Every finding on record at Jenkin's Living Center

Based on observation, interview, and policy review, the provider failed to ensure that resident medications were secured by three of three licensed nurses, contracted travel licensed practical nurse (LPN) I, LPN M, and registered nurse (RN) nurse manager H, who left medication carts unlocked and unattended. Findings include: 1. Observation on 5/19/26 at 11:01 a.m. revealed registered nurse (RN) nurse manager H left the medication cart unlocked, in the nurse's station by the elevator and storage room marked room [ROOM NUMBER], during the fire drill. 2. Observation and interview on 5/20/26 at 8:19 a.m. outside of resident 9's room with contracted travel LPN I revealed there was a medication cart that was unlocked and no staff member was present. At 8:20 a.m., contracted travel LPN I returned to the medication cart and confirmed it was unlocked. She left the cart unlocked and went into the dining room to give a resident their medication. She stated that it was not her normal practice to leave the medication cart unlocked, had forgotten to lock it, and was away from it for a few minutes. 3. Observation on 5/20/26 at 8:53 a.m. revealed LPN I left the medication cart unlocked, in the nurse's station by the elevator and storage room marked room [ROOM NUMBER], until 9:10 a.m. when she returned to the cart. 4. Observation on 5/20/26 at 11:02 a.m. revealed LPN I left the medication cart unlocked, in the nurse's station by the elevator and storage room marked room [ROOM NUMBER]. LPN I then returned to the medication cart at 11:04 a.m. 5. Interview on 5/20/26 at 2:43 p.m. with LPN I revealed she knew she had left the medication cart unlocked and that it should be locked when she walked away from it. 6. Observation on 5/20/26 at 6:58 p.m. in the oak center unit revealed the medication cart was unlocked and unattended by any staff. There was two unidentified certified nursing assistants (CNAs) who walked past the medication cart during the observation. There were also four unidentified residents sitting four feet away from the medication cart in the television area. 7. Interview on 5/20/26 at 7:03 p.m. with LPN M revealed she had worked for the facility since December of 2025. She was the nurse in charge of the oak center unit for her scheduled shift which started at 6:00 p.m. She had just come from a resident's room and she confirmed the medication cart was left unlocked and that she had the medication cart keys. She acknowledged that the medication cart should always be locked when unattended. 8. Interview on 5/20/26 at 7:10 p.m. with RN G revealed she expected the medication cart to be locked whenever it was not attended by the nurse. 9. Review of the provider's revised July 2025 Medication Administration policy revealed 15. The medication cart should always be locked unless it is in direct view of the nurse/UAP [unlicensed assisted personnel].

A. Based on observation, interview, and policy review, the provider failed to ensure infection control practices were followed by three of three observed certified nursing assistants (CNA) (D and E) and one of one registered nurse (RN) G when assisting three of four sampled residents (2, 6, and 44) with personal care.Findings include: 1. Observation on 5/20/26 at 8:45 a.m. of CNA D assisting resident 44 in his room revealed there was a sign on the resident's door that indicated he was on enhanced barrier precautions (EBP) (the implementation of personal protective equipment (PPE) which included the use of gloves, gowns, and masks to prevent the spreading of organisms). All staff had to wear a gown and gloves when assisting the resident. Without washing or sanitizing her hands, CNA D put on a gown and a pair of gloves before entering the resident's room. With those gloved hands, CNA D opened the resident's closet door, gathered clean clothes, and laid them on the resident's bed. She moved the resident's bed and the bedside table to make more room to assist him. She tore a garbage bag off a garbage bag roll that was lying on a dresser, opened it up, and placed it on the bed. She raised the resident's bed higher and removed the blanket covering the resident. She opened the bedside stand and took out a package of wet wipes, opened it, and laid it on the resident's bed. With those same gloved hands, CNA D opened the resident's incontinent brief (an absorbent, disposable undergarment worn to help with urine and bowel leakage), grabbed wet wipes, provided personal care, and assisted the resident to turn onto his left side. She grabbed more wet wipes and cleansed his rectal area and buttocks. She removed a bottle of cream from the bedside stand, opened it, put some on her right gloved hand, and applied it to his rectal area and buttocks. While wearing those same gloves, CNA D put a clean incontinence brief on resident 44 and placed Hoyer lift (device used to assist with transferring from one surface to another) sling underneath him with assistance from RN nurse manager H. CNA D moved the Hoyer lift over to the resident's bed, attached the sling to it and used the Hoyer lift remote to lift resident 44 off his bed an transfer him into his recliner. CNA D removed the sling from the lift, opened the resident's door, and pushed the Hoyer lift into the hallway. CNA D changed the resident's shirt, covered him with a blanket, and moved the bedside table closer to him. CNA D removed and discarded her gloves in a trash can, removed her gown, and washed her hands for the first time. 2. Observation on 5/20/26 at 12:30 p.m. of CNAs D and F with resident 44 in his room revealed that without washing or sanitizing their hands, both CNAs put on a gown and a pair of gloves. Both CNAs D and F moved the Hoyer lift closer to resident 44, repositioned the sling underneath the resident, and attached it to the Hoyer lift. CNA D removed the blanket that was covering the resident. She then used the Hoyer lift remote to lift the resident out of the recliner and assisted CNA F with transferring him onto his bed. After they had completed the transfer, they unhooked the sling from the lift and removed it from underneath the resident by rolling him back and forth in bed. CNA D opened resident 44's bedside stand drawer, took out a package of wet wipes, laid it on his bed covers, opened it, and pulled out several wipes. She tore a garbage bag off a garbage bag roll that was lying on a bedside dresser, opened it, placed it on the bed, and raised the bed higher to assist the resident more easily. With those same gloved hands, both CNAs D and F lowered resident 44's pants to check his incontinent brief. He was incontinent with both urine and bowel. CNA D opened the resident's incontinent brief, removed some wet wipes, cleansed his front area, and then assisted the resident to turn onto his left side. She removed more wet wipes and cleansed his rectal area and buttocks. She retrieved a bottle of cream from the bedside stand, opened it, put some on her gloved right hand, and applied it to his rectal area and buttocks. While wearing the same gloves, CNA D put a clean incontinence brief on resident 44 and assisted CNA F with pulling up his pants, positioning him higher in his bed, covering him with a blanket, and attaching his call light to the side rail on his bed. CNA D moved the intravenous (IV) pole and IV tubing so that it was closer to the resident and his bed, and used the bed remote to adjust its height. She opened the resident's door and pushed the Hoyer lift out into the hallway. CNA D and F removed and discarded their gloves in the trash can, removed their gowns, and washed their hands for the first time. 3. Interview on 5/20/26 at 12:50 p.m. with CNA D regarding the above personal care observations with resident 44 revealed that it was her usual process. After reviewing the observed unsanitary processes with resident 44, she acknowledged that she should have changed her gloves and sanitized her hands when they were dirty. She further acknowledged that her process had the potential to create an infection for the resident. 4. Interview on 5/21/26 at 1:45 p.m. with director of nursing (DON) B regarding the observations of CNA D completing personal care with resident 44 revealed she expected hand hygiene (HH, washing and sanitizing hands) and glove changing to be done between each new task. Tasks included gathering supplies and touching items in the environment, which were dirty. Same with personal/perineal care, gloves should be changed after the completion of that task and sanitizing of hands prior to touching more items in the environment. She acknowledged that CNA D's process created the potential for an infection to occur for resident 44. 5. Observation on 5/21/26 at 11:18 a.m. of CNA E and contracted travel licensed practical nurse (LPN) I providing personal care to resident 6 in her room revealed resident 6 had a sign on his door indicating he was on EBP. CNA E and LPN I used alcohol-based sanitizer, put on a gown and a pair of gloves before entering resident 6's room. CNA E prepared wet washcloths, placed a yellow bag on the bedside table, and put the wet washcloths on top of the yellow bag. Resident 6 had personal items, which included (call light, open Gatorade container, blue water mug, and remote control) on top of his bedside table. Resident 6 was incontinent of bowel and had a urinary catheter (flexible tubing placed in the bladder to drain urine). After CNA E cleaned resident 6's rectal area with the wet washcloths, she put them in the yellow bag with the clean wet washcloths. CNA E placed resident 6's soiled incontinent brief on the bedside table on top of the clean washcloths. CNA E placed a soiled clothing protector that was on the resident's bed from the morning meal service over the yellow bag, as well as over the resident's drinking straw and mug with a drinking straw. With those same gloved hands, she touched the resident's clean incontinent supplies, blankets, the resident's bedside table, and the tops of resident 6's open Gatorade bottle, water mug, bed remote, TV remote, and call light. 6. Interview on 5/20/26 at 11:45 a.m. with CNA E revealed that she did not clean the urinary catheter at all during resident 6'spersonal cares. She would normally clean that but did not do it that time. 7. Interview on 5/20/26 at 2:43 p.m. with contracted travel LPN I revealed that she expected the staff to change their gloves after cleaning the resident before cleaning other items. She expected the urinary catheter tubing to be cleaned during the resident's personal care. 8. Observation on 5/20/26 at 7:21 p.m. of RN G assisting with resident 2's urinary catheter care revealed that RN G put on a pair of gloves from the right-side pocket of her uniform. She removed and discarded those gloves after resident 2's cares were completed. Without washing her hands RN G touched two washcloths and two used alcohol pads that were positioned under the resident's catheter tubing used during the catheter cares and then touched the resident's bedside table. 9. Interview on 5/21/26 at 12:35 p.m. with LPN/infection preventionist (IP) P revealed she expected the staff to change their gloves after providing resident's perineal care and to wash their hands? before doing anything else. She stated, It is very inappropriate to touch the resident's personal items or drinking cups with the same gloves used during their perineal care. She would prefer that the dirty linen bags to be placed on the side of the bed, and not on the resident's bedside table. If the bedside table was used during the resident's personal care, there should be no personal items on the table at the same time.(add line space) LPN/IP P expected the staff to not touch, with bare hands, soiled wash cloths, or used alcohol pads before touching additional personal items. She expected hand hygiene to be completed in between tasks. 10. Review of the provider's reviewed June 2023 Infection Prevention and Control Manual Glove Technique (Non-Sterile) policy revealed Apply clean non-sterile gloves when touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and non-intact skin. [NAME] clean gloves between tasks and procedures on the same resident after contact with blood, body fluids, secretions, excretions. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. Perform hand hygiene after the removal of gloves. Key point: Do not carry gloves in the pocket of uniform or lab coat. 11. Review of the provider's reviewed September 2022 Infection Prevention and Control Manual Standard Precautions-Gloves policy revealed it is the policy of Jenkin's Living Center that gloves will be worn by employees when it is reasonably anticipated that their hands will come in contact with blood, other potentially infectious materials, mucous membranes, non-intact skin, contaminated equipment or surfaces. 12. Review of the provider's reviewed November 2025 Foley Catheter Management policy revealed 10. Clean the catheter tubing: a. Hold the catheter securely to avoid pulling. B. Wipe away from the body down the catheter tubing approximately 4-6 inches using smooth strokes. C. Do not tug or place tension on the catheter. 13. Remove gloves and perform hand hygiene. B. Based on observation, interview, and policy review the provider failed to ensure two of two Sara Steady (non-powered sit-to-stand mechanical lift used to assist from a seated to a standing position) mechanical lift devices, and three of four sit-to-stand (a battery powered mechanical lift used to assist from a seated to a standing position) mechanical lifts were disinfected between resident use. Findings include: 1. Observation on 5/19/26 at 10:25 a.m. revealed a Sara Steady mechanical lift dated 12-2024 was sitting in east hallway from oak center nursing station had food debris on the foot board, no Sani-wipes (disinfection wipes) were attached to the device. 2. Observation on 5/19/26 at 10:25 a.m. revealed outside resident 2's room there was a sit-to-stand numbered 412020 with food debris on the foot board, and was missing a safety clip on the right side of the latching hook. 3. Observation on 5/19/26 at 10:36 a.m. revealed there was a Sara Steady mechanical lift numbered 25 outside resident 8's room with food debris on the foot board with no disinfectant wipes for cleaning on the machine. 4. Observation on 5/19/26 at 4:10 p.m. revealed there was a Sara Steady mechanical lift in the hallway with torn areas on the black footboard. There was debris in these torn areas, making it an uncleanable surface. 5. Observation on 5/20/26 at 8:43 a.m. revealed there was a sit-to-stand in the hallway numbered 25, which had food debris on the footboard. 6. Observation on 5/20/26 at 9:05 a.m. revealed there was a sit-to-stand numbered 412020 with no clip on the right side of the latching hook and had with food debris and a white powdery substance on the foot board. 7. Observation on 5/20/26 at 9:08 a.m. revealed there was a numbered 25 sit-to-stand mechanical lift sitting outside resident 2's room which had food debris on the foot board and a white colored residue on the black grip pads on the footboard. 8. Observation on 5/20/26 at 9:11 a.m. revealed there was a numbered 19 sit-to-stand mechanical lift missing grip tape on left side of the foot board, and a brownish colored substance on the lower right corner of the foot board. 9. Observation on 5/20/26 at 9:14 a.m. revealed there was a Sara Steady mechanical lift device in the hallway outside resident 8's room that had a white powder substance on the foot board. There were torn areas on the left and right sides of the black foot board. Food debris was in those torn areas and made it an uncleanable surface. 10. Observation on 5/20/26 at 11:44 a.m. revealed that after observing resident 6's personal cares, CNA E did not clean the sit-to stand used and placed it back into the hallway. 11. Observation on 5/20/26 at 7:06 p.m. revealed there was a Sara Steady mechanical lift dated 5-26 that had a blue creamy substance on the footboard. 12. Observation on 5/21/26 at 7:50 a.m. revealed there was a sit-to-stand numbered 412020 with green tape on it numbered 124 in the hallway with food debris on the footboard. 13. Interview on 5/21/26 at 10:17 a.m. with CNA F revealed that mechanical lifts should be cleaned after each resident use. She cleaned any part of the lift that the resident touches. She agreed food debris on the foot boards should be cleaned off as well after a resident used the mechanical lift. 14. Interview on 5/21/26 at 11:22 a.m. with CNA Q revealed she used Sani-wipes to clean the mechanical lifts. When she was done with a mechanical lift transfer for a resident she would clean any surface that the resident touched, so it was ready to use on the next resident. She included the footboard as a space needing to be cleaned. She would notify maintenance by calling them or filling out a maintenance slip on the computer to notify them of needed repairs to the mechanical lifts. 15. Interview on 5/21/26 at 11:30 a.m. with LPN O revealed she expected the mechanical lifts to be sanitized with the Sani cloth wipes between resident use. If something needed to be fixed on the mechanical lifts, she would call for maintenance on the walkie or put in a work order. 16. Interview on 5/21/26 at 11:44 a.m. With contracted travel LPN I revealed she expected the mechanical lifts to be wiped down with the Sani cloths that were available on the lifts or at the nurse's station. If there was something that needed to be fixed, she would use the walkie to call for maintenance or fill out a work order. 17.Interview on 5/21/26 at 12:35 p.m. with LPN/IP P revealed that she expected the mechanical lifts to be wiped down with Sani cloths that were located on the lifts or at the nurse's station. The cleaning should be from top to bottom, including the footboards. The lifts were to be cleaned after each resident use before being placed back into the hallway. Once they were in the hallway, they were considered clean. 18.Interview on 5/21/26 at 2:30 p.m. with DON B revealed she expected the mechanical lifts to be wiped down with the Sani cloths after each use. 19. Review of the provider's reviewed August 2023 Infection Prevention and Control Manual Cleaning and Disinfection of Equipment/Devices policy revealed 7. Reusable equipment will not be used for the care of another resident until it has been appropriately cleaned and disinfected, and single-use items are properly discarded.

Based on the interview, call light log documentation review, and policy review, the provider failed to ensure the staff responded promptly to one of two sampled residents (2) who reported being incontinent (involuntary urine or bowel leakage) while waiting for her call light to be answered.Findings Include: 1. Interview on 5/19/26 at 10:39 am with resident 2 revealed she had concerns that when the facility was short on staff, her call light was not answered quickly enough. She stated, we wait forever to get the call light answered. This caused her to be incontinent of bowel. She stated, she feels embarrassed and frustrated when this happens.2. Resident 2 admitted into the facility on 2/1/2021. Review of resident 2's electronic medical record (EMR) revealed her 4/7/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact.She had diagnoses of Hemiplegia (the inability to move or control the muscles) and hemiparesis (one side of a person's body is weak) affecting her left side, contracture (the muscles, tendons or skin becoming tight or stiff and permanently shortened, making it difficult to move a joint) of the left lower leg, and left foot drop (weakness or nerve damage makes it hard to lift the front part of the foot).Resident 2's care plan on 4/13/26 revealed she required substantial/maximum assistance from the staff with transfers. Staff were to monitor and document bowel sounds and frequency of bowel movements. Resident 2 was continent of bowel and had a suprapubic catheter (flexible tubing inserted in the lower abdomen placed directly in the bladder to drain urine) in place. 3. Review of resident 2's call light response time report (a summary of resident call-light activity and the staff time responses) from 5/5/26 through 5/20/26 revealed she had eleven call light response times over 20 minutes long and three call light response times over 30 minutes long.4. Interview on 5/21/26 at 9:02 a.m. with certified nursing assistant (CNA) revealed that she expected the resident's call lights to be answered within to within 5 minutes.5. Interview on 5/21/26 at 11:30 a.m. with licensed practical nurse (LPN) O revealed the facility's goal was to have call lights answered within 6 minutes, unless the staff were already helping someone else, then the expected call light response time was 15 minutes.6. Interview on 5/21/26 at 11:44 a.m. with LPN I revealed that she expected the call lights to be answered within 3-5 minutes.7. Interview on 5/21/26 at 2:30 p.m. with director of nursing (DON) B revealed that she expected the call lights to be answered within 12 to 15 minutes.8. Review of the provider's undated Call Light Response policy revealed to ensure residents receive timely assistance, maintain resident safety, uphold resident rights, and support quality care through prompt and appropriate response to all activated call lights. It is the policy of [NAME] Living Center that all resident call lights and assistance alarms will be answered promptly, court

Based on observation, interview, manufacture instruction review, and policy review, the provider failed to ensure that two of three dish machines reached the minimum temperatures for the wash and rinse cycles before washing the dishes.Findings include:1. Observation and interview on 5/19/26 at 9:32 a.m. in the main kitchen with cook K revealed a sign on the commercial dish machine that read When taking temps [temperatures] on the dish machines, please make sure you are running the dish machine at least 3 times/or getting to the correct temp before recording a temp as some of them have sat without being ran so they need to get up to temp before using., signed by food service supervisor L. [NAME] K ran the first tray of dishes through the dish machine, and the wash temperature reached 142 degrees and the rinse temperature reached 164 degrees. For the second load of dishes that cook K ran through the dish machine the wash temperature reached 154 degrees, and the rinse temperature reached 186 degrees.When asked about the dish machine temperature cook K stated, that she needed to run the dish machine a couple of times to get to the minimum temperature. She confirmed she did not run the dish machine before she started to wash the dishes, and the dish machine did not reach the minimum temperature for the first load.2. Observation and interview on 5/20/26 at 8:40 a.m. in the second-floor kitchen with cook J revealed cook J ran a tray of dishes through the dish machine. The wash temperature reached 147 degrees, and the rinse temperature reached 177 degrees. [NAME] J stated the dish machine temperatures should reach a minimum of 150 degrees for the wash cycle and a minimum of 180 degrees for the rinse cycle. She did not usually run the dish machine, but the facility let an employee go and did not replace them, so now she cooks and helps with the dishes. 3. Interview on 5/20/26 at 8:52 a.m. with food service supervisor L regarding the dish machine temperatures revealed that the staff was educated on how to run the dish machines. The staff knew to run the dish machines a couple of times before running dishes through them, because water sits in the lines and they needed to run them to get the water up to the correct temperatures. There was a sign posted on the dish machine in the main kitchen to remind the staff to run it. She expected the staff to run the dish machines before washing the dishes. 4. interview on 5/21/26 at 10:07 a.m. with maintenance worker N regarding the dish machine temperatures revealed that maintenance was aware there was an issue with the temperatures for the dish machine in the main kitchen. He thought it was fixed when the heating element was replaced in that dish machine. The dietary staff did notify maintenance if there was an issue with kitchen equipment.5. Interview on 5/21/26 at 12:48 p.m. with administrator A regarding dish machine temperatures revealed that he confirmed the wash temperature needed to be 150 degrees or above and the rinse temperature needed to be 180 degrees or above. He expected the dietary staff to follow the manufacturer's instructions for the dish machines. He agreed the staff should have run the dish machines to get the temperature up before washing dishes.6. Review of the manufacturer's dish machine instruction revealed the hot water sanitizing wash temperature should be150 degrees Fahrenheit minimum, and a rinse temperature of 180 degrees Fahrenheit minimum.7. Review of the provider's 2021 Cleaning Dishes/Dish Machine policy revealed All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review, the provider failed to ensure a contracted licensed practical nurse (LPN) (F) had followed nursing professional standards of practice for the preparation of one of one sampled resident's (1) physician-ordered medication administration delivered through a syringe driver according to the provider's policy. That failure resulted in a medication error. Findings include: 1. Review of 5/13/25 SD DOH FRI revealed: *Resident 1 was admitted on [DATE] and was receiving hospice services. *A syringe driver (a battery powered pump that delivers medications under the skin) was initiated on 5/9/25. *That pump was to continuously deliver medications for pain, anxiety, and agitation to the resident twenty-four hours a day. *On 5/12/25 at 4:30 a.m., the syringe medication was prepared by travel licensed practical nurse (LPN) F who then began its administration. *The oncoming nurse, LPN D changed the syringe at 6:30 a.m. and identified the controlled (medications at risk for addiction and abuse) medication count for morphine (controlled pain medication) was incorrect. *LPN F was then interviewed by the assistant director of nursing (ADON) (G). -LPN F reported she mixed the resident's ordered medications in the syringe, but she did not add the instructed distilled water to the syringe. *Avera pharmacy and the resident's primary care provider (PCP) were notified of the medication error. -They had no concerns of adverse outcome due to the medication error. 2. Interview on 6/10/25 at 3:15 p.m. with LPN D revealed: *She had been employed at the facility for more than ten years. *She reported using the syringe driver to administer medication to residents on a regular basis. -She reported syringe drivers were commonly used with hospice residents nearing the end of their life. *She was able to show the syringe driver kit (syringe driver and associated supplies that were stored in a plastic bin) and demonstrated its setup and function. *She stated she knew how to prepare the medication for the syringe driver by following the syringe driver procedure that was easily seen in the syringe driver kit. 3. Interview on 6/11/25 at 2:00 p.m. with director of nursing (DON) B and staff development coordinator C revealed: *Training was provided to new employees on how to operate syringe drivers. *Training was not provided to travel staff prior to working shifts. *It was the expectation of staff development coordinator C, that travel staff were educated through their employment agency. *It was DON B's expectation for LPN F to read the syringe driver procedure and ask for help if needed. *She confirmed this was a medication error. 4. Interview on 6/11/25 at 6:30 p.m. with LPN E revealed: *He worked the shift on 5/12/25 prior to LPN F taking over and he gave a shift report to her that evening. *He had never worked with LPN F before that day. *He informed LPN F when the syringe would need to be changed for resident 1, and asked if she had questions. *He asked LPN F if she was familiar with syringe drivers and how to prepare the medications, and LPN F reported to him that she was familiar with syringe driver use. *He reported education was completed as part of new employee competencies and usually at the annual skills fair. 5. Review of the provider's undated syringe driver procedure revealed: *1. Obtain initial doctor's orders *2. Assemble equipment: syringe driver, battery (9-volt), softest (needleset), 12cc (cubic centimeter) syringe, betadine [cleaning solution], alcohol wipes, transparent dressing/opsite [adhesive dressing], tape, bag, pin, sterile water, MS [morphine sulfate]/Haldol [antipsychotic medication]/Robinol [saliva and secretion reducing medication] 3.Fill syringe with MS, then sterile water, then Haldol, then Robinol if ordered to an amount to equal 10cc or 12cc. 6. Review of the providers September 2018 medication administration policy revealed: *Instructions, C, 4, If unfamiliar with the med [medication], check in the drug handbook, call the Pharmacist and/or physician for clarification or look for manufacturer guidelines if it is a recently released med.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for: *The maintenance and disposal of resident care items in one of one shower room. *Transmission based precautions by four of four staff (certified nursing assistant (CNA) T, CNA X, licensed practical nurse (LPN) P, and wound care nurse (WCN) I) for five of five sampled residents (62, 68, 25, 6, and 66) who had care concerns requiring personal protective equipment (PPE). *Hand hygiene and glove use by five of five staff (CNA W, LPN P, LPN DD, LPN N, and staff development coordinator (SDC) H) for four of four observed sampled residents (6, 66, 59, and 328). Findings include: 1. Observation on 1/28/25 from 9:53 a.m. to 10:36 a.m. in the shower room [ROOM NUMBER] on the Pine Village memory care unit on the second floor revealed there was: *A used nail file and a dirty hair pick with visible hair and lint sitting on top of the wall-mounted glove box to the left of the entrance. *A soiled plastic cup with a small amount of an unidentifiable dried green paste on top of the soap dispenser in the shower. 2. Observation and interview on 1/28/25 at 2:47 p.m. with resident 25 revealed: *There was a stop sign on her door and a cart outside that room that contained gowns and gloves. *She wore a boot on her left foot from a recent surgery on her toe. *She was frustrated that she shared a bathroom with the female resident next door. Observation and interview on 1/30/25 at 8:03 a.m. with resident 25 revealed: *There had not been any signage on her door that indicated she was on enhanced barrier precautions (EBP). *She stated she had one toe with a wound and a dressing on it, but the nurse had not looked at it today (1/30/25). *She stated that staff had worn gloves but not gowns when they assisted her. Review of her 1/24/25 weekly wound observation tool revealed resident 25 had a four millimeter (mm) by four-mm unstageable wound to her left second toe with an undeterminable depth. Review of resident 25's care plan revealed no indication that resident 25 required EBP. Interview on 1/30/25 at 2:21 p.m. with wound care nurse (WCN) I and infection preventionist (IP) C who participated by phone revealed: *Resident 25 had an open wound to her left toe. *WCN I was unsure if resident 25 was on EBP for wound care and stated she would need to consult with the infection preventionist. *WCN I called IP C at home to join the interview. *IP C stated she had removed resident 25 from EBP because she did not think a Band-Aid was a dressing that required EBP. *WCN I confirmed that resident 25 had an open wound on her left toe with a Medihoney (wound healing) dressing. *IPC stated, I would put her back on EBP with that information. 3. Observation on 1/28/25 at 11:12 a.m. with resident 62 and certified nursing assistant (CNA) X revealed: *There were two signs on resident 62's door and a cart outside that room contained gowns and gloves. -One sign indicated, STOP please see nurse, and the other indicated, Steps to put on PPE 1. Put on Gown and tie 2. Put on gloves. *Resident 62 was in her room calling out, Please come. *CNA X entered resident 62 room and closed the door. *The surveyor then entered the room. Resident 62 was seated on the toilet and CNA X was not wearing a gown or gloves. *CNA X exited the bathroom and without completing hand hygiene, put on a pair of gloves and finished assisting resident 62. Interview on 1/30/25 at 7:49 a.m. with WCN I revealed resident 62 was on enhanced barrier precautions (EBP) for a foot wound. Interview on 1/30/25 at 8:07 a.m. with resident 62 who used a whiteboard for communication revealed: *Staff sometimes wore a gown and gloves when they assisted her, but some times she had to get to the toilet so fast that they did not. *She indicated she had to use the shared bathroom frequently, had difficulty waiting, and sometimes had to wait for the other resident to be done in the bathroom. Interview on 1/30/25 at 8:10 a.m. with CNA U regarding precautions revealed: *The sign on resident 62's door indicated that staff needed to wear a gown and gloves while providing her direct care, but it was okay to go in to talk to her or deliver items to her room. *Resident 62 had an infection in her leg. *A sign was to be on a resident's door, and she used a pocket care plan to know which residents required staff to wear gowns and gloves while providing their direct care. *She stated that information was also in the residents' care plans in the EMR. The provided pocket care plan did not indicate that resident 62 required EBP. Observation on 1/30/25 at 8:15 a.m. at the North Oak nurses' station revealed: *A sign with a list indicated what residents in that area were on EBP. -There were two residents on that list however resident 25 and resident 62 were not listed. Interview on 1/30/25 between 8:31 a.m. and 8:40 a.m. with licensed practical nurse (LPN) M and WCN I revealed: *LPN M stated resident 62 was on EBP for a heel wound and staff were to wear a gown and gloves when providing direct care. *LPN M expected to see resident 62's name on the list of residents that required EBP. *LPN M expected the CNAs to find information on which residents required EBP on the pocket care plan. *WCN I stated that the EBP list had been updated yesterday (1/29/25) and that residents with wounds and catheters that required the use of EBP were on that list. *Signs were to be on those resident room doors. *Residents who required precautions for COVID-19 or contact precautions would be listed on a separate sign. *There were no other lists or signs at that nurse's station. *There were no residents in the North Oak area on COVID-19 or contact precautions. Review of resident 62's EMR revealed: *She was admitted on [DATE] with a diabetic ulcer (wound) on her right foot. *Her care plan indicated hx [history] of MRSA [methicillin-resistant Staphylococcus aureus] from the wound on her right foot. *The care plan indicated, CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. *There was no documentation in the care plan that indicated the staff were to use a gown or gloves with resident contact. Interview on 1/30/25 at 12:57 p.m. with LPN M regarding resident 62's MRSA culture revealed: *Resident 62's daughter stated that the last culture of that wound had been done at the hospital prior to her admission to the facility. *She would request those culture results from IP C. *She was unaware if the MRSA was and active infection. Review of resident 62's printed medical record documents requested revealed: *A 10/2/24 physician's order for Contact precautions: May leave room for meals and therapy as long as wound is covered and not draining. Resident must wash hands with soap and water prior to leaving. *A 9/25/24 wound culture of the right foot revealed Positive for MRSA. 4. Observation on 1/28/25 at 2:29 p.m. of CNA T and resident 68 revealed: *Resident 68 had a sign posted outside of her door that stated, STOP, check with nurse before entering and signs that indicated the correct way to put on PPE. *There was an empty three-drawer bin in the hallway outside the resident's room, and a tub containing a clear trash bag of yellow gowns beside it. *Resident 68 was sitting in her recliner in her room when CNA T came in without wearing a gown or gloves and told her she would be going to a doctor's appointment. *CNA T positioned resident 68's wheelchair next to the recliner and assisted her in standing and transferring to her wheelchair. *CNA T got the residents' jacket and asked if she wanted her shoes on as well, which she declined. *CNA T pushed resident out of her room in her wheelchair and down the hallway. Interview on 1/30/25 at 8:01 a.m. with LPN Q revealed: *She was unsure what type of transmission-based precautions resident 68 was on. *She thought she was on contact precautions for extended-spectrum beta-lactamase (ESBL) (bacteria that is resistant to some antibiotics) for the ulcers on her legs. Observation and Interview on 1/30/25 at 9:56 a.m. with LPN N and M regarding resident 68 revealed: *LPN N thought she was on enhanced barrier precautions (EBP) for the ulcers on her legs. *LPN M thought she was on contact precautions. *Both LPN M and N searched the resident's electronic medical record and paper chart for the resident's current transmission-based precautions type. *They concluded that resident 68 was on contact precautions due to ESBL in her urine based on a positive culture they found on 1/16/25. *LPN M stated that residents who have a wound or a catheter will have a stop sign by their name tag on their door that indicated to staff to see the nurse for their transmission-based precautions type. *LPN M stated EBP is for direct patient care, contact precautions are for all cares provided to a resident. Observation on 1/30/25 at 11:02 a.m. at resident 68's room revealed: *Resident 68 shared a room with resident 11. *Wound care nurse I entered the resident's room without putting on any PPE. *She wheeled resident 11 out of the bathroom, installed the foot pedals on her wheelchair, and wheeled her out of the room. *When asked what type of precautions was required for the residents in that room, she indicated that resident 68 was on enhanced barrier precautions (EBP). Interview on 1/30/25 at 11:04 a.m. with housekeeper HH revealed: *The color of the stop sign coincided with the level of transmission-based precautions (TBP). *The yellow stop sign coincided with contact precautions. *There was a cheat sheet on each housekeeping cart that listed the type of TBP associated with each colored stop sign, as well as a list of diseases that the residents may have, and the level of cleaning required for each disease. *At the nurse's station, there was a list of residents, the type of TBP the residents were on, and the reason for the TBP. *She confirmed that resident 68 was on contact precautions related to ESBL in her urine. *She explained that when cleaning the room shared by resident 11 and 68, she would put on a gown, gloves, and an eye protector. *The chemical she would use to clean that room was Betco brand pH7Q Dual concentrated cleaner, which killed viruses and organisms like COVID-19, Staphylococcus aureus, pseudomona, salmonella, VRE (vancomycin-resistant enterococcus) and MRSA (methicillin-resistant Staphylococcus aureus). Interview on 1/30/25 at 11:11 a.m. with LPN N revealed: *She confirmed resident 68 was on contact precautions because of what's in her urine. *If staff were entering the resident's room to help resident 11 instead of resident 68, they did not need to put on PPE. *She confirmed that both resident 11 and 68 used the same bathroom. Interview on 1/30/25 at 12:09 p.m. with infection preventionist (IP) C revealed: *Staff were to perform hand hygiene every time they removed gloves and before they put new gloves on. *She expected staff to know what precautions a resident was on based on a sheet of paper posted at the nurse's desk. *If a resident was on contact precautions, she expected staff to put on PPE (gown, gloves, goggles or face shields if there was a chance of spray back) with each entry into the resident's room. *If a resident had ESBL in their urine and was continent, then they would downgrade the precautions from contact precautions to EBP and the resident would be able to exit their room. *They would try not to room residents together when one of them was on a type of TBP and the other was not, such as the case with residents 11 and 68. *She expected staff to clean the residents' shared bathroom with the purple-top sanitizing wipes (Super Sani-Cloth brand) after each time resident 68 used the bathroom. -Usually we do not have them share a bathroom but at times it does happen. *She was aware that resident 68 currently had ESBL in her urine. -Resident 68 was continent, so they were in the process of changing her to EBP because resident 68 wished to go out of her room for meals and activities. *She confirmed that resident 11 was not on TBPs. -She indicated that staff did not need to wear a gown or gloves when assisting resident 11. Observation and interview on 1/30/25 at 12:58 p.m. with resident 68 revealed: *Staff wore yellow gowns while taking her to the bathroom. *Staff did not clean her bathroom after she used it. *No purple disinfectant wipes were found in her bathroom or within proximity of her room. Interview on 1/30/25 at 1:00 p.m. with CNA W revealed: *Housekeeping cleaned the residents' bathrooms once a day. *Staff would clean resident 68's bathroom if it was obviously soiled. Interview on 1/30/25 at 3:05 p.m. with director of nursing (DON) B revealed: *She confirmed she was aware that resident 68 had ESBL in her urine. *She confirmed that residents 11 and 68 shared a bathroom. -When asked about cleaning the residents' shared bathroom after resident 68 used it, she said, I would hope that it would be happening. *Staff were to clean their bathroom with the purple-top wipes after each time resident 68 used the bathroom. *If the purple-top wipes were not available, staff had the option to carry around a small package of sanitizing wipes. *She stated not cleaning the residents' shared bathroom put resident 11 at risk for contracting ESBL. *She expected staff to wear PPE when providing care for residents on EBP and contact precautions. Review of resident 68's electronic medical record revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) assessment score of 12 indicating she had moderate cognitive impairment. *Her diagnoses included weakness, acute kidney injury, and ESBL resistance. *Her active contact precaution order started on 12/20/24. *There was an order for staff to clean her arterial ulcers on her right lower extremity (RLE) daily with soap and water and to cover them with an appropriate dressing. *There was no documentation in her care plan that indicated she was on contact precautions or EBP. 5. Observation and Interview on 1/28/25 at 3:02 p.m. of resident 6 in her room revealed: *There was a sign with a stop sign on it next to her name badge outside of her room. *There was a three-drawer organizer with PPE supplies in it outside of her room. *She was lying in bed, with a pillow propped under her left side, and a call light button on the moveable tray table in front of her. *She stated she had a sore on her coccyx, but they had told her it was healing. *Staff were to change the pressure ulcer (PU) dressing every day. Interview on 1/29/25 at 8:35 a.m. with LPN O regarding resident 6's PU revealed: *She stated the PU has shown a lot of improvement. *It was considered a facility acquired stage 4 PU. Observation and interview on 1/30/25 at 10:44 a.m. of resident 6 while receiving a shower (after obtaining permission by the resident) in the bathroom with CNA W and staff development coordinator (SDC) H revealed: *Resident 6 was in a shower chair, CNA W and SDC H were both wearing a gown and gloves. *Once the shower was completed, both the staff members dried resident 6 with towels and covered her with blankets. *Both staff members removed their PPE (gown and gloves), but did not perform hand hygiene. *CNA W did not put on clean gloves before transporting resident 6 to her room. *SDC H and CNA W applied new gowns once inside her room. *SDC H performed hand hygiene and put on new gloves. *CNA touched the bed comforter on the residents' bed before putting on clean gloves. *Both staff members assisted resident 6 from the shower chair to her bed using a full body mechanical lift (lift and sling used to lift a person's full body). *There was a moveable tray table that had a black plastic bag that was used as a barrier for the clean wound dressing supplies. *LPN N entered the room wearing a gown, performed hand hygiene, and put on clean gloves. *LPN N then: -Removed the dirty wound dressing and discarded it. -Removed her gloves and discarded them. -Retrieved a clean package of gauze from the bedside table, opened it, and set it on the bed comforter without a barrier under it. -Performed hand hygiene and then put on clean gloves. -Retrieved the wound cleanser from the bedside table and gauze from the package on the bed comforter. -Sprayed the wound cleanser directly onto the wound and dried the wound with the gauze. -Removed her gloves, performed hand hygiene, and put on new gloves. -Applied collagen with silver to the wound bed, packed the wound with calcium alginate, and covered the wound with an adhesive dressing. -Removed her gloves and discarded them. -LPN N did not perform hand hygiene then picked up the leftover unused supplies from the resident's bedside table. Review of resident 6's EMR revealed: *She was admitted on [DATE]. *She had a BIMS assessment score of 14 which indicated she was cognitively intact. *She had an order for a wound dressing change daily and as needed started on 12/6/24 for her PU. *There was no documentation that indicated the resident was on EBP in her care plan. 6. Observation on 1/29/25 at 3:18 p.m. with LPN P during administration of resident 59's eye ointment revealed she did not perform hand hygiene before she put on her gloves before she administered that ointment or after she removed those gloves after she completed the administration of that eye ointment. 7. Observation and interview on 1/29/25 at 3:50 p.m. with CNA X, LPN P, and WCN I during resident 66's wound dressing change in her bathroom revealed: *There was a sign by the resident's name badge on her door with a stop sign on it. *There was no PPE inside or outside of resident 66's room. *CNA X was wearing gloves but no gown while assisting resident 66 in the bathroom with her toileting cares. *LPN P and WCN I both performed hand hygiene and put on gloves but no gowns. *After CNA X was finished helping resident 66, she removed and discarded her gloves, performed hand hygiene, and left the room. *While resident 66 was still in the bathroom, LPN P removed the adhesive wound covering and sprayed a disinfectant spray on the wound located on resident 66's coccyx (tailbone area). *LPN P blotted the area with a clean towel. *WCN I handed LPN P the opened wound care products that included a honey fiber pad for packing the wound and an adhesive covering. *LPN P applied the wound care products and then assisted resident 66 in pulling up her incontinence brief and pants and then transferred her to her wheelchair. *LPN P and wound care nurse I both then removed their gloves, discarded them, and performed hand hygiene. *They stated they should have worn a gown and gloves because the resident was on EBP due to her wound. *LPN P stated, I'm the one at risk so if the resident had some sort of infection, she would have put on a gown to protect herself. Review of resident 66's EMR revealed: *A 1/13/25 active order for wound care related to her PU. *There was no documentation that indicated she was on EBP in her care plan. 8. Observation on 1/30/25 at 8:04 a.m. with LPN DD revealed: *She did not perform hand hygiene before she applied gloves prior to administering a medication to be taken by mouth to resident 328. 9. Review of the provider's undated Enhanced Barrier Precautions Policy and Procedure revealed: *It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs). *Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). *High-contact resident activities may include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any opening requiring a dressing . *Examples of MDROs Targeted by CDC include: Methicillin-resistant Staphylococcus aureus (MRSA), ESBL-producing Enterobacterales, Vancomycin-resistant Enterococci (VRE) . *Contact precautions are recommended if the resident has acute diarrhea, draining wounds, or other sites of secretions that are unable to be covered or contained for a limited period of time during a suspected or confirmed MDRO outbreak investigation. *2. Gowns and gloves will be available immediately near or outside of the resident's room. Face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). *8. Enhanced barrier precautions should be used for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling device that placed them at a higher risk. 10. Review of the provider's revised 9/2021 Infection Prevention and Control Manual regarding Hand Hygiene policy revealed: *Hand Hygiene includes hand washing with soap and water and hand hygiene with alcohol-based hand rub (ABHR.) *Hand hygiene continues to be the primary means of preventing the transmission of infection. 11. Review of the provider's reviewed 9/2022 Contact Precautions policy revealed: *Contact Precautions will be used to prevent the healthcare acquired spread of organisms that can be transmitted by direct resident contact (hand or skin-to-skin contact that occurs when performing resident-care) or by indirect contact (touching) with environmental surfaces or contaminated resident care equipment. *Healthcare personnel caring for residents on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. 12. Review of the provider's reviewed 6/2023 Guidance for Control of Extended-Spectrum Beta-Lactamase (ESBL) policy revealed: *The purpose of this policy is to provide guidelines for prevention and control of ESBL. *Prevention -A. Appropriate resident placement -B. Gloves for all activities in resident's room -C. Gowns indicated for activities where skin or clothing will come in contact with the resident or their environment or when performing direct care -D. Dedicated equipment or adequate cleaning and disinfection of shared equipment, with particular attention to management of urinary catheters and associated equipment *Cohort symptomatic residents with ESBL in specific areas if possible. *The environment of a resident with ESBL should be cleaned thoroughly at least daily, with special attention to those items likely to be contaminated. 49958

Based on observation, interview, record review, and policy review the provider failed to ensure five of five residents (6, 7,15, 19, and 41) who received a pureed diet and assessed to have complicated eating problems were not assisted to eat by paid feeding assistants. Findings include: 1. Observation and interview on 1/28/25 between 11:42 a.m. and 12:08 a.m. with cosmetologist AA in the Dixie dining room revealed: *Cosmetologist AA was seated next to resident 19 at the assisted dining table. *Cosmetologist AA was trained as a hair stylist, certified to assist in the kitchen, and had completed a training program for paid feeding assistants. She was not a certified nursing assistant (CNA). *Resident 19 had a recent weight loss, was on a pureed diet due to pocketing of food, and had recently began receiving hospice services. *Resident 19 was served a plate with mashed potatoes with gravy, pureed meat, and a dish that contained pureed pie. *Cosmetologist AA assisted resident 19 in eating with a spoon and drinking from a cup with two handles and a lid. *Cosmetologist AA asked another staff to reposition resident 19 in her wheelchair because she was leaning back. 2. Observation on 1/29/25 at 11:32 a.m. in the dining room with licensed practical nurse (LPN) L revealed LPN L administered medication to resident 19 by spoon. 3. Interview on 1/29/25 at 11:34 a.m. with LPN L and administrator A revealed: *LPN L confirmed that resident 19 took her medications crushed and was on a pureed diet. -She stated resident 19 chews and chews her food. *Speech therapist (ST) G had recommended a downgrade of resident 19's food textures and the pureed diet had been ordered by hospice. *She confirmed that cosmetologist AA assisted resident 19 in eating her meals because she had a connection with resident 19. *Administrator A confirmed that cosmetologist AA was a paid feeding assistant and not a CNA. *Staff development coordinator (SDC) H oversaw the paid feeding assistant program and was new to that role. 4. Continued observation and interview on 1/29/25 at 11:48 a.m. in the Dixie dining room revealed: *Resident 19 was assisted in eating a pureed meal by cosmetologist AA. *Resident 41 was assisted in eating a pureed meal by activities aide (AA) Y. -AA Y confirmed she worked in the activities department, was a paid feeding assistant and not a CNA. 5. Interview on 1/29/25 at 12:04 p.m. with ST G, director of nursing (DON) B, and administrator A revealed they had approached the surveyor and confirmed that ST G had downgraded resident 19's diet to pureed. 6. Interview on 1/29/25 between 12:21 p.m. and 12:35 p.m. with SDC H and ST G regarding the paid feeding assistant program revealed: *SDC H was new in the role of staff development coordinator and oversaw the paid feeding assistant program since August 2024. *The provider had transitioned from the textbook training format to the online format during that time. *She confirmed that cosmetologist AA and AA Y were paid feeding assistants and not CNAs. *She was unsure if the training covered the topic of residents with special diets, such as pureed. *ST G stated she screened residents for swallowing difficulties at admission, quarterly, with any significant changes or when the nurse requested. *ST G stated that she determined which residents could have been assisted by paid feeding assistants. *Issues related to dental problems, oral issues, the need for altered food textures, and a pureed diet were not considered complicated feeding issues. *Issues like a feeding tube, choking, pocketing food, requiring to be fed on one side of the mouth, aspiration, and the need for special strategies to swallow would have been considered complicated feeding issues. *The decision for resident participation in the feeding assistant program was made by the interdisciplinary team based on ST G's recommendation and it was care planned. 7. Review of the provider's 1/27/25 Feeding Assistant List revealed: *Sixteen residents were participating in the Feeding Assistant program. *There were no residents listed under the Requiring CNA's [CNAs] to Feed. 8. Review of resident 6's electronic medical record (EMR) revealed: *She received a pureed diet. *Her care plan indicated on 5/29/24 that she, did agree to a pureed texture for her foods. Daughter states [resident 6] can't chew the chopped-up food even now. *She does have swallowing problems occasionally. *She was screened by speech therapy twice in April 2024 for swallowing concerns. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 9. Review of resident 7's EMR revealed: *She received a pureed diet. *Her care plan revealed, Nutrition risks include: cognition, dysphagia [difficulty swallowing]. *Dependent assist of 1 [one] for eating. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 10. Review of resident 15's EMR revealed: *She received a pureed diet. *Her care plan revealed, Nutrition Risk factors include: cerebral Infarction [a stroke], dementia, hemiplegia [paralysis of one side of the body], dyshagia [dysphagia]. *She had some difficulties with eating when her dentures are in. *A care plan intervention included Monitor/document ability to chew and swallow. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 11. Review of resident 19's EMR revealed: *She received a pureed diet. *A 1/24/25 speech therapy screen indicated a referral was made due to pocketing solids. *A 1/28/25 progress note indicated the feeding assistant reported patient was a little gaggy this morning. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 12. Review of resident 41's EMR revealed: *She received a pureed diet. *She had a diagnosis of dysphagia. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 13. Interview on 1/30/25 at 8:43 a.m. with AA EE revealed: *She was an activities assistant and had completed the paid feeding assistant training. *She assisted residents with eating about once a month. *She was allowed to assist any resident who needed assistance with eating. *No one told her which residents to assist with eating. 14. Interview on 1/30/25 at 9:41 a.m. with AA Z revealed: *She was a paid feeding assistant. *Resident 15 was on a pureed diet, required assistance to eat, and sometimes coughed with liquids. *Resident 7 was on a pureed diet, required assistance to eat, and AA Z did not think resident 7 had any swallowing issues. 15. Interview on 1/30/25 at 3:35 p.m. with SDC H and ST G regarding the paid feeding assistant program revealed: *ST G had assessed residents 6, 7,15, 19, and 41 who had pureed diets and had deemed them safe to participate in that program because They no longer need specific strategies. *ST G stated that a paid feeding assistant could assist a resident who had pocketed regular food but did not pocket pureed food because they no longer had a problem. *Only residents with a feeding tube or who require a very specific feeding strategy would be disqualified from the paid feeding assistant program. *Residents who placed food on one side of their mouth needed to have a CNA feed them. 16. Interview on 1/30/25 at 4:41 p.m. administrator A, DON B, and SDC H regarding the paid feeding assistant program revealed: *The Feeding Assistant List that was provided included all the residents within the facility who required assistance with eating. *SDC H stated that paid feeding assistants were able to assist any resident not deemed by the speech therapist, to need assistance from a CNA. *Administrator A stated that a feeding assistant could assist any resident in the facility except those who have been excluded. *At that time there were no residents that should have been excluded. *DON B stated care plans did not indicate which residents were in the paid feeding assistant program because it could change. -The care plan may include if they could not be fed by a feeding assistant, but because there was not anyone excluded, no care plans contained that information. 17. Review of the provider's revised April 2020 Assisted Dining: The Role and Skills of Feeding Assistants textbook revealed: *Paid feeding assistants are only permitted to assist residents who have no complicated eating or drinking problems as determined by their comprehensive assessment. Examples of residents that a paid feeding assistant may assist include residents who are independent in eating and/or those who have some degree of minimal dependence, such as needing cueing or partial assistance, as long as they do not have complicated eating or drinking problems. *Important! Feeding assistants are not permitted to feed residents with dysphagia. *Residents with dysphagia have difficulty or discomfort when swallowing. *Symptoms of dysphagia include: Coughing before, during or after swallowing food, liquid or medication . Pocketing food in the side of the mouth . 18. Review of the provider's February 2010 Dining Assistants policy revealed: *Assisted dining will be provided to appropriate residents when necessary in accordance with applicable federal and state requirements regarding Feeding Assistants. *An [A] FA [feeding assistant] is to feed only those residents who have no complicated eating problems. Complicated eating problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, tube or parenteral/IV [intravenous] feedings, paralysis, trauma or facial, oral or neck surgery or any other complicating condition as, high risk for choking, depressed cough or gag reflex, needing positioning during feeding or decreased gastric motility.

Based on observation and interview, the provider failed to ensure call light systems were accessible to residents in two of two observed resident shower/tub rooms, and five of eleven observed resident bathrooms (rooms 273, 278, 280, 286, and 288). Findings include: 1. Observation on 1/29/25 from 9:33 a.m. to 10:05 a.m. in the 2nd floor memory care unit revealed: *The wall-mounted call light in the bathroom of resident room [ROOM NUMBER] did not have a pull cord and was not accessible if a resident was on the floor. *The cord for the wall-mounted call light in the bathrooms of resident rooms 278, 280, 286, and 288 was wrapped around the call light box and was not accessible if a resident was on the floor. *There was no call light available in the shower room [ROOM NUMBER]. *The wall-mounted call light in the tub room did not have a pull cord and was not accessible if a resident was on the floor. 2. Interview on 1/30/25 at 3:12 p.m. with activity aide Z revealed: *The shower room was rarely used, but the toilet in that room was used for residents. *She was not aware that there was no call light available in that room. 3. Interview on 1/30/25 at 3:27 p.m. with licensed practical nurse (LPN) R revealed: *He was not aware that the shower room did not have a call light available. *The shower in the shower room was never used, but the toilet was used by residents frequently. *He said, I don't leave them alone, but I do stand outside on the other side of the door until the resident is done. *He agreed there should be functioning call lights in resident areas. *If a call light was not functioning, he would call maintenance. 4. Interview on 1/30/25 at 5:19 p.m. with administrator A revealed: *They did not have a policy regarding the minimum requirements for call lights. *He indicated he thought a call light was not necessarily needed in the shower room because a staff member would be in the room with the resident at all times. -He felt that staff would have used their radios if they needed help. *The maintenance department completed call light audits for functionality. This surveyor requested to review that documentation. That documentation was not provided by the end of the survey.

Based on observation and interview, the provider failed to maintain resident rooms and resident common areas in a clean manner free from strong odors, sticky floors, and damage to the walls and bathroom tiles for at least seven resident rooms, at least one resident common area, and at least one shower and one tub room. Findings include: 1. Observations on 1/28/25 from 9:53 a.m. to 10:36 a.m. in the Pine Village memory care unit on the second floor revealed: *In resident room [ROOM NUMBER]: -There were gouges in the corner with exposed drywall. -Phone cords were in a tangled pile on the floor behind the resident's rocking chair. *In resident room [ROOM NUMBER]: -There were at least five vertical gouges in the wall behind the tan recliner, ranging from approximately two to six inches in size. *In resident room [ROOM NUMBER]: -Drywall was exposed on the out-[NAME] corner. -Painter's tape had been left on the baseboard. -The wall next to the bed had at least eight quarter-sized gouges, with drywall exposed. -The wall behind the light brown recliner had a gouge approximately two inches by one inch in size with exposed drywall. -There was a scrape approximately six inches above the baseboard that extended about three feet along another wall with exposed drywall. -The bathroom floor was sticky and had a strong urine odor. *In resident room [ROOM NUMBER]: -There was exposed drywall near the baseboard in a corner. *In resident room [ROOM NUMBER]: -The bathroom sink was leaking a steady flow of water, even though the faucet paddles were in the off position. *In resident room [ROOM NUMBER]: -The wall behind the bed had vertical gouges with drywall exposed. -There was a gouge on a corner of a wall with exposed drywall. -The hand sanitizer dispenser was not functioning. *In the resident day room: -At least five gouges were in the walls behind the recliners. * The above conditions remained unchanged during additional observations on 1/29/25 from 9:33 a.m. to 10:05 a.m., and on 1/30/25 at 9:05 a.m. 2. Observations on 1/29/25 at 2:21 p.m. and on 1/30/25 at 7:59 a.m. in the North Oak care unit on the third floor revealed: *In resident room [ROOM NUMBER]: -A corner of wall tile in the bathroom was chipped and had jagged edges with exposed cement. -There was a missing piece of tile located just outside the doorway to the left of the sink. -The hand sanitizer dispenser was not functioning. *Outside the doorway of resident room [ROOM NUMBER]: -There were three small gouges in the wall above the railing with exposed drywall. -There was an approximate two-foot scrape on the wall below the railing with exposed drywall. 3. Interview on 1/30/25 at 3:12 p.m. with activity aide Z about what staff would do if something was not working or needed repair revealed she stated, I would have to ask the nurse to verify or go to maintenance. 4. Interview on 1/30/25 at 3:19 p.m. with CNA W about what staff would do if something was not working or needed repair revealed she stated, I would call maintenance for a repair because its faster, but we can use a maintenance green slip and send that to maintenance. 5. Interview 1/30/25 at 3:27 p.m. with LPN R about what staff would do if something was not working or needed repair revealed he stated, I would call maintenance or use a maintenance green slip. 6. Interview on 1/30/25 at 5:19 p.m. with administrator A revealed: *He explained there was no policy for submitting maintenance requests. *He expected staff to submit a green maintenance request slip, talk with someone from the maintenance department directly, or call immediate maintenance requests over the radio.

Based on observation, interview, record review, and policy review the provider failed to ensure resident care plans had been revised to reflect their current needs for: A. One of one sampled resident (19) who received hospice services. B. Five of five residents (6, 7,15, 19, and 41) who received a pureed diet and were included in the paid feeding assistants program. C. Five of five sampled residents (6, 25, 62, 66, and 68) who required transmission-based precautions (TBP). D. Three of three sampled residents (40, 45, and 70) who required monitoring for medications they received. E. One of one sampled resident (10) who required placement on a secure memory unit. Findings include: A. 1. Interview on 1/29/25 at 11:34 a.m. with licensed practical nurse (LPN) L regarding resident 19 revealed resident 19 had gallstones, no surgery was recommended, and she began receiving hospice services about two weeks ago. 2. Interview on 1/30/25 at 8:52 a.m. certified nursing assistant (CNA) FF regarding identifying residents who received hospice services revealed: *She identified resident 19 received hospice services. *That information was provided to her by the nurse, and it would be on the pocket care plan. *Hospice visited resident 19 one to two times a week to take her vitals and provide a bed bath. 3. Review of the provided pocket care plan did not indicate that the resident received hospice services. 4. Review of resident 19's care plan revealed: *She admitted to the facility on [DATE]. *Her diagnoses included mild intellectual disabilities, osteoarthritis, anemia, heart failure, fracture of left patella (kneecap), acute kidney failure, anorexia, and anxiety disorder. *A nutrition focus area indicated, Currently on hospice was revised on 1/28/25. *The nutrition goal indicated, Comfort Care Nutrition provided due to hospice. *The nutrition interventions included, 1/28/24: admitted to hospice on 1/17 [2025] due to recent diagnosis of Calculus of Gallbladder with Acute Cholylith [Cholelith, gallstones] with back pain. General surgeon recommends comfort cares over surgical intervention. *There were no other focus areas, goals or interventions related to resident 19's hospice care. 5. Interview on 1/30/25 at 4:19 p.m. with administrator A and director of nursing (DON) B regarding resident 19's hospice care revealed: *There had been a delay in getting the hospice admitting diagnosis for resident 19. *She was admitted to hospice on 1/17/25. *During the interview DON B called the hospice provider to request a copy of the physician's order and the hospice care plan. *DON B stated she updated the facility care plan to reflect that resident 19 had been admitted to hospice and the services she received. *She expected the care plan to reflect the specific care resident 19 received. 6. Review of resident 19's 1/30/25 updated care plan revealed: *Her care plan included a focus area, See the MAR/TAR [medication administration record/treatment administration record], Physician orders/protocol, CNA flow sheets and the Short Term Care Plan. Also, see the restorative nursing flow sheet and therapy plan of treatment in integrated therapy reports if applicable. Care plans are written by the exception reflecting facility standards. Administer medications as ordered. [Resident 19] was admitted to Hospice on 1/17/25 revised on 1/30/25. *There was no resident-centered goal, it directed to See Focus revised on 4/16/24. *There were no specific interventions, it directed to See Focus initiated on 5/9/18. B. 1. Observation and interview on 1/28/25 between 11:42 a.m. and 12:08 a.m. with cosmetologist AA in the Dixie dining room revealed: *Cosmetologist AA assisted resident 19 in eating with a spoon and assisted her in drinking from a cup with two handles and a lid. *Cosmetologist AA was trained as a hair stylist, certified to assist in the kitchen, and had completed a training program for paid feeding assistants. She was not a certified nursing assistant (CNA). 2. Observation and interview on 1/29/25 at 11:48 a.m. in the Dixie dining room revealed: *Resident 19 was assisted in eating a pureed meal by cosmetologist AA. *Resident 41 was assisted in eating a pureed meal by activities aide (AA) Y. -AA Y confirmed she worked in the activities department, was a paid feeding assistant and not a CNA. 3. Interview on 1/29/25 between 12:21 p.m. and 12:35 p.m. with staff development coordinator (SDC) H and speech therapist (ST) G regarding the paid feeding assistant program revealed: *SDC H was new in the role of staff development coordinator and oversaw the paid feeding assistant program since August 2024. *ST G stated that she determined which residents could be assisted by paid feeding assistants. *Participation in the feeding assistant program was made by the interdisciplinary team based on ST G's recommendation and it was care planned. 4. Review of the provider's 1/27/25 Feeding Assistant List revealed: *Sixteen residents were participating in the Feeding Assistant program. *Six of those residents (6, 7,15, 19, and 41) received a pureed diet. *There were no residents listed under the Requiring CNA's [CNAs] to Feed. 5. Review of resident 6's electronic medical record (EMR) revealed: *She received a pureed diet. *Her care plan indicated on 5/29/24 that she, did agree to a pureed texture for her foods. Daughter states [resident 6] can't chew the chopped-up food even now. *She does have swallowing problems occasionally. *She was screened by speech therapy in April 2024 twice for swallowing concerns. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 6. Review of resident 7's EMR revealed: *She received a pureed diet. *Her care plan revealed, Nutrition risks include: cognition, dysphagia [difficulty swallowing]. *Dependent assist of 1 [one] for eating. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 7. Review of resident 15's EMR revealed: *She received a pureed diet. *Her care plan revealed, Nutrition Risk factors include: cerebral Infarction [a stroke], dementia, hemiplegia [paralysis of one side of the body], dyshagia [dysphagia, difficulty swallowing]. *It was documented that she had some difficulties with eating when her dentures are in. *A care plan intervention included Monitor/document ability to chew and swallow. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 8. Review of resident 19's EMR revealed: *She received a pureed diet. *A 1/24/25 speech therapy screen indicated a referral was made due to the resident was pocketing solids [solid foods]. *A 1/28/25 progress note indicated the feeding assistant reported patient was a little gaggy this morning. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 9. Review of resident 41's EMR revealed: *She received a pureed diet. *She had a diagnosis of dysphagia. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 10. Interview on 1/30/25 at 8:43 a.m. with AA EE revealed: *She was an activities assistant and had completed the paid feeding assistant training. *She assisted residents with eating about once a month. *She was allowed to assist any resident who needed assistance with eating. *No one told her which residents to assist with eating. 11. Interview on 1/30/25 at 4:41 p.m. administrator A, DON B, and SDC H regarding the paid feeding assistant program revealed: *The Feeding Assistant List that was provided included all the residents within the facility who required assistance with eating. *SDC H stated that paid feeding assistants were able to assist any resident not deemed by the speech therapist, to need assistance from a CNA. *Administrator A stated that a feeding assistant could assist any resident in the facility except those who have been excluded. *At that time there were no residents who should have been excluded. *DON B stated care plans did not indicate which residents were in the paid feeding assistant program because it could change. -The care plans may include if they could not be fed by a feeding assistant, but because there was not anyone excluded, no care plans contained that information. C. 1. Observation and interview on 1/28/25 at 2:47 p.m. with resident 25 revealed: *There was a stop sign on her door and a cart outside that room contained gowns and gloves. *She wore a boot on her left foot from a recent surgery on her toe. Observation on 1/30/25 at 8:03 a.m. with resident 25 revealed: *There had not been any signage on her door that indicated she was on enhanced barrier precautions (EBP). *She stated she had one toe with a wound and a dressing on it, but the nurse had not looked at it today (1/30/25). *She stated that staff had worn gloves but not gowns when they assisted her. Interview on 1/30/25 at 2:21 p.m. with wound care nurse (WCN) I and infection preventionist (IP) C who participated by phone revealed: *Resident 25 had an open wound to her left toe. *WCN I was unsure if resident 25 was on EBP for wound care and stated she would need to consult with the infection preventionist. *WCN I called IP C at home to join the interview. *IP C stated she had removed resident 25 from EBP because she did not think a Band-Aid was a dressing that required EBP. *WCN I confirmed that resident 25 had an open wound on her left toe with a Medihoney (wound healing) dressing. *IPC stated, I would put her back on EBP with that information. Review of resident 25's EMR revealed: *A 1/24/25 weekly wound observation tool indicated resident 25 had a four millimeter (mm) by four mm unstageable wound to her left second toe with an undeterminable depth. *There was no documentation in the care plan that indicated that resident 25 required EBP. 2. Observation on 1/28/25 at 11:12 a.m. with resident 62 and certified nursing assistant (CNA) X revealed: *There were two signs on her door and a cart outside that room that contained gowns and gloves. *One sign indicated, STOP please see nurse, and the other indicated, Steps to put on PPE 1. Put on Gown and tie 2. Put on gloves. Interview on 1/30/25 at 7:49 a.m. with WCN I revealed resident 62 was on EBP for a foot wound. Interview on 1/30/25 at 8:10 a.m. with CNA U revealed: *The sign on resident 62's door indicated that staff needed to wear a gown and gloves when providing direct care, but it was okay to go in to talk to her or deliver items to her room. *Resident 62 had an infection in her leg. *There would be a sign on the resident's door, and she used a pocket care plan to know which residents required staff to wear gowns and gloves when providing their direct care. *She stated that information was also in the residents' care plans in the EMR. Interview on 1/30/25 between 8:31 a.m. and 8:40 a.m. with LPN M and WCN I revealed: *LPN M stated resident 62 was on EBP for a heel wound and staff were to wear a gown and gloves when providing her direct care. *LPN M expected the CNAs to find information on which residents required EBP on the pocket care plan. *WCN I stated that the EBP list had been updated yesterday (1/29/25) and that residents with wounds and catheters. The provided pocket care plan did not indicate that resident 62 required EBP. Review of resident 62's EMR revealed: *She was admitted on [DATE] with a diabetic ulcer (wound) on her right foot. *Her care plan indicated hx [history] of MRSA [methicillin-resistant Staphylococcus aureus] from the wound on her right foot. *The care plan indicated, CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. *There was no documentation in the care plan that indicated the staff were to use a gown or gloves with resident contact. A review of resident 62's printed medical record documents requested revealed a 10/2/24 physician's order for Contact precautions: May leave room for meals and therapy as long as wound is covered and not draining. Resident must wash hands with soap and water prior to leaving. 50916 3. Interview on 1/28/25 at 9:53 a.m. with CNA V revealed: *The signs posted on the residents' doorways by their name badges with a stop sign indicated they were on EBP. Observation on 1/28/25 at 2:29 p.m. outside of resident 68's room revealed: *There was a sign posted outside of her door that stated, STOP, check with nurse before entering and signs that indicated the correct way to put on personal protective equipment (PPE). *There was an empty three-drawer bin in the hallway by her doorway, and a tub that contained a clear trash bag of yellow gowns beside it. Review of resident 68's EMR revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) assessment score of 12, which indicated she had moderate cognitive impairment. *Her diagnoses included extended spectrum beta lactamase (ESBL, enzymes that breakdown some antibiotics) resistance. *A 12/20/24 active contact precaution order. *An order to clean her arterial ulcers on her right lower extremity (RLE) daily with soap and water and to cover them with an appropriate dressing. *There was no documentation that indicated she was on contact precaution or EBP in her care plan. 4. Observation and Interview on 1/28/25 at 3:02 p.m. of resident 6 in her room revealed: *There was a sign with a stop sign on it next to her name badge outside of her room. *There was a three-drawer bin with PPE supplies in it outside of her room. *She was lying in bed, with a pillow propped under her left side, and a call light button on the moveable tray table in front of her. *She stated she had a sore on her coccyx, but staff had told her it was healing. *Staff changed the pressure ulcer (PU) dressing every day. Review of resident 6's EMR revealed: *She was admitted on [DATE]. *She had a BIMS assessment score of 14 which indicated she was cognitively intact. *She had an order for a wound dressing change daily and as needed that began on 12/6/24 for her PU. *There was no documentation that indicated she was on EBP in her care plan. 5. Observation on 1/30/25 at 7:56 a.m. of resident 66's room revealed: *There was no PPE inside or outside of her room. *There was a sign by the resident's name badge on her door with a stop sign on it. Review of resident 66's EMR revealed: *She was admitted on [DATE]. *She had an active order for wound care related to her PU that began on 1/13/25. *There was no documentation that indicated she was on EBP in her care plan. 43021 D. 1. Observation on 1/28/25 at 4:09 p.m. of resident 70 revealed she was in her room lying on her bed's alternating air mattress and appeared comfortable with no facial indicators of pain. Review of resident 70's EMR revealed: *She admitted to the facility on [DATE]. *Her BIMS was scored at 4 indicating severe cognitive impairment. *She had an Alzheimer's Disease diagnosis. *Her medications included: -An antipsychotic medication QUEtiapine Fumarate [antipsychotic] Oral Tablet: --25 MG [milligrams] (Quetiapine Fumarate) Give 1 tablet by mouth in the morning for hallucinations. --25 MG (Quetiapine Fumarate) Give 12.5 mg by mouth at bedtime for hallucinations. -Two controlled (medications with risk for abuse of addiction) pain medications: --oxyCODONE-Acetaminophen Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 12 hours as needed for pain control. --fentaNYL Transdermal Patch 72 Hour 12 MCG/HR [mg per hour] (Fentanyl) Apply 1 patch transdermally every 72 hours for Pain and remove per schedule. -A hypnotic medication Zolpidem Tartrate Oral Tablet 10 MG (Zolpidem Tartrate) Give 1 tablet by mouth at bedtime for Insomnia. Review of resident 70's current care plan printed on 1/30/25 revealed: *Her care plan did not address her antipsychotic, opioid (pain), and hypnotic medications. *Her care plan included a focus area that was initiated on 1/8/25 See the MAR/TAR, Physician orders/protocol, pocket care plan and the Long-term Care Plan. Also, see the restorative nursing flow sheet and therapy plan of treatment in integrated therapy reports if applicable. Care plans are written by the direction of the resident and their wishes for their plan of care. Administer medications as ordered. *There was no resident centered goal, it directed to See Focus initiated on 1/8/25. *There were no specific interventions, it directed to See Focus initiated on 1/8/25. *The focus area regarding her medications did not include: -A goal regarding her high-risk medications. -Specific interventions including the medications' side effects that assisted her to meet that goal. 46453 2. Review of resident 40's current care plan revealed: *A focus area: See the MAR/TAR, Physician orders/protocol, pocket care plans and the Long Term Care Plan. Also, see the restorative nursing flow sheet and therapy plan of treatment if applicable. Care plans are written by exception reflecting facility standards. Administer medications as ordered. Initiated on 2/25/19. Revised on 4/25/24. -Goal: See Focus. Initiated on 2/25/19. Revised on 10/29/23. -Interventions: See Focus. Initiated on 2/25/19. *There were two separate focus areas relating to altered skin integrity due to incontinence. The interventions on one of those focus areas had not been updated since 5/13/21. *There were several interventions in other focus areas that appeared to be a copy/paste and summaries of progress notes from the resident's electronic medical record. -For example, there was an intervention under the skin focus area that read: --4/3/24: Interventions were assessed at a skin meeting. The care plan interventions were reviewed and interventions at the time were appropriate - will keep in place. --5/7/24: Interventions were assessed at a skin meeting. The care plan interventions were reviewed and interventions revised. --6/18/24: Interventions were assessed at a skin meeting. The care plan interventions were reviewed and interventions revised. --8/6/24: Interventions were assessed at a skin meeting. The care plan interventions were reviewed and interventions at the time were appropriate - will keep in place. --Initiated on 8/19/24, revised on 8/19/24. *A focus area related to a diagnosis of depression was initiated on 12/8/24. -An intervention was added on 12/8/24 that read, Administer medications as ordered. Monitor/document for side effects and effectiveness. -Review of resident 40's medication administration records from July 2024 through January 2025 revealed she had not taken any type of antidepressant or mood-altering medication. *A focus area related to pain was initiated on 7/30/20 and revised on 4/3/24. [Resident 40] has a history of taking scheduled analgesic [a category of pain-relieving medications]. Staff will monitor for s/s of generalized pain and stiffness. -An intervention was added on 2/25/19 related to pain that read, Administer analgesia as per ordered. -Review of resident 40's medication administration records from July 2024 through January 2025 revealed she had not taken any type of analgesic medication. Interview on 1/30/25 at 5:19 p.m. with administrator A and DON B revealed: *They tried to rework their resident care plan policy because of the previous recertification survey. *DON B was not aware that the interventions for depression and pain medications were still included on resident 40's care plan. *The nurse manager for the memory care units was responsible for those residents' care plans. *They had no explanation as to why the resident care plans included goals and interventions of See Focus. 3. Interview on 1/28/25 at 10:53 a.m. with resident 45 revealed that she thought she was on an antibiotic but did not know if she took an anticoagulant (a blood thinner). Review of resident 45's EMR revealed: *She was admitted to the facility on [DATE]. *Her BIMS assessment score was 14, which indicated she was cognitively intact. *She had a diagnosis of long-term (current use) of anticoagulants. *Her medications included Eliquis [an anticoagulant] Oral Tablet 2.5 MG [milligrams] (Apixaban) Give 2.5 mg by mouth two times a day for atrial fibrillation. Review of resident 45's current care plan printed on 1/30/25 revealed: *Her care plan did not address her use of anticoagulant medications. *Her care plan included a focus area that was revised on 8/7/24, See the MAR/TAR, Physician orders/protocol, CNA flow sheets and the Short Term Care Plan. Also, see the restorative nursing flow sheet and therapy plan of treatment in integrated therapy reports if applicable. Care plans are written by the exception reflecting facility standards. Administer medications as ordered. *There was no resident-centered goal; it directed to See Focus, revised on 8/15/24. *There were no specific interventions; it directed to See Focus, revised on 7/25/24. E. 1. Observation and interview on 1/28/25 at 5:05 p.m. with resident 10 revealed: *She was in her room sitting in her recliner working on a word puzzle. *She stated she was living at the facility because the doctor thought I needed more help. Review of resident 10's EMR revealed: *She had lived at the facility in the secure memory care unit since 7/31/24. *Her BIMS assessment score was 15 which indicated she was cognitively intact. *A 7/31/24 admission progress note stated . it was determined that she was unable to safely return to her own apartment d/t [due to] altered mental . Resident admitted to secured unit d/t [due to] dx [diagnosis] of dementia and history of wandering . in her own apartment building. Secured unit assessment initiated. *An 8/8/24 physician order summary stated Resident noted to have a diagnosis of Dementia, because of this condition the resident benefits from the consistent smaller therapeutic environment and the specialized care provided in a secured unit. Specific clinical indications will be reviewed by the interdisciplinary team on a quarterly and as needed basis and documented in the resident's care plan. *A 9/27/24 social service note stated She repeatedly commented on wanting to get some things from her old apartment, however she has been informed many times that it's been cleaned out by family/responsible party and her things donated. She was asked before things were dispersed what she wanted. She commented on hating it here and voiced confidently that she does not think she needs to be here. Doctor has documented her need for SNF [Skilled Nursing Facility] care. With her comments, she was asked about talking to someone about return to community and her response was well, if I can get outta here . Call placed to [first name], LTCO [long term care ombudsman]. Message left . Review of resident 10's current care plan printed on 1/29/25 revealed: *A focus area initiated on 8/8/24 indicated Resident noted to have a dx of Dementia, this resident benefits from the consistent smaller therapeutic environment and the specialized care provided in a secured unit. *There was no resident-centered goal, only the words see focus that was initiated on 8/8/24. *There were no specific interventions, only two narratives in the section for the interventions: -1/9/25 - [resident 10] she has been noted to have the following symptoms/behaviors: rejection of cares and disorientation to time. Resident's POA [power of attorney] notes that resident has intermittent periods of increased confusion. BIMS assessment completed on 1/8/25 with result of 14.0. Secured unit order received from PCP [primary care physician] on 8/7/24. [First name of resident] does not appear to be impacted by residing in a secured unit. Writer discussed secured unit placement with POA [first name] on 1/7/25, [POA's name] in agreement to with secured unit placement. [Resident 10] has been noted to benefit from the following services provided in the secure unit: specialized care, increased security to allow for independent mobility, smaller/calming environment, therapeutic activities, and consistency. Due to above information, resident will continue secured unit placement. -[Resident 10] can become very agitated and often yells/swears at staff, typically related to missing her old apartment at [Name of apartment building]. She seems to calm some when staff listen quietly and redirect her towards positive aspects. *The focus area regarding her placement on the secured memory care unit did not include: -A goal regarding her placement and adjustment to living on the secure memory unit. -Specific interventions to assist her to adjust to living on the unit. Review of the provider's revised August 2024 Care Plan, Resident-Centered and Individualized Plan of Care Policy revealed: *To ensure that each resident receives individualized, comprehensive, and person-centered care by developing and maintaining a written care plan based on their needs, preferences, and medical conditions. *Care plans should include a focus, goals and interventions for the resident. *The resident's care plan is reviewed and/or revised frequently due to changes and updates to the plan of care. *Each discipline is responsible for updating the care plan as changes to the plan of care occur. * The care plan covers focuses related to but not limited to: -Medications -Infections -Pressure injuries -Continents and Incontinence of resident -Bowel function of the resident -Fall risk and history -Dehydration and Risk of dehydration -Day-to-day activities and the assistance needed -Activities the resident enjoys doing.

Based on observation, interview, and record review, the provider failed to properly store products determined to be unsafe for cognitively impaired residents for at least 10 residents (7, 9, 15, 23, 36, 38, 40, 44, 46, and 69) on one of two memory care units. Findings Include: 1. Observations on 1/28/25 at 10:25 a.m. in resident 36's room revealed: *There was a sign posted on the mirror in the bathroom that read, Any product with 'Keep Out of Reach of Children' printed on its label needs to be kept on a closet shelf, i.e alcohol, mouthwash, [NAME] 24 [a moisturizing body cream], Baza Cleanse [a no-rinse lotion], deodorant, etc. Thanks! -Mouth Rinse, deodorant, and toothpaste were stored on a shelf in the bathroom and were accessible to the resident. *CPAP (continuous positive airway pressure) cleaning wipes were stored on top of the resident's dresser and accessible to the resident. -The container label read Keep out of reach of children. 2. Interview on 1/28/25 at 3:03 p.m. with resident 36 revealed she was pleasantly confused and was not oriented to place or situation, meaning she did not understand where she was or that she was a resident in a nursing home. 3. Interview on 1/30/25 at 9:46 a.m. with licensed practical nurse (LPN)/Nurse Manager J revealed: *The signs posted in the resident rooms were for the confused residents or for those who could not perform personal cares on their own. *The signs were placed in all resident rooms in the memory care units. *Products with the label Keep out of reach of children should have been stored away from the resident, such as the top shelf of a resident's closet, so the resident did not have access to those products. 4. Observation on 1/30/25 at 9:55 a.m. in resident 36's room revealed the CPAP cleaning wipes were still accessible on top of the dresser, and the mouthwash and toothpaste were still accessible on the shelf in the resident's bathroom. 5. Interview on 1/30/25 at 3:19 p.m. with certified nurse assistant (CNA) W revealed: *When asked how staff determined which residents on the secured memory care units should have their personal care products stored out-of-reach, she explained if a resident had dementia their products should be placed on the top shelf of their closet. -She was not aware of a policy or process to verify this practice. 6. Interview on 1/30/25 at 3:27 p.m. with LPN R revealed: *Residents were screened upon admission to the memory care unit to determine if they should have their products stored out-of-reach, when labeled with Keep out of reach of children. -Staff were to monitor for resident safety throughout each day. *If there were changes in the resident's behavior or cognition, staff were to report those changes to the nurse managers. -He was not aware of a process for determining which residents could have products accessible and which should have been placed on the top shelf of the closet. 7. Observation on 1/30/25 from 3:12 p.m. to 3:48 p.m. of the Pine Village memory care unit on the second floor revealed: *In resident rooms for residents 7, 9, 15, 23, 38, 40, 44, 46, and 69: -Products labeled Keep Out of Reach of Children were in various areas of each resident's rooms and accessible to those residents. -Products identified: mouth rinse, deodorant, Baza All-In-One Perineal Lotion, Gold Bond powder, toothpaste, Biotene mouth spray, perfume, and Head and Shoulders shampoo. 8. Review of resident 36's electronic medical record (EMR) revealed: *She was admitted on [DATE]. -The most current Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) assessment score of 4, which indicated she had severe cognitive impairment. *Diagnoses included unspecified dementia, adjustment disorder with depressed mood, and unspecified mood (affective) disorder. *Her care plan included the following: -She required staff supervision with personal hygiene tasks like oral cares. -She had impaired decision-making skills, impaired memory, impaired cognitive function and thought processes related to her dementia diagnosis. *Her care plan did not include that she required personal care products like toothpaste, mouthwash, and lotion to be stored out of reach due to her cognitive impairment. 9. Review of resident 7's EMR revealed: *She was admitted on [DATE]. *Her quarterly MDS assessment dated [DATE] included the following: -Under section C for cognitive patterns, the Staff Assessment for Cognitive Patterns was utilized rather than the BIMS assessment. --She had short-term and long-term memory issues. --She was able to recall staff names and faces. --Her daily decision-making skills were severely impaired. -She had the following diagnoses marked under section I: Non-traumatic brain dysfunction, Alzheimer's disease, dementia, anxiety disorder, depression, and manic depression. 10. Review of resident 9's EMR revealed: *He was admitted on [DATE]. *His quarterly MDS assessment dated [DATE] included the following: - Under section C for cognitive patterns, the Staff Assessment for Cognitive Patterns was utilized rather than the BIMS assessment. -He had short-term and long-term memory issues. -He was able to recall staff names and faces. -His daily decision-making skills were impaired. -He had the following diagnoses marked under section I: Dementia, Parkinson's disease, anxiety, and depression. 11. Review of resident 15's EMR revealed: *She was admitted on [DATE]. *Her quarterly MDS assessment dated [DATE] included the following: - She had a BIMS assessment score of 7, which indicated she had severe cognitive impairment. -She had short-term and long-term memory issues. -She was unable to recall year, month or day. -Her daily decision-making skills were impaired. -She had the following diagnoses marked under section I: Dementia. 12. Review of resident 23's EMR revealed: *She was admitted on [DATE] *Her quarterly MDS assessment dated [DATE] included the following: - She had a BIMS assessment score of 4, which indicated she had severe cognitive impairment. -She had short-term and long-term memory issues. -Her daily decision-making skills were moderately impaired. -She had the following diagnoses marked under section I: Alzheimer's disease, dementia, anxiety, and depression. 13. Review of resident 38's EMR revealed: *She was admitted on [DATE]. *Her significant change MDS assessment dated [DATE] included the following: -She had a BIMS assessment score of 11, which indicated moderate cognitive impairment -She required cueing on Section C; oriented to month and day, but unable to recall the year. -Her daily decision-making skills were moderately impaired. -She had the following diagnoses marked under section I: Alzheimer's disease, dementia, Parkinson's disease, anxiety, and depression. 14. Review of resident 40's EMR revealed: *She was admitted on [DATE]. *Her quarterly MDS assessment dated [DATE] included the following: -Under section C for cognitive patterns, the Staff Assessment for Cognitive Patterns was utilized rather than the BIMS assessment. -She had short-term and long-term memory issues. -She was unable to recall. -Her daily decision-making skills were moderately impaired. -She had the following diagnoses marked under section I: Dementia, and depression. 15. Review of resident 44's EMR revealed: *She was readmitted on [DATE]. *Her quarterly MDS assessment dated [DATE] included the following: -Under section C for cognitive patterns, the Staff Assessment for Cognitive Patterns was utilized rather than the BIMS assessment. -She had short-term and long-term memory issues. -She was unable to recall. -Her daily decision-making skills were severely impaired. -She had the following diagnoses marked under section I: Alzheimer's disease, dementia, anxiety, and depression. 16. Review of resident 46's EMR revealed: *She was readmitted on [DATE]. *Her significant change MDS assessment dated [DATE] included the following: -She had short-term and long-term memory issues. -She was unable to recall. -Her daily decision-making skills were severely impaired. -She had the following diagnoses marked under section I: Alzheimer's disease, dementia, and anxiety. 17. Review of resident 69's EMR revealed: *She was admitted on [DATE]. *Her admission MDS assessment dated [DATE] included the following: -She had a BIMS assessment score of 9, which indicated moderate cognitive impairment -She had short-term and long-term memory issues. -She had recall impairment. -Her daily decision-making skills were moderately impaired. -She had the following diagnoses marked under section I: Alzheimer's disease, dementia, anxiety, and depression. 19. Interview on 1/30/25 at 5:37 p.m. with director of nursing B revealed: *She stated, Products labeled with Keep Out of Reach of Children for every resident that was cognitively impaired were to be kept up on closet shelves. Like mouthwash, we don't want them to drink the entire bottle. *She stated, Residents more cognitively impaired are assisted in the bathroom and supervised. *She agreed that products in resident rooms on lower shelves in bathrooms, in 3-drawer bins, on window ledges or on the dressers were accessible to residents in the memory care unit. -She confirmed there was no process or policy in place to determine and what products for which residents should have been stored to ensure the environment remained as free of accident hazards as possible.

Based on observation, interview, record review, and review of the Hospice and Nursing Facility Services Agreement, the provider failed to ensure an integrated plan of care had been developed and made accessible between the provider's nursing staff and hospice agency for one of one sampled resident (19) who received hospice services. Findings include: 1. Observation and interview on 1/28/25 between 11:42 a.m. and 12:08 a.m. with cosmetologist AA in the Dixie dining room revealed: *Cosmetologist AA was seated next to resident 19 at the assisted dining table. *Resident 19 had a recent weight loss, was on a pureed diet due to pocketing of food, and had recently began receiving hospice services. 2. Interview on 1/29/25 at 11:34 a.m. with licensed practical nurse (LPN) L revealed resident 19 had gallstones, no surgery was recommended, and she began receiving hospice services about two weeks ago. 3. Interview on 1/29/25 at 3:07 p.m. with registered nurse (RN) K and staff development coordinator (SDC) H at the North Oak nurses' station regarding hospice revealed: *There was only one hospice provider the facility used, and they were available by phone 24 hours a day seven days a week. *Communication of when the hospice nurse would return to complete wound care or baths was provided verbally and in the electronic medical record (EMR) system. *There was no specific binder or paper records available at that nurse's station regarding resident 19's hospice plan. 4. Review of resident 19's EMR revealed there was no documentation that a physician's order for hospice had been received. 5. Interview on 1/29/25 at 3:38 p.m. with hospice RN GG revealed: *Consent forms were kept in the resident's paper medical record. *She documented her assessments, phone number, and the date of the next visit directly in the resident's EMR. 6. Review of resident 19's current facility care plan revealed: *She had been admitted to the facility on [DATE]. *Her diagnoses included mild intellectual disabilities, osteoarthritis, anemia, heart failure, fracture of left patella, acute kidney failure, anorexia, and anxiety disorder. *A nutrition focus area indicated, Currently on hospice was revised on 1/28/25. *The nutrition goal indicated, Comfort Care Nutrition provided due to hospice. *The nutrition interventions included, 1/28/24: admitted to hospice on 1/17 [2025] due to recent diagnosis of Calculus of Gallbladder with Acute Cholylith [Cholelith (gallstones)] with back pain. General surgeon recommends comfort cares over surgical intervention. On 1/29/25 a request was made to director of nursing (DON) B for resident 19's hospice care plan and physician order. 7. Interview on 1/30/25 at 8:19 a.m. DON B regarding hospice services revealed: *On 1/29/25 she had contacted hospice for a copy of resident 19's care plan. -Hospice was to put together a care plan and review it weekly with the medical doctor. *A hospice care plan was to be kept in the front of resident 19's paper medical chart and contained the contact number and the services that hospice staff provided. *She obtained a copy of resident 19's hospice physician's order on 1/29/25. *The joint care plan had not been completed. *She expected the facility care plan to be updated with the specific hospice plan by each department when resident 19 started receiving those services. *Hospice documented their notes directly in the EMR if there were any concerns. 8. Interview on 1/30/25 at 8:52 a.m. CNA FF regarding identifying residents receiving hospice revealed: *She identified resident 19 received hospice services. *That information was provided to her by the nurse, and it was to be on the pocket care plan. *Hospice visited resident 19 one to two times a week to take her vitals and complete a bed bath. 9. The provided pocket care plan did not indicate that the resident received hospice services. 10. Interview on 1/30/25 at 4:19 p.m. with administrator A and DON B regarding resident 19's hospice care revealed: *There had been a delay in getting the hospice admitting diagnosis for resident 19. *She was admitted to hospice on 1/17/25. *During the interview DON B called the hospice provider to request a copy of the physician's order and the hospice care plan. *DON B stated she updated the facility care plan to reflect that resident 19 had been admitted to hospice and the services she received. *She expected the care plan to reflect the specific care resident 19 received. 11. Review of resident 19's 1/30/25 updated care plan revealed: *Her care plan included a focus area that was revised on 1/30/25, See the MAR/TAR, Physician orders/protocol, CNA [certified nursing assistant] flow sheets and the Short Term Care Plan. Also, see the restorative nursing flow sheet and therapy plan of treatment in integrated therapy reports if applicable. Care plans are written by the exception reflecting facility standards. Administer medications as ordered. [Resident 19] was admitted to Hospice on 1/17/25. *There was no resident-centered goal, it directed to See Focus revised on 4/16/24. *There were no specific interventions, it directed to See Focus initiated on 5/9/18. 12. Review of resident 19's hospice care plan revealed: *It was dated 1/17/25. *The progressive disease process was gallbladder with acute cholylith (cholelith). *Ongoing updates will be communicated by Hospice to LTC [long-term care] and LTC will integrate changes into their care planning system. The Hospice care plan is the Plan of Treatment/485 with ongoing MD [medical doctor] orders being part of that plan. Hospice does not utilize a separate nursing plan of care [POC]. The LTC plan of care will reflect the most current POC at the LTC facility. That was marked with the responsibility code for hospice and long-term care. 14. A review of the provider's 1/8/13 Hospice and Nursing Facility Services Agreement revealed: *Joint Plan of Care . means a coordinated joint plan of care for an individual Patient for the palliation or management of the Patient's terminal illness and related conditions that (a) clearly delineates the services to be provided by Hospice and Facility; (b) is consistent with Hospice's philosophy; (c) is based on the assessment of the Patient's current medical, physical, psychological and social needs, and unique living situation; (d) reflects the participation of Hospice, Facility, the Patient and the Patient's family, as appropriate; and Euro complies with applicable federal and state laws and regulations. *Facility responsibilities included: -Participate in Development of JPOC -Coordination with Hospice Staff in implementation and update of Joint Plan of Care. *Joint Responsibilities/Mutual Promises. Development and Implementation of Plan of Care Hospice and Facility shall jointly develop and agree upon the Patient's Joint Plan of Care Hospice and Facility each shall maintain a copy of each Patient's JPOC in the respective clinical records maintained by each Party.

Based on observation, interview, and record review, the provider failed to ensure the posted daily staff data: *Was displayed in a prominent area accessible to all residents and visitors. *Included the resident census. *Included the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift and the resident census. Findings include: 1. Observation on 1/30/25 at 4:42 p.m. throughout the entire building revealed the nurse staffing data was located in an inconspicuous location near the visitor screening station to the right of the front desk. The staffing data was not posted anywhere else in the building, including the locked memory care units. 2. Review of the posted staffing data for 1/30/25 revealed: *The resident census was not included. *There were three sections for each shift. Each section was divided by resident unit. *Staff names were displayed for each shift they were working. *There was no distinction between registered nurses and licensed practical nurses. *The total number of nurse staffing hours was not included for each shift. 3. Interview on 1/30/25 at 5:18 p.m. with director of nursing B revealed: *The nurse staffing data was only posted at the front desk. *She indicated that the staffing data was supposed to have been posted more prominently, such as in front of the receptionist, rather than by the visitor screening station. *She agreed that not all residents had access to the posted staffing information. *She was not aware of all the requirements for the posted nurse staffing data, such as the resident census and the total hours worked per nursing discipline. *They did not have a policy regarding the posted nurse staffing data.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, and interview the provider failed to ensure the safety of one of one sampled resident (1) who had an unwitnessed fall and required hospitalization for injuries the next day. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include: 1. Review of provider's [DATE] DOH FRI for resident 1 revealed: *On [DATE] at 10:25 p.m. he had an unwitnessed fall. -His Brief Interview for Mental Status (BIMS) score was 7 which meant he had severe cognitive impairment. -He was found in the middle of his room on the floor, lying on his back. -His vital signs were taken and were within normal limits. -He was able to move all extremities. -He complained of right knee pain while on the floor. -He denied hitting his head. -He takes Warfarin (blood thinner medication). -Neuro checks were not indicated to be completed per the provider's Emergency Procedures policy. *After being assisted off the floor he complained of right hip pain. -He was given as needed acetaminophen (pain medication). *His physician was faxed about the fall. *His family was notified of the fall. *On [DATE] at 9:00 a.m. a nurse assessed him and found him to have fixed pupils, and not acting like himself. -His vitals were taken, and his blood pressure was low at ,d+[DATE]. -He was sent to the emergency room (ER) for evaluation. *He was admitted to the hospital for: - A fractured right hip. - A subarachnoid hemorrhage (bleeding in the brain). -A critical Troponin level (indicative of a heart attack). *He returned to the facility on [DATE] at 1:20 p.m. -He was admitted to a hospice program. -His code status was changed to Do Not Resuscitate (no CPR). *He passed away on [DATE] at 3:15 p.m. 2. Interview on [DATE] at 4:45 p.m. with administrator A and director of nursing B revealed: *Residents were categorized as fall risk based on past fall history. *No fall risk assessments were done for residents before [DATE]. *There was no Fall Policy and Procedures Policy before [DATE]. *Per provider's Emergency Procedures policy if resident hit head Neuro checks would be completed. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on [DATE] after record review revealed: *The provider followed their quality assurance process and education was provided, to all nursing care staff. -The nursing staff had been educated on their Emergency Procedures Policy update, Abuse and Neglect Policy, Reporting Requirements Policy and the new Fall Policy and Procedures for Long Term Care Facility. -Neuro checks are now to be completed for all unwitnessed falls. -Nurses are now to document in the nurse's notes for 72 hours post fall. -New Fall Risk Assessments were completed on all residents on [DATE], and they are to be completed upon admission and periodically after that, especially after a significant change in a resident's condition. -Updating of the resident's care plan is to be completed following assessment completion. -Audits on care plans and pocket care plans were started and completed on [DATE], [DATE], and [DATE]. These will be reviewed during QAPI (Quality Assurance and Performance Improvement) meetings. *Record review of other resident falls after [DATE] showed they were following their new and updated policies. *Observations and staff interviews revealed the staff understood the education provided and the revised processes. Based on the above information, non-compliance at F689 occurred on [DATE], and based on the provider's implemented corrective action for the deficient practice confirmed on [DATE], the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to ensure interventions of regular toileting, checking and changing incontinent briefs, or repositioning were consistently implemented for six of six sampled residents (15, 14, 13, 5, 12, and 2) who developed pressure ulcers after their admission to the facility. Finding include: 1. Observation on 3/20/24 at 10:53 a.m. of resident 15 lying in her bed with the head of bed in the upright position. Observation on 3/20/24 at 1:55 p.m. of resident 15 lying in the same position as when she was observed above at 10:53 a.m. that morning. Interview on 3/21/24 at 11:22 a.m. with resident 15 stated: *After meals she would sometimes had to wait up to five hours before staff would get her back to her room. *Last night she requested to use the bathroom and staff told her that they did not have time to put her on the toilet and told her to urinate in her brief and they would come back and clean her up. *She preferred to use the toilet and not have to be incontinent. Telephone interview on 3/21/24 at 12:30 p.m. with resident 15's daughter revealed: *There had been times that her mother's call light would not be answered and recalled that one time it took forty minutes for staff to respond to her mother's call light. *During one visit, the call light across the hall from her mother's room went off for an hour before it was answered by the staff. *There had been issues with her mother receiving showers. Her mother had gone two to three weeks without a shower. *That had improved since her mother started receiving care at the wound clinic. *She received a call from her mother last night and told her that staff refused to put her on the toilet and just told her to go in her brief. Interview on 4/3/24 at 8:00 a.m. with resident 15 revealed: *On 4/1/24 resident asked to use the bathroom around supper time and was told by unknown certified nursing assistant (CNA) that she did not use the bathroom implying to resident that she did not use the toilet. *On many occasions she would put her call light on, and staff would come in, shut the call light off, and would tell her that they would be right back after they assist another resident. When that happened, she was usually incontinent before they had come back to the room to assist her. *Resident stated that she had an appointment with her wound physician and was now supposed to be repositioned at least every 4 hours. *She stated that she was not repositioned last night. She had gone to bed around 8:30 p.m. on 4/2/24 and was not repositioned until she got up for the day on 4/3/24 at 7:00 a.m. *Staff did not check to see if she needed to have been changed or to use the toilet during the night. Review of resident 15's electronic medical record (EMR) revealed: *Her 2/20/24 BIMS (Brief Interview of Mental Status) score was a 15, which meant her cognition was intact. *Resident has a stage III pressure ulcer (Full thickness tissue loss. Fat tissue might be visible, but bone, tendon, or muscle was not exposed) on her sacrum. *A wound vac was placed on 03/07/24. *A 1/25/24 wound care clinic note stated Patient's daughter voices a lot of frustration with care patient is receiving from [provider's name] staff, states she hasn't received a shower in two weeks. Patient's daughter also voices concerns with nursing home never removing the sling under the patient while in bed. Review of resident 15's April 2024 Treatment Administration Record (TAR) revealed: *Resident needed to take two weekly showers per wound care orders. *Resident should have been repositioned every one to two hours. Review of resident 15's 10/5/23 care plan revealed: *The resident used incontinent briefs. *Staff were to assist resident to the toilet per care plan standard. *Staff should reposition the resident frequently. *The resident would at times refuse repositioning and had requested she only be repositioned once at night. 2. Observation and interview on 4/3/24 at 7:50 a.m. with resident 14 revealed: *She had just returned from the dining room after breakfast and was not offered the use of the bathroon by the staff. *She got out of bed at approximately 6:00 a.m. that morning and that was the last time her incontinent brief was changed. *Observation until 9:45 am of the resident was in the same position in her wheelchair. Interview on 4/3/24 at 9:15 a.m. with CNA Q revealed: *Staff had no place to document the frequency a resident would have been toileted or when the resident was checked or changed. *Staff would document if a resident was checked or changed on the End of Shift Report sheet located at the Center Oak nurses station. *When asked specifically about resident 14 and the above observation that she had not been repositioned or checked since 6:00 a.m. She stated that she would probably get checked and changed before lunch. *Resident 14 would sometimes refuse to be repositioned or get out of her wheelchair. When asked how she would document a refusal she said it would be documented in the behavior section in the EMR. Review of resident 14's EMR revealed: *Rejection of care was last documented on 3/27/24 at 13:59 (1:59 p.m.). Rejection of care was only documented twice in March 2024. *There was a history of a recent pressure ulcer that was identified on 3/12/24 and healed on 3/25/24. *Resident's 3/4/24 Braden scale assessment score was 13 which meant the resident was at moderate risk for developing pressure ulcers. Review of resident 14's 3/5/24 care plan revealed interventions included staff would encourage frequent repositioning. 3. Observation on 4/3/24 at 9:45 a.m. of morning care for resident 13 provided by CNA Q and a staff member who requested to remain anonymous revealed: *The resident had a suprapubic catheter. *She was incontinent of urine and the incontinent brief was saturated with urine. *When asked about the last time she was checked or changed, resident 13 stated she could not remember. *CNA Q and anonymous staff member were not aware when resident 13 was last checked and changed. *There were two open areas on her coccyx that were covered with a Mepilex dressing that was saturated with urine. *An anonymous staff member stated that many of the residents do not get checked and changed on the overnight shift and residents were often soaked in urine and would need to have their entire bedding changed. *The resident had one reddened area the size of a quarter on her right buttock and another reddened area the size of a dime on the left buttock. *When asked if staff applied a moisture barrier after an incontinent episode. CNA Q stated that they have moisture barrier cream at the nurse's station that they could use. *There was no barrier cream applied during the observation. Interview on 4/3/24 at 9:50 a.m. with licensed practical nurse (LPN) H regarding resident 13's treatment for the open areas on her coccyx and the reddened areas on her buttocks revealed: *The open areas were covered with a Mepilex dressing daily and as needed and a Triad cream was applied three times a week to the areas on her buttocks. *When asked about resident 13's incontinence, LPN H stated that would happen after her suprapubic catheter was flushed in the morning. LPN H stated that the resident's urologist was notified of the incontinence. Observation and interview on 4/4/24 at 7:32 a.m. during resident 13's wound care that was provided by wound care nurse (WCN) D revealed: *The two open areas on resident 13 coccyx were facility acquired pressure ulcers. *She stated the two reddened areas on the buttocks were moisture-associated skin damage (MASD). *When asked if the dime size reddened area on the left buttock was a new sore, as that sore was not present at an earlier observation. She stated that the area on the left buttock was a new MASD. Review of resident's 13's 4/3/24 progress note stated, during assessment, writer removed existing mepilex dressing to coccyx to assess skin integrity underneath the mepilex [Mepilex] and the writer did find 2 small PI's [pressure injuries] - see wound assessment for more information. Review of residents 13's 4/3/24 weekly skin assessment tool revealed that the resident acquired two new pressure injuries on the coccyx one measuring 5 millimeters (mm) x 5 mm x 1 mm and the other measuring 20 mm x 10 mm and unable to determine the depth. Review of resident 13's 3/8/24 care plan revealed: *She was at risk for skin breakdown. *She had MASD to her right inner buttocks related to occasional incontinence. *She had a history of a healed pressure ulcer to her coccyx. *Interventions included: -Encourage good nutrition and hydration. -Pressure-reducing cushion to the wheelchair and a low air loss (LAL) mattress. -Staff would monitor skin with all cares and report any new red or open areas. -Staff would reposition resident per care plan standard. 43844 4. Observation and interview on 4/3/24 at 8:24 a.m. with resident 5 revealed the following: *She was in her room sitting in her wheelchair. -The wheelchair had a pressure relieving cushion placed in the seat. *She stated she was nervous as she had been sitting a long time. -She wanted to sit in her recliner. *Dietary aide G assisted resident 5 to her recliner. Continued interview on 4/3/24 at 8:28 a.m. with resident 5 revealed the following: *She got up at 6:00 a.m. that morning. -She normally would not up until 7:00 a.m. -She was not sure as to why she had gotten up at 6:00 a.m. *She knew how to use her call light but did not know why it took so long to get help. *Stated that she needed help now, as she had to go to the bathroom, and the person that assisted her into her recliner had not helped her to the bathroom. Continued interview with resident 5 on 4/3/24 at 10:57 a.m. revealed the following: *She wore incontinent briefs but was not incontinent. *She had a sore on her butt, that sometimes hurts. -That area had been there for about a month. -The staff put an ointment of some kind on them [referring to her sore butt], two to three times a day. -Staff members assisted her to the bathroom during the night but had not put ointment on her bottom. Review of resident 5's EMR revealed the following: *She was admitted on [DATE]. *Her diagnoses included: weakness, stiffness of left hip, diarrhea, anxiety, pain, and depression. *Her BIMS score was a 13, that meant her cognition was intact. *Her 2/27/24 Minimum Data Set (MDS) indicated the resident had functional bladder incontinence r/t [related to] impaired mobility. *Her CNA task documentation for the last thirty days included the following: -Her behavior monitoring was all marked none or not applicable. -She was continent of urine and stool. *Her 2/23/24 Bowel and Bladder Program Scanner assessment indicated the following: -She was never incontinent of urine or stool. -She needed assistance of one staff member to transfer into the bathroom. -She was always aware of her need to use the toilet. -The condition of her skin on the genital perineal, and buttocks was marked as some blanchable redness. (pre-Stage I). --A Stage I pressure ulcer is an observable, pressure-related alteration of intact skin with non-blanchable redness. -Had no predisposing factors such as diabetes, stroke, bladder and prostrate, frequent urinary tract infections, spinal cord, injuries, cerebral palsy. *A 3/15/24 skin/wound care progress note that noted, Resident continues with current MASD to bilateral inner buttocks. Bilateral inner buttocks is red and blanchable with scattered open areas noted. Writer continues to believe that these open areas are not pressure related but MASD. Reddened areas and open areas are blanching and areas are moist upon assessment. Resident is incontinent and does wear and incontinence product. These areas have shown signs of healing since last assessment. *Her 3/21/24 revised care plan revealed: -She had functional bladder incontinence related to impaired mobility. -On 3/20/24 she had current MASD to her bilateral inner buttocks due to her impaired mobility and incontinence. -She was at risk for additional skin issues. -She had a pressure reducing cushion in her wheelchair and a pressure reducing mattress on her bed to help prevent PU's. Interview on 4/3/24 at 8:35 a.m. with LPN R revealed: *She had known that the night shift staff assisted residents in getting up in the morning. -The night shift usually finished at 7:00 a.m. -She was not sure who assisted resident 5 in getting up on the morning of 4/3/24. Interview on 4/3/24 at 11:06 a.m. with a CNA who wished to remain anonymous regarding resident 5 revealed the following: *Resident 5 was up, dressed, and in her recliner when she arrived at work at 6:00 a.m. on 4/3/24. *Resident 5 was usually continent of her urine. *She was aware that resident 5's had MASD on her buttocks. 5. Review of resident 12's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included stroke, dysphagia, anxiety, and hemiplegia and hemiparesis affecting her left side. *Her 2/29/24 Braden Scale assessment (for predicting pressure ulcer risk) score was a 17 that meant she was at risk for developing pressure ulcers. *A 3/1/24 physician wound care referral for a possible infection of her G (gastrostomy)-tube (feeding tube) site. *On 3/4/24 she was started on Rocephin (an antibiotic) for the G-tube infection. *On 3/7/24 she had gone to the wound clinic to assess her G-tube site. -While at the wound clinic, they identified an unstageable PU to her right lateral foot. *WCN D measure the wound upon the residents return from the wound clinic. -WCN D's measurements for the wound were 4 mm (millimeters) by 4 mm and an undetermined depth. *On 3/12/24 resident 12 was admitted to hospice for an acute physical decline related to a recent stroke. *A 3/12/24 physician order for, PU Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Right lateral foot topically one time a day every Mon, Wed, Sat for unstageable pressure ulcer secure with mepilex [Mepilex]. -The order was started on 3/13/24. 6. Observation on 3/20/24 at 7:40 a.m. with resident 2 and NA E during a transfer with a total mechanical lift revealed: *There was an alternating air-pressure mattress on the bed. *Resident 2 was lying on her back in her bed. *NA E placed a mechanical lift sling under resident 2. -She transferred resident 2 to her Broda chair and left the lift sling underneath her. *An unidentified CNA entered the room and assisted NA E to get resident 2 get dressed. *Resident 2 started to slide out of her Broda chair. -An unidentified CNA and NA E repositioned her in the Broda chair. -The lift sling underneath resident 2 was not repositioned and it had bunched up behind resident 2's back where Mepilex covered. -NA E assisted resident 2 to the dining room. Review of resident 2's EMR revealed the following: *On 1/5/24 her Braden scale score was an 8 that meant she was at a very high risk for developing a pressure ulcer. *A 2/11/24 progress that noted she had redness to her spine. -Mepilex was applied to the area and WCN D was notified. *On 2/14/24 a wound assessment was completed by WCN D. -That assessment indicated she had a pressure ulcer to her mid-back spine that measured 15 mm by 10 mm with an undetermined depth. --Interventions included a low air loss mattress, pressure relieving cushion in her wheelchair and frequent repositioning. *On 2/15/24 a nurse progress note that indicated the physician was informed of the PI (pressure ulcer) to her mid-back and the facility was awaiting a reply from the physician. *On 2/19/24 at 13:02 (1:02 p.m.) the physician ordered: -The PU to have been cleansed with soap and water and patted dry. -To apply Santyl ointment daily to the wound bed and cover with a dressing. --That order was started on 2/20/24. *A 2/22/24 Nutrition/Dietary progress note had noted, [(Resident 2)] has an unstageable new wound nursing is treating . *On 3/6/24 a nurse progress note indicated the PU was healed and requested the physician to discontinue the treatment. The provider's undated CNA's pocket care plan (a form with limited resident information that CNA's used when providing care to residents) noted resident 2: -Was incontinent. -Required the use of a full body mechanical lift for transferring. -Had a pressure ulcer to her mid (middle) back. --Interventions for pressure ulcers included the use of heel protectors, to have been laid down right after meals, and needed frequent turning and repositioning. Interview on 3/20/24 at 3:44 p.m. with DON B and ADON C regarding resident 2's PU revealed the following: *The wound was healed, and the area was covered with Mepilex as a preventative measure for a future PU in the same area. *Resident 2 preferred to spend most of her time in bed. *Interventions to prevent the PU had included a low air loss mattress and repositioning. 7. Interview on 4/4/24 at 8:00 a.m. with administrator A, director of nursing (DON) B, and WCN D revealed: *The expectation was that residents would be repositioned approximately every two hours. *Weekly skin assessments were only completed on residents with current pressure ulcers. *The follow up for residents with MASD were at the WCN D's discretion and would have been reassessed when appropriate. *There was no specific timeframe on when she would reevaluate the interventions and their effectiveness. It was at WCN D's discretion when that follow up occurred. *Interdisciplinary team (IDT) meets three times a week and they would discuss the residents skin issues. *WCN D would have weekly skin meetings with the nurses. *DON B was made aware of the concern regarding the staff working overnights not checking residents and the urine saturated beds and an internal investigation was currently being conducted. 8. Review of the provider's April 2023 Care plan, Resident-Centered Facility Standards of Care Policy stated: *All residents were to have been offered toileting frequently while awake unless otherwise specified by the resident's preferences or documented on their individualized care plan. *All residents admitted were offered frequent repositioning unless otherwise specified on the individualized care plan. Review of provider's August 2009 Perineal Care for the Incontinent policy revealed: *Staff would apply a barrier cream or ointment to all areas that may come in contact with urine and/or stool. Pay particular attention to denuded [loss of the surface area of the skin] areas. *Staff would reapply ointment or barrier cream following each incontinent episode. Review of provider's 3/2020 Pressure Sores: Prediction and Prevention Policy revealed: *Nursing staff would identify residents at risk, initiate prevention measures, and exercise early identification and treatment when noted. *The provider would identify specific residents at risk by using the Braden Scale and/or an initial assessment would have been done with each admission and interventions put in to place as indicated.

Based on interview, record review, observation, and policy review, the provider failed to ensure one of one sampled resident (1) was free from an injury caused by the use of a mechanical lift sling. Findings include: 1. Interview on 3/21/24 at 8:14 a.m. with resident 1 revealed the following: *She was left in a mechanical lift sling in her bathroom for at least two to three hours. *She stated, I cried, prayed, tried to holler, but no one heard me. I could hear them (staff members) laughing and talking. -The lift sling was pressing into her leg and really hurt, and her leg was still hurting her on the day of the interview. -She thought it was Monday (3/18/24), as the staff members were getting everyone ready for BINGO. Review of resident 1's electronic medical record revealed the following: *She was admitted on [DATE]. *Her 1/17/24 Brief Interview on Mental Status score was an 11, indicating she had mild cognitive impairment. *Her diagnoses included: hemiplegia affecting her right side, scoliosis, anxiety disorder, constipation, back pain, hallux valgus (a complex deformity of the forefoot), history of poliomyelitis, urge incontinence, macular degeneration, mild cognitive impairment, and hearing loss. *Review of resident 1's 3/21/24 care plan revealed the following: -She required the use of mechanical total lift and assistance of two staff members to transfer her onto the toilet. -She had physical impairments due to a history of Polio. -She liked to be in control of a situation. -She was very specific regarding the times she wants her care completed, she has at times voiced concern with waiting for staff to complete care for other res (residents). -She is usually alert & [and] orientated but may get details mixed up or forget at times & require reminders/cueing. She has a diagnosis of dementia with anxiety. Sudden changes or new situations may exacerbate altered cognition. -Be aware she has a pattern of being incontinent around 1 pm [p.m.] and then again around 9 pm [p.m.]so please toilet as close to these times as possible to help reduce her incontinence. *Review of her progress notes revealed that there was a 3/18/24 nurse note completed by registered nurse (RN) R that noted, Noted upon assessment of resident's skin during HS [bedtime] care; a darkish purple pink line running from mid R) [middle of right] upper thigh surrounding leg around to back of this thigh. Area is 1 cm [centimeter] in width. No open area. Rest of buttocks and skin is clear. Interview on 3/21/24 at 8:35 a.m. with director of nursing (DON) B revealed the following: *On 3/18/24 resident 1 had made an allegation of being left in a mechanical lift sling while in her bathroom. -She had reported it to administrator (ADM) A and thought he had talked to resident 1. -She was not aware of an investigation into the allegation that was initiated. -She had instructed registered nurse (RN) R to do a skin check and make a note in resident 1's EMR. Interview on 3/21/24 at 8:49 a.m. with ADM A and DON B regarding the allegation of resident 1 revealed the following, ADM A: *Was notified on Tuesday (3/19/24), after the noon meal, about the incident and had: -Talked to resident 1 and she told him that she did not want to yell because her heart was beating too fast. -Confirmed her call light was working. -Reviewed the call light log, her call light had not been on for any extended length of time. -Had not considered the allegation a reportable event to the South Dakota Department of Health. -Had not investigated the allegation. Observation and interview on 3/21/24 at 9:45 a.m. during resident 1's skin assessment with DON B revealed the following: *Resident 1 had an of upper right leg abrasion that measured approximately 2 cm wide and 9 inches long starting at the top front of the resident's right leg just below the hip bone and ran down around the back of her right leg. -The abrasion was dark pink in color about 6 inches at the top and faded to light pink at the bottom behind the leg. *Resident 1 stated the area was painful. -She thought there was a steel bar on the lift that was digging into her skin during the incident. -She stated she had hollered for help for three hours, I could hear them giggling and laughing. I was praying. *DON B confirmed the cause of the abrasion was consistent with where the edge of the lift sling would have met her skin when she was seated in the sling on the toilet. Continued interview on 3/21/24 at 10:15 a.m. with ADM A and DON B revealed the following: *ADM A clarified resident 1's allegation of being left on the mechanical lift sling in the bathroom occurred on 3/18/24 and he was notified that same day. -He stated that he had reviewed the facility's recording cameras in the hallways on 3/21/24 and confirmed that on 3/18/24 from 12:36 p.m. to 2:17 p.m. resident 1 had been left in the mechanical lift sling in her bathroom. -That was one hour and 41 minutes. *The process was to have wound care nurse (WCN) D assess at the wounds. -They had not had WCN D assess the wound. Interview on 3/21/24 at 10:46 a.m. with registered nurse (RN) revealed the following: *DON B had asked her to look at resident 1's leg and document her findings. -She documented her findings in resident 1's EMR. -She stated her measurements for the wound were completed by visualizing with her eyes and hand. *She had not communicated with any staff except DON B regarding the wound. *The process for when a wound was identified was to measure it and the WCN. -She had not notified WCN D. Review of the provider's revised 10/2023 Mechanical Lift Policy revealed the following: *16. Prior to leaving the resident confirm the resident is in a comfortable and safe position. Check that the resident's call light is within reach. Review of the provider's revised 12/2019 Abuse/Neglect/Exploitation of Residents revealed the following: *Policy: Residents must not be subjected to verbal, sexual, physical and mental abuse, corporal punishment, involuntary punishment, involuntary seclusion or misappropriation of property by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals. *Responsibility: All staff -IV. Identification: Any injury or event is communicated to at least one member of the QAPI [Quality Assurance and Performance improvement] team followed by investigation if abuse/neglect is suspected. Alleged or suspected violations involving any mistreatment, neglect, or abuse including injuries of unknown source, will be reported to your immediate supervisor and to other officials in accordance with State law. -V. Investigation: DON/Designee will review events of suspected abuse/neglect. -VII. Reporting/Response: The DON or Designee will report results of investigation to State Department of Health and other official in accordance with the law. Reporting is done per State Department of Health requirements.

43844 Based on observation, interview, electronic medical record review (EMR), and policy review, the provider failed to ensure staff interactions and services were provided in a manner that maintained a sense of dignity and respect for the following: *One of one sampled resident (3) by maintaining privacy during personal care. *Two of two sampled resident (2 and 1) resident in honoring their preference for wake time. *Two of two sampled residents (2 and 13) by using their proper name. *One of nine sampled residents (3) who needed a call light to call for assistance. Findings include: 1. Observation on 3/21/24 at 6:45 a.m. of resident 3 revealed: *He was yelling help me and motioning with his hands for assistance. *He stated his scrotum was itching and he needed a salve put on it. *He had his hand inside his incontinent brief and appeared to be scratching at his scrotum. *Licensed practical nurse (LPN) L entered his room and without closing his window curtain before completing the care she: -Provided his perineal care. -Applied salve to his scrotum. Interview on 3/21/24 at 7:25 a.m. with LPN L confirmed she did not pull the window curtain before providing perineal care to resident 3. Interview on 4/4/24 at 9:01 a.m. with licensed social worker (LSW) K confirmed it was not appropriate to leave window-curtains or doors open when providing personal cares to residents. -Privacy was to have been provided by all staff members when providing personal care to residents. Review of the provider's August 2023 A.M. Care policy revealed there was no guidance on providing privacy when completing resident care. Review of the provider's August 2022 Oral Cares/hygiene policy revealed staff members were to close the privacy curtain when providing care to residents. -There was no reference to the window curtain. 2. Observation and interview on 3/20/24 at 7:40 a.m. with resident 2 and nurse aide (NA) E revealed the following: *NA E was assisting getting resident 2 up for the day. *Resident 2 kept repeating she did not want to get up, and I was sleeping so good. 3. Observation and interview on 3/21/24 at 8:02 a.m. with resident 1 revealed she: *Was seated in her recliner. *Stated, They got me up at 5:30 a.m. this morning, never in my life have I gotten up at 5:30. Maybe 6:00 [a.m.] but never 5:30. -Was unsure as to why the staff had woken her up at 5:30 a.m. -They did not turn on the lights while getting me up or when I was in the bathroom brushing my teeth and washing my face. I have to tell them to set up the things so I can brush my teeth. They always have different staff; I have to tell them where everything is at. Review of resident 1's EMR revealed the following: *She was admitted on [DATE]. *Her 1/17/24 Brief Interview on Mental Status (BIMS) score was an 11, indicating she had mild cognitive impairment. *Her diagnoses included: hemiplegia affecting her right side, scoliosis, anxiety disorder, history of poliomyelitis, urge incontinence, macular degeneration, mild cognitive impairment, and hearing loss. *Review of resident 1's 3/21/24 care plan revealed the following: -She liked to be in control of a situation. -She was very specific regarding the times she wants her cares completed, she has at times voiced concern with waiting for staff to complete care for other res [residents]. -She is usually alert & [and] orientated but may get details mixed up or forget at times & require reminders/cueing. She has a diagnosis of dementia with anxiety. Sudden changes or new situations may exacerbate altered cognition. 4. Observation and interview on 3/20/24 at 7:40 a.m. with resident 2 and NA E revealed the following: *NA E called the resident honey, sweet pea, and sweetheart, while providing morning care. *CNA Q entered the room at approximately 8:04 a.m. and then called resident 2 mama and honey, while providing morning care and stated, what you feeling today girl? while looking in the closet for a shirt. Review of resident 2's 3/20/24 care plan revealed there was no documentation of her preferred name to have been used by the staff. 5. Observation on 3/21/24 at 8:50 a.m. of resident 13 and NA E revealed the following: *NA E called resident 13 honey and sweetheart, during morning cares. Review of resident 13's 3/21/24 care plan revealed there was no documentation of her preferred name to have been used by staff. 6. Interview on 3/21/24 at 8:55 a.m. with NA E and CNA Q revealed: *They were aware they should not call residents sweetheart, honey, or mama. -They both stated it was hard to stop calling residents by those names. *They agreed they were to use a resident's proper name unless the resident preferred an alternate name. Interview on 4/4/24 at 9:01 a.m. with licensed social worker (LSW) K revealed: *She stated, as a rule, it is not allowed for staff to call residents sweetheart, mama, honey, and sweet pea, it should be kept respectful, and they should use their names. *If a resident wanted staff to use something other than their proper name it was recorded on their care plan. 7. Observation on 4/3/24 at 8:20 a.m. of resident 3 revealed his call light was draped over the side of a rolling bedside table that was not within his reach. Observation on 4/3/24 at 11:03 a.m. of resident 3 revealed: *He was seated in wheelchair. -There was a bedside rolling table behind him with a call light push button on it. -The corded call light was draped over the side of the bedside table approximately 3 feet behind him. *Resident 3 required the use of a full-body mechanical lift and one staff member to transfer. *He was unable to reach either of the call lights. Interview on 4/3/24 at 11:30 a.m. with CNA Q revealed the following, she: *Confirmed he did not have access to a call light at this time. *Confirmed resident 3 was able to use both the corded call light and the push call light button. -She did not go into his room and ensure his call light was within his reach. Review of the provider's 8/23 A.M. Care policy revealed the following: *11. Place call light within easy reach of resident and instruct resident to push call light for assistance as needed. 8. Interview on 4/4/24 at 9:03 a.m. with LSW K regarding resident rights revealed the following: *Staff education related to resident rights and dignity was provided by online training, nurse's meetings, and departmental meetings. *Resident preferences were recorded on the baseline care plan upon admission. -That included the resident's preference for wake times and times to go to bed. Interview on 4/4/24 at 11:33 a.m. with administrator (ADM) A, director of nursing (DON) B, and assistant director of nursing (ADON) C revealed: *They were working on a new software program that would ask residents what their preferences were for when to get up and when to go to bed. -The program was to start of April 2024. -Preferences for those residents who were admitted before the implementation of baseline care plans were not known. --They were not certain when the baseline care plans had been implemented but thought it was a couple of years ago. *DON B stated, We ask the residents do you want to get up? Some [residents] get up early and some don't. Sometimes if they are wet and need to be changed, we ask if they care to get washed up and dressed at that time. Previously we used agency staff, and we identified early risers in the building for them.

Based on observation, interview, record review, and policy review the provider failed to ensure oral care was consistently performed and accurately documented for nine of nine sampled residents (16, 17, 18, 19, 20, 2, 3, 4, and 5). Findings include: 1. Observation on 3/20/24 at 7:17 a.m. of morning care for resident 16 provided by certified nurse aide (CNA) N revealed that oral care was not completed before placing her dentures in her mouth. 2. Observation on 3/20/24 at 7:30 a.m. of morning care for resident 17 provided by CNA N revealed that oral care was not performed before to placing her dentures in her mouth. 3. Observation on 3/20/24 at 7:45 a.m. of morning care for resident 18 provided by CNA N revealed: *The resident's dentures were not in the denture cup container and CNA N stated, They must still be in her mouth. *It was confirmed by CNA N that the resident's dentures were still in the resident's mouth. *When asked if the resident had slept with her dentures in, CNA N stated that the resident will sometimes refuse to let staff remove her dentures and that her dentures had been left in her mouth all night. *The dentures were not removed during morning care and oral care was not completed. *CNA N was unable to determine how long the resident's dentures had been left in her mouth without any oral care. 4. Observation and interview on 3/20/24 at 9:00 a.m. with CNA O and CNA N who were assisting resident 19 to bed revealed: *When asked when do residents get their teeth brushed, CNA O stated that the staff would have brushed the resident's teeth when they got up for the day or after breakfast depending on the staff. *When asked if resident 19 had his teeth brushed that morning, CNA O stated that she did not know. *When she went to look for resident 19's toothbrush, she could not find a toothbrush for him in his room and stated that she would normally use a disposable toothette for his oral care. *When asked if the resident had his teeth or wore dentures, CNA O was not aware if the resident had his teeth or wore dentures. *CNA N could not locate the resident's toothbrush and stated that she would use a disposable toothette. 5. Interview on 3/20/24 at 10:20 a.m. with licensed practical nurse (LPN)/nurse manager P revealed: *She would normally use a disposable toothette and water when completing oral care for resident 20. *She would not use resident 20's toothbrush due to the resident grinding her teeth and she was afraid that the resident would swallow the mouth rinse solution. *When asked if resident ever got her teeth brushed, she said sometimes. *She stated that oral care was usually completed when the resident got up for the day or after breakfast. 6. Observation on 3/20/2024 from 7:30 a.m. to 10:30 a.m. on the Pine Village unit revealed: *Every toothbrush that was examined was dry and appeared to have not been used that morning. *Residents who had the 4 ounce (oz) mouth rinse bottles in their rooms were all dated 12/6 and appeared to be full. 43844 7. Observation on 3/20/24 at 7:40 a.m. of morning care for resident 2 provided by nurse aide (NA) E revealed her dentures were in her mouth and no oral care was provided. Observation on 3/20/24 at 9:56 a.m. of resident 2's bathroom revealed the following: *Her toothbrush was dry and was lying in the emesis basin. *There was a 4 oz. size bottle of mouthwash dated 1/11/24 that contained approximately 3 ounces of mouthwash. Observation on 4/3/23 at 8:10 a.m. of resident 2 and her bathroom revealed her dentures were in her mouth and her toothbrush bristles were dry and hard. Review of resident 2's EMR revealed the following: *Her BIMS score was a 9, meaning she had mild cognitive impairment. *Her care plan revealed she: -Wore a full set of dentures. -Needed total assistance of one staff member with her personal care and oral hygiene. Interview on 3/20/24 at 10:05 a.m. with NA E regarding oral care for resident 2 revealed: *Oral care was usually completed by whomever assisted the resident when getting up in the morning. *Resident 2 already her dentures in that morning before she assisted her in getting up. -The dentures should have been removed from resident 2's mouth last night before bed. --Sometimes the day shift removed the dentures. *The night shift had not notified her that resident 2's oral care had been completed. *She confirmed she had not completed oral cares on any residents she assisted that morning. 8. Observation and interview on 3/20/24 at 9:55 a.m. with resident 4 revealed the following: *She had a partial denture that the staff brushed and then she would brush her own bottom teeth. *Her oral care had not been performed that morning. *She stated, They had been done the evening before, but they are not always done daily. *At 10:25 a.m. her partial denture remained in her cup in the bathroom. Interview on 3/21/24 at 11:16 a.m. with resident 4 revealed: *Last night she slept with dentures in her mouth. -Her oral care was provided last evening. *No oral care was completed by staff that morning. Review of resident 4's EMR morning care documentation for resident 4 revealed *Her 3/11/24 BIMS score was a 14, that meant her cognition was intact. *Her physician orders included that her oral cares be completed twice a day. 9. Observation on 3/20/24 at 10:00 a.m. of resident 5 revealed her toothbrush was dry and had hard firm bristles. 10. Observation on 3/20/24 at 10:21 a.m. resident 3 revealed a battery-operated toothbrush in his bathroom that was dry with hard bristles and appeared to have been unused. Review of resident 3's EMR revealed the following he required total assistance of a staff member for personal hygiene. 11. Interview on 3/20/24 at 3:30 p.m. with director of nursing (DON) B and the assistant director of nursing (ADON) C regarding resident's oral care revealed that the expectation was that oral care would have been completed every morning with every resident during morning care, but that it was still at the resident's discretion on when that would have been completed. 12. Review of the provider's 4/2023 Care Plan, Resident-Centered Facility Standards of Care Policy revealed: *Staff would provide resident oral cares daily and as needed. *Staff would monitor oral mucosa and integrity. Review of the provider's 8/22 Oral Hygiene policy revealed the following: *Policy: -Residents will be assisted with oral hygiene with a.m. and p.m. care and as necessary. The mouth will be cleansed for personal hygiene and to lessen the occurrence of mouth infections. Oral Hygiene will be provided when the resident able to assist or per the resident's preferences. *Responsibility: -RN/LPN - Assess oral health of residents regularly, monitor oral care procedure done by NA. -CNA Assist residents with oral hygiene twice daily and as necessary. Observe for problems and report same to nurse. *Care of residents with dentures: -2. Request resident to remove dentures and place them in an emesis basin or denture cup. 4. Place dentures in cup with fresh solution of an effervescent denture tablet and cool water or plan water during p.m. care. Clean denture cup after a.m. care. -5. Clean inside of mouth thoroughly with mouthwash diluted with 4 parts of water to 1 part of mouthwash and rinse with water. May use toothettes to clean soft tissues. 50015

Based on interview, record review, and policy review, the provider failed to ensure an allegation of neglect made by one of one sampled resident (1), was reported to the South Dakota Department of Health (SDDOH) within twenty-four hours from the time that the provider was made aware of the allegation. Findings include: 1. Interview on 3/21/24 at 8:14 a.m. with resident 1 revealed the following: *She was left in a mechanical lift sling on the toilet in her bathroom for at least two to three hours. *She stated, I cried, prayed, tried to holler, but no one heard me. I could hear them (staff members) laughing and talking. -The lift sling was pressing into her leg and really hurt, and her leg was still hurting her on the day of the interview. -She thought it was Monday (3/18/24), as the staff members were getting everyone ready for BINGO. Interview on 3/21/24 at 8:35 a.m. with director of nursing (DON) B revealed the following: *On 3/18/24 resident 1 had made an allegation of being left in a mechanical lift sling while in her bathroom. -She had reported it to administrator (ADM) A and thought he had talked to resident 1. -She had instructed registered nurse (RN) R to do a skin check and make a note in resident 1's EMR. -She had not initiated an investigation into the allegation. -She had not reported the event to the SDDOH. Interview on 3/21/24 at 8:49 a.m. with ADM A and DON B regarding the allegation of resident 1 revealed the following, ADM A: *Was notified on Tuesday (3/19/24), after the noon meal, about the incident and he had: -Talked to resident 1 and she had told him that she did not want to yell for help because her heart was beating too fast. -Confirmed her call light was working. -Reviewed the call light log, and her call light had not been on any extended length of time. -Not completed a thorough investigation into that allegation -Not considered the incident a reportable event to the SDDOH. Continued interview on 3/21/24 at 10:15 a.m. with ADM A and DON B regarding the allegation from resident 1 revealed the following: *He clarified the allegation had occurred 3/18/24. *He confirmed that on 3/18/24 from 12:36 p.m. to 2:17 p.m. resident 1 had been left in the mechanical lift sling on the toilet in her bathroom. -That information was based on his review of the facility's recording cameras and interviews conducted with staff on 3/21/24. Review of the provider's revised 12/2019 Abuse/Neglect/Exploitation of Residents revealed the following: *Policy: Residents must not be subjected to verbal, sexual, physical and mental abuse, corporal punishment, involuntary punishment, involuntary seclusion or misappropriation of property by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals. *Responsibility: All staff -IV. Identification: Any injury or event is communicated to at least one member of the QAPI team followed by investigation if abuse/neglect is suspected. Alleged or suspected violations involving any mistreatment, neglect, or abuse including injuries of unknown source, will be reported to your immediate supervisor and to other officials in accordance with State law. -V. Investigation: DON/Designee will review events of suspected abuse/neglect. -VII. Reporting/Response: The DON or Designee will report results of investigation to State Department of Health and other official in accordance with the law. Reporting is done per State Department of Health requirements. Refer to F600.

Based on interview, record review, South Dakota Department of Health (SD DOH) incident report review, and manufacturer's recommendations review, the provider failed to ensure one of one sampled resident (13) was assessed for the appropriate lift type Maxi Move ( a mechanical device used to transfer residents), the correct size of sling, and the number of staff required to perform a transfer with a Maxi Move lift safely. Findings include: On 10/4/23 at 5:00 p.m. an immediate jeopardy was identified related to quality of care F684. Notice: Notice of immediate jeopardy was given verbally and in writing on 10/4/23 at 7:00 p.m. to administrator A and director of nursing (DON) B and assistant director of nursing (ADON) C. On 10/4/23 at 5:00 p.m. an immediate jeopardy was determined when the facility failed to ensure the following: *A resident assessment for proper mechanical lift equipment use and the number of staff required to operate the lift equipment safely was followed by manufactures recommendations which include: -A clinical assessment of the patient's suitability for transfer must be carried out by a qualified health professional considering that, among other things, that transfer may induce substantial pressure on the patient's body. A transfer conducted when it should not, can degrade the patient's health condition. *The need for a second attendant to support the patient must be assessed in each individual case. *There are circumstances, such as combativeness {sic}, obesity, contractures etc. of the individual that may dictate the need for two-person transfer. It is the responsibility of each facility or medical professional to determine if a one or two transfer is more appropriate, based on task, resident load, environment, capability, and skill members. *Ensure that certified nurse assistant are not assessing for the resident's suitable for transfer. *Ensure that residents who require the use of the mechanical lift are also assessed for the proper sling size to be used during transfers. *A resident 13 who had not been assessed for safe mechanical lift use, fell from a mechanical lift on 7/12/23 while being transferred by one staff member and sustained a head injury. *All residents who require the use of a mechanical lift have the potential for harm as a result of not having been assessed for the use of a mechanical lift and include the specific number of staff to safely operated the mechanical lift. *Ensure that residents who require the use of a mechanical lift have been assessed for the specific number of staff required to ensure the safety of the resident while being transferred with a mechanical lift. *Assessments will need to be completed by a licensed healthcare professional (RN, PT, OT). *Ensure that residents who require the use of the mechanical lift are also assessed for the proper sling size to be used during transfers. On 10/4/23 at 7:00 p.m. administrator A, DON B and ADON C were asked for an immediate removal plan. Plan: 1. Initial assessments were conducted on all residents requiring a mechanical lift on 10/5/23. Educated nurses, CNAs, therapy services, and nursing management on assessing when a resident requires a mechanical lift for transfer. Nursing staff will be responsible for communicating a change in condition for resident's transfer status requiring a mechanical lift. An assessment will be initiated to determine if a resident requires a sit-to-stand lift or full-body lift. If a full-body lift is determined, the assessment will indicate the appropriate size of the sling and if the resident requires one or two people while operating the full-body lift. The IDT team will evaluate the change in transfer status with therapy. Care plan will be updated to show appropriate transfer status. Education initiated on 10/4/23 will be provided by DON, ADON or designee to all nursing staff and therapy services prior to their next working shift. Education provided to staff. Nursing assistants will notify the charge nurse if there is a change in the resident's condition. This would trigger a clinical assessment by a health professional. The assessment will determine whether sit-to-stand or total lift is required. If a full-body lift is needed, the size of the sling and the personnel necessary for transfer are either one or two staff. Mechanical lift recommendations will be communicated to staff through a daily morning huddle, and the care plan will be updated in PCC. 2. An initial audit will be conducted by DON, ADON, or designee on all residents who currently require mechanical lift. This audit will review the initial assessment for proper lift and if the total body lift is required the fit of sling and the appropriate staff needed to operated the full body lift. 3. Compliance date 10/5/23. On 10/5/23 at 11:59 a.m. the provider's immediate jeopardy removal plan was accepted. On 10/5/23 at 12:35 p.m. while onsite the immediacy was removed. Once the immediacy was removed the scope and severity was changed to a G. Interview on 10/3/23 at 10:45 a.m. with resident 13 revealed: *She had fallen from the Maxi Move lift and had obtained a cut to the back of her head. -Her head laceration required an emergency room (ER) evaluation and two staples to close the wound. *She did not think that all the straps were secured to lift and that was why she fell out of the lift. *Only one certified nurse aide (CNA) was transferring her at that time with the Maxi Move lift. Review of resident 13's electronic medical record (EMR) revealed: *She had a Brief Interview for Mental Status (BIMS) score of 12 suggesting she had moderate cognitive impairment. *She had the following medical diagnoses: -Post-polio symptoms. -Hemiplegia (loss of the use of limbs on one side of the body) affecting the right side of her body. Review of resident 13's care plan initiated on 3/7/2018 revealed: *Focus: Resident 13 is at risk for fall related to her taking psychotropic medication to treat her diagnosis of depression. *Interventions: Resident 13 chooses to use the standing lift versus the total lift. She is at risk for falls and significant injury secondary to her insisting the seat strap not be used. -She had been instructed on the risk associated with not using the seat strap however she stated I will deal with that. *Focus: Resident 13 has an activities of daily living (ADL) self-performance deficit related to her decreased mobility and need for assistance with all of her ADL's. She had physical impairments related to her diagnosis of polio. *Intervention: Toilet use: one to two total assist. Staff will toilet resident 13 per the care plan standard. She will be seated on the toilet with the assistance of the total lift when she prefers to use the restroom. Review of the SD DOH incident report submitted on 7/13/23 revealed: *On 7/12/23 at 11:00 a.m. resident 13 was transferred using the Maxi Move lift from her bed to her motorized wheelchair by one CNA. *Resident 13's weight shifted while lowering her in the Maxi Move lift causing one of the four hooks to become unhooked resulting in her falling from the total lift to the floor in her room. *The resident was transferred to the ED for evaluation and closure of the laceration with two staples to back of her head. Interview on 10/4/23 at 11:00 a.m. with an anonymous employee regarding transferring residents with the Maxi Move lift revealed: *Staff felt uneasy about transferring a resident with the Maxi Move lift with just one person. *Staff would ask another staff member for help with transferring a resident with the Maxi Move lift. -Staff had never refused help from another staff member while transferring a resident with the Maxi Move lift. Interview on 10/4/23 at 1:00 p.m. with CNA H regarding transferring a resident with the Maxi Move lift revealed: *She had worked at other facilities that required two staff members to transfer residents with the total lift. *She would have made the decision depending on the resident what type of lift would have been required to safely transfer a resident. *The majority of the time she felt that transferring residents with the Maxi move lift was appropriate with one staff member. Interview on 10/4/23 at 3:30 p.m. with administrator A, and DON B regarding CNAs assessing for the type of mechanical lift and the number of staff that would have been required to transfer the residents revealed: *They both felt that the CNAs use the mechanical lift equipment and would have been able to determine what type of lift and the number of staff required to transfer the residents. *The CNAs would have determined the size of the sling to have been used with the resident during a Maxi Move lift transfer. -The sizes of the sling were not determined by the resident's weight but by how the sling fit around the resident. *Resident 13 had not been reassessed for appropriate mechanical lift used for transferring following her fall from the Maxi Move lift. *Her fall was the result of a strap coming unhooked and there was not an issue with the Maxi Move lift. *DON B had completed a competency for the Maxi Move lift use with the CNA involved in the fall. *They had not been aware of the manufactures recommendation that stated before using the total lift a clinical assessment of the resident's suitability for transfer must be carried out by a qualified health professional. *They had not assessed the residents prior to using the Maxi Move lift as well the proper sling size for that resident. *They had not assessed for the correct number of staff required to perform a safe resident transfer using the Maxi Move lift. Review of the provider's revised 3/2022 Maxi Move lift policy revealed: *The total lift will be used correctly and safely with one or more staff assisting, as necessary. *Equipment require: total lift and proper fitting sling. *Instructions: -Correct sling size is important. -Make sure the sling is clean and not damaged. -Make sure the residents weight is lower than the safe work load for the total lift, slings and accessories used. -If a resident becomes agitated, you may need to stop the transfer and safely lower the resident. Review of the 12/2015 Maxi Move lift instructions for the proper use revealed: *Safety instructions: -Before using the total lift, a clinical assessment of the resident's suitability for transfer must be carried out by a qualified health professional considering, that among other things, the transfer may induce substantial pressure on the resident's body. A transfer conducted when it should not, can degrade the resident's health condition.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (6) with a history of a pressure ulcer had the appropriate interventions in place to prevent further skin issues. Findings include: 1. Observation on 10/29/13 at 11:20 a.m. of resident 6 revealed she had been sitting at the dining room table in a high back rocking wheelchair (w/c). She had her eyes closed and had appeared to have been asleep. Review of resident 6's complete medical record revealed: *She had been admitted on [DATE]. *She had the following Diagnoses: [REDACTED]. -Diabetes. -Cardiovascular disease. -Anxiety state. -Delusional disorder. *On 8/8/12 she had a pressure area to her inner right buttock. *On 10/25/13 she had a Stage 2 (partial thickness loss of dermis (skin) presented as a shallow open ulcer with red or pink wound bed) to her right buttock area. The area was 1.0 centimeter (cm) by 0.5 cm. -The treatment of [REDACTED]. Interview on 10/29/13 at 12:20 p.m. with licensed practical nurse (LPN) A regarding resident 6 revealed she: *Had a Stage 2 pressure ulcer to her right buttock region. *Had a pressure alternating mattress on her bed. *Was unable to reposition herself and had required assistance of one or two staff persons to reposition while in bed. *Had required total assistance of a stand-aid (mechanical lift) for toileting and positioning to get in and out of bed. Interview on 10/29/13 at 2:30 p.m. with certified nursing assistant (CNA) F regarding resident 6 revealed: *She was totally dependent on staff for all repositioning. *The staff would reposition her every two hours. *She used a wheelchair (w/c) for mobility. Observation on 10/29/13 from 1:00 p.m. until 3:05 p.m. of resident 6 revealed she had not been repositioned in her w/c during that time. Observation on 10/29/13 from 4:00 p.m. through 6:10 p.m. revealed resident 6 had been sitting in her w/c and had been moved from the dining room into the hallway outside of the dining room. She had not been repositioned and had not laid down in her bed throughout the observation period. Observation on 10/30/13 at 9:00 a.m. of resident 6 revealed: *She had been sitting in her w/c in the dining room. *She had finished breakfast and was sleeping in her w/c. Observation on 10/30/13 at 9:15 a.m. with LPN A, CNA F, and resident 6 during the pressure ulcer dressing change revealed: *The CNA had placed resident 6 in the stand-aid in the bathroom. *LPN A had changed the dressing to the resident's right buttock region. *The resident's buttocks were quite reddened. *There was a darkened area on the right buttock region. Interview immediately following the above observation with CNA F regarding resident 6 revealed: *The resident had not been laid down consistently. *She usually sat up in her w/c. *CNA F confirmed the resident had not laid down on 10/29/13 throughout her shift. CNA F had worked 6:00 a.m. through 2:30 p.m. Interview with LPN A immediately following the above observation regarding resident 6 revealed: *She believed she had a history of [REDACTED]. *The stage 2 pressure ulcer had been noted on 10/25/13. *She was not consistently laid down, as she usually sat in her w/c throughout the day. Interview on 10/30/13 at 2:20 p.m. with the director of nursing regarding resident 6 revealed: *Staff should have been repositioning her every two hours and that should have included lying her down to relieve pressure on her buttocks. *She would have expected the resident to have laid down during the day to relieve pressure off her buttocks because of her history of a pressure ulcer. Review of the provider's November 2011 Pressure Ulcer policy revealed: *Pressure relieving measures not already in place should have been implemented. *Nursing judgement should have been used on characteristics of the wound and the individual resident's needs. *Residents with Stage 2 pressure ulcers should have offloading (removing the pressure from the area) and frequent positioning. Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, Mo., 2005, p. 1430-1431, revealed: *"Any break in the skin's integrity is difficult to heal in the immobilized client. Preventing pressure ulcers is much less expensive than treating one." *"When a client lies in bed or sits in a chair, the weight of the body is on bony prominences. The longer the pressure is applied, the longer the period of ischemia (decreased blood supply to an area) and therefore the greater the risk of skin breakdown." *"To prevent skin breakdown, immobilized clients should be turned every 2 hours at a minimum."