Every finding on record at Medicine Wheel Village

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to protect the residents' right to be free from neglect for two of two sampled residents (1 and 2) by one of one certified nursing assistant (CNA) H who had not provided for the residents' activities of daily living needs. This failure resulted in resident 1 not being assisted with her toileting needs after using the call light and resident 2 developing moisture-associated skin damage to his buttock region. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's submitted SD DOH FRI report revealed that on the night of 1/15/26 through the morning of 1/16/26, licensed practical nurse (LPN) C had difficulty with traveling certified nursing assistant (CNA) H providing care to residents. CNA H was refusing to answer residents' call lights, was on her cell phone multiple times, and neglected to toilet and change the residents' incontinence (involuntary urine or bowel leakage) products. The call light for resident 1 alarmed; CNA H entered resident 1's room, turned off the call light, and exited the room. LPN C noticed that resident 1's call light alarmed shortly after CNA H exited the room, so LPN C responded to the call light and entered resident 1's room to turn it off. Resident 1 told LPN C she needed to use the bathroom and stated that CNA H would not help her. LPN C asked registered nurse (RN) I for help, and together they assisted resident 1 to the toilet, provided her with hygiene care, and assisted the resident to her bed. On the morning of 1/16/26, before the night shift ended, LPN C asked CNA H to assist residents who were awake in getting up and ready for breakfast. LPN C also asked if CNA H had finished her resident rounds (regular scheduled checks a CNA completes to ensure residents are safe, comfortable, and have their basic needs met), and CNA H replied yes. However, LPN C later found out that CNA H did not assist any residents that morning or finish her resident care rounds. Resident interviews and skin checks were conducted on 1/16/26 by DON B to determine if CNA H's neglect in providing resident care caused any residents' harm. It was found that residents 1 and 2 had not been checked by CNA H during the previous scheduled night shift and were discovered with heavily saturated incontinent products. Their beds were also saturated with urine. Resident 1 showed no skin issues, but resident 2 had redness and moisture-associated skin damage in the buttock area. No open sores were observed, and his redness and skin damage resolved by 1/20/26. On 1/16/26, administrator A contacted the contract company that CNA H was employed with and informed them of her disregard for resident care and poor performance. The contract company canceled CNA H's contract with the facility, and the facility was instructed to have CNA H leave the premises immediately and have no further contact with CNA H. CNA H returned her facility key and was escorted by maintenance staff F to the front door. She left the facility, and her employee badge was deactivated. 2. Review of resident 1's electronic medical record (EMR) revealed that she was recently re-admitted to the facility on [DATE] from a hospitalization stay. Her diagnoses included arthritis (stiffness, pain, and swelling in one or more joints), a history of a hip fracture, a chronic non-pressure ulcer of the right lower leg, a disorder of bone density, and mild dementia. Her 3/15/26 Brief Interview for Mental Status (BIMS) assessment score was 11, which indicated her cognition was moderately impaired. Resident 1's care plan, dated 3/15/22 with a revision on 1/30/26, revealed that she had focus areas for her impaired functional abilities and activities of daily living (ADL), which indicated she had self-care, mobility, and ADL deficits. Resident 1's goals were for her to show no decline in her self-care and mobility deficits, and for the staff to provide total assistance with ADLs through the review date. The interventions included her dependence on staff to provide all assistance with transfers using a Hoyer lift (a mechanical lift and sling used to lift a person's full body). Resident 1 was to be assisted by nursing staff with toileting or using a bedpan and provided with hygiene assistance as needed. Resident 1 was to be turned and repositioned every one to two hours while she was in bed. 3. Review of resident 2's EMR revealed that he was re-admitted to the facility on [DATE] from a hospitalization stay. His diagnoses included obesity, arthritis, muscle weakness, encephalopathy (a brain dysfunction that can result from head trauma, infections, lack of oxygen), a history of traumatic brain injury (a brain injury caused by a forceful bump, blow, or jolt to the head), a left lower leg contracture, and mild dementia. Resident 2's care plan, dated 1/30/19 with a revision on 5/28/24, revealed that he had a focus area for his ADLs, indicating a self-care deficit related to his traumatic brain injury and a left lower leg contracture. Resident 2's interventions included his need for extensive assistance from two staff members to use a sit-to-stand lift (a mechanical lift used to move from a seated to a standing position). Resident 2 was to be assisted by two nursing staff with his toileting schedule and provided with hygiene assistance. Staff were to help resident 2 with his toileting when he woke up in the mornings, before and after his meals, at bedtime, and during nursing rounds at night. 4. Review of CNA H's personnel file showed that she was hired at the nursing home facility on 1/5/26, and her background check was completed, with no issues found. She completed her new hire orientation training. Her training and education revealed that she completed Reporting Abuse and Neglect, Abuse, Neglect, and Exploitation, and Assisting with Elimination with her contracted travel company on 12/20/25. CNA H also received Abuse Reporting and Resident Abuse on 1/5/26 at the nursing home facility. 5. Interview on 3/25/26 at 3:15 p.m. with Maintenance staff person F revealed that on the evening of 1/16/26, he was asked by administrator A to escort CNA H off the premises. He stated he found CNA H outside, explained that he was to escort her off the premises, and she questioned him about why that was happening. He said that he explained to CNA H that her contract to work at the facility had been terminated, told her to gather her personal belongings, and informed CNA H that she was to leave. Maintenance staff F then escorted CNA H to her boarding room (a room within a building, often rented or used by employees for sleeping and living quarters). CNA H gathered her personal items, returned her facility key, was escorted to the front entrance, and left the facility. 6. Resident 1 was unable to participate in an interview during the survey as she was hospitalized . 7. Interview on 3/25/26 at 3:00 p.m. with resident 2 in his room revealed that he did not recall having any concerns with staff or their care of him. 8. Interview on 3/25/26 at 4:00 p.m. with administrator A and director of nursing (DON) B revealed that CNA H's neglect, involving her disregard for resident care on 1/16/26, was identified immediately after LPN C reported her concerns to management on 1/16/26. Administrator A stated that interventions were implemented on 1/16/26 to obtain resident interviews and skin assessments to determine if any harm occurred. DON B said that all nursing staff were provided with training and education on 1/21/26 regarding abuse and neglect, incident reporting, and the grievance process. Administrator A and DON B acknowledged that CNA H's failure to provide resident care led to resident 1 not receiving assistance when she asked CNA H to help with her toileting needs after using her call light, and resident 2 developing moisture-associated skin damage to his buttock region. Administrator A stated that it was the facility's responsibility to ensure that nursing staff provided quality care to residents and to initiate disciplinary action with staff if abuse or neglect were found. Administrator A and DON B acknowledged that CNA H was terminated from the facility on 1/16/26 as a result of their investigation into the resident's neglect. They both acknowledged that audits of incident reporting were being conducted and that the results were being presented at monthly quality assurance meetings. 9. Interview on 3/25/26 at 6:30 p.m. with LPN C revealed that on the night of 1/15/26 through the morning of 1/16/26, LPN C had difficulty with traveling certified nursing assistant (CNA) H providing care to residents. CNA H was refusing to answer residents' call lights, was on her cell phone multiple times, and neglected to assist residents to the toilet and change the residents' incontinence (involuntary urine or bowel leakage) products. The call light for resident 1 came on; CNA H answered it, turned it off, and exited resident 1's room. LPN C noticed the light coming right back on and re-entered resident 1's room to turn it off. The resident told LPN C she needed to use the bathroom and that CNA H would not help her. LPN C and registered nurse (RN) I assisted resident 1 to the toilet, with her hygiene, and assisted her back to her bed. On the morning of 1/16/26, prior to the end of the night shift, LPN C asked CNA H to assist residents who were awake in getting them up and ready to go out for breakfast. LPN C also inquired if CNA H had completed her resident rounds, to which CNA H replied yes. However, LPN C stated that CNA H did not assist any residents that morning or complete her resident care rounds prior to leaving her night shift. LPN C reported to management her concerns about resident neglect by CNA H, who failed to provide proper care and showed disregard for the residents' well-being on 1/16/26. 10. Review of the provider's Certified Nursing Assistant job description revealed that The primary purpose of this position is to provide residents with routine daily nursing care and services in accordance with the resident's assessment and care plan and as directed by supervisors. 11. Review of the provider's revised March 2018 Abuse and Neglect policy revealed Neglect, as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress, and the Facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 12. Review of the provider's revised August 2022 Nurse Aide Qualifications and Training Requirements policy revealed that Nurse Aides are any individuals providing nursing services to residents in a facility, and Must possess a sincere desire to serve the ill, aged and infirm. 13. Review of the provider's revised August 2022 Staffing, Sufficient and Competent Nursing policy revealed that Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident, and responding to resident needs. 14. Review of the provider's revised March 2018 Activities of Daily Living (ADL) policy revealed that Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. and residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene. 15. The provider's implemented actions to ensure that the deficient practice does not reoccur were verified on 3/25/26 after record reviews and interviews revealed that the facility had followed its quality assurance (QAPI) process regarding abuse and neglect. Education was provided to the nursing department on 1/21/26 regarding abuse and neglect, the grievance procedure, incident reporting, supervision of certified nursing assistants, completing ADL resident care, and implementation of the new nurse schedule to accommodate resident needs. Staff were expected to attend; if they were unable to attend in person, a Zoom meeting (a virtual, real-time gathering that allows people to connect via video) was available. An education signature sheet was provided, and signatures were documented. Results of the audits would be reported to the quality assurance committee at their scheduled monthly meetings. Based on the above information, non-compliance at F600 occurred on 1/16/26, and based on the provider's 1/16/26 and additional corrective action plans implemented for the deficient practice confirmed on 3/25/26, the non-compliance is considered past non-compliance.

Based on a South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interviews, and policy review, the provider failed to ensure services were delivered according to professional standards. One physician (J) gave a verbal order to the director of nursing (DON) B to borrow a controlled medication from one resident (3) and administer it to another resident (4). As a result, licensed practical nurse (LPN E) removed resident 3's controlled medication and administered it to resident 4, which is considered unacceptable clinical practice and a violation of professional standards. This citation is considered past noncompliance based on the corrective actions implemented by the provider following the incident. Findings include:1. Review of the provider's submitted SD DOH FRI report revealed that on the night of 3/22/26, at approximately 8:50 p.m., DON B received a verbal telephone order from physician J. Physician J's order was documented in resident 4's electronic medical record for the nursing staff to follow. The physician's order was for resident 4 to receive Lorazepam (a medication to treat anxiety) 0.5 milligrams (mg) (1 tablet) by mouth STAT (to be given immediately or without delay) when resident 3 was experiencing an anxiety episode. This was a new medication order for resident 4 and DON B explained to physician J over the phone that the facility did not have that medication on hand to administer to resident 4. DON B also explained that they could not obtain the medication from the distributing pharmacy at that time since it was closed, and that resident 4's family did not want her sent to the emergency room (ER) for evaluation. Physician J instructed DON B that nurses were to borrow the Lorazepam from resident 3, as resident 3 had Lorazepam 0.5 mg tablets available in the facility. [NAME] B reported to the nursing staff that physician J instructed them to use resident 3's Lorazepam for resident 4 when other comfort or distraction measures failed during resident 4's anxiety episodes. LPN E took a 0.5 mg Lorazepam tablet from resident 3's medication card and gave it to resident 4, who took it orally on 3/23/26 at 12:23 a.m. The Lorazepam was effective, and resident 4 experienced relief from her anxiety. The FRI report indicated no harm occurred to residents 3 or 4 due to LPN E's actions of administering resident 3's medication to resident 4. DON B sent an order to the pharmacy to replace resident 3's borrowed 0.5 mg Lorazepam tablet. Resident 3's emergency contact and law enforcement were notified of the incident of her medication being used for another resident. The incident was also promptly reported to the SD DOH. 2. A telephone call on 3/25/26 at 2;30 p.m. was attempted with LPN E. There was no answer, and a message was unable to be left on her voicemail to interview her about the above FRI. 3. Interview on 3/25/26 at 4:00 p.m. with administrator A and DON B revealed that the facility failed to maintain professional standards when staff had borrowed resident 3's medication and gave it to resident 4. Administrator A and DON B acknowledged that borrowing medication from a resident was not an acceptable standard of care and that the facility did not follow its policies and procedures for medication ordering or resident treatment. Both Administrator A and DON B stated that this was the first time an incident like this had occurred that involved borrowing medication from a resident. Administrator A said that borrowing a resident's medication for someone else should not have been done, but staff felt there was no other choice at the time. DON B said that resident 3's medication was borrowed for resident 4 because the family refused to send resident 4 to the ER that night, the pharmacy was closed due to off-hours, and no emergency medication kit containing Lorazepam was available to the nursing staff to utilize for resident 4. Administrator A said the issue was promptly identified and that education and interventions were implemented. She stated that physician J and DON B received education on 3/23/26. DON B stated that consultant pharmacist G provided education to the nursing staff on 3/25/26 and that LPN E attended the meeting and was provided with the education. They both acknowledged that audits of incident reporting, including medication availability and not borrowing medications, were being conducted and that the results were being presented at monthly quality assurance meetings. 4. Interview on 3/25/26 at 4:35 p.m. with consultant pharmacist G revealed that she was employed by the local pharmacy and her services for the nursing home were contracted through that pharmacy. She was responsible for the residents' monthly charts and medication reviews. Consultant pharmacist G stated that she helped the nursing home develop policies and procedures for pharmacy services and provided medication information and education to the nursing staff. Consultant pharmacist G acknowledged that borrowing medications from other residents was not standard nursing practice and not an acceptable standard of care. She stated that she provided the nursing staff with education on 3/25/26 regarding the pharmacy services available and the steps the nursing staff was to follow when emergency medications were needed. She said that the pharmacy emergency contact numbers were posted, several pharmacy policies were reviewed, education was provided on the regulations for medication accountability and physician orders for the use of medications for the resident it was ordered for, and advised them to access the tele-health services (a digital technology service provided remotely through a computer to allow healthcare advice or monitoring) available to them. Consultant pharmacist G stated that resident 3's Lorazepam 0.5 mg tablet, which was borrowed for resident 4, was replaced on 3/25/26. She stated that the pharmacy would work with Administrator A and the medical director to implement an emergency medication kit for nursing staff use in emergency situations. 5. Review of the provider's revised January 2018 Medication Orders policy revealed that Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations, and A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription to ensure delivery of medication. 6. Review of the provider's revised January 2018 Miscellaneous Special Situations policy revealed that The facility must make every effort to ensure that medications are available to meet the needs of each resident, and nursing staff shall Notify the attending physician of the situation and explain the circumstances, expected availability, and optional therapy(ies) that are available, and Obtain a new order and cancel/discontinue the order for the non-available medication. 7. The provider's implemented actions to ensure that the deficient practice does not reoccur were verified on 3/25/26 after record reviews and interviews revealed that the facility had followed its quality assurance (QAPI) process to maintain acceptable professional standards of clinical practice. Education was provided to the physician and DON on 3/23/26 regarding borrowing any medication, including controlled medications, federal regulations for medication accountability, and physician orders for resident use only. The nursing department received training on 3/25/26 about the facility's medication administration policies, medication delivery, controlled medications, physician orders, pharmacy communication, medication ordering, clarifying orders, and the use of an emergency medication kit. Staff were expected to attend; if unable to do so in person, a Zoom meeting (a virtual, real-time gathering that allows people to connect via video) was available. An education signature sheet was provided, and signatures were recorded. Results of the audits would be reported to the quality assurance committee at their scheduled monthly meetings. Based on the above information, non-compliance at F658 occurred on 3/22/26, and based on the provider's 3/23/26 and additional corrective action plans implemented for the deficient practice confirmed on 3/25/26, the non-compliance is considered past non-compliance.

A. Based on observation, interview, record review, manufacturer's instruction review, and policy review, the provider failed to ensure that staff followed standard food safety practices to sanitize dishware used to prepare and serve residents' food to prevent potential food-borne illness. That failure had the potential to affect all 28 residents who resided in the facility and placed them in immediate jeopardy for harm, illness, or death. Findings include: 1. Notice of immediate jeopardy of F812 was given verbally and in writing on 11/19/25 at 10:25 a.m. to administrator A regarding: *Observation on 11/19/25 at 9:00 a.m. revealed the commercial dishwasher in the kitchen was not working. *Interview on 11/19/25 at 9:20 a.m. with dietary manager F and maintenance staff AA revealed that the dishwasher stopped working 10/30/25 at about 10:23 a.m. and could not be repaired. A new dishwasher was ordered, received on 11/14/25, and was not installed as of 11/19/25. Dietary Manager F revealed all dishes were being washed in the three-compartment sink, with sanitation occurring in the third compartment of that sink since the dishwasher was not operational on 10/30/25. DM F was asked to test the sanitation of the third compartment sink. The test strips to test the sanitation level showed an expiration date of 11/1/2023. DM F used one of those expired test strip to test the solution. That solution currently being used in the sink revealed the test strip did not change color to indicate proper sanitizer levels. The dietary manager was unable to find any other test strips to test the sanitizer level of the solution in the sink. The Dietary Manager confirmed there were no other supplies or other processes for the staff to know if the sanitizer level met the required level for proper sanitization of the dishes. *The above findings had the potential to cause serious widespread food-borne illness by failing to ensure sanitizer solution levels of 150 to 400 PPM (parts per million) according to the sanitizer's manufacturer's recommendations to effectively sanitize the dishes in a three-compartment sink. *A plan for the removal of the immediacy was requested at that time. IMMEDIATE JEOPARDY REMOVAL PLAN On 11/19/25 at 4:30 p.m. the provider submitted the following immediate jeopardy removal plan for review: *Dietary Manager or Designee provides the Three-Compartment Sink Sanitization Log form ready for dietary staff each Tuesday of the month. Re-education of dietary staff completed by DM and LPN on proper procedure of sanitation range, testing the sanitizer chemical, and ensuring the three-compartment sink is functioning properly after being educated by the Administrator. *The New Dishwasher is in the facility awaiting installation. Eco Lab will be at the facility for chemical programming by Wednesday, November 26, 2025, for the new dishwasher. *Contacted Sysco Food and received the correct test strips. Order placed from the supplier for more sanitizer test strips. It will be delivered to the facility on Monday, November 24, 2025, from Amazon. *[Name redacted] [MDS consultant I] completed the sanitization strip test at the 3-compartment sink. The Test Strip Bottle arrived at 1310; the test was completed at 1320. The Test Result was in the 200 range, and a picture is attached to the result. The Test Expiration Date is June 15th, 2027. *Edits made to the current Three Compartment Sink Sanitizer Log to include checking test strip expiration dates, Monthly Audit Check List for Dietary Manager to complete, RD is adding those items to her facility report to review during her facility visits. Audit will be monitored by DM or Designee daily x30 days, weekly x 8 weeks, and monthly x 12 months. It will be checked three times a day (Breakfast, Lunch, Dinner) by Dietary Staff Members. If the result is out of range, they are to notify the dietary manager immediately within one hour. *PIP [performance improvement project] in place 11/19/2025. *Mandatory Inservice Education will be done with all dietary staff on 11/19/2025 at 2:00 pm, by the Dietary Manager [F] and [name redacted] [MDS consultant I], and a Verbal Disciplinary will be given to all dietary staff members. *Medicine Wheel Village Census of 28 displays no symptoms of having a food-borne illness as of 11/19/2025. They have been eating meals without any complaints of nausea, vomiting, abdominal discomfort, or any elevated temperatures. The IJ removal plan was accepted on 11/19/25 at 4:31 p.m. 1. Observation and interview on 11/17/2025 at 2:10 p.m. with dietary aide T in the kitchen revealed: *There was a sign on the dishwasher that stated I did not work. *It stopped working about a week and a half ago. *A new dishwasher came in last Friday, and he was not sure when it would be installed. *To wash dishes, they used a three-compartment sink. The first compartment contained soap and water to wash, the second contained water to rinse, and the third contained sanitizer to sanitize the dishes. *Sanitizer levels were to be checked and documented once per day. *According to the November 2025 sanitizer level documentation sheet, the sanitizer level checks were not completed on 11/3/25, 11/15/25, 11/16/25, or 11/17/25. *When asked who was responsible for completing the sanitizer level checks, he replied, whoever does it. *The checks were usually done in the morning before breakfast. *He reported he checked the sanitizer level today (11/17/25), but review of the sanitizer log indicated it was not documented yet. He then documented it, as within an acceptable range on the log. *They used ECOLAB Oasis 146 Mulit-Quat Sanitizer. *They did not check the temperature of the water. 2. Interview on 11/17/25 at 2:30 p.m. with dietary manager F revealed that if the sanitization levels of the three-compartment sink were not documented, she could not ensure that they met the required sanitization levels for effective sanitization. 3. Observation and interview on 11/18/2025 at 11:25 a.m. with dietary manager F in the kitchen revealed: *She removed her gloves, did not wash her hands, picked up a washcloth that was used to clean dishes from the first compartment of the three-compartment sink, wet the washcloth in the first compartment, and used that washcloth to wipe a cart and the counter. *The first compartment contained water and Dawn dish soap with a splash of bleach. *She washed dishes in the three-compartment sink. *When she was done washing dishes, she dried her hands on the apron she wore. *Without washing her hands, she put on oven mitts and took a pan out of the steamer. *She walked over to the dirty dishwasher area, dumped the pan's liquid contents into the sink, used the dish sprayer and sprayed out the inside of the pan, dumped that liquid into the sink, and then set the pan on the counter. *Without washing her hands, she obtained a thermometer and checked the temperature of the contents of what was that same pan, which was observed to be chicken breasts. *Those chicken breasts were to be served for lunch to the residents who had a heart-healthy diet ordered. *She washed a knife in the first compartment, rinsed it in the second compartment, did not put it in the third compartment of sanitizer, and put it on the drying rack. *She verified that she did not put the knife in the sanitizer solution. She then grabbed the knife, dipped it into the sanitizer solution, and did not let it sit for one minute in the sanitizer solution as the sign indicated. 4. Observation on 11/18/25 at 11:54 a.m. of dietary aide T in the kitchen revealed: *Plates were sitting on the cart, that was cleaned with soap and bleach water. *He moved plates from the cart to the counter, dished lunch meals on those plates for the residents, placed the plates of food back on that same cart, and served it to the residents using that cart. 5. Observation and interview on 11/19/25 at 9:00 a.m. with dietary manager F revealed: *The expiration date of the QT-40 sanitizer test strips was [DATE]. *She verified they were expired and thought she had more test strips, but she was unable to find them. *She placed an order for more sanitization test strips, but they were not expected to be delivered until Tuesday of the next week. *The dishwasher was scheduled to be installed the next Friday. *Residents were served food with reusable plates and cups and disposable silverware. 6. Interview on 11/19/25 at 9:20 a.m. with dietary manager F and maintenance staff AA revealed that the dishwasher stopped working 10/30/25 at about 10:23 a.m. 7. Interview on 11/19/25 at 10:25 a.m. with administrator A revealed: *They had been trying to get a vendor to come install the dishwasher. *The dishwasher came in last week. *She verified that the sanitization test strips were outdated and could not ensure the sanitizer solution met the levels required to sanitize the dishes using the three-compartment sink method. *She reported she was working on obtaining more sanitization test strips. 8. Interview on 11/19/25 at 1:10 p.m. with administrator A revealed they obtained unexpired sanitizer test strips, and that the dietary staff were coming in at 2:00 p.m. for education on using the sanitizer test strips. 9. Review of the provider's sanitizer log for the three-compartment sink from August 2025 through November 17, 2025, revealed that: *Sanitizer solution levels were not documented eight times in August 2025, fourteen times in September 2025, six times in October 2025, and three times in November 2025. 10. Interview on 11/20/25 at 11:14 a.m. with dietary manager F revealed: *Staff were to wash their hands with soap and water when they entered the kitchen, between tasks, if they touched their face or hair, after taking trash out, and after doing dishes. *Staff were expected to dry their hands with a paper towel and not on their apron. *Rinsing the chicken on the dirty side of the dishwasher could contaminate the food and could cause residents to become ill. *She expected staff not to touch the food or the rim of the glass when serving it to residents. *She used bleach water to sanitize the counters and carts, and did not test its sanitation level. *Not ensuring sanitizer or bleach levels could put residents at risk for food-borne illness. 11. Interview on 11/20/24 at 4:10 p.m. with administrator A revealed that not completing hand washing, not checking the sanitizer levels, or using outdated sanitizer test strips to ensure accurate testing, could put residents at risk for food-borne illness. 12. Interview and observation 11/19/25 at 5:44 p.m. with dietary staff V revealed: *The sanitizer solution in the three-compartment sink was checked with test strips that were not outdated and was at an appropriate sanitization level of 150-400 ppm. The immediate jeopardy was removed on 11/19/25 at 5:44 p.m. after the survey team verified on site on 11/19/25 at 5:44 p.m. that the provider had implemented their removal plan through observation, document review, and staff interviews. After the removal of the immediate jeopardy, the scope and severity of the non-compliance remained an F. Current census was 28 residents. 13. Review of the ECOLAB Oasis 146 Multi-Quat Sanitizer laminated sign posted on the wall by the third compartment sink revealed: * Directions for use: Expose all surfaces of equipment, ware, or utensils to the sanitizing solution for a period of not less than one minute. Air dry. * The testing solution should be at room temperature- 65 degrees F-75 degrees F.testing solution should be at 150-400 ppm. 14. A review of the provider's 10/2025 Manual Warewashing-3 Compartment Sink policy revealed: *To prevent the spread of bacteria that may cause food borne illness, this facility washes, rinses, and sanitizes pots, pans, and other utensils using a 3 compartment sink in accordance with current standards for food safety. *The facility utilizes a 3 compartment sink to wash, rinse and sanitize pots, pans and other utensils to prevent the spread of bacteria that may cause food borne illness. *A 3-step process is used to manually wash, rinse and sanitize dishware correctly: -First step: Thorough washing using hot water and detergent after food particles have been scraped off. -Second step: Rinsing with hot water to remove all soap residues. -Third step: Sanitizing with . a chemical sanitizing solution used according to manufacturer's instructions. * A temperature measuring device shall be provided by the facility and readily accessible for frequent measuring of the washing and sanitizing temperatures. * Sanitizing solutions shall be tested by a test kit or other device that accurately measures the concentration in MG/L [milligrams per liter]. Testing will occur periodically but not limited to: -When sink is initially filled, -At least once per shift, -With extended use, and -As needed. *The temperature of the wash solution in the manual warewashing equipment shall be maintained at not less than 110 degrees F or the temperature specified on the cleaning agent manufacturer's label instructions. *Sanitizing procedures for the three-compartment sink are as follows: -Step one, fill first sink/wash sink with hot water and detergent (follow product instructions), Fill second sink/rinse sink with hot clear water, fill third sink/sanitizing with.QAC ammonia at 150-200 ppm [parts per million]. Confirm appropriate temperature or concentration prior to washing and record on sanitation control log. -.Immerse rinsed pots/utensils in sanitizer per manufacturer instructions. B. Based on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure food was served in a sanitary manner by dietary staff (T and U) who did not wash their hands or change their gloves after potentially contaminating them while serving meals to residents. 1. Observation on 11/18/25 of the noon meal service revealed: *Dietary staff U pushed a cart of various drinks from the kitchen to the dining room with gloves on his hands. *With those same gloved hands, he handed out the drinks to the residents in the dining room, while also retrieving sugar, creamer, salt, and pepper from a drawer on the cart for the residents. *With those same gloved hands, he touched the drinking rims of one coffee cup and two juice glasses while he provided them to three different residents. *Dietary staff T had gloves on and pushed a cart out of the kitchen that had the residents' plated meals on it. *With those same gloved hands, he touched the plates beyond the rimmed edges of the plates and passed plates of food to the residents. *When he gave resident 31 and resident 9 their plated meals, he touched the food on their plates with his gloved hands. *Dietary staff T touched resident 9's food on her plate with the same gloved hand that he had touched resident 21's food with. He continued to pass plated meals to residents with those same gloved hands. 2. Review of the provider's August 2019 Handwashing/Hand Hygiene policy revealed: *The facility considers hand hygiene the primary means to prevent the spread of infection. *All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *Use and alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g. urinary catheters, IV [intravenous] access sites); f. Before donning sterile gloves; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident cares; i. After contact with a resident's skin; j. After contact with blood or body fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings; o. Before and after eating or handling food; p. Before and after assisting a resident with meals; and q. After personal use of the toilet or conducting your personal hygiene. *Hand hygiene is the final step after removing and disposing of personal protective equipment. *The use of gloves does not replace hand washing/hand hygiene. *Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. 4. Hold the removed glove in the gloves hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. Review of the providers' 2001 Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices revealed: * Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. * All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. * Employees must wash their hands: -.Before coming in contact with any food surfaces;. -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or -After engaging in other activities that contaminate hands. * Contact between food and bare (ungloved) hands is prohibited. * Food service employees will be trained in the proper use of tongs, gloves.to prevent foodborne illness.

Based on observation, record review, and interview, the provider failed to post the required daily nursing staffing information in a location readily visible to residents, staff, and visitors that clearly reflected actual hours worked by the nursing staff for 18 of 18 days reviewed for November of 2025.Findings include: 1. Observation on 11/18/25 at 11:51 a.m. of the provider's Staffing Census Sheet revealed:*It was posted on the wall beside a door labeled staff only behind the 400 hall nurses' station.*It was hanging approximately six feet off the floor.*It included the date and resident census.*Under the Day Shift heading of that form numbers documented behind the RN (registered nurse), LPN (licensed practical nurse), CMA (certified medication aide), CNA (certified nursing assistant), and Restorative/Activity Aide areas.*Under the Night Shift heading of that form numbers were documented behind the RN, LPN, and CNA areas.*Those documented numbers were not identified as to what they represented.2. Interview on 11/18/25 at 11:51 a.m. with LPN/restorative nurse N revealed the Staffing Census Sheet was only posted in the 400 hallway.3. Observation on 11/19/25 at 10:35 a.m. of the Staffing Census Sheet revealed there were zeros documented behind the day shift and night shift RN.4. Interview on 11/20/25 at 8:03 a.m. with resident 5 revealed:*Resident 5 was seated in her wheelchair below the Staffing Census Sheet hanging on the wall.*When she was asked if she was able to read the Staffing Census Sheet, she stated it was too high, but she thought she could if it was lowered.*The Staffing Census Sheet was lowered down in front of resident 5, and she read the entirety of the sheet.*She stated she was unsure what the numbers on the form meant.5. Interview on 11/20/25 at 12:06 p.m. with LPN O revealed:*The night nurse was responsible for the completion of the Staffing Census Sheet.*It was completed each night according to the assignment sheets that were completed by management up to three days prior.*Nursing staff attempted to keep the Staffing Census Sheet up to date if there were any staffing changes.*Leadership staff hours were not included on the Staffing Census Sheet.*Leadership staff assisted with resident cares and daily tasks on the floors when needed.*The numbers behind RN, LPN, CMA, CNA, and Restorative/Activity Aide represented scheduled hours.*She verified the Staffing Census Sheet did not identify what the numbers represented.*She stated the Staffing Census Sheet was only displayed on the 400 hallway and would not be readily visible for residents or family members on the 300 hallway.*She verified that the Staffing Census Sheet was not readily visible to residents in wheelchairs due to the height it was posted.6. Review of the Staffing Census Sheets from 11/1/25 through 11/19/25 revealed that on 11/1/25, 11/8/25, and 11/19/25 the Staffing Census Sheet indicated there were no RNs on duty during those day or night shifts.7. Interview on 11/20/25 at 4:32 p.m. with administrator A and Minimum Data Set (MDS) consultant I revealed:*Administrator A verified the 11/19/25 Staffing Census Sheet for RN hours was not accurate because Administrator A was an RN and director of nursing (DON) B was an RN, and both of them were in the building available to assist residents during the day shift on 11/19/25.*She the posted Staffing Census Sheet was not readily accessible to all residents, staff, and visitors.*She agreed the numbers on the Staffing Census Form behind RN, LPN, CMA, CNA, and restorative/activity aide were not clearly identified as to what they represented.*She stated there were no days when an RN was not scheduled to be in the facility.A provider's policy for the daily nurse staff posting was requested on 11/19/25 at 8:30 a.m. and was not received by the conclusion of the survey.

Based on interview, observation, record review, and policy review, the provider failed to ensure nine of nine sampled residents (1, 2, 4, 5, 6, 7, 14, 17, and 18) were served foods in the appropriate form according to their physician-ordered therapeutic diets.Findings include: 1. Observation and interview on 11/18/25 at 12:01 p.m. with dietary aide T revealed: *He served whole chicken breasts, whole slices of ham, and cubed pieces of ham that were approximately one-inch pieces. *He did not have residents' diet cards to reference what the residents' ordered diets were. He explained that he had worked here for a year and had the residents' diets memorized and had a cheat sheet, so he knew which residents should be served the chicken breasts, as they were for residents on heart-healthy diets. *There was a list posted on a cupboard that listed all the residents' diet orders. *All the mechanical soft residents were served the cut-up ham. *He did not have any ground meat prepared to serve to residents. *He added carrot cake to all the meal plates before serving them to residents, including the residents with orders for consistent carbohydrate diets. *For residents with orders for no-added-salt (NAS) diets, he indicated that meant that salt was not added to their food. 2. Observation on 11/19/25 at 5:15 p.m. in the dining room revealed that no residents had ground meat on their meal plate, and any cut-up meat was in approximately one-inch-sized pieces. 3. Review of resident 4's 9/26/25 electronic medical record (EMR) revealed: *He had physicians' orders on 11/7/25 for a mechanical soft diet. *He was dependent on one staff member to assist him with eating, required a mechanical soft diet, and had only a few of his teeth left. *His current care plan indicated he had a nutritional problem due to having a mechanical soft diet and needing staff to assist him with eating. *A 9/27/25 registered dietitian's progress note indicated: his diet order was for a regular diet, with mechanical soft textures, thin liquids, and the RD recommended to continue that same diet. 4. Review of resident 5's EMR revealed: *She had physicians' orders on 8/25/25 for a heart-healthy, mechanical soft diet. *Her current care plan indicated she did not wear her top dentures, she had her own bottom teeth, and she was to follow her diet as ordered and to consult with the dietician and change if chewing/swallowing problems were noted. 5. Review of resident 6's EMR revealed: *His current care plan indicated he required a consistent carb, heart-healthy diet; it did not indicate he required a mechanical soft diet per his physician's orders, had several teeth extracted, and he would eat other residents' food if left at the table and choked and/or coughed when eating and drinking at times. * He had physicians' orders on 4/15/25 for a mechanical soft diet and all his food cut up into one-quarter-inch pieces. 6. Review of resident 18's 11/17/25 care plan revealed she: *Her current care plan indicated she had dental health problems related to broken teeth, was to have her diet as ordered and consult with the dietician and change if chewing/swallowing problems were noted, had potential nutritional problems, so she required a mechanical soft diet. *She had physicians' orders on 10/6/25 for a regular diet with a mechanical soft texture. 7. Observation and interview on 11/19/25 at 5:30 p.m. with certified nursing assistant (CNA) CC revealed: *She had resident 4's plate, and it contained a whole piece of pork cutlet, mashed potatoes, a slice of bread, canned apricots cut in half, and a cup of bean soup. *She was to cut up his food and feed it to him. *He has difficulty chewing big pieces of meat. 8. Interview on 11/17/25 at 2:30 p.m. with dietary manager F revealed: *The current menus were from last year and were not signed off by a dietician, as they did not have one. *The new menus were being created and then would be sent to the dietician for approval. *She has to complete training for the new menu system. *The RD H was the new dietician for the facility. 9. Interview on 11/20/25 at 11:14 a.m. with dietary manager F revealed: *She had been the dietary manager at the facility since 3/6/13. *Resident 1 was to have ground meat. However, at a care conference, it had been changed to being cut up, per her preference. The order should reflect that, but it does not. *The dietician wanted her to try the ground meat again to see if she would accept it. *Resident 14 was to have ground meat, but did not like it. *Mechanical soft diets should be prepared in one-quarter-inch pieces and add gravy to it to make it moist. *She agreed, the one-inch pieces of meat were too large for a resident who required a mechanical soft diet. *She indicated resident 4 was on a regular diet, but said they cut it up for him. After looking at the diet order, she verified that resident 4 was to have a mechanical soft diet and the CNA would not be able to easily cut his meat into one-quarter-inch pieces and add gravy to it in the room. 10. Interview on 11/20/24 at 4:10 p.m. with administrator A revealed: *She verified that the current menus followed to serve residents were not signed as RD H, the new dietician, did not feel comfortable with their current menu system. *They purchased a new menu system three weeks ago, and the training on that needed to be completed and was scheduled for the next day. 11. Interview on 11/20/25 at 5:09 p.m. with registered dietician H revealed: *The facility's menus were not signed by her before the survey, as she determined they did not include nutritionally appropriate menu extensions. *Mechanical soft diets were comparable to the National Dysphagia Diet level 3 (NDD3) and would require meats cut up into pieces smaller than one inch, unless the doctor's orders specified something else. *The mechanical soft diet allowed for some interpretation of the diet, and she had past experience of a speech therapist or a doctor who indicated the size of meat pieces, but the facility did not have a speech therapist to do this. *The meat of the mechanical soft diet was to be moist, tender, and easily mashed with a fork. *If a resident did not want to follow their physician-ordered diet, they had the resident/family sign a risk/benefits form to complete. 12. Review of resident 2's electronic medical record (EMR) revealed His diet order was Renal, Consistent Carb [carbohydrate] diet Regular texture, Regular consistency, 1400cc [cubic centimeters] Fluid restriction- 900cc Dietary, 500cc Nursing, 300cc with each meal by dietary=900cc 200cc with each water pass, 2 passes= 400cc sips with med [medicine] pass, 3passess= 100cc. If more than 3 med passes, use from water pass in room. 13. Review of resident 17's EMR revealed: *She was admitted on [DATE]. *Her diet order was Consistent Carbohydrate diet Regular texture, regular consistency, 2 gram sodium. 14. Interview on 11/18/25 at 9:00 a.m. with resident 14 revealed she: *Did not have any teeth. *Stated she could not chew hard food, but that was what she was given so she did not eat all her meals. 15. Observation on 11/19/25 at 5:24 p.m. of resident 14's meal plate revealed she was served a pork cutlet cut into pieces approximately one inch by one-half inch. 16. Review of resident 14's EMR revealed: *She was admitted on [DATE]. *Her 11/5/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her diagnoses included diabetes, abnormality of plasma protein (an increase or decrease in protein levels often indicating an underlying condition such as liver disease, kidney problems, nutritional deficiencies, or certain cancers), and muscle wasting (muscle loss). *Her diet order was, Consistent Carb [carbohydrates], NAS [no added salt] Mechanical soft, Ground Meat texture, Regular consistency, Arginaid [a nutritional supplement to support wound healing] BID [two times per day] with meals for skin, Offer Yogurt at Breakfast, and Large Protein Portions at all meals. *Her 11/20/25 care plan stated she had no teeth or dentures. 17. Observation on 11/19/25 at 5:48 p.m. of resident 1 during the supper meal revealed she was served a pork cutlet cut into one-inch cubes with gravy over it. She did not eat the cut-up meat. She had eaten the rest of her meal. Review of resident 1's EMR revealed her 3/22/25 therapeutic diet order was Consistent Carbohydrate diet, Mechanical Soft, Ground Meat texture, Nectar consistency, with ground meats add extra gravy. 18. Review of the providers 10/2025 Therapeutic Diet Orders policy revealed: * The facility provides all residents with foods in the appropriate form and/or appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. * Definitions: - 'Mechanically Altered Diet' is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. -'Therapeutic Diet' is a diet ordered by a physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease or increase specific nutrients in the diet. Examples include low salt, diabetic, or low cholesterol diets. A mechanically altered diet is not automatically considered a therapeutic diet. 1. Each resident's nutritional status is assessed by the interdisciplinary team in accordance with assessment policies. 2. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: a. Inadequate nutrition b. Nutritional deficits c. Weight loss d. Medical conditions such as diabetes, renal disease, or heart disease. e. Swallowing difficulty 3. Therapeutic diets are provided only when ordered by the attending physician or registered or licensed dietitian who has been delegated to write diet orders, to the extent allowed by state law. Should the attending physician delegate the prescribing of therapeutic diets, he or she will supervise the dietitian and remain responsible for the resident's care. 4. The reason for the therapeutic diet is to be documented in the medical record and/or indicated on the resident's comprehensive plan of care. All diet orders are to be communicated to the dietary department in accordance with facility procedures. 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.

Based on observation, interview, and policy review, the provider failed to ensure temperatures were maintained within a proper temperature range for safe medication storage in one of one medication room.Findings include:1. Observation and interview on 11/20/25 at 12:32 p.m. with registered nurse (RN)/ staff development K in the medication room revealed:*She stated the facility had one medication room.*The medication room felt significantly warmer than the hallway outside the medication room.*There was documentation on the side of the refrigerator in the medication room which contained daily temperature readings from the refrigerator and freezer.*There was no documentation of temperatures for the medication room itself.*When asked if the temperature of the medication room were monitored, RN/staff development K pointed to the thermostat on the wall which was set at 72 degrees Fahrenheit (F).*RN/staff development K stated she did not know of any temperature monitoring or documentation for the medication room.2. Interview on 11/20/25 at 3:04 p.m. with RN/infection control (IC) C and licensed practical nurse (LPN)/restorative nurse N revealed:*There was no temperature monitoring or documentation for the medication room temperature to ensure it was in a safe medication storage range.*RN/IC C stated the temperature of the medication room had not been monitored in the five years she had been employed at the facility.3. Interview on 11/20/25 at 5:38 p.m. with director of nursing (DON) B revealed:*The temperature of the medication room often seemed warmer or cooler than the rest of the facility, but she was not aware if the temperature of the medication room had ever been checked to determine what the temperature was in the medication room.*The temperature of the medication room was not monitored to ensure it was in a safe medication storage range.*She was not aware the medication room was required to be maintained between 59- and 86-degrees F for safe storage of medications.Review of the provider's February 2023 Medication Labeling and Storage policy revealed:* The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls.* The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, record review, and policy review, the provider failed to ensure the care plans were revised and individualized for one of one sampled resident (2) with schizophrenia, one of one sampled resident (8) who reported constant pain, and one of one sampled resident (21) who had a diagnosis of depression and anxiety and made statements of no longer wanting to live, to reflect their current needs.Findings include:1. Observation and interview on 11/18/25 at 8:00 a.m. with resident 21 in her room revealed:*She was sitting in her wheelchair beside her bed with her head lowered towards her chest.*She stated she was tired of doing the same things, so she sleeps all the time.*Resident 21 began to cry, and stated she did not want to live anymore.*She missed her children, and no one came to see her anymore.*She stated she had spoken to staff about not wanting to live anymore, and they reassured her and told her they were there to help her.*Resident 21 began to cry harder and stated she should just try to kill herself.Review of resident 21's EMR revealed:*She admitted to the facility on [DATE].*She had 10/31/25 Brief Interview of Mental Status (BIMS) assessment score of 8, which indicated her cognition was moderately impaired.*Her diagnosis included dementia (a group of symptoms affecting memory, thinking, and social abilities), anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and depression.*A 10/18/25 a progress note stated medical director BB was at the facility to see resident 21 and that resident 21 has been feeling more sad and this writer informed [medical director BB] that [resident 21] had increased episodes of feeling sad and at times is tearful.*She had a 10/18/25 physician's order for FLUoxetine HCL Oral Capsule 10 MG [milligram] (Fluoxetine HCl) Give 1 capsule by mouth one time a day related to ANXIETY DISORDER, UNSPECIFIED (F41.9); DEPRESSION, UNSPECIFIED (F32.A).Review of resident 21's 11/20/25 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) revealed:*A focus area that indicated, The resident has a dementia diagnosis with periods of forgetfulness and anxiety.-The goal for that focus area was, The resident will be able to communicate basic needs on a daily basis through the review date.-The interventions identified for that area were, Ask yes/no questions in order to determine the resident's needs and Cue, reorient and supervise as needed.*Another focus area stated, [Resident 21] uses psychotropic medications r/t [related to] Diagnosis of Depression and Anxiety.-The goal for that focus area was, Will remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension [low blood pressure], gait disturbance or cognitive/behavioral impairment through review date.-The interventions for that area were, Administer PSYCHOTROPIC medication as ordered by physician and Consult with pharmacy, MD [medical doctor] to consider dosage reduction when clinically appropriate at least quarterly.*Her care plan did not identify her depression and anxiety symptoms such as her tearfulness or statements of no longer wanting to live.*Her care plan did not address any potential triggers of her depression or anxiety.*Her care plan did not identify any nonpharmacological interventions to help her if she complained of or displayed symptoms of anxiety and depression.2. Observation and interview on 11/18/25 at 8:30 a.m. with resident 2 revealed he:*Was diagnosed with schizophrenia about seven years ago.*Had been seeing a mental health provider for his schizophrenia.Review of resident 2's electronic medical record (EMR) revealed:*He admitted to the facility on [DATE].*He had a BIMS assessment score of 15, which indicated his cognition was intact.*He had a diagnosis of schizophrenia.*He had a 6/22/25 physician's order for RisperDAL Tablet 1 MG [milligram] (risperidone) [a medication that alters the activity of neurotransmitters in the brain to reduce symptoms of psychosis, a state of losing touch with reality] Give 1 mg by mouth three time a day every Mon [Monday], Wed [Wednesday], Fri [Friday] for Unspecified Mood Disorder.*He had a 6/22/25 physician's order for RisperDAL Tablet 1 MG [milligram] (risperidone) Give 1 mg by mouth three time a day every Tue [Tuesday], Thu [Thursday], Sat [Saturday], Sun [Sunday] for Unspecified Mood Disorder.*A progress note on 8/12/25 at 10:55 a.m. stated, Writer entered resident's room and attempted to talk with [the] resident as he is refusing to shower. Resident turned the other way from writer and when writer touched resident's shoulder resident shrugged away from writer. Writer attempted to communicate with resident and resident laid on [his] right side [and] faced the wall with [his] eyes closed.*A progress note on 8/12/25 at 11:05 a.m. stated, It was reported to this writer that [resident 2] has become more resistant to doing things for himself and wants staff to do everything for him that he is fully capable to do for himself to keep him as independent with some area's [areas] in caring for himself. This writer did talk with [medical director BB] and received a verbal [order] to schedule a Psych [psychiatric] evaluation through [name redacted] Tele-Health. This writer updated his nurse today, LPN to schedule the appointment.*The 9/3/25 behavioral health progress note stated,- He has a history of schizophrenia with hallucinations [to see, hear, smell, taste, or touch something that is not there]. Currently not having any auditory hallucinations and he reports last occurrence was in the 90s.- He has been on Risperdal for many years and was hospitalized in 1998 due to hallucinations.- Document all behaviors and nonpharmacological interventions in the EMR.- Monitor resident for daytime somnolence [excessive sleepiness or drowsiness], worsening of ambulation or falls, return of hallucinations, and notify provider with any concerns.*The 10/28/25 behavioral health progress note stated, Patient [resident 2] did not appear for scheduled appointment and identified the same plans of care as the 9/3/25 behavioral health progress note.Review of resident 2's 11/20/25 care plan revealed:*A focus area that stated, [Resident 2] used smokeless tobacco. [Resident 2] and his family feel tobacco helps with his Schizophrenia symptoms.*A focus area that stated, [Resident 2] uses psychotropic medications r/t Schizophrenia Diagnosis.-The goal for that focus area was, [Resident 2 will remain free from psychotropic drug related complications through review date.-The interventions identified were, Administer PSYCHOTROPIC medications as ordered by physician; Consult with pharmacy, MD to consider dose reduction when clinically appropriate with appropriate documentation; Discuss with MD, family re [regarding] ongoing use of medications. Review behaviors/interventions and alternate therapies attempted and their effectiveness as needed with care conferences & [and] MD visits and Monitor/document/report PRN and adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person.*Resident 2's care plan did not identify his behaviors or symptoms of schizophrenia or interventions to attempt if his exhibited behaviors or symptoms of schizophrenia.*It did not address his displayed refusal to care for himself and participate in his activities of daily living, such as showering and interventions for this or any interventions that 3.had been attempted and failed.*It did not indicate he was seeing a mental health provider for his symptoms or behaviors.*There were no nonpharmacological interventions for his behaviors or symptoms to help him if or when they may occur.3. Review of resident 8's 9/12/25 comprehensive Minimum Data Set submission section J revealed:*Resident 8 had a scheduled pain medication regimen, had received PRN [as needed] pain medications or was offered and declined, did not receive non-medication interventions for pain.*Resident 8 had pain or hurting in the last five days, she indicated the pain was experienced almost constantly, and in the past five days pain had made it hard for resident 8 to sleep almost constantly.Review of resident 8' EMR revealed:*She admitted to the facility on [DATE].*She had a 9/4/25 BIMS assessment score of 11, which indicated her cognition was moderately impaired.*Her diagnoses included, pain in her foot and diabetic neuropathy (nerve damage caused by diabetes, most often affecting the feet and legs, and is characterized by symptoms like numbness, tingling, burning, or sharp pains).*She had a 10/22/19 physician's order for Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for pain to feet bilat [both feet].*She had a 3/11/20 physician's order for Muscle Rub PRN every 8 hours to feet.*She had a 10/5/21 physician's order for Acetaminophen Tablet 325 MG Give 2 tablet by mouth one time a day for Pain.*She had a 4/14/23 physician's order for Muscle Rub apply to both feet topically at bedtime.*She had a 2/27/25 physician's order for Gabapentin Capsule 300 MG Give 2 capsule by mouth at bedtime for Foot pain.*She had a 5/23/25 physician's order for Gabapentin Capsule 300 MG [a medication used to treat nerve pain] Give 1 capsule by mouth two times a day for Foot pain.Review of resident 8's 11/19/25 care plan revealed she did not have a focus area goal or any identified pharmacological (medication) or nonpharmacological interventions identified for her pain.4. Interview on 11/20/25 at 12:13 with licensed practical nurse (LPN) O revealed:*If she had a question related to a resident's care needs, she would reference the resident's care plan.*LPN O stated she did not know what resident 2's schizophrenia symptoms were because she had not witnessed him having any symptoms.*She stated she would not know what resident 2's schizophrenia symptoms were, to monitor for them, if they were not identified on his care plan.*She expected the behaviors identified on the care plan to have interventions for those behaviors.*She expected nonpharmacological interventions to treat a resident's pain to be identified on the resident's care plan.*She was unsure who was currently responsible to update resident care plans, but the MDS nurse used to be responsible.5. Interview on 11/20/25 at 4:32 p.m. with administrator A and MDS consultant I revealed:*It was the responsibility of the MDS coordinator to update residents' care plans.*Care plans were to include a resident' behaviors, and triggers for identified behaviors being treated with pharmacological interventions and non-pharmacological interventions for those behaviors.*MDS consultant I stated pain should be a part of every resident's care plan especially those with identified acute or chronic pain.-The resident's pain care plan should include nonpharmacological intervention specific to that resident.*Resident 2's symptoms of schizophrenia were expected to be identified in his care plan so staff would be able to monitor for those symptoms and the effectiveness of his treatment, and interventions identified for those symptoms.*They expected pain to be identified in resident 8's care plan and include nonpharmacological interventions to manage her pain.*MDS consultant I verified resident 21's care plan had not been updated to include the symptoms or behaviors resident 21 had or identify the target symptoms.6. Interview on 11/20/25 at 5:38 p.m. with director of nursing (DON) B revealed:*Resident 21 struggled with sadness and depression since she admitted to the facility.*When she was admitted she often refused to leave her room.*Her anti-depressant medication was changed from sertraline to fluoxetine because she had become more tearful.*DON B did not know if her not leaving her room, tearfulness, or expression so of not wanting to live any longer had been included in resident 21's care plan.Review of the provider's 8/21/24 Comprehensive Care Plans policy revealed:* It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.* The comprehensive care plan will describe, at minimum the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated.* The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objective will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview, record review, and policy review, the provider failed to ensure ten of ten sampled residents (1, 2, 3, 7, 8, 14, 15, 17, and 20) who used side rails on their bed had alternatives attempted prior to the implementation of those side rails and four of ten sampled residents (3, 7, 8, and 17) with side rail son their beds were assessed for safe use of those rails within the last three months according to the provider's policy.Findings include: 1. Observation on 11/17/25 at 1:23 p.m. of resident 15's room revealed two quarter-length side rails in the up position at the head of her bed. Interview on 11/18/25 at 8:46 a.m. with resident 15 in her room revealed she: *Used both side rails to get out of bed, depending on which side of the bed she was getting out of. *Was provided education on the risks versus benefits of the side rails when she admitted to the facility. Review of resident 15's EMR revealed she: *Was admitted on [DATE]. *Had a 11/4/25 Brief Interview of Mental Status (BIMS) assessment score of 15, which indicated her cognition was intact. *Had a 7/29/25 physician's order, All residents of MWV [facility name] NH [Nursing Home] may have Positioning/Assist Bars [side rails] if indicated after Safety Assessment, Device Assessment and IDT [intradisciplinary team] review. *Had a 7/31/25 Positioning/Assist bar- Safety Assessment which indicated the symptoms that contributed to her need for the device [side rails] were cognitive impairment and a history of falls. -The check box in front of the Risk of using side rails in bed include: Accident hazard (falls, entrapment, injuries); Barrier from safely getting out of bed; Physical restraint (hinders independence getting out of bed); Decline in function, such as muscle functioning/balance; Skin integrity issues; Decline in other areas of daily living, such as using the bathroom, continence, eating, hydration, walking, and mobility; Negative psychosocial outcomes, such as altered self-esteem, feelings of isolation, or agitation/anxiety section was not checked. -The check box in front of the My signature below specifies that I have discussed and reviewed the following items and was given the opportunity to ask questions and state my preferences in these aspects of my care section was not checked. -The assessment did not include if any alternatives were attempted prior to the implementation of the side rails. -The form was signed on 7/31/25 by resident 15. 2. Observation on 11/17/25 at 1:55 p.m. of resident 2's room revealed two quarter-length side rails in the up position at the head of his bed. Interview on 11/18/25 at 8:30 a.m. with resident 2 in his room revealed: *He used the side rails to get in and out of his bed. *He was provided information on the risks and benefits of the side rails. Review of resident 2's EMR revealed: *He was admitted on [DATE]. *He had an 8/21/25 BIMS assessment score of 15, which indicated his cognition was intact. *Had a 3/24/20 physician's order, All residents of MWV [facility] NH may have Positioning/Assist Bars if indicated after Safety Assessment, Device Assessment and IDT review. *Had an 8/21/25 Positioning/Assist bar- Safety Assessment which indicated the symptoms that contributed to his need for the device were cognitive impairment, contracture/fracture and a history of falls. -The check box in front of the Risk of using side rails in bed section was not checked. -The check box in front of the My signature section was not checked. -The assessment did not include if any alternatives were attempted prior to the implementation of the side rails. -The form was signed on 8/21/25 by resident 2. 3. Observation and interview on 11/17/25 at 3:08 p.m. of resident 3 in her room revealed quarter bed rails attached to the sides of her bed, and they were in the up position. Resident 3 did not answer whether she used the side rails. Review of resident 3's EMR revealed she was admitted on [DATE]. Her 10/21/25 BIMS assessment score was an 8, which indicated her cognition was moderately impaired. *A 6/18/25 nurses progress note indicated resident [3] was very agitated . resident was uncooperative with dressing. CNA reports sitting resident's bed up in fowlers position to put on a sweatshirt and resident put her arm through the siderail and hung on. CNA was able to get residents arm free from rail by laying the bed flat. Resident is now calm, dressed, and in bed watching TV [television]. *A 7/1/25 Positioning/Assist bar- Safety Assessment forms signed by resident 3 on 7/1/25 indicated: -The check box in front of the Risk of using side rails in the bed section was not checked. -The check box in front of the My signature section was not checked. -The assessment did not include if any alternatives were attempted prior to the implementation of the side rails. *There were no other documented side rail assessments completed after 7/1/25. 4. Observation on 11/17/25 at 3:14 p.m. of resident 8's room revealed two quarter-length side rails in the up position at the head of her bed. Review of resident 8's EMR revealed she: *Was admitted on [DATE]. *Had a 9/4/25 BIMS assessment score of 11, which indicated her cognition was moderately impaired. *Had a 3/24/20 physician's order, All residents of MWV NH may have Positioning/Assist Bars if indicated after Safety Assessment, Device Assessment and IDT review. *Had a 6/3/25 Positioning/Assist bar- Safety Assessment which indicated the symptoms that contributed to the need for the device were dementia (a group of symptoms affecting memory, thinking, and social abilities), a history of falls, Neurological disorder-seizures, and visual impairment- glaucoma (a groups of eye diseases which can lead to visions loss and blindness). -The check box in front of the Risk of using side rails section was not checked. -The check box in front of the My signature section was not checked. -The assessment did not include if any alternatives were attempted prior to the implementation of the side rails. -The form was signed on 6/3/25 by resident 8. *There were no other documented side rail assessments completed after 6/3/25. 5. Observation on 11/17/2025 at 3:15 p.m. of resident 7's room revealed a fall mat on the floor next to the bed, quarter-length side rails attached to the sides of her bed in the up position. Review of resident 7's EMR revealed she was admitted on [DATE]. Her 11/11/25 BIMS assessment score was a 4, which indicated her cognition was severely impaired. *A 7/9/25 Positioning/Assist bar- Safety Assessment forms signed by resident 7 on 7/9/25 and her guardian on 8/6/25 indicated: -The check box in front of the Risk of using side rails section was not checked. -The check box in front of My signature was not checked. -The assessment did not include if any alternatives were attempted prior to the implementation of the side rails. *There were no other documented side rail assessments completed after 7/9/25. 6. Observation on 11/17/25 at 3:21 p.m. of resident 1's room revealed quarter- length side rails attached to the sides of her bed in the up position. Review of resident 1's EMR revealed she was admitted on [DATE]. Her 9/12/25 BIMS assessment score was a 15, which indicated her cognition was intact. *An 8/26/25 Positioning/Assist bar- Safety Assessment forms signed by resident 1 on 8/26/25 indicated: -The check box in front of Risk of using side rails section was not checked. -The check box in front of My signature was not checked. -The assessment did not include if any alternatives were attempted prior to the implementation of the side rails. 7. Observation and interview on 11/18/25 at 9:00 a.m. with resident 14 in her room revealed she: *Had one quarter-length side rail in the up position at the right side of the head of her bed. *Used the side rail to sit up in bed and transfer to and from her wheelchair. *Did not recall being provided education on the risks versus benefits of the side rail. *Did not recall being asked to give consent for the side rail to be attached to her bed. Review of resident 14's EMR revealed she: *Was admitted on [DATE]. *Had a 11/5/25 BIMS assessment score of 15, which indicated her cognition was intact. *Had a 11/9/23 physician's order, All residents of MWV NH may have Positioning/Assist Bars if indicated after Safety Assessment, Device Assessment and IDT review. *Had an 8/5/25 Positioning/Assist bar- Safety Assessment which indicated the symptoms that contributed to the need for the device were arthritis, a history of falls, cognitive impairment, contracture/fracture, and visual impairment. -The assessment indicated resident 14 had two side rails on her bed. -The check box in front of the Risk of using side rails was not checked. -The check box in front of the My signature section was not checked. -The assessment did not include if any alternatives were attempted prior to the implementation of the side rails. -The form was signed on 8/5/25 by resident 14. 8. Observation and interview on 11/18/25 at 9:33 a.m. with resident 17 in her room revealed she: *Had two quarter-length side rails in the up position at the head of her bed. *Used the side rails to get in and out of bed. *Was provided education on the risks and benefits of the side rails when she admitted but had not received any education about them since that time. Review of resident 17's EMR revealed she: *Was admitted on [DATE]. *Had a 9/29/25 BIMS assessment score of 15, which indicated her cognition was intact. *Had a 3/18/25 physician's order, All residents of MWV NH may have Positioning/Assist Bars if indicated after Safety Assessment, Device Assessment and IDT review. *Had a 6/3/25 Positioning/Assist bar- Safety Assessment which indicated the symptoms that contributed to the need for the device were arthritis, history of falls, and dizziness- sometimes. -The check box in front of the Risk of using side rails section was not checked. -The check box in front of the My signature section was not checked. -The assessment did not include if any alternatives were attempted prior to the implementation of the side rails. -The form was signed on 6/3/25 by resident 17. *There were no other documented side rail assessments completed after 6/3/25. 9. Observation and interview on 11/18/25 at 9:23 a.m. with resident 20 in his room revealed he: *Had two quarter-length side rails in the up position at the head of his bed. *Used the side rails on his bed to sit up when he was in bed. *Did not remember receiving any education related to the risks and benefits of the side rails. *Did not recall being asked to give consent for the side rails to be placed on his bed. *Stated the side rail on the left side of his bed was already on the bed when he admitted to the nursing home, and he asked for the second bed rail to be installed. Review of resident 20's EMR revealed he: *Was admitted on [DATE]. *Had an 8/28/25 BIMS assessment score of 14, which indicated his cognition was intact. *Had an 8/13/25 physician's order, All residents of MWV NH may have Positioning/Assist Bars if indicated after Safety Assessment, Device Assessment and IDT review. *Had an 8/26/25 Positioning/Assist bar- Safety Assessment which indicated the symptoms that contributed to the need for the device were history of falls, weakness, and dizziness. -The check box in front of the Risk of using side rails section was not checked. -The check box in front of the My signature section was not checked. -The assessment did not include if any alternatives were attempted prior to the implementation of the side rails. -The form was signed on 8/26/25 by resident 20. 10. Interview on 11/20/25 at 9:20 a.m. with director of nursing (DON) B revealed: *Side rail assessments were to be completed on all residents upon admission to the nursing home. *During quarterly care conferences the side rail assessment, the risks versus benefits of the side rails, and the consent were to be reviewed with each resident. *Alternatives to the side rails were not attempted prior to the installation of the side rails. *She verified the Positioning/Assist bar- Safety Assessment for residents 3, 7, 8, and 17 were not completed quarterly. xx. Interview on 11/20/25 at 4:32 p.m. with administrator A revealed: *She verified the side rail assessments that were provided were the most recent assessments in each resident EMR. *She was aware that some of the resident's side rail assessments were not completed quarterly. Review of the provider's 11/20/25 Rail Safety Audit instructions revealed: *Nursing works with the Resident's Doctor and Family members to determine if the rails are necessary. *All attempts should be made, and documented, by nursing to show that rails are necessary, if all other alternatives failed to assist the Resident. 12. Review of the providers October 2025 Proper Use of Bed Rails policy revealed: *The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. *Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. *The information that the facility should provide to the resident, or resident representative includes, but is not limited to: a. What assessed medical needs would be addressed by the use of a bed rails; b. The resident's benefit from the use of bed rails and the likelihood of these benefits; c. The resident's risk from the use of bed rails and how these risks will be mitigated; and d. Alternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate. *Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptoms, or functional reason for the use of the bed rail. *If no appropriate alternatives are identified, the medical record should include evidence of the following: a. Purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful b. Assessment of the resident, the bed, the mattress, and rail for entrapment risk (which would include ensuring bed dimensions are appropriate for the resident size/weight), and c. Risk and benefits were reviewed with the resident or resident representative, and informed consent was given before installation or use.

Based on record review, observation, interview, and policy review, the provider failed to ensure infection control practices were followed by:*Two of two certified nursing assistants (CNAs) (X and Y) who did not wear a gown while providing direct resident cares to one of one sampled resident (4) on enhanced barrier precautions (EBP) for a pressure ulcer.*One of one nursing assistant (NA) (Z) who did not change gloves and perform hand hygiene (handwashing) when she changed a resident 5's incontinence brief and assisted her into her wheelchair.*One of one licensed practical nurse (LPN) applicant (P) who did not perform hand hygiene during an insulin administration to resident 23.*One of one registered nurse (RN)/Minimum Data Set (MDS)/skin and wound nurse (L) who did not perform hand hygiene when she changed resident 14's dressing.Findings include:1. Review of Resident 4's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had diagnoses of a pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) of the sacral region (low back), stage 3 (open wound with full-thickness skin loss. Fatty tissue may be visible). *He had 9/26/25 physician's orders for EBP related his use of a urinary catheter (flexible tubing inserted into the bladder to drain urine) and his sacral pressure ulcer. Resident 4's 9/26/25 care plan indicated: *He required EBP related to his urinary catheter and sacral pressure ulcer. -the staff were to Follow facility protocol for enhanced barrier precautions as needed. -Gowns and gloves [were] to be worn for high contact resident care activities. *He needed 2 staff to assist him with repositioning. *He had a pressure ulcer on his sacrum. -Staff were to Administer treatments as ordered. Observation on 11/17/2025 at 2:59 p.m. of CNAs X and Y with resident 4 in his room revealed: *He had a sign on his door indicating he was on enhanced barrier precautions. *He had a container hanging on a door in his room of gowns and gloves. *CNAs X and Y repositioned him, while wearing gloves but did not have gowns on. *He had a urinary catheter and a wound dressing on his sacrum. *CNA Y emptied his urinary catheter and did not have a gown on. 2. Review of Resident 5's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Had diagnoses of non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity (a break in the skin that fails to heal due to poor circulation, not caused by prolonged pressure), cellulitis (bacterial skin infection) of right lower limb, and personal history of methicillin-resistant staphylococcus aureus infection(a type of staph bacteria that has become resistant to antibiotics) (MRSA). *She had a 10/23/25 physician's orders for EBP related to her skin wounds. Resident 5's 9/26/25 care plan indicated: *She required EBP related to her skin wounds. -The staff were to Follow facility protocol for enhanced barrier precautions as needed. -Gown and gloves [were] to be worn for high contact resident care activities. -The staff Is to use Hoyer (a mechanical lift and sling used to lift a person's full body) with 2 assist [assistance by two staff members], when she refuses to use assist of 2 [staff members] with [the use of a] gait belt [a waist strap gripped as support for safe mobility and transfers]. *She had a chronic, open non-pressure ulcer to her right lower extremity (leg). -Her Dressings [were] to be changed per MD [medical doctor] orders. Observation on 11/18/25 at 8:18 a.m. of CNA X and nursing assistant (NA) Z with resident 5 in her room revealed: *She had a sign on the outside of her door that indicated she required EBP. *She had a container over her bathroom door that contained gowns and gloves. *There was a Center for Disease Control and Prevention (CDC) sign posted on that container about multidrug-resistant organisms (a type of bacteria that resists many common antibiotics, making infections it causes very hard to treat)(MDROs). *There was a magnet on the outside of her door frame that stated wash hands before and after patient care. *While CNA X and NA Z were in resident 5's room and were wearing gowns, gloves and masks (PPE). -NA Z removed her incontinence brief, completed the resident's personal hygiene care, and then put a new incontinence brief on the resident. -With her same gloved hands,NA Z pulled the residents pants up, put a lift sling under her, hooked the sling to the total body lift, transferred her into her wheelchair, and pushed her in the wheelchair. -CNA X and NA Z removed their PPE and performed hand hygiene. -NA Z then pushed the total body lift into the hallway and did not clean the lift. 3. Interview on 11/18/25 at 8:20 a.m. with travel contracted registered nurse M revealed resident 5 had a history of MRSA, and gowns and gloves needed to be worn by staff when providing direct care for the resident. 4. Interview on 11/20/2025 at 10:18 a.m. with CNA X revealed: *She had been a CNA at the facility for two months and previously worked in the dietary department. *When caring for residents who were on EBP, she would wear gloves, gowns, and masks. *Residents needed EBP if they had open wounds or a urinary catheter. *Staff were to wear gowns, gloves, and masks when dressing, repositioning, handling the urinary catheter and emptying the catheter bag, and transferring residents on EBP. *She verified she did not have a gown on when she repositioned resident 4 and should have. *She was to perform hand hygiene before putting on gloves and after removing gloves. *She was to remove dirty gloves and perform hand hygiene before completing clean tasks, such as pulling a resident's pants up and using the lift. *She was not aware she was to clean the lift after it was used or before using it for another resident, and verified the lift was not clean the lift after using it to assist resident 5. 5. Observation on 11/19/25 at 9:20 a.m. of licensed practical nurse (LPN) applicant P revealed: *LPN applicant P did not perform hand hygiene before she gathered the supplies for resident 23's insulin administration. *She put her gloves without having performed hand hygiene. *With her gloved hands LPN applicant P touched the keyboard on the computer on the medication cart. *LPN applicant P entered resident 23's room, administered the resident's insulin, removed her gloves, and then exited resident 23's room. *LPN applicant P returned to the medication cart, applied alcohol-based hand sanitizer (ABHS) to the palm of her left hand. -She did not rub her hands together to apply the ABHS to her right hand or rub her hands together until the ABHS dried. 6. Observation and interview on 11/20/25 at 9:31 a.m. with registered nurse (RN)/ minimum data set (MDS)/skin and wound nurse L while changing resident 14's foot dressing revealed RN/MDS/skin and wound nurse L: *Entered resident 14's room, applied a gown, mask, and gloves. She did not perform hand hygiene before she put on her gloves. *Prepared the area for the dressing change, removed the dirty dressing from resident 14's foot, removed her gloves and put on a new pair of gloves, cleaned the wound and placed a new clean dressing on the resident's foot wound. -Did not perform hand hygiene after she removed the dirty gloves used to remove the dirty dressing or before she applied put on clean gloves. *Verified she did not perform hand hygiene after she removed her dirty gloves or before she put on clean gloves during the above observed dressing change. *Stated she had performed hand hygiene before entering the room but agreed she touched items within the room before she put on her gown, mask, and gloves. 7. Interview on 11/20/25 at 3:04 p.m. with RN/infection control nurse C and LPN/restorative nurse N revealed: *Hand hygiene was expected to be completed before entering a room, after exiting a room, before gloves were applied and after they were taken off, before preparing each resident's medications, and after the medication administration, after a dirty procedure was completed and before a clean procedure such as during a dressing change or providing perineal personal hygiene care (washing of the genital and anal areas). *Mechanical lifts were to be cleaned with a disinfectant wipe after each resident use and as needed if they were visibly soiled. *Staff were to wear a gown and gloves while they provided direct care with a resident on EBP, to include repositioning the resident, and emptying a resident's urinary catheter. Review of the provider's April 2019 Administering Medications policy revealed, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 8. Review of the CDC EBP sign revealed: *Wear gloves and a gown for the following High-Contact Resident Care Activities. -Dressing.Transferring.Providing Hygiene.Changing briefs.Device care or use.Wound Care. 9. Review of the providers' 8/12/24 Enhanced Barrier Precautions policy revealed: * Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. * All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. * All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. * An order for enhanced barrier precautions will be obtained for residents with any of the following: -wounds.indwelling medical devices. * PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned [applied] prior to entering the resident's room. * The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. * High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: .urinary catheters. h. Wound care: any skin opening requiring a dressing 10. Review of the provider's August 2019 Handwashing/Hand Hygiene policy revealed: *The facility considers hand hygiene the primary means to prevent the spread of infection. *All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *Use and alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g. urinary catheters, IV [intravenous] access sites); f. Before donning sterile gloves; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident cares; i. After contact with a resident's skin; j. After contact with blood or body fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings; o. Before and after eating or handling food; p. Before and after assisting a resident with meals; and q. After personal use of the toilet or conducting your personal hygiene. *Hand hygiene is the final step after removing and disposing of personal protective equipment. *The use of gloves does not replace hand washing/hand hygiene. *Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. 4. Hold the removed glove in the gloves hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene.

Based on policy review, interview, and record review, the provider failed to develop and implement an effective antibiotic stewardship program to monitor for appropriate antibiotic use according to the provider's policy.Findings include:1. Review of the providers 2024 Antibiotic Stewardship Program policy revealed:* It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.* The program includes antibiotic use protocols and a system to monitor antibiotic use.-a. Antibiotic use protocols:--i. Nursing stall shall assess residents who are suspected to have an infection and complete a Medical Care Referral Form prior to notifying the physician.--ii. Laboratory testing shall be in accordance with current standards of practice.--iii. The facility uses the (CDC's [Center for Disease Control] NHSN [National Healthcare Safety Network] Surveillance Definitions) to define infections.--iv. The Loeb Minimum Criteria are used to determine whether or not to treat an infection with antibiotics.* Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g. antibiotic time-out).* Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness.* Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure).* At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data. Examples include: tracking C. difficile infections, antibiotic resistance, or adverse drug events related to antibiotic use.* A review of the facility's antibiogram will be performed every 18-24 months to guide development or revision of antibiotic use protocols or prescribing practices.* Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 hours of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings.* At least annually or per facility policy, feedback shall be provided on the facility's antibiotic use data in the form of a written report shared with administration, medical and nursing staff, and the QAA [quality assessment and assurance] Committee.* At least annually or per facility protocol, each attending physician shall be provided feedback on his/her antibiotic use data in the form of a written report.* Documentation related to the program maintained by the Infection Preventionist, including but not limited to:-a. Action plans and/or work plans associated with the program.-b. Assessment forms.-c. Antibiotic use protocols/algorithms.-d. Data collection forms for antibiotic use, process, and outcome measures.-e. Antibiotic stewardship meeting minutes.-f. Feedback reports.-g. Records related to education of staff, residents, and families.-h. Annual reports.2. Review of the provider's September 2017 Surveillance for Infections policy revealed:* Nursing Staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infection, and will document and report suspected infections to the Charge Nurse as soon as possible.* Analyze the data to identify trends.a. Compare the rates to previous months in the current year and to the same month in previous year, to identify seasonal trends.b. Consider how increases or decreases might relate to recent process changes, events, or activities in the facility (i.e., change in handwashing preparations, increased turnover in personnel or residents, etc.)c. If the infection rates rise each month over a period of six (6) months, additional advice is warranted.* Surveillance data will be provided to the Infection Control Committee regularly.3. Review of the provider's October 2025 Facility Assessment revealed:* Describe how you evaluate if your infection prevention & [and] control program is effective in preventing, identifying, reporting, investigating & controlling infections & communicable diseases according to accepted national standards.- Antibiotic Stewardship and monitoring-[Contracted] Telehealth-Utilize McGirrs [McGeers] and education on McGirr's training-I Car [Infection Control Assessment and Response] completion with SD [South Dakota] Dept. [Department] of Health-APIC [Association for Professionals in Infection Control and Epidemiology] and AHCA [American Health Care Association] memberships.4. Interview and review of the provider's antibiotic stewardship binder on 11/20/25 at 3:04 p.m. with registered nurse (RN)/infection control (IC) C and licensed practical nurse (LPN)/restorative nurse N revealed:*RN/IC C was new to the position of infection control and antibiotic stewardship.*LPN/restorative nurse N had oversaw the antibiotic stewardship prior to RN/IC C starting that position.*The antibiotic stewardship binder contained a monthly breakdown of physician's orders for the antibiotics ordered that month for each resident and an annual listing of the antibiotics ordered for each resident.*Each month RN/IC C was responsible to print off the list of antibiotics for that month and present them to the QAPI (Quality Assurance and Performance Improvement) committee.*She was also responsible to be sure the lab results from any of the identified infections were in the resident's electronic medical record (EMR).*At the end of the year a report is run that lists all the antibiotics ordered and administered that year by resident.*McGeer criteria (a set of standardized definitions used in long-term care facilities, to identify and track infections for surveillance and research purposes) was used by the provider to identify potential infections.*There was no written documentation to support that McGeer criteria was being used when the staff suspected a resident had an infection prior to notifying the director of nursing or the practitioner.*RN/IC C and LPN/restorative nurse N stated they used common knowledge if a resident was suspected to have a urinary tract infection (UTI) and did not follow specific criteria to identify when the resident's symptoms met the criteria for a urinalysis (lab test for urine infection).*If the nursing staff suspected that a resident had an infection, they would report the information about that to the director of nursing (DON) B and she would relay that information to medical director BB.*If DON B was not available the nursing staff could utilize telehealth (electronic remote health service).*Nursing staff did not follow up in 48-72 hours after the initiation of an antibiotic to review the culture reports that indicated which antibiotic would be effective to treat that infection. Medical director BB would inform the nursing staff if the antibiotic was appropriate.5.Interview on 11/20/25 at 5:38 p.m. with director of nursing (DON) C regarding the facility's antibiotic stewardship program and policy revealed:*When the nursing staff suspected a resident had an infection, they were to complete an assessment and then call DON B. DON B would then call medical director BB with the assessment information and medical director BB would give orders, such as, if the resident was to be monitored, have labs completed, or go to the emergency room. DON B would then notify the nursing staff and enter those orders, if applicable, into the resident's EMR.*Medical director BB recently begun ordering cultures to be completed with all urine samples collected.*DON B stated there was no written form for nursing staff to refer to or document on to determine if the criteria was met for a lab or to request an antibiotic.*Nursing did not review antibiotics for effectiveness 48-72 hours after an antibiotic was initiated (antibiotic timeouts). Medical director BB would receive the culture reports and notify the nursing staff if the antibiotic was appropriate.*There was no documentation of infections trends within the facility.*The provider did not use an antibiogram (a report summarizing antibiotic susceptibility test results for a specific population of bacteria, showing which antibiotics are effective against them) as their policy indicted.*There was no tracing of clusters or documentation that that information had been reviewed or evaluated with antibiotic use monthly, quarterly, or annually.*There was not a written action plan or work plan associated with the antibiotic stewardship program as the provider's policy indicated.*There were no written assessment forms as the provider's policy indicated.*There was no antibiotic use protocols as the provider's policy indicated.*There were no data collection forms for antibiotic use, process, and outcome measures as the provider's policy indicated.*There were no feedback reports or annual reports other than the listing of the antibiotics prescribed monthly and annually.*There were no records that education had been provided to physicians, residents, and families related to antibiotic stewardship.

Based on interview and policy review, the provider failed to ensure Medical Director (BB) attended and meaningfully participated in the provider's Quality Assurance (QA) meetings at least quarterly. Findings include:1. Interview on 11/20/25 at 3:33 p.m. with administrator A and Minimum Data Set (MDS) consultant I regarding the provider's QA meetings revealed:*QA meetings were held in person and through Zoom (a communications platform that provides real-time video meetings and other collaboration tools).*QA meetings were conducted every four to five weeks.*The QA committee members included the maintenance supervisor, director of nursing B, administrator A, MDS consultant I, the MDS coordinator , staff development K, infection control preventionist C, the restorative nurse, and medical director BB. Medical director BB was provided information after the meetings and did not attend those meetings in person or through Zoom quarterly.*Administrator A was aware that medical director BB was required to attend the facility's QA meetings quarterly in person or through another real-time method, such as Zoom. Review of the provider's 2024 QA policies revealed:*All identified problems will be addressed and prioritized, whether by frequency of data collection/monitoring or by the establishment of sub-committees chartered to complete performance improvement projects. Considerations include, but are not limited to:- High-risk, high-volume, or problem prone areas.- Incidence, prevalence, and severity of problems in those areas.- Measures affecting resident health, safety, autonomy, choice, and quality of care.*The policy did not indicate who comprised the QA committee or how often they were required to attend.

Based on resident council minutes review, interview, and policy review, the provider failed to ensure one of one certified nursing assistant (CNA)/activity staff (Q) who documented allegations of neglect regarding residents' personal care reported by residents, during an 11/12/25 resident council meeting reported those allegation to the administrator according to the provider's policy which resulted in those allegations not being reported to the South Dakota Department of Health (SD DOH) in the required time frame of no more than 24 hours after the allegations were made. Findings include: 1. Review of the provider's 11/12/25 resident council meeting minutes revealed: *Resident concerns/comments included: -Nursing-Resident's concerns, with some resident[s] that can't comb their own hair and wash their own faces are sometimes messy at meals and activity time. Also, that some resident[s] have their legs or stomachs showing when they come into [the] dinning [dining] room for meal[s] and for activities. Some residents are also concerned with how staff are sometimes seem to [too] busy and sound upset when answering call light[s]. -Residents brought up nursing cares being done during activity time or in front of other residents, they want vital signs [measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate] done in private. 2. Interview on 11/20/25 at 4:52 p.m. with administrator and A and Minimum Data Set (MDS) consultant I regarding the reporting of allegations of abuse and neglect to the South Dakota Department of Health (SD DOH) revealed: *Certified nursing assistant (CNA)/activity staff Q coordinated, attended, and wrote the minutes for the 11/12/25 resident council meeting. -She had recorded allegations of neglect made by residents and had not reported those allegations to her supervisor or the administrator. *Administrator A stated that CNA/activity staff Q should have notified administrator A immediately of those allegations. *Administrator A was notified of the allegations on 11/17/25. -That was 5 days after the allegations were made. *Social service/activity supervisor E reported those allegations to the SD DOH on 11/18/25. *The provider initiated an investigation for the allegation. 3. CNA/activity staff Q was not at the facility and not available for an interview throughout the survey. 4. Review of the provider's 2024 QAPI [Quality Assurance and Performance Improvement] Coordination of Abuse, Neglect and Exploitation policy revealed The QAA [Quality Assessment and Assurance] committee will determine through a coordinated effort: . Whether there is further need for systemic action such as: . Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about. Review of the provider's 2016 Abuse Prevention Program policy revealed: *Investigate and report any allegations of abuse within timeframes as required by federal requirements. *Involve the resident council in monitoring and evaluating the facility's abuse prevention program. *Reporting: -All alleged violations involving abuse, neglect, . will be reported by the facility Administrator, or his or her designee, to the following persons or agencies: --The State licensing/certification agency responsible for surveying/licensing the facility. -An alleged violation of abuse, neglect, . will be reported immediately, but not later than: --Two (2) hours if the alleged violation involves abuse OR has resulted in bodily injury; or --Twenty-four (24) hours if the alleged violations does not involve abuse AND has not resulted in serious bodily injury. Review of the provider's 2017 Abuse Investigation and Reporting policy revealed All reports of resident abuse, neglect, . shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. A review of the provider's 2001 Grievances/Complaints-Staff Responsibility policy revealed Any alleged abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, must be reported to the administrator immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the provider's 2001 Grievances/Complaints, Filing policy revealed The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse, and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law.

Based on the resident council meeting, resident council meeting minutes review, grievance logs review, observation, interview, record review, and policy review, the provider failed to respond to the resident concerns communicated at resident council meetings regarding nursing care being performed in public and loud televisions. Findings include:1. A resident council meeting held on 11/19/25 at 2:12 p.m. revealed:*Residents voiced complaints that their concerns communicated during previous resident council meetings were not resolved, which included:-Loud televisions at night-Staff taking residents' vital signs, giving insulin injections, combing residents' hair, and fixing residents' clothing in shared common areas. *Complaints were heard by staff, but there was no follow-through.*Resident 17 reported, The loud televisions are so bothersome it makes me physically sick.2. A review of the providers' July-November 2025 resident council meeting minutes revealed:*On July 22, 2025, residents had concerns about televisions and radios being on and loud all night. -A 7/22/25 Grievance Log did not list the loud televisions or radios being on all night. *On August 20, 2025, residents had concerns about residents' televisions and radios being on all night and being loud. -An 8/20/25 Grievance Log stated, No problems/concerns.*On September 17th, 2025, residents had concerns with residents not being presentable for meals and not adjusting residents' clothing and brushing residents' hair in the dining room or at activities in front of other residents. -A 9/17/25 Grievance Log revealed the problem with residents not being presentable for meals had been resolved by explaining to the residents that other residents had the right to not have their hair combed. It did not address the adjustment of the resident's clothing and hair combing in front of others.*On November 12, 2025, residents had concerns about nursing care being performed in front of others and loud televisions at night. -The 11/12/25 Grievance Log was not completed by the provider yet, as the meeting was a week ago.3. Interview on 11/20/25 at 10:29 a.m. with activity/social services staff D revealed:*She oversaw the resident council meetings.*She acknowledged that the resident's concerns about the loud televisions and not adjusting the resident's clothing or combing hair in front of others were not addressed on the grievance log. *When receiving a complaint, she would bring the complaint to the department head responsible for the area regarding the complaint, and the department head would talk to the resident who had the concern. *She stated that DON B addressed concerns about staff not administering shots or checking vital signs in the dining room and educated her staff. *She ordered headphones that hook up to the televisions that some residents were using, but some of those headphones were broken.4. *Resident 2 who lived across from resident 17, who had the loud television at night, had not been offered headphones.*She talked with the staff about asking the residents, who wanted their televisions loud, to have their doors closed when their television was loud.5. Observation and Interview on 11/20/25 at 7:48 a.m. with resident 23 in her room revealed:*Resident 2 had his door open, and the television was on at a loud volume.*Resident 17's room was across the hall from him, and her door was opened a crack. -Resident 2's television was heard from standing by her door. *Resident 23's room was diagonally across the hall from resident 2, and she reported difficulty sleeping due to the loud television volume at night. -Resident 2's television was heard from inside her room.6. Interview on 11/20/25 at 7:55 a.m. with certified nursing assistant (CNA) R revealed:*In change of shift report that morning (11/20/25), it was brought up that resident 2's television was loud.*If staff were to ask him to turn his television down, she thought he would.*When asked if anyone had asked resident 2 to turn his television down that day, she replied no. 7. Interview on 11/20/25 at 5:53 p.m. with director of nursing (DON) B revealed:*She had asked the caregiver staff to complete nursing care and medication administration in a private place.*She had an in-service scheduled for next week with the nursing staff regarding medication administration, checking vital signs, and adjusting residents' clothing and combing their hair in common areas. *She had observed nursing staff combing residents' hair, performing blood glucose checks, and administering medications in the dining room. 8. Interview on 11/20/25 at 4:10 p.m. with administrator A revealed: *Activity/social services D reported to her on 11/17/25 that a concern regarding providing nursing care in front of others was discussed at the 11/12/25 resident council meeting.*Resident council meeting grievance logs were reviewed with her, and she acknowledged that concern was brought up at the 9/17/25 meeting.*There were two to three residents who resided near resident 17's room who liked to have their televisions loud. *They purchased headphones and gave them to some of the residents. *She verified that providing resident care in the dining room and the loud television volume had not been addressed. 9. Review of resident 17's electronic medical record (EMR) revealed her 9/29/25 Brief Interview for Mental Status (BIMS) score was 15, which indicated her cognition was intact. 10. Review of resident 23's EMR revealed her 11/7/25 BIMS score was 11, which indicated her cognition was moderately impaired. 11. Review of the provider's 2001 Resident Council policy revealed: * The purpose of the Resident Council is to provide a forum for:-Residents.to have input in the operation of the facility;-Discussion of concerns and suggestions for improvement.*The facility department related to any issues will be responsible for addressing the item(s) of concern. 12. Review of the provider's 2001 Grievances/Complaints, Filing policy revealed:* Residents.have the right to file grievances, either orally or in writing.* The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident.* The Grievance Office, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.13. Review of the provider's 2001 Grievances/Complaints, Recording and Investigating policy revealed:* All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s).-Upon receiving a grievance and complaint report, the Grievance Officer will begin an investigation into the allegations.-The department director(s) of any named employee(s) will be notified of the nature of the complaint and that an investigation is underway.* The 'Resident Grievance/Complaint Investigation Report Form' will be filed with the Administrator within five (5) working days of the incident.* The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse, and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law.

Based on interview and record review, the provider failed to ensure one of one dietary manager (DM) (F) was certified according to the requirements. Findings include: Interview on 11/20/2025 at 11:14 a.m. with DM F revealed:*She was hired on 3/6/2013 as the dietary manager.*She was not a certified dietary manager.*Registered dietitian (RD) H had encouraged DM F to take the certified DM course.-DM F had registered for the DM course and had started it the week prior to 11/20/25.-DM F had registered for the DM course a year ago, but a personal situation happened, and she was not able to complete it. Interview on 11/20/25 at 1:14 p.m. with administrator A regarding DM F's certification revealed:*She confirmed DM F was hired in 2013 and was not certified.*DM F was unable to complete the course in past years for various reasons.*DM F was enrolled in a DM certification course currently. Review of DM F's employee file revealed she was hired on 3/16/13, there was no documentation that she had taken a dietary manager course in the past.

Based on observation, interview, record review, and policy review, the provider failed to follow professional standards to ensure the effectiveness and adverse reactions of an antidepressant medication were documented for one of one sampled resident (21) with a newly ordered antidepressant medication (fluoxetine) for anxiety and depression.Findings include:1. Periodic observations on 11/17/25 between 1:34 p.m. and 3:53 p.m. of resident 21 revealed each time she was visualized in her room she was resting on her back in her recliner, with her eyes closed, and her feet elevated.2. Observation and interview on 11/18/25 at 8:00 a.m. with resident 21 in her room revealed:*She was sitting in her wheelchair beside her bed with her head lowered towards her chest.*She stated she was tired of doing the same things, so she sleeps all the time.*Resident 21 began to cry, and stated she did not want to live anymore.*She missed her children, and no one came to see her anymore.*She stated she had spoken to staff about not wanting to live anymore, and they reassured her and told her they were there to help her.*Resident 21 began to cry harder and stated she should just try to kill herself.3. Observation on 11/18/25 at 9:52 a.m. of resident 21 beside the 300 hallway nurses station revealed she was in her wheelchair with her chin on her chest, and her eyes closed.4. Review of resident 21's electronic medical record revealed:*She admitted to the facility on [DATE].*She had 10/31/25 Brief Interview of Mental Status (BIMS) assessment score of 8, which indicated her cognition was moderately impaired.*Her diagnosis included dementia (a group of symptoms affecting memory, thinking, and social abilities), anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and depression.*She had a 10/18/25 physician's order for FLUoxetine HCL Oral Capsule 10 MG [milligram] (Fluoxetine HCl) Give 1 capsule by mouth one time a day related to ANXIETY DISORDER, UNSPECIFIED (F41.9); DEPRESSION, UNSPECIFIED (F32.A).*Resident 21's 11/20/25 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) had focus areas that stated:- The resident has a dementia diagnosis with periods of forgetfulness and anxiety.- [Resident 21] uses psychotropic medications r/t [related to] Diagnosis of Depression and Anxiety.*Review of resident 21's progress notes revealed one entry after the initiation of the fluoxetine on 10/20/25 which stated, Resident started on Prozac [fluoxetine] 10mg on 10/21/25. Resident pleasant and cooperative. No behaviors noted this shift.5. Interview on 11/20/25 at 12:05 p.m. with licensed practical nurse (LPN) O revealed:*When a resident had new orders for medication such as an antibiotic or antidepressant the resident's name and the medication name were placed on a hot charting form, which would prompt the nursing staff to document symptoms and/or adverse reactions of the medication on each shift.*The nursing staff were responsible for monitoring and documenting adverse reactions and the effectiveness of the medication.*She was not sure how long they were to document about an antidepressant after they were started, but antibiotics documentation was to be completed each shift for the first 72 hours after the start of the antibiotic.6. Review of the provider's hot charting forms for October 2025 revealed:*An area labeled medication changes/monitoring and a location to write the resident's name, medication, start date, and end date.*Instructions on the bottom of the medication changes/monitoring area stated:- *Antipsychotic meds [medications]- ADRs [adverse drug reactions] need [to be] charted x [times] 3 days.- *Antihypertensive, cardiac, diuretics, etc. -System specific vitals [vital signs], ADRs, & [and] edema need to be charted on x 3 days.- *Discontinues or decreased dose of medication need to be.*On 10/20/25 the hot charting form included [resident 21] - fluoxetine 10mg*On 10/21/25, 10/22/25, and 10/23/25 the hot charting form included [resident 21] Prozac (fluoxetine) 10mg7. Interview on 11/20/25 at 4:32 p.m. with administrator A and Minimum Data Set (MDS) consultant I revealed:*Administrator A expected newly ordered psychotropic meds to be reviewed at the time a new order was received.*The newly ordered psychotropic medications should then be added to the provider's hot charting form to prompt the nursing staff to monitor and document any adverse effects and the effectiveness of the medication for each shift for the first 72 hours.*The social services personnel were expected to document the effectiveness of behavior management related to a resident's newly ordered psychotropic medication.*Administrator A and MDS consultant I verified there was only one progress note entered by nursing for resident 21 in the first 72 hours after she was started on fluoxetine and there was no documentation by the social service personnel related to on the effectiveness of the fluoxetine in resident 21's first month of use.8. Interview on 11/20/25 at 5:38 p.m. with director of nursing (DON) B revealed:*Resident 21 struggled with sadness and depression since she admitted to the facility.*When she was admitted she often refused to leave her room.*Her anti-depressant medication was changed from sertraline to fluoxetine because she had become more tearful.*DON B was not aware resident 21 had reported her feelings of wanting to die to staff and verified this had not been documented in resident 21's EMR.*DON B verified there was no consistent documentation of resident 21 symptoms of tearfulness prior to the change in medication from sertraline to fluoxetine and there was only one nurse progress note after the fluoxetine was started.*She agreed there was not a resident complaint, symptom or behavior identified as the intended use for Prozac.*DON B agreed resident 21's symptoms had not been documented, so she was not able to determine if the fluoxetine was helping with resident 21's tearfulness.*DON B verified adverse reactions were not being monitored or documented on resident 21's TAR as other residents on psychotropic medications were.Review of the provider's undated Psychotropic Medication Policy and Procedure policy revealed:* The purpose of the Psychotropic Drugs Policy and Procedure is to develop a facility system to ensure a resident is not given psychotropic medications unless a comprehensive assessment identifies clear indications and parameters for use, based upon regulatory compliance and best practice. In addition, the facility will manage and monitor the resident's medication regimen, identify the need for gradual dose reductions, use of non-pharmacological interventions in an effort to decrease or discontinue psychotropic drugs and limit PRN [as needed] orders to be used only when necessary, consistent with regulatory compliance, to maintain or promote the highest level of resident function and quality of care.* A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:(i) Anti-psychotic;(ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic.* Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in effort to discontinue these drugs;* A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (2) diagnosed with schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a distorted sense of reality) had an accurate level I (1) Preadmission Screening and Resident Review (PASRR) evaluation after having been identified as having a possible serious mental illness.Findings include:1. Review of resident 2's electronic medical record (EMR) revealed:*He admitted to the facility on [DATE].*He had an 8/21/25 Brief Interview of Mental Status (BIMS) assessment score of 15, which indicated his cognition was intact.*He had a diagnosis of schizophrenia.*Resident 2's9/19/19 PASRR level II Pre-admission Screening and Resident Review stated, The diagnosis of mental illness is unsubstantiated [Resident 2's current diagnoses list did not contain a diagnosis that was considered a serious mental illness].*There was a 6/22/25 physician's order for resident 2 to be given a one milligram (mg) tablet of Risperdal [a medication that alters the activity of neurotransmitters in the brain to reduce symptoms schizophrenia] by mouth three time a day.*Resident 2 did not have a current diagnosis of unspecified mood disorder.*Review of resident 2's 9/3/19 physician's progress note identified as the history and physical for admission to the facility revealed resident 2's diagnosis for unspecified mood disorder had a line through it and schizophrenia was written behind with the initials of medical director BB.*Review of diagnoses printed on 10/16/24 for resident 2 revealed the diagnosis of schizophrenia PER 9/29/09 VST [visit].2. Interview on 11/18/25 at 8:30 a.m. with resident 2 revealed he:*Was diagnosed with schizophrenia about seven years ago.*Had been seeing a mental health provider.3. Interview on 11/19/25 at 9:03 a.m. with South Dakota (SD) PASRR screening manager revealed:*The PASRR submitted in September 2019 was unsubstantiated because the diagnosis was unspecified mood disorder and that was not considered a serious mental illness.*The provider was not compliant with resident 2's PASRR requirements because they should have submitted a new PASRR when resident 2's diagnosis changed from unspecified mood disorder to schizophrenia upon admit on 9/3/19.4. Interview on 11/20/25 at 10:19 a.m. with activity/social service staff (SS) D and SS/activity staff E revealed:*A referral for a level II PASRR evaluation and determination would need to be submitted for any resident with a new mental health diagnosis, a change in mental health diagnosis, or a new mental health medication to evaluate for a possible serious mental illness.*Activity/SS D was responsible for completing those referrals for level II PASRRs at the time resident 2 admitted to the facility.*Activity/SS D was unaware that resident 2's mental health diagnosis had changed during the admission process.*She stated the initial PASRR level I screening was completed with a diagnosis of unspecified mood disorder and the PASRR level I screening indicated the diagnosis of mental illness was unsubstantiated.*Activity/SS D had not submitted a referral for a level II PASRR evaluation and determination for resident 2 because she was not aware his diagnosis had changed from unspecified mood disorder to schizophrenia on 9/3/19.*Activity/SS staff D reviewed resident 2's 9/3/19 physician's note that was identified as his history and physical for admission and verified unspecified mood disorder was crossed out and changed to schizophrenia by medical director BB.5. Review of the provider's September 2025 PASRR policy revealed:* The PASRR process requires that all individuals applying to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have a SMI [serious mental illness] or ID/DD [intellectual disability/developmental disability]. This is called a 'Level I screen'. Those individuals who test positive at a Level I are then evaluated in depth, called a 'Level II' PASRR. The findings of this evaluation result in determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care.* If the Screening Form fails to identify any criteria of the individual having SMI and/or ID/DD, then no additional action is required and the admission to the nursing facility is automatically approved. The admitting/receiving facility must obtain a copy of the completed negative pre-screening form and confirm that the form was appropriately completed before admitting any individual to a Medicaid certified facility.* Ensure the Screening form is completed and accurate prior to every admission.-If a negative screen- ensure screening is completed accurately based on all the presenting medical records available for review and screening form is filed in the medical records.

Based on Certification and Survey Provider Enhanced Reports (CASPER) reporting data review, interview, and policy review, the provider failed to ensure their Payroll Based Journal (PBJ), (information of the provider's daily staffing hours for the appropriate care of the residents) had been complete and the data had been submitted to the Center for Medicare and Medicaid Services (CMS) for one of four quarters (Quarter 1, 2024). Findings include: 1. Review of the provider's CASPER reporting data revealed no PBJ data had been submitted for the time period of October 1, 2023, through December 31, 2023. Interview on 10/1/24 at 3:47 p.m. with administrator A regarding the submission of PBJ data to CMS revealed: *She was aware the data had to have been submitted. *She knew there were deadlines to submit the data. *They had a vendor who kept track of payroll and PBJ data. *The vendor had missed the deadline for submitting the Quarter 1, 2024 PBJ data to CMS. Interview on 10/3/24 at 9:00 a.m. with administrator A and outsourced chief financial officer (CFO) L regarding the submission of PBJ data to CMS revealed: *Outsourced CFO L was responsible for ensuring the PBJ data was submitted to CMS. *His office would get the data from the provider and ensure it was submitted by the deadline. *A staff member from outsourced CFO L's office missed the deadline for submitting the data by one day. *It was both their expectations that the data would be submitted to CMS before the deadline each quarter. Review of the providers revised 1/4/23 Payroll Based Journal policy revealed, It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

Based on observation, interview, record review, and policy review, the provider failed to serve a well-balanced diet that: A. Considered the food preferences for 3 of 3 sampled residents (6, 13, and 16). B. Contained dietician-approved nutritional equivalent food substitutions for 21 of 21 sampled residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21) for one of one observed meal service. Findings include: 1. Observation and interview on 10/1/24 at 9:09 a.m. with resident 6 revealed: *She stated, You get what you get, when asked what she ordered for breakfast. *She had not received a menu of meals for the day. *She had not selected or been asked what she wanted to eat that day. *Menus had been posted in the hallway near the dining room, but it was not always accurate. *The residents had been quarantined in their rooms due to a COVID-19 outbreak and had not been able to check that menu. *She stated, If you refuse [the meal provided], you get soup. *She had requested softer foods because she did not wear dentures. -She stated, This fruit [[NAME] and grapes] is hard. Review of resident 6's electronic medical record revealed: *A 11/3/22 physician's order for Diet Regular diet, Mechanical Soft texture. *She had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. Observation and interview on 10/1/24 at 10:34 a.m. with resident 13 revealed: *There were uneaten pancakes with syrup and sausage on her plate that had been covered. *She had not liked what was served that day and wanted another choice. -She had wanted malt-o-meal. *She stated, You get what is provided. *If she had been given a choice she would have ordered something different. Review of resident 13's electronic medical record revealed: *A 4/13/2 physician's order for a Consistent Carbohydrate diet, Regular texture, Regular consistency. *She had a Brief Interview for Mental Status (BIMS) score of 12 which indicated she was moderately cognitively impaired. *Her diagnosis included Type 2 Diabetes Mellitus with Hyperglycemia. *Her care plan indicated: -Poor appetite. -Refuses to eat at times. -Monitor nutritional status. -Serve diet as ordered. Interview on 10/1/24 at 11:07 a.m. with resident 16 revealed she stated: *I don't care for a lot of things they have. *If I don't like what they bring me I can have soup. *They put it [the menu] up on the board. *I am tired of hamburgers. *You get what they bring. Review of resident 16's electronic medical record revealed: *A 12/1/23 physician's order for Diet Consistent Carb [carbohydrate], NAS [no added salt] diet, Regular texture, Regular consistency. *She had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. *Her diagnosis included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Essential (Primary) Hypertension. Interview on 10/1/24 at 8:00 a.m. with dietary manager (DM) E regarding an alternative menu revealed they did not have an alternative menu, but if the resident did not like what was served they would be able to have soup or hot/cold cereal. 50915 2. Observation on 9/30/24 at 3:45 p.m. of unidentified CNA during the initial tour in the kitchen revealed: *CNA was making ham salad sandwiches for the residents' evening meal. *CNA was not using a measuring scoop to correctly portion the amount of salad put on each sandwich. *The bread used for the sandwich was a slider bun, approximately one-half the side of a standard hamburger bun. Observation on 10/2/24 at 4:13 p.m. of cook J revealed: *While preparing the cucumbers with ranch portions, she was not using a measuring utensil to measure the portion for each meal tray. *While preparing the three bean salad portions, she was not using a measuring utensil to measure the portion for each meal tray. Interview on 10/1/24 at 8:35 a.m. with dietary manager E revealed: *The CNA that was making the ham salad sandwiches was not part of the regular kitchen staff. -The CNA was helping due to short staffing. *She stated that she had trained the CNA to use the one-half cup scoop to portion the ham salad, but the thought the CNA must have been nervous because the surveyors were watching her. *When asked what options the resident would have if they did not like what was being served, she stated that the resident could have soup or cereal. There was no alternate meal prepared. Interview on 10/1/24 at 9:35 a.m. with resident 14 revealed: *This was the first time he had lived in a nursing home, and he had been there for a few months. *He stated that the food was good, but he did not get enough. *When asked if he was able to get more food if he asked for it, he stated, Sometimes. *When asked if he was offered an alternate option if he did not like what was being served, he stated No. *When asked if the staff brought him snacks between meals, he stated Sometimes. *When asked how often staff brought him snacks, he stated Maybe two to three times a day. Interview on 10/2/24 at 10:52 a.m. with registered dietician M revealed: *She was a contracted employee, and her role was to approve food menus. *She did not visit the facility. *She approved the menus the facility used, they were provided to the facility by US Foods, which was the facility's food distributor. *She stated that the facility should have been notifying her when substitutions were made, but that was not happening. *She stated the diet extensions should be used, but that was difficult when staff were not making food from the menu. Interview on 10/3/24 at 9:40 a.m. with administrator A revealed: *The kitchen had recently had a difficult time with adequate staff due to COVID-19 and staff turnover. *She acknowledged that substitutions were made regularly, and this was due to food availability and resident preference. *She stated that substitutions were allowed to be done but needed to be documented as to why they were being done and the dietician needed to be made aware of the substitution menus. *It was her expectation that serving sizes would be consistent by using appropriate serving utensils. *She stated that the facility planned to work with a new company that would be able to accommodate the resident's dietary needs as well as cultural food preferences. Review of the provider's April 2019 Frequency of Meals policy revealed: *Policy Statement: Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests and the plan of care.

Based on observation, interview, record review, and policy review, the provider failed to provide the therapeutic diet prescribed by a physician for 16 of 21 (2,3,4,5,7,8,9,11,12,13,14,16,17,18,19,21) residents. Findings include: 1. Observation on 9/30/24 at 3:40 p.m. revealed: * Spaghetti had been served for the lunch meal instead of the approved scheduled menu item of Asian barbecue turkey. *There was no indication on the kitchen menu that the substitution was approved by the dietician or documentation that the substitution was made. *All residents received the same meal with no differentiation between their individually prescribed diets (regular, heart healthy, renal, consistent carbohydrate, and no added salt diets). 2. Observation on 9/30/24 at 4:45 p.m. revealed: *A ham salad sandwich on a slider-sized roll was served for the evening meal instead of spinach and cheese quiche that was listed on the approved scheduled menu. *There was no indication on the kitchen menu that the substitution was approved by the dietician or documented that the substitution was made. *All residents received the same meal with no differentiation between prescribed diets. 3. Observation on 10/1/24 at 11:40 a.m. revealed: *Taco burgers and chicken noodle soup with potato wedges were served for lunch instead of the approved scheduled menu item of ham steak with honey mustard sauce, twice baked sweet potato, sauteed Brussel sprouts, dinner roll/margarine, and pineapple with toasted coconut. *There was no indication on the kitchen menu that the substitution was approved by the dietician or documentation that the substitution was made. *All residents received the same meal with no differentiation between their prescribed diets. 4. Interview on 10/1/24 at 8:35 with dietary manager E revealed: *She stated that the kitchen made substitutions due to the lack of availability of the menu items. *She stated that she did not know what some of the items on the menu were. *She stated that she had not been documenting when and what substitutions had been made. *She stated that she made taco burgers every Tuesday because the residents liked them. *When asked if the substitutions had been approved by the dietician, she stated that they had not been. *When asked if an alternate menu option was available, she stated that if a resident doesn't like what is being served, they can have soup or cereal. 5. Interview by phone on 10/2/24 at 10:52 a.m. with registered dietician M revealed: *Her involvement with the facility is to review and approve the food menus for the facility. *She stated, They should be notifying me of the substitutions, but they are not. *She stated that she had previously voiced concerns about kitchen staff not following the menu. *She stated that she had previously asked for the menu substitution log but did not receive accurate substitutions menus. 6. Interview on 10/3/24 at 8:40 am with administrator A revealed: *She was aware that ordered menus were not being followed. *She stated there were challenges to following the menu due to residents not wanting to follow their prescribed diet. *She stated that there were times when elderly protection would complain on behalf of the resident and that was part of the reason that diets were not being followed. *There was no written documentation that residents refused to follow their prescribed diets. *She agreed that diets ordered by a physician should be followed but stated many of the residents would not follow their prescribed diet. 7. Record review on 10/2/24 of the provider's dietary orders revealed: *Residents 2,3,4,5,7,8,9,11,12,13,14,16,17,18,19, and 21 did not have specific dietary orders addressed. -Eight residents were ordered a consistent carbohydrate diet. -Five residents were ordered a heart healthy diet. -Six residents were ordered a no added salt diet. -Two residents were ordered a renal diet. 8. Review of the provider's April 2019 Frequency of Meals policy revealed: *Policy Statement: Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests and the plan of care. 9. Policy review of the provider's October 2017 Foods Brought by Family/Visitor policy revealed: *Policy Interpretation and Implementation, line 13, When meals or snacks are provided by family/visitors, the nurse will inform the dietician of these substitutions.

Based on South Dakota Department of Health (SD DOH) facility reported incidents (FRI) review, interview, and policy review, the provider failed to provide timely and thorough notification to SD DOH for two of two sample residents (2 and 6) who required evaluation at the emergency room , after sustaining an injury during a transfer (2), and after an unwitnessed fall (6). Findings include: 1. Review of the SD DOH FRI submitted on 3/01/24 at 9:30 p.m. revealed: *On 2/28/24 at 10:00 a.m. resident 2 reported she had heard a pop while staff transferred her from the toilet to her wheelchair. *She stated that her right knee was hurting. *No swelling or open sores noted to her R [right] knee. *The final report submitted on 3/4/24 stated: -Neither staff member heard anything, but they did report it to their nurse . -The nurse noted no redness or swelling at this time. *There was no indication that resident 2 had been sent to the emergency room for evaluation in the provider's FRI report. *There was no indication that resident 2 sustained a proximal right tibial fracture. *The assessment of pain and swelling did not match the progress notes (PN) in the residents' electronic medical record (EMR). Review of resident 2's EMR revealed: *On 2/28/24 at 10:00 a.m. there was no nurse progress note (PN) that indicated resident 2 had reported she had heard a pop while being transferred from the toilet to her wheelchair. *On 2/28/24 at 11:25 p.m. a PN indicated [Resident 2] Can't sleep. Right knee still hurts. -This was the first PN after the incident that mentioned her right knee. *On 2/28/24 at 11:29 p.m. a PN indicated Right knee swollen and was elevated on a pillow from day shift. Muscle rub applied to both knees. This writer tried to elevate HOB [head of bed] to give resident her meds. Resident cried out in pain with tears noted. Resident was reassured that knee is just stiff and joint inflammation is what's going on here. Resident was reminded that she hasn't walked for awhile. Resident also received ice pack to right knee. *On 2/28/24 at 11:59 p.m. a PN indicated CNA [certified nursing assistant] stated that resident also cries out in pain when turning over to have brief [incontinence product] changed. *On 2/29/24 at 4:07 p.m. a PN indicated This writer was not able to measure wound, C/O [complains of] knee pain and wasn't able to have leg moved, [telehealth provider] was contacted in reguards to knee pain. *On 3/1/24 at 9:34 a.m. a PN indicated knee pain rated a consistent 8. Pts [patient's] right knee is swollen to about double the size of her other knee, and it is discolored. -This information was omitted from the SD DOH FRI initial and final reports. *On 3/1/24 at 10:04 a.m. a PN indicated resident 2 had been transferred to the emergency room for evaluation of her right knee pain. -This information was omitted from the SD DOH FRI final report that was submitted on 3/4/24. *On 3/1/24 at 5:05 p.m. a PN indicated Pt was in the hospital today. *On 3/1/24 at 6:03 p.m. a telehealth provider note indicated Phone call to facility to speak with nurse. Fx [fracture] of tibia on the right side. She is back in LTC [long-term care] facility. *On 3/1/24 at 7:39 p.m. a PN indicated f/u [follow up] from [telehealth]. Gave them report of what happened at [hospital] with the Tibia break. -This information was omitted from the SD DOH FRI final report submitted on 3/4/24. *There was no PN that indicated the time that resident 2 returned to the facility. 2. Interview on 10/1/24 at 9:15 a.m. with resident 6 revealed she: *Had fallen about a month ago. *Stated she went for a scan but nothing was broken. *Reported she still had some pain. Review of the SD DOH FRI submitted on 9/16/24 at 2:15 p.m. revealed: *On 9/14/24 at 3:30 p.m. resident 6 was found sitting on the floor on her bottom with her feet stretched out in front of her. *Pain was a 2 on pain scale 0-10. *Resident 2 had stated, The invisible man pushed me down. *A telehealth visit had been completed. *The final report due 9/21/24 had not been submitted to SD DOH. *There was no indication that resident 6 had been sent to the emergency room for evaluation. Review of resident 6's EMR revealed: *On 9/14/24 at 3:30 p.m. there was no nurse PN that indicated resident 6 had fallen. *On 9/14/24 at 5:32 p.m. a PN indicated resident 6 stated, When are you going to send me to the doctor for mt [my] brittle bones? My bone on my bottom hurts. *On 9/15/24 at 2:45 a.m. a PN indicated follow up unwitnessed fall from 9/14/24 day shift. *On 9/16/24 at 1:20 p.m. a PN indicated resident 6's family wanted resident 6 to be seen for an x-ray. She is complaining of left side abdominal pain Ambulance here at 12:45 to transport resident to the ER [emergency room ]. -This information was omitted from the SD DOH FRI initial report that was submitted on 9/16/24 at 2:15 p.m. Interview on 10/2/24 at 12:12 p.m. with director of nursing (DON) B revealed: *She had not reported resident 2's transfer to the emergency room or injury because: -We didn't have the information at that time. -[The resident's primary care physician] didn't think it was a fracture. *She was aware of the SD DOH FRI reporting guidelines. *She had fallen behind in reporting incidents to SD DOH. *She confirmed that the initial report for resident 2 had not been completed on time. *She had not reported resident 6's transfer to the emergency room or injury because: -Her family wanted her to be seen. -She always wants to go to the emergency room . She was fine. *She confirmed that the final report for resident 6 had not been completed on time. Review of the provider's 10/2/24 Reporting of injuries of Unknown Source and Reasonable Suspicion of a crime education packet revealed: *Review with all IDT [interdisciplinary team] team members and those designated to report to Department of Health Complaint office. *Copy of reporting guidelines given to each team member on this date. *IMMEDIATELY notify the Administrator of the Event, the 2 HOUR clock starts. *REPORT the reasonable suspicion not later than 2 HOURS after forming the suspicion. REPORT to: SD DOH COMPLAINT Coordinator . *CONDUCT a thorough internal investigation and Send in findings report within 5 working days. *DON B had signed that she was provided the above information.