed: *She stated she does not wash out the neb mask, reservoir cup, or tubing. *She indicated that the resident washes out neb mask, reservoir cup and tubing himself after the treatment. Review of resident 18's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had a Brief Interview for Mental Status (BIMS) assessment score of 10, which indicated he was moderately cognitively impaired. *He had a diagnosis of chronic obstructive pulmonary disease (COPD). *A physician's order on 10/29/24 for ipratropium and albuterol (med to relax muscles in the airways and increase air flow to the lungs) inhalation suspension to be given four times a day by neb for COPD. *A physician's order on 10/29/24 for albuterol (med to reduce inflammation) inhalation suspension 0.083% to be given four times a day by neb for shortness of breath (SOB). *His care plan did not include that he washes the neb mask, reservoir cup, and tubing himself. Interview on 5/8/25 at 10:41 a.m. with director of nursing (DON) B revealed: *Nurses were responsible for cleaning the nebulizers and storing them appropriately as part of the post-treatment assessment, and it was her expectation that they were doing that. *It was her expectation that the BiPAP was being cleaned daily, stored, and the daily cleaning of the BiPAP was documented on the MAR. Interview on 5/8/25 at 11:13 a.m. with registered nurse (RN)/infection control preventionist E revealed: *It would be a concern if nebulizer tubing and BiPAP machines were not being cleaned and stored to dry. *She stated they were supposed to be cleaned, left to dry, and stored after each use. 4. Observation and interview on 5/8/25 at 9:34 a.m. with certified nursing assistant (CNA) K in the shower/tub room revealed: *Several containers of partially used and unlabeled soap, shampoo, and lotion next to the whirlpool tub. -She stated those items were shared and used for residents who did not have their own caddy of personal hygiene items available in the shower/tub room. -She agreed that each resident should have had their own personal hygiene products to limit the potential for cross-contamination. *The arm of the bath chair had several areas of rust and areas that were cracked and bubbled. -She agreed that those were not cleanable surfaces. Observation and interview on 5/8/25 at 12:04 p.m. in the shower/tub room with RN/infection control preventionist E revealed: *They had experienced similar issues in the past with the bath chair and had repaired it. -She stated it was not a cleanable surface in that condition and was a risk for possible infection control concerns. Interview on 5/8/25 at 1:10 p.m. with DON B and RN/infection control preventionist E revealed: *They did not have a policy on shared use of personal hygiene products. *It was their expectation that personal hygiene products were not shared between residents to limit the potential for cross-contamination and infection control concerns. *They expected staff to bring each resident's own caddy of personal hygiene products from the resident's room to the shower/tub room and to only use those products for each resident. 5. Observation and interview on 5/7/25 that began at 3:04 p.m. with laundry assistant L of the clean linen closets revealed: *There were two clean linen storage closets with a coded keypads on the doors. *Items other than clean linens were stored in the first closet, including the following unclean items: -A rolling rack that held packages of disposable bathing cloths, a stack of individual disposable briefs, and towels. -A resident's walker with a quilted basket on it that contained a gait belt. -A pair of shoes. -A single shoe. -An open package of heel protectors. -A wheelchair foot pedal. -Opened packages of disposable briefs. -Various cushions, pillows, and wheelchair cushions. *The second clean linen closet had unclean items stored, including: -Opened packages of briefs. -A gait belt. -A blue plastic basket that contained a resident's open and labeled personal care items, including deodorant, lotion, denture care tablets, and lotion. -Packages of disposable bathing cloths. -Christmas decorations. -Wheelchair cushions. *She stated that because linen was not covered in the closet, only clean linen should have been stored there to prevent potential contamination of the linen. Interview on 5/8/25 at 10:41 a.m. with DON B revealed: *It was her expectation that only clean linen be stored in linen closets. *She expected unclean items like wheelchair foot pedals and personal care items to be stored in the storage room. Interview on 5/8/25 at 11:13 a.m. with RN/infection control preventionist E revealed: *She expected linen closets to contain only clean linen. *Unclean items stored with clean linens could result in contamination of clean linens. 6. Interview on 5/8/25 at 12:15 p.m. with administrator A about their water management plan to prevent waterborne pathogens revealed: *They had not assessed their water systems to determine where Legionella (a bacteria that can grow in water and cause serious illness) or other opportunistic pathogens could grow. *They had not implemented any measures to prevent the growth of Legionella in their facility. *They had not established any testing protocols to monitor for the presence of Legionella in their water system. *She stated they did not have a policy related to Legionella. 7. Review of the provider's 12/24 Respiratory Equipment Cleaning Instructions revealed: *Purpose: -To provide proper cleaning of respiratory equipment to maintain proper working order of equipment and to ensure proper infection control methods are adhered to. *Hand Held and Mask Nebulizers: -Clean after each treatment. --Disassemble nebulizer pieces. --Rinse thoroughly with distilled water. --Allow to dry on a clean paper towel or cloth. *CPAP or BiPAP Machine/Equipment: -Daily: --Remove headgear and any other pieces that will detach from the mask. --Remove tubing from any connectors, the humidifier or machine. --Fill a small sink, tub, or basin with warm water. Add a small amount of gentle dish soap. --Submerge the mask, headgear, tubing and connectors in the warm soapy water. Allow to soak for a short period of time (about 20-30 minutes). Rinse. --Allow everything to air dry on a towel. Review of the provider's 1/10 Handling Clean Linen Policy and Procedure revealed: *Purpose: -To prevent contamination of clean linen. *Procedure -Linen must remain covered at all times until it is placed in the resident's room. -This reduces the potential for mishandling linen causing cross-contamination. 51471

Based on observation, interview, and policy review the provider failed to follow standard food safety practices for: *One of one cook (G) who had not changed her gloves or washed her hands while serving resident food items to prevent potential contamination. *Kitchen equipment that had not been cleaned to maintain a sanitary environment. Findings include: 1. Observation on 5/5/25 at 5:28 p.m. of cook G during a meal service revealed with her gloved hands she: *Removed the lids from the covered food items on the steam table. *Touched a ladle and then grabbed the handle of a cart. *Organized resident meal cards and opened the microwave door to heat up the pureed food. *Used a sanitizer wipe to clean the serving ledge of the steam table. *Used a thermometer to check the temperature of the sloppy joe meat. *Opened a drawer and retrieved a spoon to stir the microwaved pureed food. *Opened the microwave door and placed a bowl of potato soup in it. *Retrieved the bowl of potato soup from the microwave. *Retrieved a roast beef and cheese sandwich from a Ziplock bag and potato chips from a bag and placed them on a serving plate. *Checked the temperature of the potato soup and placed the bowl of soup on a tray to be served to residents. *Retrieved hamburger buns from a package sliced the buns into pieces and then put sloppy joe meat on the buns. *Tore up another bun, placed meat on it, and sent it to be served to residents. *Used those same gloves throughout the observed meal service. 2. Interview on 5/6/25 with cook G immediately after the above observation revealed: *She stated it was her normal practice to not change her gloves during food service. *She agreed she should have used tongs to retrieve the buns and the sandwiches from the packages. 3. Observation on 5/6/25 at 11:25 a.m. of the prep table in the kitchen across from the stove revealed: *A 9 by 13 (9x13) inch pan had food spatter and debris on the inside of the pan. *Lids for pans had food spatter and debris on them. *The lower shelf of the prep table had food spatter and debris on it. 4. Observation on 5/6/25 at 11:35 a.m. of the steam table revealed: *The wooden surface had bare wood exposed, making it an uncleanable surface. *The front of the steam table had food spatter and stains on it. *The storage shelf had food stains and debris on it. 5. Interview on 5/6/25 at 11:42 a.m. with dietary manager (DM) F regarding the cleaning of the shelves and the steam table revealed: *The prep table shelf had not been cleaned in a while. *She had a weekly and monthly cleaning schedule posted for staff to follow. *She agreed that those cleaning schedules had not been followed. *She thought that cook D had cleaned the steam table two weeks ago, but food would get spilled on it, and the staff sometimes would not clean the spilled food off the steam table. 6. Interview on 5/6/25 at 11:50 a.m. with cook I regarding the cleaning of the steam table revealed: *He had cleaned the steam table about two weeks ago. *He agreed the steam table needed to be cleaned again. 7. Interview on 5/8/25 at 10:35 a.m. with DM F regarding the observation with cook C revealed: *She had agreed that cook C should have changed her gloves after touching multiple surfaces. *She agreed [NAME] c should not have worn the same pair of gloves when she touched multiple surfaces and then continued to plate and serve food. *Staff should have only worn gloves when preparing ready to eat food items. *DM B agreed that wearing gloves and touching multiple surfaces and then handling ready to eat food items with those same gloves would have been an infection control concern that created the potential for cross-contamination. Review of the provider's cleaning schedule revealed: *The steam table had been signed-off as having been cleaned on 2/11/25, 2/25/25, and 3/4/25. *There was no area to sign-off the completion of cleaning the prep table shelves. Review of the provider's October 2014 Dietary Department Infection Control Policies and Procedures revealed: *Clean and sanitize work surfaces, utensils, and equipment after each use. Review of the provider's undated Use of Gloves and Washing Hands policy revealed: *Only single-use gloves will be used. *Hands must be washed before putting on gloves and when changing to a new pair. *Food handlers will change gloves when: -Gloves become soiled or torn. -Before beginning a different task. -At least every four hours during continual use, and more often as necessary. -After handling raw meat, seafood, or poultry and before handling ready-to-eat foods.

Based on interview, observation, and grievance review, the provider failed to ensure a private area was available for residents and families to meet. This concern was identified by four residents (6, 13, 17, and 22). Findings include: 1. Interview on 5/5/25 at 4:06 p.m. with resident 6 in his room revealed: *He resided in a shared room with another resident. *He had concerns about not having privacy when visitors were there. *He did not like his room full of visitors who visited his roommate. *He stated he had expressed his concerns about privacy to social services director (SSD) C and administrator A. *He stated, I guess I just have to live with it. 2. Interview on 5/5/25 at 4:19 p.m. with resident 22 and her family in her room revealed: *Resident 22 stated there was no private space for a family to meet in the facility. *Her family stated they would like to have a space where the family could gather when they visited the resident that was private. 3. Interview on 5/5/25 at 4:25 p.m. with resident 17 in her room revealed she wished there was a space in the facility where residents and visitors could meet privately. 4. Interview on 5/7/25 at 12:34 p.m. with SSD C revealed: *There were a couple of residents' families that had complained to her about the lack of a private space to meet with residents in the facility. *The previous owner had decided to turn the Family Room into a resident room for financial reasons. *There had been a 4/28/25 grievance filed by a family member about that issue. 5. Interview on 5/7/25 at 12:42 p.m. with director of nursing (DON) B revealed: *They used to have a Family Room that residents and their visitors could use. *It was the previous owner's decision to turn it into a resident room. *They tried to make accommodations for families to meet with residents in the dining room when meals were not being served and activities were not scheduled. *One resident had complained to her about the lack of a private space. *They were planning to eventually get the Family Room back so that residents and their families could have a private space to meet. *She confirmed that there was currently no space available for residents to meet with visitors privately if they shared a room with another resident. 6. Interview on 5/7/25 at 12:49 p.m. with administrator A revealed: *One resident's family member had complained about the lack of a private space for residents and their visitors to meet in the facility. *She had received the go-ahead from current ownership to return that room to the Family Room. *They had not made that change. *She confirmed that there currently was no available space for residents and their visitors to meet privately. 7. Review of the 4/28/25 grievance filed by the family member of resident 13 revealed: *He was very frustrated by having no private space for families to gather. *He offered to go to the board to explain why they needed the space. *Administrator A had written on the bottom of the grievance form, I am going to bring it to the nursing home board at the next meeting on 5/20/25. 8. Review of the provider's undated Resident's Rights in a Nursing Home revealed that residents have a right to have proper privacy, property, and living arrangements.

Based on observation, record review, interview, and policy review, the provider failed to ensure an investigation had been conducted and documented to rule out abuse and neglect for one of one sampled resident (26) who had sustained a skin laceration while being transferred to the bath chair by staff with the use of a total mechanical lift. Findings include: 1. Observation and interview on 5/6/25 at 8:53 a.m. of resident 26 in his room while he was seated in his Geri-chair (a high-backed padded wheelchair with reclining capabilities) revealed: *He had been reclined back in his Geri-chair. *He was non-verbal during the interview. *A total mechanical lift (lift and sling used to lift a person's full body) had been in his room. 2. Record review of resident 26's electronic medical record (EMR) revealed: *He had a diagnosis of Alzheimer's disease and dementia and had been receiving hospice services. *His 3/4/25 Brief Interview for Mental Status (BIMS) assessment score was 99 (which indicated the interview was not completed successfully). *On 3/8/25 at 3:58 p.m. a progress note entered by licensed practical nurse (LPN) J revealed: -Resident has approximately a 2.5-inch laceration on the tip of his penis from the bath sling. -Area was cleaned due to the location it's very difficult to apply a bandage. -Skin protectant applied to the area; MD notified as well as POA. -There we no additional notes to determine how the injury was caused specifically due to the transfer or the bath sling, which staff were involved, or if the transfer was done safely. *On 3/10/25, 3/11/25, and 3/13/25 the laceration had been assessed for healing. *Resident 26 was dependent on staff for mobility and required assistance for: -Transferring with the use of two staff and the total mechanical lift. -Toileting due to him being incontinent of bowel and bladder. -He was not able to communicate his needs consistently. 3. Interview on 5/7/25 at 2:00 p.m. with director of nursing (DON) B regarding resident 26's 3/8/25 injury investigation revealed: *She did not think that she had needed to investigate the acquired injury. *She agreed that an investigation of the incident could have ruled out resident abuse or neglect. *She had not interviewed the staff involved in the incident because she did not think it was a potential abuse or neglect. *An incident report and investigation had not been completed by the nurse who had assessed resident 26's laceration at the time of the event. 4. Interview on 5/7/25 at 3:10 p.m. with DON B regarding her 5/7/25 investigation of resident 26's incident from 3/8/25 revealed: *She had been able to interview the certified nursing assistants (CNAs) who had been involved with the 3/8/25 incident that caused resident 26 skin laceration. *DON B had interviewed licensed practical nurse (LPN) J that had assessed resident 26's skin laceration. *LPN J informed her that the injured area was more of an abrasion than a laceration. *DON B had thought that the words abrasion and laceration were interchangeable. *She had stated that both CNAs involved had been competent to use the full body lift. -No documentation of competencies of the CNA's lift use had been provided. 5. Interview on 5/7/25 at 3:30 p.m. with CNA H who had witnessed the incident on 3/8/25 involving resident 26 revealed: *She was behind the bath chair to assist in guiding him onto the bath chair using the total lift. *She helped to assist him to the back of the chair while he was lowered down by the total mechanical lift by another CNA. *While he was lowered onto the bath chair he said ouch, and they had stopped and noticed he was bleeding from his penis. *They notified the nurse immediately. 7. Review of the provider's November 2018 Abuse and Neglect Policy revealed: *What injuries to report: Injuries investigated and not witnessed. For example, bruises or abrasions, skin tears or lacerations. 8. Review of the provider's November 2018 Abuse, Neglect, and Misappropriation of Property Prevention Policy: *Abuse: Physical harm, bodily injury, or attempt to cause harm or injury, or the infliction or fear of imminent physical harm or bodily injury on an elder of disabled person. 9. Review of the provider's undated Resident Accident Prevention Policy and Procedures revealed: *In the event an accident does occur, the appropriate incident report is completed, depending on the accident. *All reports are reviewed by Administration and Director of Nursing.

Based on the Payroll Based Journal (PBJ) record review and interview, the provider failed to submit PBJ data accurately for three of four federal fiscal quarters (Quarter 1, 2023; Quarter 3, 2023; and Quarter 4, 2023). Findings include: 1. Review of PBJ records submitted to the Center for Medicaid and Medicare (CMS) services revealed the PBJ report for the provider for the three quarters listed above included: *The following items were triggered: -Failure to submit data for the quarter. -One-star staffing rating. *The following metrics were suppressed for invalid data: -Excessively low weekend staffing. -No registered nurse hours worked. -Failure to have licensed nursing coverage 24 hours per day. Interview on 2/25/24 at 3:45 p.m. with administrator A regarding the PBJ reporting information revealed: *She was aware there were issues with the correct reporting of staff member's hours worked. -She thought that was related to incomplete reporting of agency nursing staff member's hours worked. --Each agency staff member had their own number and would clock in and out using the electronic time clock system. *Business office manager (BOM) N was responsible for the coding of all staff hours for the PBJ report. -BOM N would monitor the hours worked on a regular basis and adjust them as needed, rather than waiting until the end of the calendar quarter to fix any identified issues. *Administrator A thought they had resolved issues related to inaccurate PBJ reporting. BOM N was not available for an interview during the survey period.

Based on observation, interview, and policy review, the provider failed to ensure food items were appropriately stored in a safe and sanitary manner in one of one observed kitchen for the following: *One of one commercial refrigerator that contained food items that were not labeled, dated, or discarded by the use by date, and staff items were stored where resident food items were stored. *One of one upright freezer contained food items that were not labeled or dated. *One of two small chest freezers that did not have a functioning thermometer to ensure foods were stored at a safe temperature. *One of one commercial freezer contained food items that were not stored, labeled or dated. *Two of two containers of a food thickening product had scoops stored in them. *One of one container of powdered milk had a scoop stored in it. *Staff food items were being stored where resident food items were blended. Findings include: 1. Observation of the kitchen on 2/25/24 at 3:20 p.m. revealed: *A commercial refrigerator contained: -One opened container of half and half that had a use by date of 2/4/24. -One lidded cup of red liquid that was not labeled or dated. -One covered cup of white liquid that was not labeled or dated. -One Ziploc bag of shredded cheese was not labeled or dated. -One Ziploc bag of diced ham was not labeled or dated. -One plastic grocery bag containing a burrito and a snack-sized package of cheese that belonged to a staff member. *An upright freezer contained two covered cups that were not labeled or dated. *An opened container of powdered milk that had a scoop stored inside of it. *Two opened containers of a food-thickening product that had scoops stored inside of them. *A small chest freezer had a thermometer inside of it that had frozen and was not functioning. *A commercial freezer had a plastic bin that contained two pancakes that were not packaged or labeled. *An opened can of Red Bull that belonged to a staff member placed on the windowsill above the area where residents' food was blended. 2. Observation on 2/25/24 at 5:37 p.m. of the kitchen revealed two outdoor jackets were on the counter where staff would blend residents' food. 3. Observation and interview on 2/26/24 at 5:14 p.m. with dietary manager (DM) M in the kitchen revealed: *Two uncovered slices of pumpkin pie and one and one-half doughnuts placed on Styrofoam plates on counter where resident food items were being blended. *DM M stated they were from lunch for staff and then covered them. 4. Interview and observation on 2/28/24 at 9:49 a.m. with DM M in the kitchen regarding the above observations revealed: *The commercial freezer contained the same unpackaged, unlabeled items as observed on 2/25/24. *She was not aware of the undated, unlabeled, stored food items, or that the freezer thermometer had not been functional. *She felt that staff items could be stored in the kitchen if they were not in direct contact with food items. *She would have expected the following: -All food items should been stored in containers, labeled and dated. -Staff food items should have been stored separately from the resident food items. -She should have been notified by staff of any non-functioning thermometers for replacement. 5. Review of the provider's undated (food) storage policy and procedures revealed: *All perishable foods are refrigerated at the appropriate temperature and in an orderly and sanitary manner. Thermometers are provided in all refrigerators and freezers. Refrigerators are kept at temperatures of 35-45 degrees F and freezers are kept at 0 degrees or less. *All refrigerated left over food is labeled and dated and discarded if not used in 72 hours. 49958

Based on interview, resident council meeting minutes review, and policy review, the provider failed to ensure: *Resident council meetings were conducted on a monthly basis. *Residents were notified of the time and place of the resident council meetings. *There was an investigation, follow-up, and documented responses to resident council grievances brought forward by an undisclosed number of residents identified in three of five monthly meeting minutes sampled (September 2023, December 2023, and January 2024). Findings include: 1. Resident council interview on 2/27/24 at 10:30 a.m. revealed: *There were twelve residents in attendance. *Three anonymous residents stated that grievances were not followed up by staff and communicated with the residents. *Two anonymous residents stated they did not know how to file a grievance. *One anonymous resident stated they were not aware that there was a resident council and that the council met monthly. Review of resident council minutes from September 2023 through January 2024 revealed: *In September 2023 an undisclosed number of residents met with activity director L individually: -An undisclosed number of residents requested an activity called Balloon Act more often. --The response documented in the September 2023 minutes included, Planning on putting it into the calendars more but that doing this my [may] lessen other things or move them around a bit. -There was no resolution that concern. *The 10/16/23 meeting minutes included a meeting that was held with 17 residents in attendance. -Activity director L included, I am going to be moving these meetings to a Tuesday morning at the beginning of each month at 10:30 a.m. This will start in December . *The 12/12/23 the meeting minutes included a meeting that was held with four residents in attendance. -One resident stated she does not like it when a certain resident was allowed to sit beside her because that resident touched things that she should not. --The minutes included, I told her I would talk to the nurse to relay to the CNA's, and I would talk to the Activity staff. -One resident stated that the stop sign in place at her door does not stop a resident from wandering into her room and that resident breaks things in her room. --The minutes included, I told her I would put on [maintenance director D's] clipboard to maybe lower the Velcro [for the stop sign placement] to se if that may help with that resident going under it. -One resident stated that sometimes there was water on her bathroom floor that she had to wipe up before she could use it safely. She thought that was from staff members not wringing out the mop head and other times it was from the toilet leaking. --The minutes included, I let her know I would also put this on his clipboard [maintenance director D] and talk to him about it. She explained that she has talked to him personally about it before and he is aware. -An undisclosed number of residents stated that they get a lot of fruit and is always has a lot of syrup in it. --The minutes included, I let them all know there are state guidelines that we have to follow but I would talk to .[the dietary manager M] about the syrup. -Two residents expressed concerns that their bathroom garbage was not removed as often as it should have been and it was getting too full. --The minutes included, I let them know I will talk to .[maintenance director D] about this and see if he can talk to his staff. -One resident stated she needed extra help in the morning and to be woken up. --The minutes included, I will talk to the DON [director of nursing B] and charge Nurse to talk with CNAs about her needing more help. ---There was no resolutions to the above resident concerns. *On 1/9/24 the meeting minutes included a meeting was held with seven residents in attendance. -An undisclosed number of residents expressed a concern as to why are we short of help around here lately? --The minutes included, I let them know that sense [census] is down and that we must cut some hours. That is why they do not see as many staff on the floor. ---There was no resolution to the concern. Interview on 2/28/24 at 3:00 p.m. with activity director L regarding resident council grievances revealed: *Resident council meetings should have been held on a monthly basis. -Some months she visited residents individually for their input rather than have a meeting. *When a grievance was received during a meeting she: -Would speak to the department head that the grievance pertained to. -For the maintenance department she would write it on his clipboard and maybe speak to him. --He would write his initial next to the grievance on the clipboard when he resolved the concern. -For the social service department, she would fill out a form, talk to registered nurse (RN)/social service designee (SSD) H. *Asked the residents in the next resident council meeting if they wanted to revisit their concern or if it was resolved. -She thought she documented that in the minutes. *She would fill out a formal grievance form, but there hasn't been anything lately that I felt I needed to fill out right away for them. *She had received a grievance from a resident a while ago regarding a nursing concern, she was not certain of how long ago. -For that grievance, she had talked to a certified nursing assistant and a charge nurse. --She had not followed up with the resident to ensure the grievance was resolved. Interview on 2/28/24 at 3:17 p.m. with director of nursing B regarding resident council grievances revealed: *She has never received a grievance from the resident council. *The process for resident council grievances was for a concern specific to a department to be given to that department head to resolve. Interview on 2/28/24 at 3:34 p.m. with administrator A regarding resident council grievances revealed: *Activity director L has never filled out a grievance form from a grievance expressed during a resident council meeting. -Activity director L would speak to administrator A if there was a concern and she would then go talk to the resident to, determine what was going on. --Administrator A would try to resolve the issue, but would not write up a grievance. *Administrator A confirmed a grievance form should have been completed, investigated, and a resolution reviewed with the residents. Review of the provider's undated Grievance Policy revealed: *Policy: -It is the policy of .[provider] to have accessible, responsive grievance procedure which protects residents and their families' ability to report any grievances with this facility. Complaints will be addressed promptly and fairly. *Procedure: -1. Residents and their families have the following rights: --a. To voice concerns and complaints, either orally or in writing, relating to the treatment or care we provide or the behavior of other residents. --b. To receive a timely response by us in which we agree to consider the issue or issues you raise and to act upon them. --c. To be free from any pressure intended to discourage you from voicing your concerns and complaints. -2. Any grievance of a resident or someone acting on behalf of a resident should be directed to our Administrator, the Director of Nursing, or appropriate department head. Details concerning time, place[,] nature of occurrence or condition, persons involved, and other pertinent facts should be included in order to facilitate the investigation and follow-up action. -3. When we receive a grievance, we will: --a. Promptly investigate. --b. Correct any condition found to be inconsistent with our policies and procedures and the rights and responsibilities of our residents.

Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans were updated to accurately reflect the current care needs of four of five sampled residents (2, 11, 31, and 189) including fall interventions, code status, and assist bars. Findings include: 1. Observation on [DATE] at 10:01 a.m. of resident 189's room revealed there were two fall mats on the floor and a twin-sized bed mattress up against a wall. Observation of resident 189 on the following dates and times revealed: *On [DATE] at 10:58 a.m. he had been standing with the right side of his body leaned up against the doorframe. *On [DATE] at 2:10 p.m. and again at 3:10 p.m. he was asleep in his bed that was in a low position with another bed mattress on the floor next to his bed. *On [DATE] at 11:20 a.m. he had been sitting on his bed with his back against the wall and his feet were rested on the fall mat that was on the floor next to his bed. *On [DATE] at 1:58 p.m. he had been resting in his bed on his back and there was a fall mat on the floor next to his bed. Review of resident 189's electronic medical record revealed he was: *admitted on [DATE]. *Diagnoses included Wernicke's encephalopathy (a brain disorder affecting memory), mild cognitive impairment, and repeated falls. *A fall risk assessment was completed on [DATE] that indicated he was at a high risk for falling. *A care plan area goal that he Will not sustain serious injury through the review date. *Care plan interventions included: -A wheelchair is his primary mode of transportation. -Be sure call light is within reach and encourage to use it for assistance as needed. -Coordinate with appropriate staff to ensure a safe environment with: Floors even and free from spills or clutter, Adequate, glare-free light, Call light, Bed in low position at night, Handrails on walls, Personal items within reach. Interview on [DATE] at 2:03 p.m. with director of nursing (DON) B regarding the use of fall mats, the bed mattress on the floor, fall risks, and the care plan for resident 189 revealed: *She confirmed resident 189 had fallen multiple times since his admission. *She was aware a fall mat had been used as an intervention and had thought it was on his care plan. *She then reviewed his care plan and agreed it: -Had an intervention to ensure a safe environment with: Floors even and free from spills or clutter. -Did not include the use of a fall mat or the bed mattress. *She stated the use of a bed mattress on the floor was not a typical intervention, but she felt it was acceptable for staff to use a mattress if they were not able to find a fall mat. *She would have expected the use of the fall mats to have been included in resident 189's care plan. 43844 2. Review of resident 2's medical record revealed: *Her [DATE] signed CPR (Cardiopulmonary resuscitation) Statement of Decision (code status) form indicated she did not wish CPR to be performed. *Her [DATE] care plan indicated she wanted CPR to be performed in the event of a cardiac event. 3. Review of resident 31's medical record revealed: *Her [DATE] signed CPR Statement of Decision indicated she wanted to have CPR initiated in the event of cardiac arrest. *Her [DATE] care plan indicated she did not want CPR performed. Interview on [DATE] at 12:56 p.m. with registered nurse/social service designee (RN/SSD) H regarding code status care planning revealed: *She obtained a resident's preference of code status when they were admitted . *She would add the code status to the care plan at that time. *The interdisciplinary team would review the code status with the resident or their representative at each care conference. *Resident 2's care plan was not updated when her code status changed from CPR to do not resuscitate (DNR) on [DATE]. -She was not certain why the care plan had not been updated to reflect the DNR code status on [DATE]. *She confirmed the care plan should have been updated when the resident's code status changed. Review of the provider's undated Health Advance Directive Policy and Procedure revealed the following: *Objective of Advance Directive Policy and Procedure -E. Resident wishes will be communicated to the staff via the care plan and (identify facility protocol for communication of advance directives either in written or oral format) and to the resident physician. -G. During the quarterly RAI (Resident Assessment Instrument) process and with any significant changes of condition, facility staff will: --v. Changes to the resident choices for advance directives will be documented, included in the resident plan of care, State specific documents will be updated as necessary, physician orders will be obtained to reflect new choices as applicable and all items will be communicated to staff providing resident care. 4. Observation on [DATE] at 4:49 p.m. of resident 11's room revealed bilateral assist bars attached to the bed and they were in the upright position. Observation and interview on [DATE] at 11:07 a.m. with resident 11 revealed: *He was admitted from a hospital two or three weeks ago. -He had broken a bone close to his tailbone. *The bilateral assist bars on his bed were in the upright position. -He used those bars to assist him in getting in and out of bed. Review of resident 11's [DATE] care plan revealed the use of the bilateral assist bars were not included in his care plan. Interview on [DATE] at 2:37 p.m. with RN/Minimum Data Set G regarding resident care plans revealed she was not aware that resident 11 used bed assist bars so she had not added that to his care plan. Review of the provider's updated [DATE] Care Plan policy and procedure revealed: *Basic Responsibility: -MDS Coordinator or designee -Purpose: --Care plans will be developed by an interdisciplinary team with participation of the resident, family, and/or representative (when available). Care plans include active and historical diagnoses, goals and/or expected outcomes, specific nursing interventions so that any nursing staff member is able to quickly identify a resident's individual needs and to decrease the risk of incomplete, incorrect, or inaccurate care, and to enhance continuity of nursing care. *General instructions: -5. Care Plans will be reviewed quarterly, annually and with any significant change in resident condition. Changes that may involve updating the care plan will be discussed and implemented during daily IDT meetings. -6. Care Conferences are offered/scheduled on admission, quarterly, with significant change, and at the request of residents, families, or staff.

Based on observation, record review, and interview, the provider failed to ensure a safe environment, free from potential accident hazards in the room of one of one sampled resident (32) with a history of multiple falls. Findings Include: 1. Observation on 2/26/24 at 11:22 a.m. of resident 32 while in his room revealed: *He had been asleep, seated in his wheelchair, with his feet on the floor, next to his bed, facing his recliner. *There were four areas of flooring around and his recliner that had peeled up and had visible underflooring. -Those areas ranged in size from approximately three inches by four inches to approximately five inches by six inches. *He moved his feet and revealed another area of exposed underflooring and flooring with peeled edges. *He then moved his wheelchair back and the wheel caught on one of the exposed edges. 2. Observation on 2/27/24 at 11:19 a.m. of resident 32's room revealed additional areas of peeled flooring and exposed underflooring beside his bed, in front of his recliner. 3. Review of resident 32's electronic medical record revealed: *He had impaired mobility and cognition. *A wheelchair was his primary mode of transportation. *He had fallen on 08/21/23, 10/29/23, 11/19/23, 11/26/23, 12/8/2023, 12/25/23 and 12/29/23. *He was assessed and found to be at a high risk for falls. *His care plan indicated staff were to coordinate with appropriate staff to ensure a safe environment, that included even floors. 4. Interview on 2/28/24 at 1:37 p.m. with administrator (ADM) A regarding the flooring in resident 32's room revealed: *She was aware of issues with flooring. *The facility was going through a sale and being bought by the city. *It was her expectation that the flooring was to have been repaired at that time. *She stated that the new company will put in new flooring once the sale is complete. *She moved resident 32's recliner and exposed additional areas of torn flooring. *After she observed resident 32's floor she stated, I guess it's getting really bad. *She proceeded to peel back sections of the flooring with her foot.

Based on observation, interview, record review, and policy review, the provider failed to ensure controlled medications (drugs easily diverted by staff) were securely stored for one of one observed medication rooms. Findings include: 1. Observation and interview on 2/27/24 at 2:40 p.m. of the medication room with registered nurse (RN) K revealed: *The cupboard used to store controlled medications that were to have been destroyed was not locked and had several medications placed inside of it. *She stated the director of nursing (DON) B was the only one who had a key for that cupboard. *She immediately requested the DON B to the medication room. 2. Observation and interview on 2/27/24 at 2:44 p.m. with the DON B regarding the controlled medication cupboard revealed she: *Confirmed the cupboard was unlocked and had several controlled medications inside it. *Stated the last time she had accessed that cupboard was to put resident 195's bottle of morphine in it because it did not fit in the slot in the cupboard door. *A count of the medications inside that cupboard and it contained the following controlled medications: -One bottle of liquid morphine sulfate containing one milliliter (ml). -One bottle of liquid morphine sulfate containing 15 mls. -193 tablets of 50 milligrams (mg) of tramadol. -68 doses of 0.5 mg of lorazepam. -43 half-tablets of 5 mg of oxycodone. -56 tablets of 5 mg of hydrocodone and 325 mg of acetaminophen. -86 capsules of 75 mg of pregabalin. -45 tablets of 200 mg of Modafinil. -31 tablets of 2.5 mg of Lomotil. *The count was correct. 3. Observation and interview on 2/27/24 at 2:54 p.m. and again at 3:22 p.m. with the DON B revealed: *Controlled medications would routinely be destroyed about once a month by herself and another RN. *She kept the originals count sheets (controlled drug receipt/record/disposition forms) in her office and would place a copy of the count sheets with the controlled medications and place them in the locked cupboard in the medication room. *She then completed a comparison of those count sheets and the controlled medications amounts on hand, with no missing medications found. *She stated resident 195 had passed away on 2/17/23. His two bottles of morphine sulfate had been kept in the locked box in the locked medication cart and counted by two nurses at each shift change until she was able to place them in the controlled medications cupboard on 2/19/24. *She stated she must not have locked that cupboard door and that it had remained unlocked until it was discovered on 2/27/24, that was 9 days. 4. Interview on 2/27/23 at 3:24 p.m. with RN K revealed she confirmed the controlled medication counting process at each shift change as stated by DON B. 5. Review of the February 2024 narcotic count signature sheet (shift change count sheet) and interview with the DON B on 2/27/24 at 3:33 p.m. and again at 3:54 p.m. revealed: *One missing nurse signature on that narcotic count sheet as follows: -2/6/24 at 7:00 p.m. -2/16/24 at 7:00 p.m. -2/18/24 at 7:00 a.m. and 7:00 p.m. *She identified the two nurses that were on duty during those times as and provided them re-educated them on the controlled medications counting process on 2/27/24. 6. Review of the provider's 2006 Medication Storage In The Facility Controlled Substance Storage policy revealed: *Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances re subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. *The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. *At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented. *Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed. Accountability records for discontinued controlled substances are maintained with the unused supply until it is destroyed or disposed of.

Based on observation, interview, and policy review, the provider failed to ensure one of one whirlpool (WP) tub was cared for in a manner that maintained the quality of the WP tub's interior surface. Findings include: Observation on 2/27/24 at 1:50 p.m. of the shower room on the 100-hallway revealed: *The WP tub had: -Rust-colored areas on the interior bottom of the WP tub around the power jets. -Lime build-up and what appeared to have been grime covering the bottom one-fourth of the interior walls and extending from the waterspout to the drain. -Several areas of paint, on the edge of the WP tub, that were missing exposing the underlying material, the largest area measuring approximately two inches by one inch. *There was a scrub brush for cleaning the WP tub that had bristles that appeared frayed from over-use. Interview on 2/27/24 at 3:43 p.m. with registered nurse/infection control preventionist C regarding the WP tub revealed she: *Agreed the WP tub had lime build-up and what appeared to be grime on the interior walls. -She used her fingernail to scrape off an area of the grime. *Stated the WP tub was disinfected after each resident use but needed a thorough cleaning. -Maybe it is just time for a new one. *Agreed the scrub brush was frayed. *Confirmed the chipped areas on the WP tub made it a non-cleanable surface Observation and interview on 2/28/24 at 8:18 a.m. with certified nursing assistant F regarding the WP tub cleaning and disinfecting revealed: *She disinfected the WP tub according to the instructions that she was provided. -She stated the WP tub was disinfected after each resident use. -The WP tub appeared to be in the same condition as detailed above, after the disinfecting process. *Maintenance director D descaled the WP tub once a month. -She was not sure when that was last done. Interview and review of the maintenance monthly log 2/28/24 at 8:32 a.m. with maintenance director D and director of nursing B regarding cleanliness of the WP tub revealed: *The monthly log included a one-page checklist by month of various items, including Whirlpool Tub. *The month of January 2024 had a check mark by each of the items that were listed. *Maintenance Director D stated he cleaned the WP tub once a month. -He was not sure which day in the month of January 2024 he had cleaned the tub. -He had not cleaned the WP tub in the month of February 2024. -He stated he used LSR (Lime Scale Remover, a potent acid-based compound that dissolved stains and deposits). -He sprayed the LSR on the interior of the WP tub, left the LSR on for ten minutes, then used a power scrub brush to clean it. *DON B stated, It could be better (referring to the cleanliness of the WP tub). *Maintenance director D indicated he might try to clean it more often. Interview on 2/28/24 at 3:35 p.m. with administrator A regarding the WP tub revealed she confirmed the interior surface of the tub was deteriorated, possibly from too strong of a cleaning chemical, and that made it an un-cleanable surface. Review of the provider's updated 11/16/21 Whirlpool Cleaning policy and procedure revealed it did not reference using LSR as a cleaning product.

Based on observation, interview, record review, and policy review, the provider failed to ensure a baseline care plan accurately reflected the resident's care needs for one of one sampled newly admitted resident (90). Findings include: 1. Observation and interview on 2/26/24 at 3:07 p.m. with resident 90 and his spouse revealed he had: *Recently been admitted following a hospital stay. *Was sitting in a wheelchair *Had a urinary catheter in place. *Had an open area to his heel and to his coccyx (tailbone) area. 2. Review of resident 90's medical record revealed: *He was admitted on [DATE]. *At the time of his admission, he had the following: -A blister on his heel and an open wound to his coccyx area. -A catheter was in place. -He used a wheelchair for mobility. 3. Review of resident 90's baseline care plan revealed it indicated: *He did not: -Have a catheter. -Use a wheelchair. -Have any current skin issues. *The Signatures of Staff Completing Baseline Care Plan area indicated it had been completed by registered nurse(RN)/Minimum Data Set coordinator (MDS) G and the RN/social services designee (SSD) H. 4. Interview on 2/28/24 at 8:59 a.m. with director of nursing (DON) B regarding resident 90's baseline care plan revealed she: *Agreed he had a blister on his heel, an open wound to his coccyx, a catheter, and he used a wheelchair at the time of his admission. *Confirmed those areas were not indicated on his baseline care plan. *Would have expected those areas to be addressed on his baseline care plan. 5. Review of the provider's 3/23 Care Plan Policy and Procedure revealed: *It was the responsibility of the MDS coordinator or designee. *Care plans include active and historical diagnoses, goals and/or expected outcomes, specific nursing interventions so that any nursing staff member is able to quickly identify a resident's individual needs and to decrease the risk of incomplete, incorrect, or inaccurate care, and to enhance continuity of nursing care. *Upon admission, resident will be assessed by the MDS Coordinator or designee and a baseline care plan will be developed with information gathered from the resident and resident's family within 48 hours.

Based on closed medical record review and interview the provider failed to ensure one of one sampled resident's (37) closed record included a recapitulation (a summary of the resident's nursing home stay). Findings include: 1. Review of resident 37's closed medical record revealed: *She was admitted on [DATE]. *She was discharged to her home on 12/15/23. *A discharge summary was completed. *There was no documented recapitulation of her stay. Interview on 2/28/24 at 5:31 p.m. with director of nursing B revealed: *Registered nurse/Minimum Data Set G was responsible for completing a discharge summary to include the recapitulation of a resident's stay when they discharged . *Her expectation was for the discharge summary to also include the recapitulation. *She confirmed there was no recapitulation of resident 37's stay in the facility. *There was no policy for a discharge summary or recapitulation of a resident's stay upon their discharge from the facility.

Based on observation, interview, medical record review, and policy review, the provider failed to ensure one of five sampled residents (11) received benefits of use versus the risks of use for bilateral bed assist bars on his bed, had an informed consent signed, and had alternatives attempted before installation and use of those bilateral bed assist bars on his bed. Findings include: 1. Observation on 2/25/24 at 4:49 p.m. of resident 11's room revealed his bed had bilateral bed assist bars attached to the bed in the upright position. Observation and interview on 2/26/24 at 11:07 a.m. with resident 11 revealed: *He was admitted to the facility from a hospital two or three weeks ago. -He had broken a bone close to his tailbone from a fall at home. *The bilateral assist bars on his bed were in the up position. -He did not remember: --Receiving education on benefits of use versus the risk of use for those assist bars. --Signing an informed consent. Review of resident 11's medical record regarding the bilateral assist bars revealed: *There was no documented education for benefits of use versus the risks of use of those assist bars. *There was no signed informed consent. *There was no safety assessment completed for use of those assist bars. *His care plan had not included the use of those assist bars. Interview on 2/27/24 at 2:12 p.m. with certified nursing assistant (CNA) E regarding resident 11's use of the bilateral assist bars revealed that he used those assist bars on the right side of the bed to turn when staff members provided care to him, but he did not use the assist bar on the left side of the bed. Continued interview on 2/28/24 at 9:52 a.m. with CNA E revealed she clarified resident 11 used both assist bars during the night when staff members assisted with his care. Interview on 2/28/24 at 2:03 p.m. with director of nursing B regarding the use of the bilateral assist bars used by resident 11 revealed: *She thought he used the assist bars to get in and out of bed, due to his shoulder pain. *Registered nurse (RN)/Minimum Data Set (MDS) G was responsible for completing the assist bars education, obtaining the informed consent, and completing the assessments. Interview on 2/28/24 at 2:37 p.m. with RN/MDS G regarding the bilateral assist bars used by resident 11 revealed: *She was responsible for assessing residents for safe use of the assist bars. *She was not aware that resident 11 had used bilateral assist bars on his bed. *The process for determining the use of assist bars was for: -The interdisciplinary team to discuss the resident's need for the use of the assist bars. --She was part of the interdisciplinary team. --There was no discussion by the team regarding resident 11's use of those assist bars on his bed. Review of the provider's revised March 2023 Bed Assist Bar Policy and Procedure revealed: *Policy: -Use bed assist bars to enhance resident mobility and independence. -Make resident and/or representative aware of risks of bed assist bars. -Ensure ongoing assessment and maintenance of resident bed assist bar use. *Procedure: -1. Prior to installation of bed assist bar: --a. Alternative must be attempted (i.e. adjusting bed height, raising head of bed, trapeze, concave mattress, bed wedges/bumpers) and reason alternative did not work. --b. MDS Coordinator or designee must complete Bed Assist Bar User Defined Assessment (UDA) in .[electronic medical record program] to determine appropriateness of using it. -2. Decision to install bed assist bar should be made based on the following information assessed in the Bed Assist Bar UDA: --a. Determine the reason for the bed assist bar and if it is likely to the resident meet his or her needs. --b. Evaluation of any bed assist bar alternatives attempted that failed to meet the resident's needs prior to use and installation and alternatives considered but not attempted because they were considered inappropriate. --c. Assess the resident for safety with use of bed assist bar including cognition, mobility, communication, etc. --d. Risk for resident to suffer from entrapment and how the risks will be mitigated. -3. Obtain informed consent of the safety risks after reviewing those potential risks with resident and/or resident representative.

Based on observation, interview, and record review, the provider failed to ensure a safe environment, free from potential accident hazards for all residents who may be at risk for falls or other injury. Findings include: 1. Observation on 2/27/24 at 9:47 a.m. in the dining room revealed: *The laminate flooring in the doorway in the area that transitioned from the front room to the back room had a patch of torn flooring. -That area was approximately three inches by fifteen inches long. -The edges were rough and raised and the underflooring was exposed. 2. Observation on 2/27/24 at 11:31 a.m. in the dining room revealed: *An unidentified dining room staff member had been pushing a metal cart towards the kitchen. *The cart had been unable to avoid the torn flooring and the wheel caught on the upward peeling edges. 3. Observation on 2/28/24 at 1:45 p.m. in the lobby revealed: *The carpeted flooring had a tear that extended from the front of the nurses' station into the 100 hallway over six feet long and approximately two to three inches wide. *Residents had to move through that area to access the dining room and the front door. 4. Interview on 2/28/24 at 1:37 p.m. with administrator (ADM) A regarding the flooring in the dining room and the lobby revealed: *She was aware of issues with flooring. *The facility was going through a sale and being bought by the city. *It was her expectation that the flooring was to have been repaired at that time. *She stated that the new company will put in new flooring once the sale is complete. *She moved resident 32's recliner and exposed additional areas of torn flooring. *After she observed resident 32's floor she stated, I guess it's getting really bad. *She proceeded to peel back sections of the flooring with her foot. Refer to F689

Based on observation, interview, record review, and policy review, the provider failed to investigate two incidents of resident-to-resident altercation involving two of two sampled residents (89 and 90). Findings include: 1. Observation and interview on 2/27/23 at 3:54 p.m. with resident 89 in his room revealed he: *Was sitting in his recliner. *Had been admitted earlier in the month because he had fallen at home and fractured his pelvis. *Had communicated during the interview that his roommate (resident 90) was in the room touching his belongings. He had asked him to stop and the roommate had continued to touched his personal items. *Then pushed the roommate. *Was able to slide up to the front of the recliner seat and displayed how he pushed his roommate back behind the privacy curtain by using a motion with his arm. *Stated the roommate had stumbled back, had fallen, and staff came into the room and picked him up off the floor. *Stated that if his roommate touched his belongings again he would 'lay him out'. *Then expressed he understood resident 90 was not well and had not always understood what was going on. Review of resident 89's medical record revealed: *He was admitted on [DATE]. *His 2/15/23 Brief Interview for Mental Status (BIMS) score was 15, indicating his cognition was intact. *His diagnoses included: fracture of superior rim of right pubis, contusion right shoulder, fracture of unspecified parts of lumbosacral spine and pelvis, chronic kidney disease, pain, repeat falls, pressure-induced deep tissue damage of left heel, and obesity. Observation on 2/27/23 at 3:54 p.m. of resident 90 revealed: *He was confused wandering in the hallway outside of his room. *His speech was garbled. *He could not answer questions when asked. *He did not appear to have any injuries or bruising. Review of resident 90's medical record revealed: *He was admitted on [DATE]. *He was unable to complete the BIMS. *His 2/16/23 Medical Data Set assessment indicated he had short and long-term memory problems. *His diagnoses included: Alzheimer's disease, cellulitis of left upper limb, heart failure, anxiety disorder, and amnesia. Review of resident 89's 2/22/23 nursing progress note revealed: *Resident became angry at roommate and started shouting at him. *nurse intervened just as this resident was about to kick and hit his roommate. *Resident was talking to his son on the phone during this time. *Nurse immediately removed roommate from the situation. *It appeared roommate was previously just standing in the room. *[Resident 89's] son called nurse and spoke to nurse expressing concern for the situation and worried that his dad has a temper. *DON [director of nursing] notified of situation. Interview on 2/28/23 at 3:15 p.m. with DON B and social services designee (SSD) G regarding the situation between residents 89 and 90 revealed: *They both were unaware that resident 89 had pushed resident 90. *DON B was aware of the incident that occurred between the residents on 2/22/23. *DON B had not really identified that the incident on 2/22/23 was resident-to-resident abuse. *The nurse involved in the incident had educated resident 89 that it was not appropriate to yell or threaten his roommate. *There was no documentation of resident 89's education by the nurse. *Since there had been no other incidents since 2/22/23 the residents had not been moved or separated. *Residents were not monitored twenty-four hours a day. *Staff may not have been aware of another incident had occurred between the residents because the residents had not been monitored twenty-four hours a day. *They had not completed an investigation of the incident that occurred on 2/22/23 between the residents. Interview on 2/28/23 at 4:29 p.m. with occupational therapist (OT) L regarding resident 89 revealed he: *Was admitted and receiving OT services. *Had not informed her he had pushed or hit his roommate. *Had not spoken to her about expressing verbal or physical behaviors towards his roommate or other residents. Interview on 3/1/23 at 8:18 a.m. with DON B regarding the situation between residents 89 and 90 revealed: *They had planned on moving resident 90 into another room but had been waiting on a family consent to move another resident first. *No other resident safety interventions had been put into place to protect resident 90 until the room move was completed. *No investigation for the resident-to-resident incidents been started. Interview on 3/1/23 at 8:58 a.m. with administrator A and DON B regarding the situation between residents 89 and 90 revealed: *SSD G had spoken with resident 90 yesterday about his behaviors. *Had been waiting for resident 22's family to call and consent to a room change so the residents could be moved away from each other. *Staff had been observing the residents when they were awake but not when they were asleep. *Agreed either resident could have awoken and staff would not have known if they were up and moving. *They did not have one-to-one staff monitoring in place for resident 89 or 90 to ensure their safety. *Agreed they had not investigated the verbal abuse that had occurred on 2/22/23. IMMEDIATE JEOPARDY HARM Interview with resident 89 revealed he had pushed resident 90 resulting in resident 90 falling. Resident 89 indicated if resident 90 had touched his belongings again he would lay him out. There had been documentation in resident 89's medical record showing staff had been aware of his verbal and physical aggression towards resident 90. IMMEDIATE JEOPARDY NOTICE On 3/1/23 at 8:58 a.m. an immediate jeopardy had been determined when the provider failed to ensure resident 90 had been safe from abuse by his roommate. Administrator A and DON B were asked for an immediate removal plan. IMMEDIATE JEOPARDY REMOVAL PLAN: On 3/1/23 at 12:08 p.m. administrator A provided the survey team with a final written approval plan. The approval plan had been approved by the long-term care advisor for the department of health on 3/1/23 at 12:22 p.m. The facility provided the following acceptable removal plan on 3/1/23 at 12:08 p.m.: Corrective Action: 1. Resident 90 was moved to 111-2. Care plan updated to reflect monitoring of resident to detour from wandering unwanted into other resident rooms. A Velcro stop sign has been placed on resident 89's door. Reviewed and revised resident 89's care plan to reflect the Velcro STOP sign on door as deterrent for entry of wandering or unwanted resident entry. Reviewed and revised as needed resident incident policy. Identification of Others: 2. All other residents will be reviewed by the interdisciplinary team today regarding aggression toward residents who wander in their room. All staff will be educated on resident Incidents immediately on 3/1/2023. System Changes: 3. Any resident that is identified as having aggression toward residents who wander will have a Velcro stop sign placed in their doorway. Monitoring: 4. Director of Nursing or designee will do audits every 15 minutes for 24 hours then hourly audits for the next 24 hours If there are no further issues then the audits will be 3 times a shift for 3 days to ensure stop signs are preventing wandering resident from entering resident 89's room and getting into his belongings. 5. Anticipated completion date: 3/1/2023 The immediate jeopardy had been removed on 3/1/23 at 12:45 p.m. after verification that the provider had implemented their removal plan. After removal of the Immediate Jeopardy, the scope/severity of the citation level is G. Review of resident 89's 2/24/23 care plan revealed his mood and behavior had not been addressed so there had been no goals or interventions in place. Review of resident 90's 3/1/23 care plan revealed: *He had behaviors related to dementia and being in a new environment. *His behaviors were wandering, exit-seeking, and going through others belongings. *The interventions included the following: -Anticipate and meet needs of resident including toileting on a schedule every 2 hours at the least. -Attempt non-pharmacological interventions such as giving resident a magazine, the tinkering box with locks and latches, a snack. -Ensure that hallways are free from spills, clutter and other hazards. -Redirect resident to a new activity if he is wandering into other's rooms or getting into other's stuff. Review of the provider's September 2012 Long Term Care Facilities Resident's Bill of Rights booklet provided in the resident's admission packet revealed: *A facility must provide care and an environment that contributes to your quality of life including: -1. A safe, clean, comfortable and home-like environment. -4. Freedom from theft of personal property; verbal, sexual, physical or mental abuse; and involuntary seclusion, neglect or exploitation imposed by anyone. Review of the provider's November 2018 Abuse, Neglect, and Misappropriation of Property Prevention Policy revealed: *Employees will identify, intervene, and correct situations in which abuse, neglect and/or misappropriation of patient/resident's property may occur. This includes assessment of the patient's/resident's environments, adequate staffing to meet patient needs, and supervision of staff to identify inappropriate behaviors. *Patients/residents will be continually assess, care planned, and monitored in order to identify needs and behaviors which might lead to conflict or neglect. *When an incident occurred, a report would be completed and followed up on by the administrator or DON. *All incidents will be investigated thoroughly by administration. Any complaints will be reported within 24 hours to the South Dakota Department of Health, [NAME], SD, followed by a written report within 5 working days. Review of the provider's November 2022 Resident Incident Policy and Procedure revealed: *A resident incident report/unusual occurrence report will be completed following any unusual occurrence involving a resident including but not limited to: falls, abuse, neglect, resident-to-resident altercations, injury of unknown source, elopement, and medications errors. *2) Resident-to-Resident Altercations: -a) Take immediate and necessary actions to intervene while providing appropriate supervision and monitory to protect the resident and other resident(s). -b) Determine if the altercation was willful. Willful means the individual intended the action itself that he/she knew or should have known could cause physical harm, pain, or mental anguish. Even though a resident may have cognitive impairment, he/she could still commit a willful act. -ii) If the act was willful and resulted in the infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish, then do an investigation and report to DOH [Department of Health] per the appropriate timeline. *Document occurrence, effect, and resolution in notes.

Based on observation, interview, record review and policy review, the provider failed to ensure one of one sampled resident (90) was protected from verbal and physical abuse by his roommate (resident 89). Findings include: 1. Observation and interview on 2/27/23 at 3:54 p.m. with resident 89 in his room revealed he: *Was sitting in his recliner. *Had been admitted earlier in the month because he had fallen at home and fractured his pelvis. *Had communicated during the interview that his roommate (resident 90) was in the room touching his belongings. He had asked him to stop and the roommate had continued to touched his personal items. *Then pushed the roommate. *Was able to slide up to the front of the recliner seat and displayed how he pushed his rommate back behind the privacy curtain by using a motion with his arm. *Stated the roommate had stumbled back, had fallen, and staff came into the room and picked him up off the floor. *Stated that if his roommate touched his belongings again he would 'lay him out'. *Then expressed he understood resident 90 was not well and had not always understood what was going on. Review of resident 89's medical record revealed: *He was admitted on [DATE]. *His 2/15/23 Brief Interview for Mental Status (BIMS) score was 15, indicating his cognition was intact. *His diagnoses included: fracture of superior rim of right pubis, contusion right shoulder, fracture of unspecified parts of the lumbosacral spine and pelvis, chronic kidney disease, pain, repeat falls, pressure-induced deep tissue damage of the left heel, and obesity. Review of resident 89's 2/24/23 care plan revealed his mood and behavior had not been addressed so there had been no goals or interventions put in place. 2. Observation on 2/27/23 at 3:54 p.m. of resident 90 revealed: *He was confused wandering in the hallway outside of his room. *His speech was garbled. *He could not answer questions when asked. *He had not appeared to have any injuries or bruising. Review of resident 90's medical record revealed: *He was admitted on [DATE]. *He was unable to complete the BIMS due to his cognition. *His 2/16/23 Medical Data Set assessment indicated he had short and long-term memory problems. *His diagnoses included: Alzheimer's disease, cellulitis of left upper limb, heart failure, anxiety disorder, and amnesia. *He had fallen on 2/11/23, 2/19/23, and 2/20/23. Review of resident 90's interdisciplinary progress notes from 2/11/23 through 3/1/23 revealed he was having multiple behaviors that included: -Wandering throughout the facility and into other resident's rooms. -Looking through other residents' belongings. -Exit seeking. -Becoming verbally and physically abusive with staff. -Removing his clothing in public areas. Review of resident 90's Fall Reports revealed on: *2/11/23: -He had an unwitnessed fall in the dining room. -No investigation had been completed. -No interventions had been put into place to prevent another fall. *2/19/23: -He had been found lying on the floor in his room. -No investigation had been completed. -No interventions had been put into place to prevent another fall. *2/20/23: -He had been found on the floor in his room and had been incontinent of bowel. -No investigation had been completed. -No interventions had been put into place to prevent another fall. Review of resident 90's 3/1/23 care plan revealed: *He had a Potential for falls r/t [related to] impaired cognition. *Interventions were: *Appropriate non-slip footwear. *Be sure call light is within reach and encourage to use it for assistance as needed. *Coordinate with appropriate staff to ensure a safe environment with: Floors even and free from spills or clutter, Adequate, glare-free light, Call light, Personal items within reach. *PT evaluate and treat as ordered or PRN [as needed]. *No new fall interventions had been added to the care plan since 2/13/22. *He had behaviors related to dementia and from being in a new environment. *His behaviors were wandering, exit-seeking, and going through other's personal belongings. *The interventions included the following: -Anticipate and meet needs of resident including toileting on a schedule every 2 hours at the least. -Attempt non-pharmacological interventions such as giving resident a magazine, the tinkering box with locks and latches, a snack. -Ensure that hallways are free from spills, clutter and other hazards. -Redirect resident to a new activity if he is wandering into other's rooms or getting into other's stuff. 3. Review of resident 89's 2/22/23 nursing progress note revealed: *Resident became angry at roommate and started shouting at him. *The nurse intervened just as the resident was about to kick and hit his roommate [resident 90]. *The resident was talking to his son on the phone during that time. *The nurse immediately removed the roommate from the situation. *It appeared the roommate [resident 90] was previously just standing in the room. *[Resident 89's] son called nurse and spoke to nurse expressing concern for the situation and worried that his dad has a temper. *DON [director of nursing] notified of situation. 4. Interview on 2/28/23 at 3:15 p.m. with DON B and social services designee (SSD) G regarding the situation between residents 89 and 90 revealed: *They both were unaware that resident 89 had pushed resident 90. *DON B was aware of the incident that occurred between the residents on 2/22/23. *DON B had not really identified that the incident on 2/22/23 was resident-to-resident abuse. *The nurse involved in the incident had educated resident 89 that it was not appropriate to yell or threaten his roommate. *There was no documentation of resident 89's education by the nurse. *Since there had been no other incidents since 2/22/23 the residents had not been moved or separated. *Residents were not monitored twenty-four hours a day. *Staff may not have been aware of another incident that had occurred between the residents because the residents had not been monitored twenty-four hours a day. *They had not completed an investigation of the incident that occurred on 2/22/23 between the residents. Interview on 3/1/23 at 8:18 a.m. with DON B regarding the situation between residents 89 and 90 revealed: *They had planned on moving resident 90 into another room but had been waiting on a family consent to move another resident first. *No other resident safety interventions had been put into place to protect resident 90 until the room move was completed. *No investigation for the resident-to-resident incidents had been started. Interview on 3/1/23 at 8:58 a.m. with administrator A and DON B regarding the situation between residents 89 and 90 revealed: *SSD G had spoken with resident 90 yesterday about his behaviors. *Had been waiting for resident 22's family to call and consent to a room change so the residents could be moved away from each other. *Staff had been observing the residents when they were awake but not when they were asleep. *Agreed either resident could have awoken and staff would not have known if they were up and moving. *They did not have one-to-one staff monitoring in place for resident 89 or 90 to ensure their safety. *Agreed they had not investigated the verbal abuse that had occurred on 2/22/23. 5. Interview on 3/2/23 at 10:52 a.m. with DON B regarding falls revealed: *Nurses did not document interventions put into place after a resident had fallen. *Falls had only been reviewed by the interdisciplinary team (IDT) on Monday mornings. *The IDT did not complete an investigation or implement new interventions when a resident had a fall. Refer to F610 finding 1 for policies.

Based on interview, record review, and policy review, the provider failed to investigate and report alleged abuse to the South Dakota Department of Health (SD DOH) for two of two sampled residents (89 and 90) who had inappropriate verbal and physical behavior between each other and one of the residents (90) was cognitively impaired. Findings include: 1. Observation and interview on 2/27/23 at 3:54 p.m. with resident 89 in his room revealed he had pushed his roommate (resident 90) causing his roommate to fall. Refer to F600 finding 1 and F610 finding 1. Review of resident 89's 2/22/23 nursing progress note revealed: *Resident 89 had been found to be shouting at resident 90 and threatening to hit and kick him when a nurse intervened. *There was no investigation related to that incident. -This incident had not been reported to the South Dakota Department of Health (SD DOH). Refer to F610 finding 1. Interview on 2/28/23 at 3:15 p.m. with director of nursing (DON) B and social services designee (SSD) G revealed: *They were not aware resident 89 had pushed resident 90 causing him to fall. *DON B was aware of the incident that had occurred between residents 89 and 90 on 2/22/23 but there had been no investigation completed. *Neither incident had been reported to the SD DOH. Refer to F610 finding 1.

Based on observation, interview, record review, and policy review, the provider failed to assess and document timely, implement, monitor, and review and update care for three of four sampled residents (21, 28, and 89) who had multiple medical conditions and were at risk for pressure ulcer development. Findings include: 1. Review of resident 89's medical record revealed: *He was admitted on [DATE]. *His 2/15/23 Brief Interview for Mental Status (BIMS) score was 15, indicating his cognition was intact. *His diagnoses included the following: fracture of superior rim of right pubis, contusion right shoulder, fracture of unspecified parts of lumbosacral spine and pelvis, chronic kidney disease, pain, repeat falls, pressure-induced deep tissue damage of left heel, and obesity. *His Braden Scale score (used to predict risk of developing a pressure ulcer) on 2/15/23 was 20, indicating he was not at risk. Review of resident 89's nursing progress notes from 2/14/23 through 2/28/23 revealed: *On 2/14/23 he had a discoloration to his left heel measuring 0.5 centimeters (cm) x 0.9 cm. -He was places on a list for physician to see him on 2/16/22. *On 2/16/23 he was seen by a physician. The nurses note addressed a sore behind his ear and a corn on his left lateral foot, but had not addressed the area to his heel. *On 2/23/23 Brought to nurse's attention that resident continues with left heel discoloration. Upon assessment, wound is oblong in shape, 1.2 cm x 1 cm, black/blue in color. Resident states area is very tender, but when he is walking on it the pain goes away. It was brought to [physician's name] attention on 2/16/23 with no new orders. Resident does off load pressure on boney surfaces himself. He does reposition himself. Is mobile with assist of one r/t [related to] safety. Wears shoes while walking. Pressure relieved mattress and cushion to chair. *On 2/24/23 the dietary manager was informed of the suspected deep tissue injury to his right heel and consulted with a registered dietician (RD) to increase his protein intake. Review of resident 89's 2/16/23 physician's long-term care progress note revealed there was no documentation about the suspected deep tissue injury to his left heel. Review of resident 89's 2/24/23 weekly wound documentation revealed: *The wound to his left heel was a suspected deep tissue injury (SDTI) and measured 1.2 cm x 1 cm. *Date of onset was 2/14/23. *The wound was not open or draining. *AMT (American Medical Technologies) guidelines would have been followed for treatment of the wound, and no treatment was required at the time of the nurse's assessment. Continued review of resident 89's medical record revealed: * On 2/24/23 the nurse faxed the physician a copy of the 2/24/23 weekly wound documentation. *On 2/24/23 the physician returned a fax back to the facility that read Noted, deep tissue injury precautions noted for left heel area. Monitor closely. Review of resident 89's February 2023 medication and treatment administration records revealed: *A physician order for a skin assessment to have been completed weekly on Tuesdays and as needed. *A physician order with a start date of 2/24/23 for the following: -Pressure Injury Treatment/Prevention on each shift two times a day. --1. Check that air mattress is on bed and operating correctly. --2. Float heels when in bed. --3. Pressure redistribution cushion in w/c [wheelchair]. --4. Reposition q2-3h [every two to three hours]. --5. Pericare as indicated. --6. Heel protectors while in bed. *They had not addressed the resident had a SDTI or where it was located. *There had been no treatment or daily monitoring orders of the SDTI to his left heel. Review of resident 89's 2/23/23 care plan revealed it had been updated on 2/23/23 to include: *The SDTI to his left heel. *1. Float heels while in bed *2. Wear heel protectors as tolerate while in bed *3. Weekly wound assessments *4. Encourage resident to keep shoes off except while transferring. Interview on 3/1/23 at 2:31 p.m. with registered nurse (RN) D regarding resident 89 revealed: *She had found the spot on his heel on 2/14/23. -She did not put any interventions in place at that time. -She added him to the list to have been seen by his physician on 2/16/23. *His physician had seen him on 2/16/23 and all he seen was a corn on his foot so nothing further was ordered for SDTI to his left heel. *When she observed it again during his next skin assessment on 2/24/23 it was larger. *The area would only have been assessed weekly during his skin assessment. *There were no treatments ordered because the wound was not open. Interview and observation on 3/02/23 at 10:20 a.m. with RN D of resident 89's SDTI to his left heel revealed: *He had a discolored brownish area to his left heel about the size of a quarter. *He denied pain to the area. *There was no dressing on the area of his left heel and it was left open to air. Interview on 3/2/23 at 10:52 a.m. with director of nursing (DON) B regarding pressure ulcers revealed: *The week after the physician had assessed at the wound on resident 89's left heel it had worsened. *After the area had worsened then it was decided it was a SDTI. *Staff was encouraging resident 89 to take his shoes off when not up walking and to elevate his heels off the mattress when he was in bed. *Nurses only assessed SDTI's to heels weekly when scheduled skin assessments were completed. *Certified nursing assistants (CNAs) looked at residents skin during personal care and would let the nurse know if there had been a change. *It was not in the CNA's scope of practice to assess resident wounds. *AMT guidelines were used when deciding on a treatment for wounds. *Having the nurse assess SDTIs weekly had not followed the AMT guidelines. 43021 2. Observation and interview on 2/27/28 at 11:25 a.m. with resident 28 revealed: *She had been here a couple of months. *There were bilateral assist bars on her bed, an air mattress on her bed, and a cushion in her chair. *She was able to easily engage in conversation. Review of resident 28's medical record revealed: *She had been admitted on [DATE]. *Her 1/12/23 brief interview for mental status (BIMS) score was a 15, meaning she was cognitively intact. *Her diagnoses included multiple medical conditions and a Stage II pressure ulcer of the sacral region. *She had required staff support to ensure all her needs had been met. -Stage II pressure ulcer identified as oval-shaped and present on her coccyx. --1.5 centimeters (cm) x 0.6 cm. --No drainage was noted. --Had 100% granulation. --The pressure ulcer caused the resident pain. -Treatment and interventions for pressure ulcer included cleanse with normal saline (NS), apply hydrogel gauze cut to fit, and cover with foam dressing. --Reposition approximately Q [every] 2-3 hours. --Pressure relieving mattress and pressure reducing cushion in chair. --Air mattress to bed. *Family or resident notified of wound and educated on 01/06/2023. Review of resident 28's care plan revealed: *The plan was initiated on 1/6/23, with a focus area pressure ulcer related to diagnoses of severe malnutrition and impaired mobility. *Goal to have pressure ulcer show signs of healing and remain free from infection through review date of 1/24/23. *Identified interventions included the treatment interventions as well as assist rails to aid in turn and repositioning. *Weekly skin inspections by licensed staff with daily skin inspections with cares. Review of resident 28's Weekly Wound Documentation revealed: *From admission on 1/6/23 through 1/13/23, the pressure ulcer had increased and worsened in size from an oval-shaped 1.5 centimeters (cm) by 0.6 cm Stage II pressure ulcer on her coccyx with no drainage and 100% granulation (an indicator of healing) to 2.0 cm by 1.5 cm with serous drainage (thin, watery fluid), and deteriorated to 75% granulation and 25% slough (dead tissue). *On 1/23/23, ten days later, the wound assessment identified two separate pressure ulcers. -The first identified on admission 1/6/23, remained the same as noted on 1/13/23. -The new, facility-acquired circular shaped pressure ulcer was on her right buttock and measured 0.3 cm by 0.3 cm with serous drainage, 75% granulation and 25% slough. On 1/31/23, the wound assessment identified the first pressure ulcer and noted an increase in size to 2.5 cm by 1.5 cm, serous drainage and 100% granulation. -The facility-acquired pressure ulcer was not addressed. On 2/7/23, the wound assessment addressed both pressure injuries. -The first pressure ulcer remained the same as noted on 1/31/23. -The facility-acquired pressure ulcered was indicated as an onset of 2/7/23 and was noted as 0.2 cm by 0.2 cm with serosanguineous (thin, watery pink tinged fluid) drainage with 90% granulation and 10% slough. --Same treatment for coccyx wound and right middle buttock wound. *From 2/8/23 through 2/21/23, there were no documented wound assessments. *On 2/22/23, the wound assessment addressed both pressure ulcers. -The first pressure ulcer on her coccyx measured 1.5 cm by 0.5 cm with serous drainage and 100% granulation. -The facility-acquired pressure ulcer on her right buttock had increased in size to 0.6 cm by 0.4 cm by 0.1 cm and had serosanguineous drainage with 90% granulation and 10% slough. Review of resident 28's treatment administration record (TAR) revealed: *Her January 2023 TAR included the treatment plan for the pressure ulcer to her coccyx. -It did not reflect any plan for care for the facility-acquired right buttock pressure ulcer identified on 1/23/23. *Her February 2023 TAR reflected change on 2/7/23, to include care for both coccyx and buttock pressure ulcer. Interview and review about resident 28's wound assessment, wound care, and documentation on 3/2/23 at 1:11 p.m. with DON B revealed and confirmed: *Resident 28 had been admitted on [DATE], with the pressure ulcer to her coccyx. *The pressure injury was deteriorating on 1/13/23. *On 1/23/23, a facility-acquired pressure injury was identified by registered nurse D. -She had not documented notification of family or physician. -No new treatment plan had been initiated from 1/23/23 through 2/6/23. -There was no assessment of the new pressure ulcer on 1/31/23 -On 2/7/23, the physician was notified of the facility-acquired pressure ulcer with treatment orders. - --Family was not notified. *No wound assessments of either pressure ulcer were conducted from 2/8/23 through 2/21/23. *The only intervention change reflected the initiation of wound care for the right buttock pressure ulcer on 2/7/23. 43844 3. Observation on 2/27/23 at 12:22 p.m. of resident 21's room revealed: *She was not in her room. *A sign attached to the wall above her bed that read, Blue heel protectors to be worn in bed. Observation on 2/28/23 at 2:23 p.m. and at 3:01 p.m. of resident 21 in her room revealed: *She was in her bed with her eyes closed. *She did not have on blue protector boots. *There were blue protector boots on floor at the end of her bed. Observation on 3/02/23 at 7:50 a.m. of resident 21 revealed: *She was in her bed with her eyes closed. *Her legs were covered with a blanket. *There was one blue protector boot on the floor next to the bed. Interview on 3/1/23 at 1:58 p.m. with CNA J regarding resident 21 revealed: *She was to wear the blue protector boots when in bed and up in her chair. *Sometimes she would kick off her blue protector boots. Review of resident 21's medical record revealed: *She was admitted on [DATE] and her diagnoses included: a 1/24/23 diagnosis of pressure-induced deep tissue damage of her left and right heels, pain, dementia, mood disturbance, and anxiety. *Her 1/25/23 BIMS score was a 3, meaning she had severe cognitive impairment. *Review of her hospital notes from 1/18/23 to 1/24/23 revealed she had bilateral heel pain during her hospital stay. *Her 1/30/23 Braden scale score was 18, meaning she was at low risk for development of pressure ulcers. Review of resident 21's 1/25/23 nursing admission assessment revealed: *She had no open areas, ulcers, or other skin issues identified. *Both of her heels were boggy, reddened, but blanchable and she had reported pain to both heels. Review of resident 21's physician orders revealed: *On 1/24/23 to complete skin assessments weekly. *On 2/2/23 to treat her left heel SDTI per AMT guidelines. *On 2/8/23 to have pressure Injury treatment/prevention on each shift two times a day related to pressure-induced deep tissue damage of her right and left heels. --To check that air mattress was on the bed and operating correctly. --To ensure bilateral heel protectors were worn at all times except during transfers. --To ensure dressings were in place as ordered. --To have a pressure redistribution cushion in her wheelchair. --Reposition her every two to three hours. Review of resident 21's 2/8/23 care plan included: *She required extensive assist of two staff members for care including repositioning in bed. *A 1/25/23 focus of a potential for pressure ulcer related to her impaired mobility and incontinence. -Her goal for the focus was to have intact skin, free of redness, blisters, or discoloration. -Interventions on 1/25/23 for the focus and goal included weekly skin inspections by licensed staff and daily skin inspections with care, turn and reposition every two to three hours and as needed (prn), and to float heels. --Interventions added on 2/8/23 included heel protectors in bed and shoes for transfers only. -Her care plan had not included that she had SDTI of her left and right heels or that she kicked off her heel protectors at times. Review of resident 21's progress notes revealed: *On 2/4/23 her heels were slightly reddened, and she was wearing blue protector boots when in bed for her boggy/painful heels. -Staff floated her heels using pillows under her legs. -She had a pressure redistribution mattress on her bed and a pressure redistribution cushion in her wheelchair. -She was repositioned every two to three hours and prn. *On 2/8/23, Brought to nurse's attention this morning that resident's heels have dark spots. Nurse assessed and sees dark purple/maroon area of discolored in tact [intact] skin to bilat [bilateral] heels. Upon admission, resident had reddened, boggy heels. Area is oval in shape. Peri-wound is slightly reddened and boggy. Resident does c/o pain to heels. Does wear heel protectors/booties at all times except for transfers. Air mattress to be placed on bed. Review of resident 21's weekly wound documentation assessments revealed: *They had been completed on 2/8/23, 2/16/23, and 2/23/23 and included: -Wound onset date of 2/8/23 with the wounds being classified as SDTI. --Measurements of her left heel included: ---On 2/8/23 2.7 cm (centimeters) x 1.7 cm. ---On 2/16/23 2.7 cm x 1.7 cm. ---On 2/23/23 2.5 cm x 2 cm. --Measurements of her right heel included: ---On 2/8/23 2 cm x 1.5 cm. ---On 2/16/23 2 cm x 1.5 cm. ---On 2/23/23 1.9 cm x 2.5 cm. Observation and interview on 3/2/23 at 10:31 a.m. of resident 21 with physical therapist (PT) H in the therapy room revealed: *She had dark brown areas to bilateral heels. -The left was about the size of a nickel. -The right was about the size of a dime. *Resident stated she had pain to those areas on her heels. *PT H stated they had tried not having any heel protectors on when resident 21 was first admitted but she was digging her heels into her footrest, so the heel protectors were put on her feet. *PT H confirmed that resident 21 often rubbed her heels on the bed. Interview, record review, and AMT guidelines review on 3/2/23 at 11:07 a.m. with registered nurse D revealed: *Resident 21's wound assessments were completed weekly by a nurse unless the CNA's notified the nurse of a skin concern. -She confirmed they had not been following the 2/2/23 physician's order or AMT guidelines for SDTI. --She stated the AMT guidelines indicated to assess the wounds daily. --There was no designated wound care nurse on staff, the charge nurse for the day would have been responsible for assessing the wounds. Interview, record review and AMT guidelines review on 3/2/23 at 11:39 a.m. with DON B regarding resident 21's SDTI revealed: *The charge nurses completed weekly wound assessments on all wounds. *CNAs would observe the wounds daily when providing routine personal care. -There was no documentation to reflect daily CNA observing and reporting wound observation to the nurse(s). *She confirmed they had not been following the 2/2/23 physician's order or AMT guidelines for the SDTI for resident 21's bilateral heels. 4. Review of 2013 AMT guidelines for SDTI revealed: *Avoid topical agents until wound had fully evolved; eschar is present and begins to separate; and/or drainage is present with the exception of moisture barrier products for incontinence prone areas. *Eliminate pressure as much as possible. *Off-load heels. *Monitor diligently and document tissue characteristics daily, as DIT [deep tissue injury] can change rapidly.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (25) with a facility acquired pressure ulcer had received necessary care and interventions to prevent her wound from developing and worsening. Findings include: 1. Review of resident 25's medical record revealed: *She had been admitted on [DATE]. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her 11/9/21 Braden scale for predicting pressure sore risk was 19 indicating she was low risk for developing a pressure ulcer. *She had skin assessments completed on 11/8/21, 11/15/21, 11/22/21, 11/29/21, 12/6/21, 12/13/21, and 12/20/21. *On 11/28/21 a calloused area had been noted to be pulling away from the skin bed on her right heel. *On 11/30/21 the nurse practitioner had seen her and assessed the right heel. *On 12/2/21 an order had been received to apply [MEDICATION(S)] to the callous area on her right heel. The area was to be left open to air during the day and covered with an adhesive foam pad at bedtime. *On 12/3/21 a nurse note revealed the right heel was a stage II pressure ulcer. -The heel was dressed as ordered with the adhesive foam pad and elevated on a pillow. -She did not have complaints of pain. *On 12/5/21 she was noted to have pain in the right heel. *On 12/14/21: -She had an appointment with a podiatrist: --The wound to her right heel was a stage III pressure ulcer. --The wound treatment order had been changed. --A Multi Podus [is made of firm plastic and thick foam or sheepskin and intended to protect the heel from pressure and friction] boot was ordered. -Her son had been notified of the stage III pressure ulcer and updated on the treatment plan. -She had been noted to have complaints of pain in the right heel. -Was the first time a weekly wound user-defined assessment had been completed to document the size and appearance of the wound. Observation on 12/19/21 at 3:55 p.m. of resident 25 on her back in bed revealed she had a pair of shoes on, her right heel was flat on the bed, and her left foot was hanging off the left side of the bed. Observation on 12/19/21 at 4:30 p.m. of resident 25 sitting up in her wheelchair revealed she was wearing a pair of shoes. Observation on 12/20/21 at 9:02 a.m. of resident 25 sitting in her wheelchair at a table in the dining room revealed she was wearing gripper socks. Observation on 12/20/21 at 9:31 a.m. of resident 25 sitting in her wheelchair in her room revealed she was wearing gripper socks and there had been a pair of foam heel protectors on the foot of her bed. Observation on 12/20/21 at 10:28 a.m. of resident 25 sitting in her recliner with the footrest in the up position revealed: *She was wearing gripper socks. *Her heels had been resting on the footrest. *A pair of foam protectors had been on the foot of the bed. Observation on 12/20/21 at 12:31 p.m. of resident 25 sitting in her wheelchair at a table in the dining room revealed she had been wearing gripper socks. Observation on 12/20/21 at 1:53 p.m. of resident 25's pressure ulcer during wound care treatment by registered nurse (RN) G revealed: *The pressure ulcer was to the back of the right heel. -The center of the wound bed was black and the size of a nickel. -The edges of the wound were moist and white. Interview on 12/20/21 at 2:00 p.m. with RN G regarding resident 25 revealed: *The wound on the right heel appeared as a callous. *When resident returned from her appointment with the podiatrist the podiatrist had diagnosed it as a stage III pressure ulcer. *She had agreed that because the wound bed was black it should have been an unstageable pressure ulcer. Observation on 12/20/21 at 2:30 p.m. of resident 25 revealed she had been assisted with a bath and was sitting in her wheelchair with a pair of shoes on. Interview on 12/20/21 at 3:30 p.m. with certified nursing assistant (CNA) J regarding resident 25 revealed: *She had given her a bath and the dressing on her right heel had fallen off. *She had told the nurse and the nurse was going to redress the wound. *She did not know if the resident should have been wearing her shoes or not. Observation on 12/20/21 at 4:45 p.m. of resident 25 revealed: *Her right shoe had been removed and she was wearing a Multi Podus boot. -A Multi Podus boot is used to eliminate pressure or friction on the heel and increase blood flow to the area. *She was still wearing her left shoe. Interview on 12/20/21 at 4:50 p.m. with RN G revealed the Multi Podus boot had just been delivered and initiated. Observation on 12/21/21 at 8:15 a.m. of resident 25 sitting at a table in the dining room revealed she was wearing a gripper sock on her left foot and a Multi Podus boot on her right foot. Observation on 12/21/21 at 10:03 a.m. of resident 25 revealed she had been: *On her back in her bed. *Wearing the Multi Podus boot on her right foot. *Wearing a gripper sock on her left foot. -The left heel was flat on the bed and not elevated to relieve pressure to the heel. Observation on 12/21/21 at 1:09 p.m. of resident 25 revealed she: *Had been on her back in her bed. *Had been wearing the Multi Podus boot on her right foot. *Had been wearing a gripper sock on her left foot. -The left heel was flat on the bed and not elevated to relieve pressure to the heel. *Had a small blanket folded up, a comforter, and the sheets between her heels and the bed. Review of the progress notes from resident 25's 12/14/21 podiatry appointment revealed: *She had a stage II pressure ulcer. *It was imperative they offload the heel. *A Multi Podus boot was recommended. Review of resident 25's doctor order sheet revealed on 12/14/21 a verbal order had been received to: *Order a Multi Podus boot for right heel and to use the foam heel protectors until it had arrived. *Apply iodine gauze to pressure ulcer, cover with dry gauze, and tape in place daily. *Have a follow-up appointment in one month. Review of resident 25's turning and repositioning documentation revealed: *It had been added to the CNA's task list on 12/20/21. *She had been turned and repositioned on: -12/20/21 at 1:33 p.m. and 9:54 p.m. -12/21/21 at 4:50 a.m. and 1:50 p.m. *Staff had not documented turning and repositioning prior to 12/20/21. Review of resident 25's 11/10/21 care plan revealed: *She had a focus area related to risk for pressure ulcer development due to impaired mobility and incontinence. *She had a goal revised on 12/14/21 for the pressure ulcer to show signs of healing and remain free from infection . *Interventions included: -To provide treatments as ordered. -A pressure redistributing mattress had been initiated on 5/28/21. -Licensed staff to perform weekly skin assessments. -Assist rails allowed her to turn side to side independently. *It had not included the foam heel protectors, Multi Podus boot, turning and repositioning, or off-loading of her heels. *It had not included the location of the pressure ulcer. Review of resident 25's Weekly Wound Documentation User Defined Assessments revealed: *The first one had been completed on 12/14/21 and it had indicated: -The onset date of the wound was 11/30/21. -The wound was a stage III pressure ulcer on the right heel and measured 2 centimeters (cm) x 1 cm. --There had been no depth to the wound. --The wound was not open. --The wound had a scant amount of bleeding. --The edges of the wound had been macerated. -There was pain noted to the pressure ulcer that had been managed with scheduled doses of Tylenol. -Heel protectors had been worn at night. -A pressure-relieving mattress on the bed and pressure-relieving cushion in the wheelchair. *On 12/21/21: -The wound was an unstageable pressure ulcer to the right heel that measured 2 cm x 1.2 cm. -There was no depth to the wound. -The wound had a scant amount of bleeding. -The wound was covered with 90 percent dead tissue and 10 percent new tissue. -Pain was noted to the pressure ulcer and was managed with scheduled doses of Tylenol and a [MEDICATION(S)] patch. Interview on 12/21/21 at 8:13 a.m. with CNA E about resident 25's pressure ulcer revealed: *She was not to be wearing her shoes because it caused her to have pain. *Staff should have been putting on the foam heel protectors and floating the right heel when she was in bed. *The Multi Podus boot had just been put into place. Interview on 12/21/21 at 11:03 a.m. with MDS coordinator C regarding resident 25's pressure ulcer revealed: *She had agreed the location of the pressure ulcer should have been on the care plan. *When asked what interventions had been put into place after the pressure ulcer was discovered she had indicated they had done daily dressing changes. *All wounds were discussed at the interdisciplinary team (IDT) meeting on Mondays. *When a new wound was found she would hear about it from the charge nurse. *She had not read the resident's progress notes daily and did not know that it had been called a stage II pressure ulcer on 12/3/21. *She agreed no other interventions were care planned after the discovery of the pressure ulcer. *She stated a dressing had been ordered, the doctor was called, and the doctors order had been followed. -She did not think there needed to be any further interventions. *She agreed that shoes could have caused pressure on the heels. Interview on 12/21/21 at 1:13 p.m. with director of nursing (DON) B regarding resident 25's pressure ulcer revealed: *Resident 25 had been mobile and able to move herself so she did not know how the pressure ulcer had developed. *Before the podiatrist appointment the right heel was not open, it had been covered with a white callous. *She had not been aware that a nurse had documented the wound on the right heel as a stage II pressure ulcer on 12/3/21. *She had not seen the pressure ulcer since the podiatrist appointment, but had been told the podiatrist had debrided the wound. *She had expected the staff to put on the foam heel protectors when she was in bed. *The foam heel protectors had been put into place prior to the podiatrist appointment. -This had not been documented, so she had not known when they were implemented. *She agreed interventions after the pressure ulcer had developed had not been documented. *The pressure ulcer had been discussed during interdisciplinary team (IDT) meetings on Mondays, with a discussion about using the stand lift as needed and doing the dressing changes. -No other interventions had been discussed. -IDT notes had been copied and given to all departments and CNAs. *She agreed the turning and repositioning task had just been added to CNA's documentation on 12/20/21, so there had been no documentation of resident being turned or repositioned prior to that. *She agreed the care plan should have included interventions such as the Multi Podus boot, foam heel protectors, not to put her shoes on, and to elevate her feet on a pillow when in bed. *She agreed that having a folded-up blanket and a comforter under the resident's feet while in bed could have affected the pressure reducing function of the mattress. Review of the provider's updated 7/24/20 Skin and Wound Management Policy and Procedure revealed: *Wounds are identified as avoidable or unavoidable -If unavoidable, documentation in the medical record includes assessments, interventions, re-assessments and additional interventions, as well as the identification of the resident's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *Care plans were to be individualized and updated on an ongoing basis. *In the event of eschar or necrotic tissue [dead tissue] the facility typically regards this wound as unstageable. A fundamental requirement of staging is the ability to visualize the base of the wound, which is not possible when eschar or necrotic tissue is present.

Based on observation, interview, record review, and policy review, the provider failed to ensure complete nutritional support services were in place for one of three sampled residents (3) with nutritional concerns. Findings include: 1. Review of resident 3's medical record revealed: *She had been admitted on [DATE]. -There had been a readmission on 2/12/16. *Her weight had declined over the past year: -144 pounds (lb) on 9/30/16. -140.5 lb on 11/4/16. -130 lb on 12/30/16 indicated a 10% weight loss. -127 lb on 2/17/17 indicated a 10% weight loss. -119.5 lb on 4/21/17 indicated a 10% weight loss. -120 lb. 0n 7/28/17. *The annual Minimum Data Set (MDS) assessment dated [DATE] had been coded as having a weight loss of 5% or more in the last month or loss of 10% or more in last six months that was not physician prescribed. *The quarterly MDS assessment dated [DATE] had been coded as having a loss of 5% or more in the last month or loss of 10% or more in last six months that was not physician prescribed. Observation on 8/7/17 from 5:30 p.m. through 6:30 p.m. of resident 3 in the dining room revealed: *She had been sitting at a table in the back smaller dining room where the residents requiring assistance with dining sat. *There had been five residents at the table with her. *After thirty minutes she was served her food. *Her food had been in a divided plate. *She had been given four drinks. -Two were chocolate Boost, a commercial supplement. -One had been water and the other cranberry juice. *A certified nursing assistant (CNA) had been sitting across the table from her. *Four times in a one hour period she had been encouraged to take a drink. *One time she had been encouraged to take a bite. *All four drinks had been consumed. *No food had been eaten. Observation on 8/8/17 from 8:45 a.m. through 9:45 a.m. revealed: *She walked to the dining room with her walker and a CNA. *She sat in the same location in the back dining room. *At 9:07 a.m. breakfast had been brought to her. *Her food was served on a small plate. -Breakfast was one slice of toast with jelly that had been cut in half and four drinks. *The drinks were: -Two were chocolate Boost. -One had been water and the other cranberry juice. *There had been one CNA across the table from her assisting another resident. *The nurse's medication cart was next to where she had been sitting. -Neither the nurse nor the medication aide had spoken to her during the meal. *At 9:27 a.m. the CNA had encouraged her to drink. -The CNA then left the table to start assisting residents back to their rooms. *All four drinks had been consumed. *No toast had been eaten. Observation on 8/8/17 from 12:10 p.m. through 12:30 p.m. revealed: *At 12:10 p.m. she had been brought to the dining room in her wheelchair. *Her food had already been placed on the table prior to her arrival. *Her food had been in a divided plate. *She had been given four drinks. -Two were chocolate Boost. -One had been water and the other cranberry juice. *A linen napkin was next to her plate. *At 12:20 the speech therapist asked if she could assist her with the napkin. -The linen napkin was placed around her neck. *At 12:22 p.m. a CNA had sat next to her and cued her to drink her juice. *At 12:25 p.m. the CNA had moved to another table to assist someone else. *All four drinks had been consumed. *No food had been eaten. Observation on 8/8/17 from 5:30 p.m. through 5:50 p.m. revealed: *She had been brought to the same location in the back dining room. *Her food had been in a divided plate. *She had been given four drinks. -Two were chocolate Boost. -One had been water and the other cranberry juice. *After twenty minutes a CNA sat next to her and began to encourage her to drink. Review of the CNA Information Sheet dated 8/7/17 revealed: *No direction to staff in regards to nutrition. -No information regarding supplement use. -No amount of assistance with eating had been included. Review of meal intake sheets dated 7/10/17 through 8/8/17 revealed: *Eighty meals had been documented. -Forty-eight meals had been documented as 0 to 25% consumed. -Five meals had been documented as 26 to 50% consumed. -One meal had been documented as 51 to 75% consumed. -One had been miscoded to tube feeding. -Two times the resident had not been available. -Twenty-three times had been documented as resident refused. Review of fluid intake sheets dated 7/10/17 through 8/8/17 revealed: *In parenthesis it stated 'Boost- kitchen will warm it up for you and put [MEDICATION NAME] in if you ask.' *Twenty-nine days had been documented. -Each day had between one and three entries documented. -Thirty-three times had been documented as 0 to 25% consumed. -Twelve times had been documented as 26 to 50% consumed. -One time had been documented as 51 to 75% consumed. -Two times had been documented as resident not available. -Sixteen times had been documented as resident refused. *There had been no way to know how many of the above times [MEDICATION NAME] had been added. Review of the registered dietitian (RD) consultant reports revealed: *12/14/16 report listed interventions as: -Carnation instant breakfast at breakfast. -4 ounces (oz) warmed chocolate Boost at lunch and supper. -They would increase that to 8 oz of Boost with lunch and supper. *1/30/17 report listed interventions as: -Carnation instant breakfast at all meals. -8 oz Boost at lunch and supper. *2/28/17 report had stated to continue current interventions. *3/28/17 report had stated to continue current interventions. *4/28/17 report had stated to continue current interventions. -Family and physician aware of decline. -Provider note dated 4/11/17 had stated the goal was comfort. -Weight might be unavoidable due to end stage dementia. *5/30/17 report had continued Carnation instant breakfast three times a day and had increased Boost to three times a day. *6/27/17 report continued above interventions and had added a Boost or Breeze supplement at the PM snack pass. *7/24/17 report had stated to continue current interventions. Review of resident 3's 7/6/17 revised care plan revealed: *Focus area: Potential for alteration in nutrition due to impaired cognition. *Goal: Will maintain adequate nutritional status as evidenced by maintaining stable weight. *Interventions: -Monitor laboratory tests and results as ordered and follow-up as needed. -Monitor weights per protocol or as ordered by physician. -Provide adaptive equipment as needed. -Provide and serve supplements as ordered for weight loss. -Registered dietitian (RD) to evaluate and make diet change recommendations PRN. -Serve diet as ordered. -Staff will supervise and cue as needed at meals. *Focus area: Activities of daily living self-care performance deficit due to impaired cognition. *Goal: Will maintain current level of function through the review date. Interventions: -Eating: Requires limited assist of one for eating. Interview on 8/9/17 at 10:10 a.m. with CNA C revealed: *There was no formal communication process to find out about changes to residents required level of assistance in regards to eating. *Notes were often placed in the communication book. *She would ask other CNAs if care had changed if she had not worked recently. *If a resident had a change in regards to supplements the kitchen would label them on the snack cart. *All the staff communicated well at this facility. Interview on 8/9/17 at 10:20 a.m. with nurse D revealed: *There was no formal form in regards to communicating a level of care change. *The CDM would tell the charge nurse if a resident needed more assistance with eating. *The charge nurse would let the CNAs know, and they would pass it on to the next shift. *If there was time for report at shift change the nurse would pass on the information. *There was a weekly meeting where resident's changes would be discussed. Interview on 8/9/17 at 1:30 p.m. with the CDM regarding resident 3 confirmed: *An ongoing list of residents weight was maintained on a clipboard on her desk. -She would check it daily. -If a weight was off she would ask nursing for a re-weigh. *She was aware of resident 3's continued decline in regards to nutrition. *She communicated with the RD through text, phone call, fax, or email whenever she felt there was a concern. *After review of the RD notes she could not explain why the RD listed one Carnation instant breakfast and one Boost, and why they had been serving two Boost and no Carnation instant breakfast. -She did agree the RD should have been aware of what supplements were being served to the resident. -She did agree there could be ingredients in a supplement that when taken in excess could cause harm to a resident. *They did not have a physician's orders [REDACTED]. -She was unaware if they would need one. -She was unsure if the RD knew they were using [MEDICATION NAME]. -Documentation did not show if any [MEDICATION NAME] had been used. *Residents were reviewed at the weekly manager's meeting. *Weights were reviewed with families during quarterly care conferences. -Family was aware of her decline. -They had declined a feeding tube during the 1/25/17 care conference. *She usually would not question the RD's recommendations. -She was unsure why they were not fortifying her drinks. -She did not know if the resident would consume more if they liquefied the food. *If the RD made a recommendation she brought it to the CDM. -The CDM would bring it to the director of nursing services (DNS). -The DNS would bring it to the physician. *She had been aware the resident liked chocolate. -She agreed they could have tried serving more chocolate items. Interview on 8/9/17 at 2:10 p.m. with the SSC and DNS confirmed: *There was no formal communication system to discuss resident's weight concerns. *They were discussed at the weekly manager's meeting. *Changes were passed on through report or the communication books. *The RD would frequently stop into the DNS office if she had concerns. *Staff had access to the online care plans. *CNA assignment sheets would sometimes include dining assistance instructions. -She agreed that information would have been helpful to the CNAs. *Tube feeding had been discussed with the family at the 1/25/17 care conference. Review of the untitled, undated supplements policy revealed: *Unplanned weight loss of 5 lb. in one week or 5% in one month would receive added calories/nutrients as needed. -Calories/nutrients would be in the following forms: --Super cereal, whole milk, pudding snack, sandwich, cookies, etc and/or supplements such as instant breakfast and commercial products.

Based on record review, observation, interview, and policy review, the provider failed to ensure: *One of one resident (2) who had been hospitalized for [REDACTED]. *Insulin administered per injection pen for one of one randomly observed resident (16) had been done correctly by one of one observed licensed practical nurse (LPN) (F). *Medication had been stored securely from residents, staff, and visitors during one of two observed medication passes. Findings include: 1. Review of resident 2's medical record revealed: *An admission date of [DATE]. *Admitting [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] arthritis. -Chronic pain. -Dorsalgia. -Weakness. -Constipation. -Gastritis. -Moderate protein calorie malnutrition. -Depression. -High blood pressure. -[MEDICAL CONDITION]. -Right below-the-knee amputation. -Pressure ulcer of the right and left buttocks. *Review of the hospital admission notes from a 2/13/16 hospitalization revealed: -CT scan of the abdomen and pelvis at the time of that admission revealed Severe distention of urinary bladder. Mild hydro[DIAGNOSES REDACTED] of bilateral kidney which is secondary to the bladder distention. Moderate to severe fecal retention within the proximal colon. -Hospital emergency room (ER) physician's assessment revealed: --Abdominal pain secondary to the bladder distention. --Constipation. --Dehydration with [MEDICAL CONDITION]. -Hospital ER physician's plan for treatment included: --Foley catheter inserted with almost 1700 (cubic centimeters) (56.6 ounces) urine output. --Magnesium [MEDICATION NAME] administered for constipation. --Severe dehydration and [MEDICAL CONDITION] treated with intravenous therapy and monitoring of the patient's sodium, blood urea nitrogen, and creatinine. *Review of the resident's hospital admission assessment by the ER physician revealed: -No BM (bowel movement) for several days and some nausea. -Chronic constipation. -Bowel sounds present, Distended (Mildly tympanic), Soft. -Urinary outlet obstruction. Review of the provider's Nurse's Notes for the following dates revealed: *On 2/11/16 at 2:40 p.m., Resident up @ 0730 when this nurse got on shift. Went to therapy shortly after. @0830 he left therapy. Staff told me he was requesting a sleeping pill and to be put back into bed. Staff put him back into bed. -Resident complained he was so sick and nauseated and had diarrhea all night and today. His pain was 9.5 so he received requested MS IR ([MEDICATION NAME], strong opiate narcotic). His temperature was 99.9 so he received ES (extra strength)Tylenol. - At 10:45 a.m. his pain was unchanged and his temperature was 98.6. He still complained of nausea so [MEDICATION NAME] was given. At 11:00 he had no relief. Staff reports that he had had no loose BM's today. Will continue to monitor. That note had been signed by LPN F. *No further nurses' notes until 1:45 a.m. 2/12/16. *On 2/12/16 at 1:45 a.m., Complains of nausea refuses antacids. Says they don't work. No emesis. Resident refuses to eat. MS given at 12:00 a.m. Says pain is a 10. That note had been signed by LPN H. *No further nurse's notes until 2/13/16 at 3:30 a.m. *On 2/13/16 at 3:30 a.m., Resident complained of nausea. He assured me he was comfortable and might take his [MEDICATION NAME] ER (extended release) later if his stomach felt better. He did appear to be sick. He felt he just had the flu At 4:20 a.m. still complains of nausea. [MEDICATION NAME] 4 milligram order received from physician assistant and if he wasn't better by 8:00 a.m. to call ER and send resident over for nausea concerns regarding dehydration, ongoing abdominal pain and nausea since Wednesday. The notation had been signed by RN I. **On 2/13/16, Physician contacted at 11:00 a.m. Resident reported pain in right upper quadrant of his abdomen at 9. He stated he felt like someone hit me. He has been in bed for two consecutive days. Very nauseated. Low grade fever of 99.3 range for consecutive days. Left in the ambulance at 11:35 a.m. Family had been notified. That note had been signed by LPN J. *On 2/14/16 at 0005, Report from ER was he was full of stool. That note had been signed by RN I. There had been no documentation in any of the above nurses' notes or in the medical record for resident 2 regarding assessment or examination of his abdomen. There had been no mention of urinary or bowel elimination assessments or monitoring. There had been no documentation of assessment for bowel sounds. There had been no documentation of palpation to his lower abdomen for nursing assessment reasons. Review of resident 2's Pain/PRN Monitoring Tool revealed on 2/11/16 at: *9:30 a.m., his pain level remained at 9.5. That was one hour and fifteen minutes after the prn medication had been received by resident 2. *10:45 a.m., [MEDICATION NAME] was given with no relief. *3:30 p.m., MS IR was given to the resident with no relief at 4:20 p.m. Review of resident 2's February 2016 Medication Administration Record [REDACTED]. Resident 2's bowel elimination record was requested from the director of nurses (DON) on 6/15/16 at 11:00 a.m. She stated We don't keep those. There are more than one resident's names listed on it, so we shred them at the end of each month. She stated she thought He had been having bowel movements. She stated there had been no record available of the resident's bowel or bladder elimination. Interview on 6/15/16 at 1:20 p.m. with the DON revealed: *The February 2016 resident bowel elimination records had been shredded. *She agreed she could not verify if resident 2 had been urinating or having bowel movements. *She agreed there had been no assessment of the resident's lower abdomen documented from 2/11/16 at 2:40 p.m. through 2/13/16 at 11:00 a.m. *She thought He had been having bowel movements and urinating. *She knew [MEDICATION NAME] was a narcotic and could cause drug induced constipation. *The night nurse was responsible for checking to see who needed to have laxatives. She was to review the bowel elimination records each night. She then made a list for the day nurse of those residents needing laxatives. Review of Patricia A. Potter et al., Fundamentals of Nursing, 8th Ed., Televise, St. Louis, Mo., 2013, pages 1046 and 1091 revealed: *With [MEDICAL CONDITION] a patient (resident) may void small amounts of urine 2 or 3 times an hour. Assess the abdomen for evidence of bladder distention and tenderness. Medication side effects may result in [MEDICAL CONDITION] (1046). *Constipation can be caused by medications. Opiates for pain often require a stool softener or laxative to prevent constipation (1091). 2. Observation on 6/14/16 at 11:30 a.m. of LPN F while she administered insulin with an insulin pen to resident 16 revealed she did not prime the pen prior to the injection Interview on 6/15/16 at 11:00 a.m. with the consultant pharmacist revealed his expectation was for insulin pens to be primed with two units of insulin prior to injecting. Interview on 6/15/16 at 11:30 a.m. with LPN F confirmed she had not primed the insulin pen prior to using it. She stated she knew she should have, but forgot. Interview on 6/15/16 at1:30 p.m. with the DON revealed her expectation for using insulin pens was for them to have been primed with two units of insulin before injecting the insulin. She agreed LPN F had not followed the correct process for use of the insulin pen. Review of the provider's July 2012 Skills Checklist: Administration of Insulin Via Medication Pen revealed the insulin pens were to have been primed before each injection. 3. Observation on 6/15/16 at 8:30 a.m. of the medication cart while in the dining room revealed two medication pill cards laying part way inside a three ring binder. That binder laid on top of the medication cart. One of the medication cards had been empty. The other medication card contained fourteen tablets of [MEDICATION NAME] 80 mg. Interview with LPN F at that same time revealed she laid the cards there, so she would remember to take them to the medication room. She agreed they were not secured, and there had been residents, staff, and visitors present in the dining room area. Review of the provider's January 2005 Medication Administration General Guidelines policy revealed no medications were to have been kept on top of the cart.