Every finding on record at Monument Health Sturgis Care Center

Based on observation, interview, and policy review, the provider failed to ensure the staff followed infection prevention and control practices regarding:*Hand hygiene (handwashing) and glove use by one of one registered nurse (RN) (E) during resident blood sugar level testing (measuring the amount of sugar in the blood using a glucometer or a blood glucose meter) for one of one sampled resident (29), and by one of two certified medication aides (CMA) (F) during medication administration for one of three sampled residents (24).*Hand hygiene and no gown use by one of one RN (E) during wound care for one of one sampled resident (13). Findings include:1. Observation on 3/17/26 at 8:10 a.m. of RN E revealed with her gloved hands, RN E used the computer keyboard and mouse to review resident 29's medication administration record (MAR), then opened the medication cart to retrieve a glucometer, glucose test strip, packaged alcohol pads, and a lancet. RN E closed the medication cart and the computer screen, and walked into resident 29's room. With those same gloved hands, she inserted the test strip into the glucometer, wiped resident 29's finger with an alcohol pad, pricked his finger with the lancet, applied a drop of blood from the resident's finger to the test strip, wiped the finger again with another alcohol pad, and waited for the blood sugar level reading. RN E exited the resident's room and returned to the medication cart. She removed and discarded her gloves, performed hand hygiene, then disinfected the glucometer before placing it back inside the medication cart. 2. Interview on 3/17/26 at 12:10 p.m. with RN E regarding the above observation revealed she should have removed and discarded her gloves, performed hand hygiene, and put on a pair of clean gloves before she checked resident 29's blood sugar level to mitigate the risk of cross-contamination. 3. Interview on 3/19/26 at 9:38 a.m. with director of nursing (DON) B regarding infection control practices related to checking the resident's blood sugar levels revealed RN E should have performed hand hygiene and put on a pair of clean gloves before checking resident 29's blood sugar. 4. Review of the provider's undated Glucometer Competency Checklist revealed a staff member Understands the need for Personal Protective Equipment (PPE) and performs hand hygiene before performing the blood sugar check. 5. Observation on 3/18/26 at 8:35 a.m. of CMA F revealed she performed hand hygiene before preparing resident 24's medications for administration. CMA F had clear-colored medical tape around the top of her fourth finger on her left hand and the third finger on her right hand. Using her bare hands with those two taped fingers, she touched individual pills when she pushed them out of ten medication blister packs into the medication cup. CMA F periodically applied an alcohol-based hand sanitizer (ABHS) while she prepared resident 24's medications for administration. 6. Observation and interview on 3/18/26 at 9:00 a.m. after CMA F administered resident 24's medications revealed CMA F stated there was no medical reason for why she had taped her fingers. She removed the medical tape from her fingers, acknowledged that the tape was discolored and unclean, and that she had touched some of the medications she had administered to resident 24 with those taped fingers. 7. Interview on 3/19/26 at 9:40 a.m. with DON B regarding the above medication administration observation revealed that resident 24's medications were expected to be pushed out of their blister packs directly into the medication cup, preventing the need to physically touch medications. The medical tape was an uncleanable surface (a material that cannot be sanitized or cleaned). The tape should not have been worn for non-medical reasons. If the tape was necessary, glove use was expected to prevent the potential for cross-contamination occurring. 8. Observation on 3/18/26 at 11:05 a.m. with RN E in resident 13's room revealed RN E performed hand hygiene, put on a pair gloves, and prepared clean supplies to perform the resident's wound care. RN E removed the unclean wound dressing from resident 13's gluteal fold and discarded that dressing in the trash can. RN E removed her gloves and discarded them in the trash can, performed hand hygiene and put on a new pair of gloves. She then used the cleaning supplies to clean resident 13's open wound. After cleaning that open wound, RN E picked up a piece of hydrogel dressing (a specialized dressing that maintains a moist healing environment) from the clean supplies and placed that hydrogel dressing to the wound using a cotton-tipped applicator. RN E covered that dressing with a foam dressing with adhesive dressing to keep the hydrogel in place. She discarded the unclean wound supplies in the trash can, removed her gloves, discarded them in the trash can, and then performed hand hygiene. 9. Interview immediately after the above dressing change observation with RN E revealed she acknowledged that the gloves she was wearing were considered dirty after directly touching resident 13's open wound. RN E acknowledged that she did not wear a gown while performing the resident's wound care. She was aware of the sign for enhanced barrier precautions hanging on the wall outside of resident 13's room that instructed the staff to wear a gown and gloves while performing wound care. 10. Review of resident 13's electronic medical record (EMR) revealed that nursing staff documented a Stage II pressure injury to her left intergluteal cleft (groove between the buttocks) on 1/15/26 that measured 0.4x0.3x0.2cm (centimeters). She was placed on an air mattress, a chair cushion, and a physician's order was documented on how the staff were expected to treat that wound. 11. Interview on 3/19/26 at 10:59 a.m. with DON/infection preventionist B revealed she expected the staff to perform hand hygiene after cleaning a resident's wound and before putting on new pair of gloves. She also expected the staff to follow instructions on the enhanced barrier precautions sign, which included the staff were to wear a gown when performing high-contact care such as wound care. 12. Review of the provider's enhanced barrier precautions sign revealed that there were three sections to the sign. Under the everyone must section of the sign, everyone was expected to clean their hands, including before entering and when leaving the room. Under the providers and staff must also section of the sign, they were expected to wear gloves and a gown following high-contact resident care activities. There was a list under that section of the sign that included wound care: any skin opening requiring a dressing. 13. Review of the provider's 4/2024 hand hygiene policy revealed staff were expected to perform hand hygiene after contact with body fluid or excretions, mucous membranes, non-intact skin, and wound dressings and before preparing or handling medications.

Based on observation, record review, and interview, and policy review, the provider failed to follow professional standards regarding one of one registered nurse (RN) (E) who provided a Trelegy Ellipta (a medication to improve lung function) inhaler (a portable device for administering a medication that is breathed into the lungs) to one of one sampled resident (43) who did not have a physician's order or a medication self administration assessment completed for the inhaler and was observed self administering the medication. Findings include: 1. Observation and record review on 3/18/26 at 9:00 a.m. of RN E preparing resident 43's Trelegy Ellipta inhaler for administration revealed she compared the prescription label on the inhaler box to the physician's order in the resident's medication administration record (MAR). The instructions for use of that inhaler indicated: 1 puff, inhale orally one time a day .RN E cleaned her hands with an alcohol-based hand sanitizer, brought the inhaler into the resident's room, and handed the inhaler to resident 43. She self-administered one puff from the inhaler. The resident then swished water into her mouth and spit it out in a basin before handing the inhaler back to RN E to return to the medication cart.2. Review of resident 43's electronic medical record (EMR) revealed a medication self-administration assessment completed by director of nursing (DON) B on 3/6/26, which assessed resident 43's ability to safely self-administer her nebulizer (a device that converts liquid medication into an inhalable mist) treatment. The resident's ability to safely self-administer her inhaler was not included in that assessment.3. Interview on 3/18/26 at 1:00 p.m. with RN E revealed a physician's order was needed before a resident could self-administer a medication. RN E confirmed resident 43 had no physician's order indicating she was able to self-administer her inhaler. RN E agreed the resident should not have been handed her inhaler to self-administer.4. Interview on 3/19/26 at 9:51 a.m. with DON B revealed she did not evaluate resident 43's ability to self-administer her inhaler because she did not know the resident wanted to self-administer that medication. All residents requesting to self-administer a medication were expected to be assessed for and have a physician's order that supported their ability to safely self-administer that medication. She confirmed resident 43 was not assessed and did not have a physician's order to self-administer her inhaler.5. Review of the provider's March 2026 revised Medication: Self Administration policy revealed: B. the patient [resident] or patient's [resident's] designee for self administration must be deemed competent by the provider to perform self administration and that C. Self administration of any medication requires a provider's order for that specific medication.

Based on observation, record review, interview, competency checklist review, the provider failed to follow professional standards regarding one of one certified medication aide (CMA) (F) who administered the wrong dose of medication to one of one sampled resident (24) according to their physician's order. Findings include: 1. Observation and record review on 3/18/26 at 8:35 a.m. of CMA F preparing resident 24's potassium chloride ER medication for administration revealed she compared the label on the medication's blister pack (a card with medications in individual plastic bubbles) to the physician's order listed in the resident's medication administration record (MAR) for any discrepancies. The label and MAR order matched. She then pushed one potassium chloride ER pill out of the blister pack into a medication cup. CMA F administered all resident 24's medications that she prepared. After resident 24 swallowed those medications, CMA F returned to the medication cart, opened the resident's MAR, and documented that the medication administration was completed. 2. Interview and record review on 3/18/26 at 9:00 a.m. with CMA F regarding the above medication administration revealed she confirmed she administered one potassium chloride ER pill to resident 24. She then re-read that 10/28/25 medication's physician's order which instructed to: give 2 tablet[s] by mouth one time a day . CMA F confirmed she did not administer resident 24's potassium chloride ER medication as ordered. 3. Interview on 3/19/2026 at 9:48 a.m. with director of nursing (DON) B regarding the above medication administration observation revealed that CMA F failed to administer the correct dose of potassium chloride ER medication to resident 24.Review of the provider's April 2024 Medication Administration Clinical Skills4. Checklist revealed that after certified and licensed nursing staff selected the medication to administer to a resident, they were expected to Complete the 'Rights' of medication administration including right drug, dose, route, time, and patient [resident].

Based on observation, interview, and policy review, the provider failed to ensure resident insulin pens were labeled and discarded when they expired for two of two sampled residents' (30 and 39) whose insulin pen labels were unable to be read by the staff, and one of one sampled resident (39) who received expired insulin. Findings include:1. Observation, interview, and record review on [DATE] at 9:55 a.m. with registered nurse (RN) E revealed that inside the [NAME] Unit medication cart, a Lispro insulin pen was stored in the manufacturer's packaging box. The pharmacy label on that insulin pen was smeared, and only resident 30's first name was legible.RN E indicated it was not her usual practice to compare the insulin pen's label to the resident's medication administration record (MAR) order for any discrepancy before she administered that insulin. RN E would only refer to the insulin pen's label to verify that it belonged to the resident to whom she was administering that insulin. Continued observation of the Lispro insulin pen box with RN E revealed that the open date (the date the insulin was first opened and used) written on the insulin pen box was [DATE], and the expiration date of [DATE] was written on that box.Review of resident 30's [DATE] MAR and continued interview with RN E revealed she confirmed resident 30's Lispro insulin pen was expired. The insulin pen was to be removed from the medication cart and discarded on [DATE]. Between [DATE] and [DATE], it was documented in resident 30's MAR that he was administered insulin from that expired Lispro insulin pen five times.2. Observation and interview on [DATE] at 12:15 p.m. with RN G revealed that in the [NAME] Unit medication cart, there was a Lantus insulin pen. The pharmacy label on that pen was illegible except for resident 39's first name. RN G stated the nursing staff were expected to compare the pharmacy label on the Lantus pen to the resident's MAR order and reconcile any discrepancies between the two before that insulin was administered. RN G confirmed that expectation could not be followed because the label on that insulin pen was illegible. 3. Interview on [DATE] at 10:02 a.m. with director of nursing (DON) B regarding medication storage and labeling revealed that staff administering resident medications were expected to review medication packaging and labels for expired medication before that medication was administered.Review of the provider's revised [DATE] Medication Labels policy revealed: 7. Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels are returned to the issuing pharmacy for relabeling or destroyed in accordance with facility medication policy.

Based on observation, record review, interview, and policy review, the provider failed to ensure one of one cognitively impaired sampled resident's (2) bruises of unknown origin had been thoroughly investigated to: *Identify their root cause. *Develop interventions to prevent or decrease the likelihood of them recurring. *Rule out potential abuse or neglect. Findings include: 1. Observations on 6/10/25 at 8:30 a.m. and again at 9:30 a.m. of resident 2 revealed: *She sat in her wheelchair at a dining room table. She was assisted by staff to eat her breakfast. *A sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) was used to transfer her from the bathroom to a recliner in her room. -Staff had provided her basic instructions like put your hands here along with physical assistance to have the resident hold the handles of the lift while she was brought to a standing position. *The resident was able to answer simple yes and no questions, but she initiated no verbal interactions. Review of resident 2's electronic medical record (EMR) revealed: *Her admission date was 4/16/24. *Her diagnoses included diabetes, dementia (a group of symptoms affecting memory, thinking, and social abilities), heart failure, and depression. *Her 4/18/25 Brief Interview for Mental Status (BIMS) assessment score was five, which indicated she had severe cognitive impairment. *She required assistance from staff to complete all her activities of daily living. Review of resident 2's 4/30/25 through 5/28/25 weekly skin assessments revealed: *On 5/7/25: Skin injuries not found on the previous week's assessment had included: fading bruise to right inner knee, fading bruise to right LFA [lower forearm] and fading bruise right upper arm. *On 5/14/25: Skin injuries not found on the previous week's assessment had included:Discoloration areas both arms-bruising above et [and] inside R/L [right and left] knee/front L thigh/upper outer L thigh . *On 5/21/25: Discoloration areas both arms-bruising above and inside R & L knee, front L thigh left hand, upper outer L thigh . *On 5/28/25: .has large dark purple bruises to LFA and RFA. -Purple-colored bruises were indicative of an injury that had occurred within the past one to two days. Those skin injuries would not have been found on the previous week's assessment. *On 6/4/25: Resident has large bruises to RFA [right forearm] and LFA [left forearm] . *The above skin assessments had: -No measurements of the resident's documented bruises. -Not defined what a discolored or faded bruise was. -Not indicated a cause or potential cause for the newly identified bruises. -Not indicated what was done to prevent additional bruises from recurring. Review of resident 2's care plan revealed: *She had the potential for pressure ulcer (injury to skin and underlying tissue from prolonged pressure) development related to incontinence, her history of a pressure ulcer that was present at the time of her admission to the facility, and a history of skin breakdown on her toes. *Her revised 5/1/25 skin interventions had included documenting weekly and as-needed skin checks completed by a nurse. -There was no indication she had a history of bruising or that she was at risk for frequent bruising. Interview on 6/10/25 at 2:05 p.m. with long term care (LTC) supervisor B regarding resident 2's bruises of unknown origin and the above weekly skin assessments revealed: *She thought resident 2 had bruised more easily because she was taking a blood thinning medication. *She had re-educated certified nurse aide (CNA) D recently for improperly transferring resident 2. *Nursing staff had not completed the above weekly skin assessments correctly. Nurses were expected to have: -Used the body outlines on the assessment to identify the places on the resident's body where there were skin injuries. -Measured each documented skin injury, described the color of the injury, and identified the known or possible cause of the skin injury and document that information in the resident's EMR. *Incidence/Variance reports were expected to have been completed by the nurse for any bruises of unknown origin that were identified during the resident's weekly skin assessments, but that had not occurred. *Completing an Incidence/Variance report would have: -Triggered an investigation to determine the root cause of resident 2's bruises. -Helped staff develop a plan for mitigating or preventing future bruises from recurring. -Identified if the bruises of unknown origin were caused by possible abuse or neglect. Incidence/Variance reports were requested from LTC supervisor B for resident 2's bruises of unknown origin documented on her 5/7/25, 5/14/25, and 5/28/25 skin assessments. LTC supervisor B stated no Incidence/Variance reports had been completed. Telephone interview on 6/10/25 at 3:50 p.m. with director of nursing (DON) A revealed she confirmed the expectations for the thorough completion of weekly resident skin assessments and the procedure for completing an Incidence/Variance report related to resident 2's bruises of unknown origin was not followed. Review of the provider's revised April 2025 Resident Incidence/Variance Reports policy revealed: *The types of variances that should be documented on that report had included bruises of unknown origin. *3. c. The nurse initiating the investigation must complete the fall/abuse investigation report and turn into the Director of Nursing or designee. *8. The environment, cause/effect/prevention of events are reviewed and assessed. Alterations to the environment and/or plan of care implemented and adjusted as needed to decrease the risk of another event.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to implement a fall prevention intervention to have a call light placed within the resident's reach to reduce the risk of falling for one of one sampled resident (1) who fell. 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 6/6/25 submitted SD DOH FRI initial report regarding resident 1 revealed: *On 6/6/25, he was heard by staff calling out Help me from inside his room. -The resident was found on the floor by staff. He had stood himself up from his recliner and fallen as he reached for his call light. *A physical assessment of the resident was completed by a nurse. The resident's power of attorney and a physician were notified of his fall. -He was evaluated in the attached emergency room and he returned to the nursing home later that same evening. Observation on 6/10/25 at 8:30 a.m. in resident 1's room revealed: *He was asleep in his bed. -His call light was attached to the inside of the raised quarter side rail on the exit side of his bed, and was within his reach. 2. Observation on 6/10/25 at 9:30 a.m. of certified nurse aide (CNA) D and CNA E in resident 2's room revealed they: *Transferred the resident from her bed to her recliner. -Ensured the resident's call light was within her reach before they exited the room. 3. Observation on 6/10/25 at 10:00 a.m. of CNA D and CNA E in resident 3's room revealed they: *Transferred the resident from her wheelchair to her bed. -Ensured the resident's call light was within her reach before they exited the room. 4. Observation and interview on 6/10/25 at noon with long term care (LTC) supervisor B in resident 1's room revealed: *The resident was asleep in his bed. His call light was within his reach. *His recliner sat across from the exit side of his bed. *His call light system was attached to the wall between the bed and the recliner. -The call cord split into two separate call lights. One was attached to the side rail on his bed and a second call light would be accessible to the resident when he would sit in his recliner. *The provider's investigation of resident 1's 6/6/25 fall had concluded CNA F failed to ensure the resident's call light was within his reach after he was positioned in his recliner earlier that evening. -LTC supervisor B stated that failure was identified as the root cause of resident 1's fall. *He made his needs known by using his call light and by calling out for staff assistance and not using his light. Review of CNA F's personnel file revealed: *Her hire date was 5/27/25. *She had been a CNA since 6/3/19 and her CNA certification was current. *Her orientation checklist indicated on 5/27/25 that she had been educated regarding the provider's Fall policy. *She had completed her Safety and Quality training on 5/28/25. Telephone interview on 6/10/25 at 3:35 p.m. with director of nursing (DON) A revealed: *CNA F was counseled regarding fall prevention expectations on 6/6/25 by registered nurse C after resident 1 had fallen. *A detailed corrective fall prevention action plan would be identified in the provider's SD DOH FRI final report. The provider's implemented actions to ensure the deficient practice does not recur was confirmed onsite on 6/10/25 after observations and interviews revealed the facility had followed their quality assurance process and: *Counseled CNA F regarding ensuring resident call lights were accessible for them to activate. *Random observations confirmed call lights had been positioned within the resident's reach after caregivers exited residents' rooms. *There was a plan to include the following in the provider's SD DOH FRI final report: -Re-education of all staff regarding resident safety and expected fall prevention interventions. -Implementation of audits to ensure that staff were consistently positioning all resident's call lights within their reach before exiting resident rooms. -Reporting to the Quality Assurance (QA) committee the above audit findings. Based on the above information, non-compliance at F689 occurred on 6/6/25, and based on the provider's implemented corrective actions on 6/6/25 and additional corrective action plans, for the deficient practice confirmed on 6/10/25, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure prescribed pain medication was acquired and administered in a timely manner for one of one resident (1) who had pain. *Maintain records to account for controlled (medications with risk for abuse and addiction) medications according to the provider's policy. *Ensure proper documentation and destruction of medications according to the provider's policy. Findings include: 1. Review of the provider's 2/5/25 SD DOH FRI regarding resident 1 revealed: *On 1/31/25 two tablets of oxycodone (a controlled pain medication) were found by registered nurse (RN) B in an unoccupied room. *On 2/3/25 RN B notified director of nursing (DON) A that resident 1's as needed medication card of oxycodone could not be located. *On 2/5/25 DON A confirmed resident 1's card of oxycodone and that medications' controlled medication count sheet was not accounted for. *An audit of the controlled medication count sheets was completed and identified two additional controlled medication sheets, in the past year that were unable to be located. 2. Observation on 2/19/25 at 8:57 a.m. of the [NAME] hallway treatment cart revealed: *There was a book labeled controlled substance on the cart. *That book contained a form labeled Shift Audit Record and individual Controlled Drug Administration Records identified with pharmacy labels. *There were times identified beside each date on the Shift Audit Record. *The times were 0600 (6:00 a.m.) and 1800 (6:00 p.m.). *Beside each time were two columns titled Signature of Nurse Leaving Shift and Signature of Nurse Coming on Shift. *The bottom of the shift audit record indicated Signing acknowledges that you have counted the controlled medication on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug Administration Record. *The current shift audit record was started on 2/12/25. *On 2/13/25 beside 0600 there was no signature in the nurse leaving shift column. *On 2/19/25 in the 1800 area a signature was present in the nurse leaving the shift column. Interview on 2/19/25 at 9:00 a.m. with licensed practical nurse (LPN) E revealed: *She was administering medications on the [NAME] hallway. *The shifts for nurses were from 6:00 a.m. to 6:00 p.m. and 6:00 p.m. to 6:00 a.m. *The shift audit record was to be signed by the oncoming nurse and the outgoing nurse. *The signatures indicated that the controlled medication counts were correct. *She stated the nurse leaving shift signature in the 2/19/25 1800 column was her signature. *She had not counted the controlled medication with the oncoming nurse prior to signing the shift audit record. 3. Observation on 2/19/25 at 9:57 a.m. of the Berry hallway treatment cart revealed: *There was a book labeled controlled substance on the cart. *The book was organized the same way as the controlled substance book on the [NAME] hallway treatment cart. *The current shift audit record was started on 2/10/25. *On 2/19/25 in the 1800 area, a signature was present in the column for the nurse leaving the shift. *There was an oxycodone medication card for resident 1, labeled for as needed use, with a received date of 2/10/25. 4. Observation on 2/19/25 at 10:05 a.m. of the Berry hallway medication cart revealed: *A card of oxycodone 5mg (milligrams) tablets for resident 1. *Each tablet was secured into a bubble with a foil backing. *The bubble numbered 25 had a punctured foil backing and the tablet was secured in the bubble with clear tape. 5. Interview on 2/19/25 at 10:05 a.m. with unlicensed medication aide (UMA) D revealed: *Controlled medications that were scheduled to be administered were stored in the medication carts in the [NAME] and Berry halls. *Controlled medications that were to be administered as needed were stored in the treatment carts in the [NAME] and Berry halls. *The nurses had the keys to open those treatment carts. *The nurses administered the as needed controlled medications. *At 8:00 a.m. that morning (2/19/25) she had mistakenly punched out resident 1's oxycodone from the card. *She had placed the oxycodone tablet back into the card and secured it in the bubble with tape. *She had not notified anyone that she had mistakenly punched out and secured the oxycodone tablet in the card with tape. 6. Observation on 2/19/25 at 10:05 a.m. of the [NAME] hallway medication cart revealed: *A controlled substance book that was organized the same as the ones on the treatment carts. *The times beside the dates on the Shift Audit Record were titled 6-2 (6:00 a.m. to 2:00 p.m.), 2-10 (2:00 p.m. to 10:00 p.m.), and 10-6 (10:00 p.m. to 6:00 a.m.). *The current shift audit record was started on 2/12/25. *On 2/13/25 beside the 6-2 time there was no signature in the nurse leaving the shift column. *On 2/19/25 in the 2-10 area, a signature was present in the nurse leaving the shift column. 7. Observation on 2/19/25 at 9:30 a.m. of the medication room revealed: *There was a Stericycle container and a lock box on the wall. *There was a [NAME] (a container for hazardous waste) on the floor. *The Medication Destruction Log was on the counter. 8. Interview on 2/19/25 at 12:50 p.m. with DON A revealed: *She had been checking the controlled medication cards since Resident 1's oxycodone card was located but she did not have a formal audit in place. *The consultant pharmacist had been to the facility on [DATE] and completed a random controlled medication audit with all controlled medications accounted for. 9. Interview on 2/19/25 at 3:25 p.m. with resident 1 revealed: *She had pain related to having had a back surgery and arthritis. *Her pain was controlled by the pills she was given. *Her pain was most often in her back and down her left leg. *If she had pain, she would ask for a pain pill. *She stated that she was unsure if she could receive an as needed pain medication at that time because she was told the provider was waiting for the doctor. 10. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 12/27/24 Brief Interview of Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact. *Her diagnoses included: Chronic pain, Rheumatoid arthritis, osteoarthritis, contracture left hand, pain in left knee, depressive disorder, anxiety, and pain in her right shoulder. *Her physician orders included: -Acetaminophen 650 mg [milligrams] 3x [three times] day for chronic pain - 0000 [midnight], 0800 [8:00 a.m.], and 1600 [4:00 p.m.] - don't [do not] change times NP [nurse practitioner] would like these staggered with other scheduled pain meds. -Oxycodone HCI 5 MG 3x day for chronic pain - do not change times this is per the NP order- 0600 [6:00 a.m.] 1200 [noon], and 1800 [6:00 p.m.]. -Oxycodone HCI 5 MG every 24 hours as needed for pain related to rheumatoid arthritis. Review of resident 1's 2/19/25 care plan revealed: *There was a focus area related to pain management with a goal to not have interruption in normal activities due to pain. *Identified interventions for that goal included: -Anticipate my need for pain relief and respond immediately to any complaint of pain. -I am able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain. Review of resident 1's nurse progress notes revealed: *On 2/2/25 at 5:27 a.m. a late note was entered by LPN F -The effective date and time of that late note were indicated as 2/1/25 at 10:25 p.m. -The progress note indicated, Resident yelling out and crying. C/O [complaint of] back pain 10/10 [on a zero to ten pain scale]. Midnight Tylenol given now as no PRN [as needed] oxy [oxycodone] available. 11. Interview on 2/19/25 at 3:44 p.m. with DON A regarding resident 1's pain management revealed: *She had not been made aware resident 1's as needed oxycodone was not available on 2/1/25. *The nurse could have called the on-call provider in the hospital to obtain a prescription. *With the prescription, the nurse could have obtained a code to remove an emergency dose of that prescribed pain medication from the automated medication dispensing cabinet to administer to resident 1. *She was not aware resident 1's replacement as needed oxycodone medication card had not arrived until 2/10/25. 12. Review of the controlled medications shift audit records from 10/1/24 through 2/9/25 revealed: *The shift audit records were labeled as narcotic count sheets. *The times beside the dates on those audit records for the Berry and [NAME] medication carts were listed as 0600 (6:00 a.m.), 1400 (2:00 p.m.), and 2200 (10:00 p.m.). The column of incoming and outgoing staff signatures referenced a Med Aide (UMA). *The times on the audit record for the Berry and [NAME] treatment carts were listed as 0600 and 1800 (6:00 p.m.). *There were no shift audit records for the Berry medication cart from 10/10/24 through 11/13/24. *There were no signatures : -On 11/28/24 at 1400 for the incoming and outgoing UMA. -On 1/11/25 at 1400 for the outgoing UMA. -On 2/3/25 at 1400 for the incoming UMA. -On 2/8/25 at 0600 for outgoing UMA. *There were no signatures on the shift audit records for the [NAME] medication cart. -On 11/6/24 at 2200 for the incoming UMA. -On 11/7/24 at 0600 for the outgoing UMA. -On 12/1/24 at 2200 for the incoming UMA. -On 12/2/24 at 0600 for the outgoing UMA. -On 12/13/24 at 1400 for the outgoing UMA. -On 12/14/24 at 2200 for the incoming UMA. -On 12/15/24 at 0600 for the outgoing UMA. -On 12/23/24 at 0600 for the incoming UMA and 1400 for the outgoing UMA. -On 12/26/24 at 2200 for the incoming UMA. -On 1/6/25 at 2200 for the incoming UMA. -On 1/7/25 at 0600 for the outgoing UMA. -On 1/17/25 at 1400 for the incoming UMA and 2200 for the outgoing UMA. -On 1/19/25 at 0600 for the incoming UMA and 1400 for the outgoing UMA. *There were no signatures on the shift audit records for the [NAME] treatment cart on 11/17/24 at 1800 for the incoming nurse. *There were no signatures on the shift audit records for the Berry treatment cart: -On 10/8/24 at 1800 for the incoming nurse. -On 10/28/24 at 1800 for the incoming nurse. -On 12/6/24 at 0600 for the incoming nurse and 1800 for the outgoing nurse. -On 12/31/24 at 0600 for the incoming nurse and 1800 for both the incoming and outgoing nurse. -On 1/1/25 at 0600 for both the incoming and outgoing nurse. -On 1/4/25 at 1800 for the incoming nurse. -On 1/5/25 at 0600 for the outgoing nurse. 13. Interview on 2/19/25 at 5:35 p.m. with DON A revealed: * She was unable to locate the shift audit records from 10/19/24 through 11/13/24. *It was her expectation that the controlled substances be counted between each shift by the outgoing and incoming UMA and nurses. *If a single medication was refused by a resident or for some other reason was not administered after it was removed from the bubble pack two nurses were to destroy the medication by putting the medication in the Stericycle (a container used to dispose of pharmaceutical waste) and document the destruction. *A medication should not be returned and secured with tape once removed from the bubble pack. *She was aware that there were signatures that were missing on the shift audit report but was not aware that the UMAs and nurses were signing the forms prior to completing the controlled medication count between shifts. *She was not aware that resident 1's as needed oxycodone had not arrived at the facility until 2/10/25. *She had reordered the as needed oxycodone replacement card on 2/5/25. *There were three methods of disposal for medications, the mailbox, the Stericycle container, and the [NAME]. *Controlled substances were not to be disposed of in the [NAME]. *When medications were destroyed two nurses documented the destruction unless the medication was a controlled substance then two nurses were to indicate the method for destruction was the mailbox and the two nurses would then sign in the column Destroyed by 2 Individuals Name/Name and the controlled substance would later be destroyed by the DON and the pharmacist. *If there was a single dose of a controlled substance that needed to be destroyed it could be placed in the mailbox or two nurses could destroy the medication in the Stericycle. *She indicated Lyrica should not have been destroyed in the [NAME]. *The [NAME] did not prevent someone from retrieving a medication that was disposed in it. *The [NAME] did not alter the texture, taste, or consistency of the medication that was disposed in it. *Medications should not be placed in the sharps container as a method for destruction. Review of the provider's 2/24 Drug Diversion Policy revealed, All controlled substances will be counted every shift and documentation signed for oncoming and off-going nurse and/or medication aid. 14. Review of the providers Medication Destruction Log revealed: *Oxycodone (a controlled pain medication) 5mg, one tablet, was wasted in a sharps container (a puncture-resistant container used to dispose of sharp instruments and needles) on 10/18 and 11/22. *Fourteen vials of Haldol (an antipsychotic medication) were wasted in a sharps container on 2/10/25. *Lyrica (a controlled pain medication) was wasted in a [NAME] on 2/16/25 and 2/18/25. *There were no prescription numbers Review of the provider's 02/2024 Security, Destruction, Return and Logging of Medications/Drugs policy revealed: *1. A Drug Destruction Log will be completed when medications are destroyed or returned to the dispensing pharmacy. *2. A separate Drug Destruction Logs must be completed for each of the following: controlled, uncontrolled, and returned medication. *3. Each resident must have their own Drug Destruction Log for the destruction of Controlled Medications and their own Drug Destruction Log for the destruction of non-controlled and schedule V unit dose drugs. *5. For controlled medications/drugs (schedule II, III, IV), an RN and Pharmacist are responsible for witnessing the drug destruction and ensuring that the following information (5a-5i) is correctly entered on the Drug Destruction Log. a. Resident's name b. Date drug destroyed c. Prescription number d. Name of drug e. Strength of the medication f. Quantity of medication destroyed g. Method of destruction h. Reason for destruction i. Signature of witness *7. Drug Destruction Logs and Drug Return Logs serve as the documentation record for destroyed or returned medications. *8. Drug Destruction Logs are kept on file in the facility in the Drug Destruction Log binder until the resident is discharged from the facility. The Drug Destruction Log is then placed in the resident's closed clinical record. 51816

Based on observation, interview, and policy review, the provider failed to ensure expired medications were removed from two of two medication carts and one of two treatment carts. Findings include: 1. Observation on 2/19/25 at 9:00 a.m. of the [NAME] hallway treatment cart revealed multiple medications that were past their expiration dates. Medications that were expired included: *Resident 2's card of 30 tabs of Hydrocodone/acetaminophen 5/325 (opioid pain reliever) on 12/24. *Resident 13's Novolog insulin pen had no date written on it to indicate the date it was opened. *Resident 5's CalProtect ointment (used to treat minor skin irritations) on 11/24. *Resident 8's Nystatin powder (used to treat fungal or yeast infections) on 1/6/25. *Resident 6's Nystatin powder on 2/7/25. *Resident 6's CalProtect ointment on 7/8/24. *Resident 7's Ketoconazole ointment (used to treat fungal infections) on 3/20/24. *Resident 10's Nystatin powder on 1/29/25. *Resident 14's Diclofenac gel (used to treat pain and swelling) on 12/26/24. *Resident 13's Tacrolimus ointment (used to treat eczema) on 12/10/24. *Resident 12's Nystatin powder on 10/17/24. *Resident 11's Ciclopirox topical solution (used to treat fungal infections) on 8/15/24. *Resident 9's Nitroglycerin tablets (used to treat chest pain caused by coronary artery disease) on 2/14/25. 2. Observation and interview on 2/19/25 at 9:57 a.m. of the Berry hallway medication cart with registered nurse (RN) C revealed: *Resident 3's Latanoprost eye drops (used to treat glaucoma) had no date written on it to indicate the date it was opened. *He stated checking expiration dates was not a task assigned to a specific nurse or shift, and they were to look at expiration dates before administering medications. *Medications should be dated when they are opened. *Not all medications were dated when opened. *Latanoprost was a medication with a shortened expiration date that needed to be dated when opened. 3. Observation on 2/19/25 at 10:24 a.m. of the [NAME] hallway medication cart revealed: *Resident 4's Latanoprost eye drops had no date written on it to indicate the date it was opened. -The pharmacy label indicated the refill had been issued on 12/5/24. 4. Interview on 2/19/25 at 4:15 p.m. with licensed practical nurse (LPN) E regarding the medications in the [NAME] hallway treatment cart revealed: *She confirmed resident 13's Novolog insulin pen had no date to indicate when it had been opened. *She confirmed the location of expiration dates was on the medication labels. 5. Interview on 2/19/25 at 5:39 p.m. with director of nursing (DON) A regarding expiration dates revealed she expected nurses and unlicensed medication aides to date a medication when it was opened. 6. Review of the provider's undated Abridged List of Medications with Shortened Expiration Dates revealed: *Latanoprost has a shortened expiration date of, 6 weeks (42 days) after opening or moving to room temp. [temperature]. *Novolog has a shortened expiration date of, 28 days after accessing insulin for first use. 7. Review of the provider's 2/25 Expiration of Medications policy revealed: All 'time-dated' medications have an expiration date printed on the container. If the manufacturer's date occurs before the expiration date based upon date of opening, the earlier of the two is to be followed.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and policy review, the provider failed to ensure one of one allegation of controlled (medication with risk for abuse and addiction)medication diversion was reported within the required time frame. Findings include: 1. Review of the provider's 2/5/25 SD DOH FRI regarding resident 1 revealed: *On 1/31/25 two tablets of oxycodone (a controlled pain medication) were found by registered nurse (RN) B in an unoccupied room. *On 2/3/25 at approximately 3:00 p.m. RN B notified director of nursing (DON) A that resident 1's as needed medication card of oxycodone could not be located. *On 2/3/25 DON A confirmed the card of oxycodone was unable to be located and initiated an internal investigation with the provider's drug diversion team. *On 2/5/25 DON A confirmed resident 1's card of oxycodone, and that medication's controlled medication count sheet was not accounted for. * On 2/5/25 at 9:24 a.m. DON A filed a SD DOH FRI and notified law enforcement. 2. Interview on 2/19/25 at 10:28 a.m. with DON A revealed: *On 1/31/25 RN B found two tablets of oxycodone in an unoccupied room. *Who the oxycodone belonged to was unable to be determined. *On 2/3/25 at 2:30 p.m. or 3:00 p.m. RN B notified DON A that she was unable to locate resident 1's card of oxycodone. *DON A notified the consultant pharmacist and the facility's drug diversion team. *On 2/4/25 DON A had been unable to locate the card of oxycodone. *On 2/5/25 DON A notified law enforcement and completed the SD DOH FRI because she had not located Resident 1's card of oxycodone. *She was able to account for all of the residents' controlled medication cards. *She audited resident 1's past controlled medication logs and determined there were three logs that were not able to be accounted for. -A medication log for a medication card that contained 30 tablets of oxycodone that was prescribed to be administered as needed from 6/3/24. -A medication log for a medication card that contained seven tablets of oxycodone from 8/3/24. -A medication log for the medication card that contained 30 tablets of oxycodone from 1/20/25. *She audited one other resident's controlled medication logs and was unable to locate one medication log for that resident. *On 2/5/25 she initiated a new procedure to account for controlled medication cards and controlled medication logs under the recommendation of the consultant pharmacist. *On 2/10/25 she emailed the facility staff education on the new procedure related to the controlled medication cards and logs. Interview on 2/19/25 at 5:35 p.m. with DON A revealed: *She was unsure when the oxycodone went missing. *She was responsible for filing the report to the SD DOH. *She did not report the missing card of oxycodone on 2/3/25 because she was not sure it was missing. 3. Review of the provider's 2/2025 Abuse Prevention/Intervention, Investigation, Complaints, Grievances & [and] Reporting policy revealed: *It is the policy of [the provider] to develop a process to receive grievances and complaints, respond timely to filings and reporting dispositions to residents as described by South Dakota Department of Health Regulations. The following definitions are provided to assist all persons in recognizing incidents of abuse and are applicable to all residents regardless of their age, disability, or ability to comprehend. -THEFT/MISAPPROPRIATION OF RESIDENT PROPERTY is defined as the pattern or deliberate misplacement, exploration, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. *The provider Will notify Department of Health (DoH) that an abuse investigation is being conducted within 48 hours of caregiver becoming aware of the alleged incident. *An initial written report of abuse and any witness statement(s) are provided to DoH within twenty-four (24) hours of the reporting of occurrence of such incident. *Should investigation reveal that a false report was made/filed, the investigation shall cease.

Based on observation, interview, and policy review the provider failed to maintain appropriate temperatures for one of one high-temperature dishwasher utilized to clean dishes used to prepare and serve resident food items according to the manufacturer's instructions. Findings included: 1. Observation and interview on 10/1/24 at 8:10 a.m. with retail manager H in the kitchen revealed: *The wash cycle temperature of the dishwasher was supposed to be between 170 and 175 degrees Fahrenheit. *The final rinse cycle temperature of the dishwasher was supposed to be between 180 and 190 degrees Fahrenheit. *The retail manager said if the temperatures of the dishwasher were below the manufacturer's recommended minimal temperature the staff were to have maintenance service the dishwasher. *The wash temperature on The Dishmachine Temperature Record September 2024 log was recorded as follows: -19 out of 90 documented temperatures were below the manufacturer's recommended minimal temperature. -No corrective actions were written down as taken when the temperatures were below the manufacturer's recommended minimal temperature. *The final rinse temperature on The Dishmachine Temperature Record September 2024 log was recorded as follows: -36 out of 90 documented temperatures were below the manufacturer's recommended minimal temperature. - No corrective actions were written down as taken when the temperatures were below the manufacturer's recommended minimal temperature. Interview on 10/1/24 at 8:35 a.m. with kitchen director C revealed: *She had called the manufacturer's service department the past year and a half, five to six times, and had serviced the dishwasher. *The staff were to have maintenance service the dishwasher when the temperatures were below the manufacturer's recommended minimal temperature. Interview on 10/1/24 at 10:32 a.m. with kitchen manager F revealed: *She had been employed with the facility since 6/11/2019. *She usually worked in the evenings. *When the dishwasher temperature was below the manufacturer's recommended minimal temperature, she had called maintenance and they would service the dishwasher that evening and then would run the dishes back through the dishwasher at the correct temperature. Interview on 10/1/24 at 10:43 a.m. with dishwasher E revealed: *He had been employed with the facility since 8/10/21. *He worked in the mornings. *When the dishwasher temperatures were below the manufacturer's recommended minimal temperature, he had called maintenance to service the dishwasher and then would run the dishes back through the dishwasher at the correct temperature. *He confirmed some of the morning temperatures on The Dishmachine Temperature Record September log were below the manufacturer's recommended minimal temperature. -He did not call maintenance to service the dishwasher. -He agreed he should have called maintenance to service the dishwasher. Interview on 10/1/24 at 11:20 a.m. with cook/back of the house manager D revealed he: *Had been employed with the facility since 1/19/2024 *Was responsible for reviewing The Dishmachine Temperature Record log each month for the correct temperatures. *Would have notified the kitchen director when the temperatures were below the manufacturer's recommended minimal temperature. *Was unaware he was supposed to write down the corrective action that was taken. Interview on 10/2/24 at 8:59 a.m. with plant operations manager G revealed: *Maintenance had changed a fuse in the dishwasher three times in the past year when the kitchen staff requested service due to low temperatures. *Maintenance had been requested once for dishwasher service during September. Interview on 10/2/24 at 11:37 a.m. with director of nursing B revealed she: *Agreed some of the temperatures on the dishwasher log were below the manufacturer's recommended minimal temperature. *Confirmed there had been no gastrointestinal illness during September. Review of the [NAME] Instructions Mode Manual revealed: *Minimum Temperatures Using High-Temperature -Wash Tank 160*F {degrees Fahrenheit} -Final Rinse 180*F {degrees Fahrenheit} Review of the providers January 2024 Dishmachine Temperatures Policy revealed: *Single-tank, conveyor, dual-temperature machine: -Wash temperate 160*F {degrees Fahrenheit} -Final rinse temperature 180-194 *F {degrees Fahrenheit} *Supervisor/Food and Nutrition Associate as assigned -High Temperature Dishmachine-record on Dishmachine Temperature Record form: *Director -Determines if reading is due to malfunctioning temperature gauge or inappropriate temperature. -Contacts sources of repairs. -Documents action taken on back of form.

Based on observation, interview, record review, and policy review, the provider failed to ensure oral hygiene was provided for three sampled residents (3, 45, and 148) who were dependent on staff for their care needs according to their personalized care plan and facility policy. Findings include: 1. Observation on 10/1/24 at 8:40 a.m. of resident 3 while sitting in a wheelchair in her room and interview with her visiting daughter revealed: *The resident was able to answer simple questions but was very hard of hearing and had poor vision. -Her daughter stated the resident had returned from the hospital yesterday (9/30/24) following a suspected heart attack last Thursday (9/26/24). -When asked if she had any concerns regarding her mother's care, the daughter stated, Her oral care could be better. Review of resident 3's electronic medical record (EMR) revealed: *She had a Brief Interview of Mental Status (BIMS) assessment score of 12, which indicated she was moderately cognitively impaired. *Her 7/4/24 care plan revealed she had her own teeth and required partial to moderate assistance from one staff member to provide her oral care upon rising and at HS (hour of sleep) or twice a day. *Review of the certified nurse aide (CNA) task documentation of her oral care provided in the last 30 days, from 9/2/24 through 10/2/24, revealed she had received oral care for 10 out of 52 opportunities (subtracting the four days she had been hospitalized ). -During that period, staff did not provide her oral care 42 times. 2. Observation and interview on 10/1/24 at 4:42 p.m. with resident 45 and his wife, who was his power of attorney (POA), revealed: *His wife was in his room while he rested in bed and agreed to be interviewed. *Her only concern regarding his care was the staff not providing oral care. -She stated, I always give him oral care when I come to visit, not sure the aides would do it. -Recently she had to clean dried food off his mustache that had been caked on. Review of resident 45's EMR revealed: *He was receiving hospice care and had a BIMS score of two, which indicated he had severe cognitive impairment. *His 7/8/24 care plan revealed he had his own teeth and required partial to moderate assistance from one staff member to provide his oral care upon rising and at HS. *Review of the CNA task documentation of his oral care provided in the last 30 days, from 9/2/24 through 10/2/24, revealed he had received oral care for 10 out of 60 opportunities with one refusal documented. -During that period, staff did not provide him oral care 49 times. 3. Observation on 10/1/24 at 4:08 p.m. of resident 148 while he slept in his bed revealed: *He was breathing with his mouth open, and he had a slimy phlegm build-up in the corners of his mouth, a white pasty build-up on his teeth along his red-rimmed gums, and his tongue had a yellowish-white fuzzy coating. -His right lower lip had several dark pink areas. *Resident 148 awoke during the surveyor's presence and nodded his head yes when asked if he was agreeable to the interview. -He was unable to speak and was given his word communication sheet that was sitting on his dresser. -He was unable to confirm if the CNAs provided him with oral care. Review of resident 148's EMR revealed: *He had a BIMS score of five, which indicated he had severe cognitive impairment. *His 7/16/24 care plan revealed he had his own teeth and required substantial to maximal assistance from one staff member to provide his oral care upon rising and at HS. He also had a chipped tooth on his right upper side. *Review of the CNA task documentation of his oral care provided in the last 30 days, from 9/2/24 through 10/2/24, revealed he had received oral care for 13 out of 60 opportunities. -During that period, staff did not provide him oral care 47 times. Interview on 10/3/24 with director of nursing/ infection preventionist (DON/IP) B regarding CNAs provision of oral care to dependent residents revealed: *Her expectation was for oral care to be offered or provided to all residents twice a day and documented. -She was not aware those cares were not being provided according to their care plans or policy. Review of the provider's 1/1/24 Oral Hygiene: Conscious Resident policy revealed: *Key procedural Points: -1. Provide dental care in the morning and at bedtime. Or as indicated by provider. -7. Examine the resident's mouth and gums at for any paleness of gums, broken or loose teeth, decaying teeth, mouth sores, and areas of discoloration. *Post-Procedure: Demonstrates proper technique for providing oral care. -3. Report any changes in patient condition to nurse. -4. Documents procedure in HER [electronic health record/EHR].

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one registered nurse (RN)(J) had prepared and administered insulin according to the physician order and provider policy for one of one sampled resident (25). Findings include: 1. Observation and treatment administration record (TAR) review on 10/3/24 at 9:27 a.m. of RN J, while he prepared insulin for resident 25, revealed: *Resident 25's TAR indicated she was to be given 10 units of Novolog insulin every morning after breakfast along with sliding scale (additional dose based on blood sugar level) Novolog if her blood glucose was greater than 150. -There was an order to Hold Novolog at breakfast if resident does not eat. If her glucose level is elevated, use sliding scale but do not give scheduled. -She had a continuous glucose monitor that was placed in her upper left arm and an order for self-administration of insulin. *RN J verified the resident had eaten her breakfast. *RN J cleansed the resident's insulin auto-injector port with an alcohol pad, applied the needle to the auto-injector, and dialed up 8 units of insulin for administration, not the ordered 10 units of insulin. -He had not primed the insulin needle with insulin before dialing up the incorrect dosage of 8 units of insulin. *This surveyor stopped RN J at the door of the resident's room and asked that he double-check the TAR for the correct dosage. -RN J checked the order, verified the correct dosage was 10 units and dialed up an additional 2 units of insulin into the pen and then returned to the resident's room. *He verified resident 25's blood glucose level to be 108 and informed the resident she would not receive any sliding scale insulin that morning. -He handed the insulin auto-injector to the resident and she self-injected the insulin correctly into her abdomen. *Following the administration of the insulin, RN J returned to the cart and documented the 10 units of insulin were administered. 2. Interview on 10/3/24 at 9:30 a.m. with RN J regarding the above insulin preparation and administration revealed: *He had been a licensed nurse for over [AGE] years, and this was his first assignment working for a temporary agency. He had been assigned to this provider for nearly three months. -He stated he had not been asked to perform an insulin administration skills audit for this provider. *He stated he was not aware auto-injector insulin pens needed to have their needles primed with insulin before dialing up the insulin dosage. -He stated, Probably a good thing to know. Didn't know that. *He verified it was not his usual practice to prime the insulin needle on auto-injector insulin pens. 3. Interview on 10/3/24 at 9:45 a.m. with director of nursing/infection preventionist (DON/IP) B regarding the above observation of RN J revealed: *RN J had been working for them as a temporary nurse since 7/8/24. *She stated she assumed travel nurses did insulin skills education with their travel agency of employment. *She had not audited her nursing staff for insulin injection skills, stating since they were licensed nurses, she would have expected them to know how to administer insulin correctly. *She had to refer to their policy to verify the correct dose of insulin that was needed to prime the auto-injector needle. -After a review of the policy, she verified the needle should have been primed with 2 units of insulin. *It was her expectation that the nursing staff would know how to prime the auto-injector needle before dialing up the insulin dose. She agreed that had not occurred. 4. Review of the temporary agency's 5/23/24 Skills Checklist on RN J revealed he had shown proficiency on a level 4 on a scale of 1-4 under the skill of insulin administration, meaning he could serve as a resource for insulin administration. The skills review had not included what items were audited under each topic of review. 5. Review of the provider's 3/2023 Injections policy revealed: *Insulin Injection -5. Prime the needle. -5. a. Turn the dose selector to select 2 units of insulin. -5. b. Hold the pen with the needle pointing up. Press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. -5. c.If no insulin drop is seen at the tip of the needle, change the needle and repeat steps 5a and 5b. -5. d. Do not administer insulin unless priming drop is visualized.

Based on observation, record review, interview, and policy review, the provider failed to ensure interventions to lessen the occurrence of urinary tract infections (UTI) were implemented for one of one resident (14) who had a UTI. Findings include: 1. Observation on 10/2/24 between 11:30 a.m. and 12:15 p.m. of resident 14 in the dining room revealed: *A plastic cup of ice water and another cup of juice were served to the resident with her meal. -She ate and drank independently. *Both cups remained mostly full at the end of the meal. -Staff provided no verbal cueing or encouragement to the resident to drink those fluids during the meal service. Review of resident 14's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. *Her diagnoses included: late onset Alzheimer's disease, hypothyroidism, depression, anxiety, and gastroesophageal reflux disorder. -A UTI diagnosis was added to her profile on 9/10/24. *Her 8/15/24 Brief Interview for Mental Status (BIMS) score was 7 which indicated her cognition was severely impaired. *Her April 2024 through September 2024 interdisciplinary progress notes revealed: -Urine analyses (UA) were ordered and the resident was started on oral antibiotics for UTIs on 8/8/24, 9/12/24, and 9/26/24. -Between April 2024 and July 2024 she had no documented UTIs. *Her 8/22/24 dietary assessment indicated her estimated daily fluid intake need was between [PHONE NUMBER] milliliters. -Between 9/4/24 and 10/2/24 her documented daily fluids consumed was less than her estimated fluid needs on 10 of those days. -A twice-daily liquid nutritional supplement (474 milliliters) was included in that fluid intake calculation. *Between 9/4/24 and 10/2/24 her daily urinary continence documentation revealed: -She was incontinent of urine 93% of the time. *Toileting assistance was documented as occurring between one and four times each day. -83% of the time there were either two or three documented times toileting assistance occurred. Interview on 9/2/24 at 4:00 p.m. with registered nurse J regarding UTI prevention interventions for resident 14 revealed certified nurse aides were expected to provide the resident with appropriate peri-care to lessen her risk for UTIs. Interview on 9/2/24 at 4:10 p.m. with certified nurse aide (CNA) O regarding UTI prevention interventions for resident 14 revealed: *Her fluid intake was documented daily but he was not aware of what her estimated daily fluid intake needs were. *CNAs were responsible for documenting on the Urinary Continence flowsheet each time the resident was assisted to use the toilet and whether or not she continent or incontinent at those times. -The resident was incontinent of bowel and bladder, not on a scheduled toileting program, and sometimes placed her hand inside of her brief after a bowel movement (BM) then smeared her BM. Interview on 10/3/24 at 8:00 a.m. with unlicensed medication aide (UMA) P regarding resident 14's fluid intake revealed: *The resident independently drank fluids. *She preferred water or juice over coffee and pop. *UMA P encouraged the resident's fluid intake by placing her nutritional supplement in a small paper cup then refilling the cup as needed. -She thought resident 14 was able to wrap her hand around the smaller-sized paper cup better than the plastic cups that were filled with water for her. -She had not tried using a cup with a handle to determine if resident 14 might handle that better than a plastic cup. Interview on 10/3/24 at 8:15 a.m. with CNA/bath aide N regarding residents' bath schedules revealed: *Resident 14 was bathed weekly on Monday. *Some residents were bathed more than one time weekly because of their preference or a medical reason. -She was not aware of any reason why resident 14 would have been bathed more than once weekly. Observation and interview on 10/3/24 at 9:20 a.m. with CNAs K and L while assisting resident 14 with toileting revealed: *The resident was transferred from her wheelchair to the sit-to-stand mechanical lift into her bathroom. *After performing hand hygiene and placing clean gloves on her hands, CNA L removed the resident's wet incontinence brief and discarded it. *The resident was lowered onto the toilet but stated I can't pee. -She was raised up from the toilet by those staff who used the lift and with those same unclean gloved hands, CNA L removed individual wipes from a container and handed them to CNA K to clean the resident's peri-area. *CNA K wiped the resident's peri-area using the wipe handed to her by CNA L. -Instead of discarding the soiled wipe after it was used, the unclean wipe was re-used to wipe the resident's peri-area again. *After a clean incontinence brief was applied and resident 14 was redressed, CNAs K and L moved her out of the bathroom with helping her perform hand hygiene. *CNA L knew she should have removed her unclean gloves, performed hand hygiene, and put on clean gloves after handling the resident's wet brief and before handing CNA L clean wipes to perform peri-care. *CNA K agreed she should have discarded each wipe after using it for peri-care rather than re-using a soiled wipe. *CNAs K and L agreed resident 14 should have been assisted with hand hygiene before she had left the bathroom. Continued observation and interview with CNA L regarding UTI prevention interventions for resident 14 revealed: *There was a lidded cup of water with a straw on the resident's nightstand. -That was placed there about 10:00 p.m. the previous night and was still full. -She had not seen the resident initiate drinking water left for her on the bedside stand. *The resident was not on a scheduled toileting program. -CNA L tried to offer and assist the resident with her toilteting after each meal. *Resident 14 was not offered water from the bedside cup by CNA L before exiting the resident's room with the resident. Interview and record review on 10/3/24 at 11:45 a.m. with director of nursing (DON)/Infection Preventionist (IP) B regarding UTI prevention interventions revealed: *Pushing fluids [encouraging residents to drink fluids throughout the day], providing proper peri-care, and changing incontinent residents in a timely manner were the primary interventions she expected staff to complete to prevent UTIs from occurring. *She agreed resident 14's daily fluid intake expectations were not consistently met based on her review of the fluid intake documentation referred to above. -The resident's daily fluid intakes were not monitored and there was no documentation to support what other alternatives had been attempted to increase her fluid intake. *The manner in which peri-care was provided by CNAs K and L put resident 14 at greater risk for UTI development. *Neither a scheduled toileting program nor a scheduled rounding program had been tried as an intervention to ensure the amount of time the resident was incontinent was as short as possible. *Increasing the frequency of the resident's bathing schedule had not been tried. *She tracked UTI frequency for all residents and reported that information to the Quality Assurance and Process Improvement (QAPI) team. Her focus was ensuring antibiotics prescribed for UTIs were appropriate based on urine cultures. Review of the June 2024 through August 2024 UTI Data Review Reports shared with the QAPI team revealed: *The State average for UTI occurrence was 3.3% of the resident population and the national average was 2.1% *The provider's average UTI occurrences were: -In June 2024, 4.8%. -In July 2024, 8.1%. -In August 2024, 12.2%. *Their goal was to be equal to or below the national average. *Their action plan to reach that goal was Continuance of monitoring residents and educating staff and families. A UTI Prevention policy was requested of DON/IP B on 10/3/24 at 11:10 a.m. An Infection Control Program policy revised on March 2020 was provided and revealed: *B. Responsibilities of the Director of Nursing in relationship to the infection control program included participation in the assessment or analysis of the success/failure of key processes within the infection prevention/control program. *D. Surveillance priorities: -1. Symptomatic Urinary Tract Infections.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for: *Hand hygiene and glove use by three of four certified nurse aides (CNAs) (I, K, and L) during peri-care for three of three observed residents (11, 14, and 28).*Incontinence care provided by three of three CNAs (I, K, and L) for three of three observed residents (11, 14, and 28). *Hand hygiene assistance for one of one observed resident (14) with hand hygiene following bathroom use. Findings include: 1. Observation and interview on 10/3/24 at 9:20 a.m. with CNAs K and L while assisting resident 14 with toileting revealed: *The resident was transferred from her wheelchair to the sit-to-stand mechanical lift into her bathroom. *After performing hand hygiene and placing clean gloves on her hands, CNA L removed the resident's wet incontinence brief and discarded it. *The resident was lowered onto the toilet but stated I can't pee. -She was raised up from the toilet by those staff who used the lift and with those same unclean gloved hands, CNA L removed individual wipes from a container and handed them to CNA K to clean the resident's peri-area. *CNA K wiped the resident's peri-area using the wipe handed to her by CNA L. -Instead of discarding the soiled wipe after it was used, the unclean wipe was re-used to wipe the resident's peri-area again. *After a clean incontinence brief was applied and resident 14 was redressed, and assisted out of the bathroom without being assisted by either CNA K or L to perform hand hygiene. *CNA L knew she should have removed her unclean gloves, performed hand hygiene, and put on clean gloves after handling the resident's wet brief and before handing CNA L clean wipes to perform peri-care. *CNA K agreed she should have discarded each wipe after using it for peri-care rather than re-using a soiled wipe. *CNAs K and L agreed resident 14 should have been assisted with hand hygiene before she had left the bathroom. 42558 2. Observation on 10/1/24 at 11:12 a.m. of CNAs I and M assisting resident 11 with her toileting needs revealed: *The resident was transferred from her wheelchair to the toilet using a sit-to-stand mechanical lift. *After performing hand hygiene and placing clean gloves on her hands, CNA I removed the resident's wet incontinence brief and discarded it. -After resident 11 used the toilet, CNA I used those same gloved hands and cleansed the resident's peri-area using disposable wipes. -Upon using the final wipe, she wiped the resident from back to front wiping her rectal area up through the urethra (opening to the bladder) and her labial folds using the same soiled wipe. -With those same unclean gloved hands, CNA I placed a clean incontinence brief on resident 11 and pulled up the resident's pants. *She then removed those contaminated gloves and washed her hands. 3. Observation and interview on 10/2/24 at approximately 1:30 p.m. of CNAs I and N while assisting resident 28 revealed: *The resident was transferred from her wheelchair to the toilet using a sit-to-stand mechanical lift. *CNAs I and N stated they were trained upon hire and annually on peri-care using the electronic Relias training system. -They stated the nurses had performed audits on their peri-care skills several times in the last two years. *After toileting the resident, she was transferred into her room using the mechanical stand lift. -CNA I washed her hands and applied clean gloves then performed the resident's peri-care using disposable wipes. -Upon performing the final wipe, she wiped the resident from back to front wiping the rectal area up through her urethra and labial folds using the same soiled wipe. -With those same contaminated gloved hands, CNA I placed a clean incontinence brief on resident 28. *CNA I then removed her gloves and without sanitizing her hands she: -Touched the resident's mechanical lift sling. -Adjusted the resident's clothing. -Applied a sweater to the resident's back and gave the resident her phone. -Combed the resident's hair. -Removed the sit-to-stand lift from the room and placed it in the hallway. *She then returned to the room and washed her hands while CNA N sanitized the mechanical stand lift. Interview on 10/3/24 at 12:30 p.m. with CNA I revealed: *She said she needed to wash her hands and apply clean gloves when entering the resident's room, when going from dirty to fresh, and when exiting the room. -She was not aware she had not removed her unclean gloves, sanitized her hands, nor applied clean gloves after providing the resident's peri-care and before she placed the clean incontinence briefs on the residents observed above. *She verbally demonstrated how she normally performed peri-care by stating she wiped up the front when using the last wipe. -She stated, I did not realize I was doing it incorrectly; I've always done it that way. Interview on 10/3/24 at 12:40 p.m. with DON/IP B regarding peri-care, hand hygiene, and glove use revealed: *It was her expectation that peri-care, hand hygiene, and glove use be performed according to facility policy, which was wiping from front to back, cleaning hands, and applying clean gloves when moving from a dirty procedure to a clean procedure. *She provided step-by-step education to staff on hand hygiene and glove use during a 4/11/24 'All Staff' meeting. *CNA I had been audited the week of 9/25/23 for peri-care and correctly demonstrated the procedure. -CNA I also completed a hand hygiene competency on 4/11/24 and correctly demonstrated hand hygiene and glove use at that time. *DON/IP B provided copies of the staff meeting, and the audits of CNA I, and all information was verified as accurate. Review of the provider's 5/2024 Pericare policy revealed: *Guidelines: -g.For the female resident, spread the labia and be sure to wash from front to back. -h. [NAME] new gloves -i. Reapply a clean disposable product. *The policy had not included hand hygiene before application of clean gloves. Review of the provider's revised April 2024 Hand Hygiene policy revealed: *A. Indications for handwashing and alcohol-based hand rub use: -14. Wash with soap and water after using a restroom. *I. Other Aspects of Hand Hygiene: -4. Change gloves during patient/resident care if moving from a contaminated body site to a clean body site and perform hand hygiene.

Substantial compliance was confirmed on 4/3/24 after record review revealed the facility had followed their quality assurance process; after mechanical lift education was provided to all nursing staff; after multiple staff interviews revealed competence and understanding of the mechanical lift training; after resident interviews confirmed transfers with a mechanical lift were provided with the proper number of staff; and after observations of staff showed they performed proper transfers with a mechanical lift.

Based on closed record review, job description review, interview, and policy review, the provider failed to ensure fall management and documentation protocols had been followed after one of one closed record sampled resident (1) had fallen. Findings include: 1. Review of resident 1's closed record revealed she: *admitted to the nursing home on 10/16/23. *Had fallen in the assisted living center (ALC) where she was residing and sustained a right hip fracture and right humerus fracture. -Was able to bear weight on her lower extremities as tolerated but was non-weight bearing to her right arm. -Had hip precautions which included no leg crossing, no bending past 90 degrees, and avoiding lower extremity rotation. *Had severe cognitive impairment including limited safety awareness and the inability to make her needs known. *Had fallen in the nursing home at 7:30 p.m. on 11/3/23. Telephone interview on 11/15/23 at 9:20 a.m. with certified nurse aide (CNA) C revealed she: *Assisted resident 1 to the bathroom in her room on the evening of 11/3/23. -Left the resident in the bathroom while she had retrieved peri-care supplies from the resident's dresser. *Observed the resident exit the bathroom, turn right towards her nightstand, and reach for candy in a bowl on top of the nightstand. -Was unable to reach the resident before she had fallen to the floor onto her right side. *Moved the resident from the floor and got her comfortable in her bed. *Notified licensed practical nurse (LPN) D of the fall. *Was aware after the resident had fallen she should have: -Ensured the environment and the resident was safe. -Not moved the resident. -Immediately notified the nurse that the resident had fallen. Telephone interview on 11/15/23 at 2:30 p.m. with LPN D regarding the fall referred to above revealed she: *Was assisting resident 1's roommate when CNA C had informed her resident 1 was in pain or something. -The pain occurred when resident 1 was rolled onto her side. *Had not previously met resident 1 but was aware she had a repaired hip fracture. *Visually assessed the resident and when she touched her observed no moaning or flinching. *Noticed resident 1's right foot was inverted in and looked like it was in an unnatural position. -Asked CNA C if the resident's foot had always looked that way and CNA C replied it had. *Asked CNA C whether or not the resident had fallen. -When CNA C said she yes she had fallen, LPN D was uncertain if CNA C had meant resident 1 had fallen prior to coming to the nursing home or that she had meant the resident had fallen that evening. -Failed to ascertain in her conversation with CNA C when the resident had fallen. *Had not contacted the on-call nurse manager or the on-call medical provider after her conversation with CNA C and her observations of resident 1's foot referred to above. -Agreed that given resident 1's recent hip fracture, CNA C's report, and her observation of the resident's foot, the resident might have re-injured her hip. *Waited until shift change the morning of 11/4/23 to report to the oncoming registered nurse (RN) E her observation referred to above regarding resident 1's foot. *Should have documented the resident assessment referred to above and initiated and/or completed the required fall and post-fall documentation. Interview on 11/15/23 at 10:00 a.m. with RN E revealed: *During the 6:00 a.m. to 6:00 p.m. shift on 11/4/23 CNA D reported that resident 1 had fallen in her room the previous evening. -CNA D had notified LPN D of that fall. *RN E completed an assessment of resident 1 while the resident sat on the edge of her bed. -That assessment was negative for any unusual findings and the resident was in no apparent pain at that time. *RN E should have completed the following: -Documented her assessment of resident 1 referred to above. -Completed the required post-fall documentation. *RN E contacted the on-call nurse manager (nurse supervisor B) on 11/4/23 and notified her of resident 1's 11/3/23 fall. --Nurse supervisor B advised RN E to wait for LPN D to arrive for her scheduled shift that same night and have her initiate and complete the fall and post-fall documentation. Interview on 11/15/23 at noon with nurse supervisor B revealed she: *Had not followed-up with LPN D until three days after the resident's fall on 11/6/23 and determined no fall or post-fall documentation had been completed. *Should have notified resident 1's family and her medical provider about resident 1's fall after she had been informed about it on 11/4/2. Review of resident 1's closed record and interview on 11/15/23 at 12:40 p.m. with director of nursing (DON) A and nurse supervisor B revealed: *They spent the morning of 11/6/23 trying to locate resident 1's 11/3/23 fall documentation and speak with CNA C and LPN D regarding that fall prior to notifying her family about what had happened. *After physical therapist F noticed resident 1 had a right leg length discrepancy around 11:00 a.m. on 11/6/23 she notified resident 1's medical provider of her findings, and an x-ray was ordered. *At 1:28 p.m. resident 1's family contacted the facility after they had received a notification from a healthcare patient portal system advising them of resident 1's x-ray results. *Around 2:08 p.m. the resident was transferred to the local emergency department for further evaluation of a displaced right hip. *DON A confirmed: -Required fall and post-fall documentation that included the Fall Scene Investigation Report (Resident Incident/Variance Report Form), a risk management report, 72-hour post-fall assessments and progress notes, and Treatment Administration Record (TAR) charting of resident 1's 11/3/23 fall was not completed. -Resident 1's family and medical provider should have been notified by LPN D of resident 1's 11/3/23 fall immediately or in a timely fashion. Review of the 6/15/23 LPN job description revealed: *Values the LPN was expected to uphold included trust. -That was achieved by Asking for help when needed and communicating in ways that others understand. Review of the provider s revised May 2021 Fall Prevention/Management/Documentation policy revealed: *Management of a fall: -3. Do not move the resident until their status has been completely evaluated. -6. If a deformity or injury is noted, call the physician for approval for transport by ambulance to the hospital. -14. Notify the attending physician of the fall . -16. Notify the resident family or POA [power of attorney] of the incident. *Documentation of a fall: -1. Complete the Resident Incident/Variance Report Form. Include investigation to rule out abuse/neglect, interview process CNA will complete initial investigation form, Primary nurse will complete initial investigation form. 3. Each shift is to assess and chart in the Interdisciplinary Progress Notes for 72 hours after any fall whether resulted in injury or no injury. 4. Place nursing order on TAR (treatment administration record) fall documentation every shift X 3 days.

Based on observation, interview, record review, and policy review, the provider failed to ensure there was licensed nursing oversight and supervision to ensure the following: *One of one CMA (I) had not crushed and administered a delayed seizure medication to one of one sampled resident (18) to prevent a medication error from having occurred. *One of one CMA (I) had received initial medication administration orientation. *One of one CMA (K) had not calculated a Lactulose medication dose for one of one sampled resident (32). *One of one CMA (J) had not decided whether or not it was safe for one of one sampled resident (47) to have taken his medications whole without crushing them. *One of one CMA (J) had received annual medication administration education or had completed a medication administration competency. Findings include: 1. Observation and interview on 7/19/23 at 11:00 a.m. of CMA I during the lunch medication pass in the [NAME] dining room revealed: *Resident 18 had a medication order for divalproex sodium (Depakote) DR (delayed-release) 250 milligrams (mg) one tablet by mouth three times daily. -The medication administration record (MAR) indicated it was given for a seizure disorder. *She crushed delayed-release medication and mixed it with pudding prior to administering it to the resident. -Stated, They [CMA's] told me to crush her [resident 18's] medications because she can't swallow whole pills. *Verified there were no directions listed on resident 18's MAR that her medications could or could not be crushed. -She had memorized which residents had crushed medications from the temporary CMA who had trained her. -That CMA no longer worked at the facility. *She would ask the nurse in charge if she had any questions about a resident's medication. -She had not asked the nurse about crushing resident 18's delayed-release medication. *She had close to four years of CMA experience and started working for the provider a little over a month ago. -She denied having any licensed professional observe her during the medications pass. Interview on 7/19/23 at 11:15 a.m. with licensed practical nurse (LPN) K, who was working as the nurse for [NAME] unit, regarding the above observation and interview with CMA I revealed: *The CMAs would pass all routine medications. *There was a list of residents who had their medications crushed that was located in the [NAME] medication cart's narcotic log binder. *She was not aware resident 18's medications were being crushed by the CMA. *Stated, Delayed-release tablets should not be crushed and the provider should be contacted for an alternative form of medication, such as a liquid. -She expected the CMAs to come to her with any medication questions. *She thought nurse supervisor D had assigned the CMA orientation training. *The CMA's were trained by CMA's. *She was unsure if the CMAs were given medication pass competencies at the facility. Review of the 6/28/23 [NAME] Unit list of resident names that were located in the narcotic binder revealed resident 18's medications as Crushed. It had not indicated what medications should not have been crushed. Interview on 7/19/23 at 11:20 a.m. with nurse supervisor D regarding the above medication pass observation revealed: *She had been employed by the facility as a nurse supervisor since November of 2022. *The charge nurses and the CMA's were responsible for filling out the sheet in the narcotic book for the residents that were to have crushed medications. -It is just a 'cheat sheet' for them to follow, it is not an official form. *Confirmed delayed-release medications should not have been crushed and the physician should have been contacted for an alternative if the resident was unable to have taken the medication whole. *She had not trained the new medication aides since they were already certified upon hire. -Since the medication aides are certified, they should know not to crush delayed-release medication. *She was unsure who trained the CMAs to the facility medication pass. Interview on 7/19/23 at 11:30 a.m. with nurse supervisor C and director of nursing (DON) B regarding the above observation, the medication aide training, competencies, and the crushing of delayed-release medications revealed: *Both agreed delayed- release medications should not have been crushed. *They would expect the CMAs to go to the licensed nurses with any medication questions. *DON B reviewed resident 18's MAR and confirmed there were no instructions to not crush the resident's delayed-release medication. *Confirmed the CMAs trained the new CMAs on the facility medication pass. *Nurse supervisor C stated they only complete a yearly medication pass competency with the CMAs. *Both confirmed new CMAs had no evaluation of their competency during the initial hire period. -They agreed most traveling CMAs would not have completed a year's employment during their assigned period at the facility and should have had a competency skills audit. *DON B stated the consulting pharmacist would perform random medication pass audits during her once a month visits to the facility. Phone interview on 7/19/23 at 2:32 p.m. and on 7/20/23 at 10:40 a.m. with consultant pharmacist R regarding resident 18's crushed medications, and the medication pass audits revealed: *She had been the facility's pharmacy consultant for little over a year. *Stated, Delayed-release medications probably should not be crushed. *During her monthly visits, she would ask who ever was passing medications which residents were getting their medications crushed. *Every resident in the facility had a routine physician's order to 'crush medications as appropriate' upon admittance to the facility. -She felt that practice needed to change. *She was unaware the CMAs were crushing resident 18's medications, but thought it might have started when the resident's diet changed to pureed foods in May of 2023. -Crushing a divalproex (Depakote) DR medication would have been considered a medication error. *She visited the facility once a month to complete resident medication reviews and random medication pass audits with the CMAs. -She could not recall auditing CMA I and felt that was because CMA I had been recently hired since her last visit to the facility in June. -Her audits of the CMAs were random, but she attempted to audit the newer CMAs. Further interview on 7/20/23 at 12:10 p.m. with DON B regarding CMA I revealed: *She agreed that no CMA competencies had been performed following the initial date of hire. -Nurse supervisor C and infection prevention nurse (IP) E were responsible for the CMA competency audits and there had been no competencies completed in 2023. -There was no nurse educator or staff development personnel at the facility. -There was no nursing involvement in the training of the newly hired CMAs. On 7/20/23 at 8:30 a.m. a request for all CMA medication administration training and competency audits for the past year were requested from DON B. By the end of survey, DON B stated the pharmacist's audits of newly hired CMAs had not been located. A medication aide training policy was requested on 7/20/23 from DON B. She stated there was no policy. Review of the provider's October 2022 Crushing Medications policy revealed: *Policy Statement -Medications may be crushed for individuals with physical limitations secondary to disease processes and/or pathological diversities, when deemed necessary for safety, by the physician, speech therapy or nursing services. -3. The need for crushing medications is indicated on the resident's MAR/TAR so that all personnel administering medications are aware of this need. -6. Long-acting or enteric-coated dosage forms should generally not be crushed and require a physician's specific order to do so. Review of the provider's February 2023 Adverse Consequences and Medication Errors policy revealed: *Policy Statement -The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems . -6. Examples of medications errors include: --h. Failure to follow manufacturer instructions and/or accepted professional standards (e.g., failure to shake medication that is labeled shake well, crushing a medication on the do not crush list without an order. 40788 2. Record review and interview on 7/17/23 at 12:47 p.m. with CMA O preparing resident 32's Lactulose medication for administration revealed: *A physician's order read: Lactulose 30 mg [milligram], four times daily. 2, 3, or 4 doses to = 120 mg. -Resident 32 was to have been administered two-30 mg Lactulose doses by CMA O during the day shift that day. Observation and interview at that same time in resident 32's room revealed: *CMA O had administered 30 mg of Lactulose. *The resident stated in addition to the two doses CMA O had administered to him during the day shift he would have taken one additional double dose [60 mg] of the Lactulose during the evening shift. Interview on 7/18/23 at 3:30 p.m. with CMA K regarding resident 32's 7/17/23 evening medication pass revealed: *She had worked the 7/17/23 evening shift and had administered to the resident one-60 mg dose of Lactulose to the resident during her shift. *CMA O had reported to her at shift change on 7/17/23 that resident 32 had taken two-30 mg doses of Lactulose on his shift so she knew one additional 60 mg dose of Lactulose had equaled the daily 120 mg that was ordered. -Resident 32 had preferred to take his evening Lactulose in that manner. *She confirmed calculating the Lactulose dose was not within her scope of practice. Interview on 7/20/23 at 12:10 p.m. with DON B regarding the observation above revealed: *It had not been within CMA K's scope of practice to have calculated resident 32's Lactulose dose without first having consulted with a licensed nurse. *That Lactulose order should not have included a range of dosing frequencies. -That would have eliminated the need for a dose calculation. 3. Interview and review of resident 47's care record on 7/20/23 at 8:15 a.m. with CMA J revealed : *His physician order summary included an order: May crush medications if indicated (unless contraindicated). May give in food or drink. -Each resident's physician order summary had that same routine order. *The upper corner of the medication blister packs had instructions: Do not crush. May cause drowsiness. May cause dizziness for those medications that had been contra-indicated to crush. -Only his Flomax blister pack had those instructions on it. *All of his other medication blister packs including an extended-release Tylenol had not had those instructions. -She was aware an extended-release medication such as Tylenol should not have been crushed. *The resident's July 2023 MAR revealed there had been no instructions for any of those medications to have been crushed. *CMA J had administered all of resident 47's medications whole because she had determined he was not having any swallowing issues or other concerns that would have suggested the need to have crushed his medications. -She had used her schooling [medication aide training] to have made that decision. Interview on 7/20/23 at 12:10 p.m. with DON B regarding the observation above revealed: *It was not within CMA J's scope of practice to determine whether or not any resident should have had their medications crushed or not without first having a discussion with a licensed nurse. *Medication-crushing information on the resident's MAR and their individual blister packs had not been consistent and was confusing to interpret. 4. Interview on 7/20/23 at 8:30 a.m. with CMA J regarding CMA education revealed: *She had been a CMA at the nursing home for two years. -She had not received any medication administration education or demonstrated a medication administration competency within the past year. *She and CMA L had been responsible for providing initial medication administration orientation for newly hired CMAs on the Berry unit. Interview on 7/20/23 at 12:10 p.m. with DON B regarding CMA medication administration education revealed: *Consulting pharmacist R had completed Med Pass Observation audits for random CMAs on a monthly basis. *Only one of those audit tools had been located and it had been completed on 9/29/22 for CMA J. *That audit tool included 23 individual medication administration-related tasks but only one of those 23 tasks had been audited. -That task had been related to her medication cart and criteria for that task had been marked Not Met. -In-Service Notes at the bottom of that form: Cart was found unlocked with med aid [CMA] in room, meds [medications] were preset and not covered, names were on cups. Communication on presetting medication reviewed with med aide. Will reassess actual med pass at the October [2022] review as cart was unlocked upon review. *That audit tool had not comprehensively assessed CMA J's ability to competently administer medications to the residents. *DON B had been unable to locate documentation to support any 2022 annual CMA medication administration education had been provided. -No annual CMA medication administration education had occurred in 2023. *Infection control (IC) nurse E was expected to have completed that education. -DON B thought she had sent IC E an e-mail communication in early 2023 regarding annual CMA medication administration education expectations but had not followed-up with her to ensure it had been started. *It was not within CMA J or L's scope of practice to have provided that education to newly hired CMAs on the Berry unit. -Initial medication administration orientation was expected to have been provided by a supervising nurse. The 6/15/23 Medication Aide job description had not identified any initial or ongoing education requirements for that position or medication administration tasks that should not have been delegated. -There was no other policy that had specifically addressed initial and ongoing CMA education and training requirements.

Based on observation, interview and policy review, the provider failed to ensure the following: *A homelike environment had been observed and staff assistance was provided in one of two dining rooms ([NAME]) during three of three observed mealtimes. *Conversations between residents and staff had occured in one of two dining rooms (Berry) during one of one observed mealtime. *Dignity had been maintained for two of four sampled residents (32 and 49) by covering the urine collection systems. Findings include: 1. Observation on [DATE] from 11:45 a.m. through 1:09 p.m. in the [NAME] dining room revealed: *Twenty residents were in the dining room and resident 12 was sleeping in her wheelchair. *Television (TV) was on, and country music was playing. *Certified medication aide (CMA) I was at the medication cart watching the residents and had not been passing any medications. *Four unidentified certified nursing assistants (CNAs) were serving lunch to the residents. -CNAs would place the food in front of the residents then walked away with out speaking to the residents. -Resident 12 was awakened to eat her lunch. -After the twenty residents were served in the dining room, the CNAs started delivering residen room trays, with one CNA that stayed in the dining room to assist a resident with their meal. *CMA I stayed in the dining room by the medication cart. *Two of the residents (2, 12) were not eating their meals and received no verbal or physical assistance from the CNA or CMA. -Resident 12 had fallen back asleep with a fork in her hand. -After five minutes resident 2 started to eat her meal. *Sixteen minutes later two CNAs came back from delivering room trays and assisted resident 12 with her meal. -A CNA sat next to the resident and placed some fruit on a spoon and offered it to the resident. --The resident refused the fruit. --The CNA had not offered or assisted the resident with any of the pasta and left the table after one attempt of assisting the resident with the fruit. -The resident had been attempting to use her fork to eat the pasta, but the pasta was sliding around the plate. *Eight minutes later resident 12 was sleeping again, with the fork in her hand. *CMA I had not offered the above mentioned residents any food or fluids until questioned about who should have been assisting those residents. -CMA I then asked resident 12 if she was still hungry which resident nodded her head yes. -CMA I then assisted resident 12 by holding a cup with her chocolate supplement for the resident to drink. --The resident refused to eat the pasta or the fruit that CMA I had offered her. -CMA I left three minutes later and returned with a straw for the resident to drink her juice with and then left. *Ten minutes later an unidentified CNA sat down next to resident 12 and offered her a bite of the pasta and the resident refused, the CNA put the fork down and left the table. --The unidentified CNA had not offered to reheat the resident's meal or offer any substitutes for the meal. *Resident 12 then grabbed her fork and attempted again to pick up the pasta, but the pasta fell to the floor. -Two minutes later the resident was falling back asleep holding the fork in her hand. -Two minutes after the resident fell asleep an unidentified kitchen worker came and took the residents fork out of her hand and removed her tray from the table. Observation on [DATE] from 8:20 a.m. to 8:45 a.m. in the [NAME] dining room revealed: *Eighteen residents were in the dining room. *TV was on, a hip-hop song was playing loudly with shirtless men and women wearing bikini's rolling around together in the sand drinking alcohol. *An unidentified CNA was assisting resident 12 with her meal. *CMA I was at the medication cart watching the residents. *Three unidentified CNAs were talking to each other at a table while one of them was sitting on a chair next to a resident. Interview on [DATE] at 9:10 a.m. with CMA I regarding the [NAME] dining room observation revealed: *She was in the dining room to monitor for choking, and chart supplement intakes. *She was cardiopulmonary resuscitation (CPR) certified and she was to have always remained in the dining room during meal service. *She agreed the hip-hop song was not appropriate for the residents but she could not change the TV channel as that was decided by the activities department. Interview on [DATE] at 9:15 a.m. with activity assistant H regarding the video on the TV revealed she: *Agreed the hip-hop video was inappropriate for the residents. *Stated, Sometimes the residents request what the younger generation listened to. *Should have asked the more alert residents what they would have liked to listen to. *Agreed some videos were not appropriate for the residents during meals. Interview on [DATE] at 1:10 p.m. with CNA G about the [NAME] dining room observation revealed: *She was watching the residents and would assist those residents that were not eating or drinking their supplements. -She would encourage the residents to eat their meals and to drink their supplements. -If a resident was not eating their meal or drinking their supplements then she would have had another CNA attempt to get the resident to eat. *She agreed other food items could have been offered when a resident was not eating. 40788 2. Observation on [DATE] between 11:50 a.m. and 12:40 p.m. in the Berry dining room revealed: *At 11:50 a.m. nine random residents had been seated in the dining room for the noon meal. -There was one table of four residents, three tables with a single resident seated at each of them, and one table with two residents. *Meals had been plated starting at 12:10 p.m. by dietary staff Y. *Between two and five staff persons (CNA V, CNA W, CMA J, restorative aide (RA)/CMA P, and RA X) were waiting in front of the serving counter with their backs toward the residents in the dining room waiting for that first plated meal. -There was no conversation between staff and residents from the time residents had been brought to the dining room and the plating of meals started. *Staff served residents their meal trays and assisted them with any meal-related needs. -They returned to the serving counter and with their backs faced toward the residents waited behind the staff lined up in front of them for another meal tray to serve. *During the observation time referred to above the only staff and resident conversations that occurred were the following: -At 12:20 p.m. CNA V verbally prompted resident 47 to eat. -At 12:23 p.m. CMA J offered resident 26 a meal substitution. -At 12:26 p.m. An unidentified resident requested staff assistance for her tablemate to have staff open her ice cream cup. -At 12:27 p.m. CMA J offered resident 47 a Kleenex to wipe his nose. -At 12:28 p.m. RA W walked around the dining room and would briefly interact with residents at each table. -At 12:32 p.m. RA X verbally prompted an unidentified resident to eat. Interview on [DATE] at 12:35 p.m. with CMA J regarding the dining room meal observation revealed she: *Usually waited until residents had nearly finished their meal before she had interacted with them. -Had not wanted to interrupt them during their meal. Interview on [DATE] at 12:50 p.m. with director of nursing (DON) B regarding the observations made in the [NAME] and Berry dining rooms revealed: *CNAs and CMAs who passed meal trays were expected to have offered and provided the necessary assistance each resident required to have eaten their meal as independently as possible. *CNAs and CMAs were expected to interact with residents throughout each meal service and to provide needed encouragement to eat their meals and drink their fluids and/or supplements. *CNAs and CMAs should have offered a meal substitution to any resident who had not eaten or had minimally eaten their meal. *Television was a distraction and was not expected to have been turned on during the resident mealtimes. *CNA or CMA presence in the dining room during mealtimes was expected to occur at all times. Review of the [DATE] revised Assisted Dining room policy revealed: *The purpose of assisted dining is to ensure that residents receive required nourishment with as much enjoyment as possible. -C. Prepare resident at table including clothing protector/napkin if needed. -F. Resident dining experience: --1. Do not visit with coworkers while assisting resident in the dining room. Conversation should be directed to the resident. --2. Televisions should not be turned on during the meal. Music may be played at a low level. --3. Try to make the meal time as pleasant and restful as possible for the resident. 3. Observation on [DATE] at 11:33 a.m. and observation and interview on [DATE] at 9:40 a.m. with resident 32 in his room revealed: *His uncovered urine collection bag had hung towards the foot of his bed. -It had been visible to any resident or visitor walking by his room. *He stated that sometimes the urine bag was covered and placed in another bag but not consistently. Observations of resident 49 on [DATE] at 12:15 p.m., on [DATE] at 12:05 p.m. in the dining room, and on [DATE] at 3:00 p.m. in his room revealed he: *Required the use of a urine collection bag. -The urine collection bag was uncovered during the above observations. Interview on [DATE] at 9:45 a.m. with CNA V and CNA W outside resident 32's room after they had emptied his uncovered urine collection bag revealed: *The resident had his own blue bag that his urine collection bag was placed in to maintain his dignity but was only used when he was outside of his room. *There had been similar bags for other residents like resident 49 who had a urine collection bag but they were unable to find any of those bags to cover the urine collection bags in the central supply room. Interview on [DATE] at 10:35 a.m. with DON B revealed she expected all residents that required a urine collection bag to have had them covered inside of another bag regardless of whether the resident was in or out of their room in order have maintained their dignity. Review of the revised February 2019 Foley Catheter Care policy revealed: G. When the resident is in bed or seated, assure collecting bag is off the floor and covered for dignity and hygiene.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Proper hand hygiene and glove use during: -One of one random observations of a medication pass by one of one certified medication aide (CMA) (I) with two of two residents (9 and 19). -One of one water passes down [NAME] Hall by one of one certified nursing assistant (CNA) (T). -One of one resident's (42) personal hygiene performed by two of two CNA's (T and U). *Handling of scissors used during one of one sampled residents (49) wound care by one of one infection control (IC) nurse (E) and one of one licensed practical nurse (LPN) (F). *Ensuring one of two sampled residents (49) who had a Foley catheter had his uncovered urine collection bag kept off the floor in his room while he was in bed. Findings include: 1. Random observation on 07/17/23 at 1:10 p.m. of CMA I administering medications to residents in the [NAME] dining room revealed: *After taking a sip of a soft drink and without sanitizing her hands CMA I: -Removed resident 19's medications from the medication cart, crushed them, mixed them in pudding, and spooned them into the residents mouth. -Touched the resident's clothing, then returned to the medication cart holding the empty medication cup and dirty spoon and disposed of it in the garbage container. *Then without sanitizing her hands she: -Documented the medication administration in the medication cart computer, opened the medication cart drawer, and removed a bottle of liquid medication. -Poured the liquid medication into a clean measuring cup, and administered the oral liquid medication to resident 9. -Returned to the medication cart holding the used medication cup and disposed of it in the garbage container. -Documented in the computer and stood at the medication cart without sanitizing her hands. Interview on 7/19/23 at 11:00 a.m. of CMA I regarding hand sanitization during the above observed medication pass revealed: *She had not liked to use hand sanitizer as it irritated her skin and she would wash her hands with soap and water if they became dirty. *She was not aware she should wash her hands before and after each resident's medication administration, especially if she had touched the resident or the supplies that had come in contact with the resident's mouth. 2. Observation on 07/17/23 from 3:16 p.m. through 3:22 p.m. of CNA T during the resident water pass down [NAME] unit from rooms 62 through 69 revealed: *She had one water pass cart that carried clean, filled, water containers on the top shelf and used, emptied, water containers on the bottom shelf that were placed into a un-enclosed plastic crate. *Without sanitizing her hands she: -Entered each room and emptied the used water containers into the resident's sink then removed the water containers and placed them on the lower shelf of the cart located in the hallway. -Picked up the clean, filled water containers and took them into the room. -She went from room to room in that same manner. *She had not sanitized or washed her hands during the entire observed resident water pass down the hallway. Interview on 07/17/23 at 3:45 p.m. with CNA T regarding the above observation revealed: *She had worked as a CNA at this facility for approximately two weeks. *She had on-line hand hygiene training and had performed a hand hygiene audit at the facility. *That was how she would normally pass resident water down the hallway. *She should have washed or sanitized her hands before entering and after leaving each room. *Agreed there were multiple missed opportunities for hand sanitization during the water pass. 3. Observation on 07/17/23 at 3:26 p.m. of CNAs T and U during a Hoyer transfer and an incontinent brief change on resident 42 in her room revealed: *Both CNAs entered the room and applied gloves without sanitizing their hands. -CNA U applied two pairs of gloves to her hands. *After applying the Hoyer sling on resident 42, the battery to the Hoyer was not working so CNA T removed her gloves and without sanitizing her hands left the room with the dead battery. -She retrieved a new battery from a storage room. -On her way back to the room, she stopped to open a snack for an unidentified resident sitting in the hallway. -She re-entered the room and applied gloves without sanitizing her hands. *Once the resident was placed on the bed, both CNA's removed the resident's brief and cleansed a bowel movement off resident 42's bottom. -CNA U removed the first layer of gloves, and without sanitizing her hands and wearing the underlying pair of gloves, she placed a clean brief under the resident. *Using the same pair of soiled gloves, CNA T opened the resident's bedside table drawer, removed a skin barrier cream tube, applied the cream to the resident's cleansed buttocks, then returned the tube of barrier cream to the drawer. -She removed her gloves and without sanitizing her hands applied a clean pair of gloves to remove the Hoyer sling, adjust the resident in bed, and move the Hoyer into the hallway. *Both CNAs then removed their gloves and sanitized their hands upon leaving the room. Interview on 07/17/23 3:45 p.m. with CNAs T and U regarding the above observation revealed: *CNA T had started working at the facility approximately two weeks ago and had over ten years of CNA experience. *CNA U had started working at the facility approximately one week ago. *They both had completed the facility's hand washing and glove use training through an online course and performed a hand hygiene competency with nurse supervisor D. *They both stated hand hygiene should have been performed when entering and upon exiting a resident's room. -Neither one identified hand hygiene and changing gloves when moving from a dirty task to a clean task or after removing soiled gloves. -CNA U had not been aware that she should not have applied two pairs of gloves at the same time. *Both agreed there had been missed opportunities for proper hand hygiene and glove use. Interview on 07/20/23 at 01:27 p.m. with infection prevention (IP) nurse E regarding the above observations revealed: *Hand sanitizing should have been performed after exiting every resident room during the water pass. -She had been unaware of the facility's water pass policy. *She had not completed any CNA audits of hand sanitization during a water pass. *If a CNA had not passed a hand hygiene audit, she would do In Time education. -Meaning she would educate them at the time of the observed occurrence. *She observed 43 hand hygiene audits last month from all the various departments. *There were no current performance improvement projects (PIP's) on hand hygiene and glove use. *Her expectation for hand sanitization and glove use was it should have been performed when going from dirty to clean, after a glove change, and after leaving every room. *She had just completed peri-care competencies in March of 2023 with all staff. *New hire training on hand hygiene and glove use was online and with another CNA on the floor. *Agreed there were missed opportunities for proper hand hygiene and glove use during the above observations. -They do a hand competency upon hire and should have known how to do it (properly). Review of the provider's February 2023 Water Pitcher and Drinking Glass policy revealed: *All resident's water pitchers were to have been emptied and placed on a cart and taken to the dirty dish area in the dietary department. *Staff were to wash their hands and then place the clean, filled, water pitchers on a clean cart to pass to the resident's rooms. Review of the provider's December 2022 Hand Hygiene policy revealed: *Hand hygiene should have been performed: -Before having direct contact with residents. -After contact with the resident's intact skin. -When moving from a contaminated body site to a clean body site during resident care. -Before preparing or handling medications. -Before applying gloves and after removing gloves. *Gloves should have been changed during resident care when moving from a soiled body site to a clean body site. 40788 4. a. Observation on 7/18/23 at 3:00 p.m. of IC nurse E and LPN F in resident 49's room revealed: *He was lying on his back in bed. *His uncovered urine collection bag hung at the foot of his bed and was touching the floor. -The bag no longer touched the floor after his bed was raised to a higher position for his wound care treatment. *IC nurse E removed a pair of scissors from the back pocket of LPN F's scrubs, laid them directly on the resident's uncleaned bedside table with other pre-packaged wound care supplies. *Without cleaning those scissors IC nurse E removed a foam wound dressing from its package and used those same scissors to cut that dressing that was applied to the resident's left heel. -She laid the scissors back down on the uncleaned bedside table and completed the dressing change. *The resident's bed was then returned to a low position causing his urine collection bag to touch the floor. Interview on 7/18/23 at 4:00 p.m. with IC nurse E and LPN F regarding the wound care observation referred to above revealed the following practices had presented an unnecessary infection control risk to resident 49: *Transporting wound care scissors inside a clothing pocket. *Failing to ensure those scissors had been cleaned prior to use. Review of the revised June 2019 Dressing Change policy revealed: A. 9. Establish a clean area for dressing supplies and necessary equipment. b. Observation and interview on 7/18/23 at 5:00 p.m. with LPN F outside of resident 49's room revealed: *He was lying in bed and his uncovered urine collection bag hung at the foot of his bed touching the floor. *LPN F stated she had not noticed the bag touching the floor at the time of his wound care earlier that day. *She knew the uncovered bag touching the floor presented an unnecessary infection control risk to the resident. Observation and interview on 7/19/23 at 10:45 a.m. with IC nurse E and LPN F outside of resident 49's room revealed: *He was lying in bed and his uncovered urine collection bag hung at the foot of his bed and was touching the floor. -His urine collection bag should have been inside a secondary bag preventing that uncovered bag from directly touching the floor. Review of the February 2019 revised Foley Catheter Care policy revealed: G. When the resident is in bed or seated, assure collection bag is off the floor and covered for dignity and hygiene. Refer to F550.

Based on observation, record review, interview, and policy review, the provider failed to adhere to professional standards of practice for the following: *Post-dialysis care per the provider's policy for one of one sampled resident (37). *The use of a physician ordered pain assessment scale prior to the administration of narcotic pain medication for one of one sampled resident (49). Findings include: 1. Observation on 7/17/23 at 3:00 p.m. of resident 37 revealed: *She had returned from dialysis and was walking independently around the facility. -The dialysis access site on her right arm was covered and had no visible signs of bleeding. Review of resident 37's care record revealed: *A physician's order summary reviewed on 7/17/23 included an order tocheck thrill and bruit daily (a rumbling sound that was heard and a rumbling sensation that was felt at the dialysis access site). -Her July 2023 medication administration record (MAR) indicated that physician order was expected to have been completed by the nursing staff at 8:00 a.m. daily. Interview on 7/18/23 at 5:00 p.m. with licensed practical nurse (LPN) F regarding resident 37 revealed she: *Had checked the resident's thrill and bruit daily at 8:00 a.m. according to the physician's order on the MAR. -That occured prior to dialysis. *Was able to visualize the resident's access site following dialysis for any unusual bleeding, thrill, and bruit. -Confirmed that the thrill and bruit would not have been assessed without a stethoscope and physically touching the resident. Interview on 7/19/23 at 11:15 a.m. with director of nursing (DON) B regarding resident 37 revealed she: *The physician's order should also have included instructions to have checked the resident's thrill and bruit after she had returned from dialysis. -Confirmed that was best nursing practice and that was the facility's policy. Review of the 20/21 Long Term Care Nursing: Dialysis Competency that DON B had identified as the provider's Dialysis policy revealed: Post-Dialysis Care: Assess access site for bruit, thrill, exudate, signs of infection, bleeding. 2. Observation and interview on 7/18/23 at 3:00 p.m. with infection control (IC) nurse (E) and LPN (F) during wound care in resident 49's room revealed he: *Had prostate cancer that had spread to his bones and was receiving hospice services. *Had dysphasia making it difficult to have made his needs known. -Used unintelligible sounds, pointed to things, and shook his head yes and no to try to have made his needs known. Review on 7/18/23 of resident 49's physician order summary revealed: *A 4/26/23 physician's order: Morphine sulfate oral solution. Give 0.25 by mouth every 3 hrs [hours] PRN [as needed] for mild pain/dyspnea and give 0.5 ml by mouth every 3 hrs PRN for moderate pain/dyspnea. -That physician order had been noted and entered into the resident's electronic medical record by nurse supervisors C and D. Review of resident 49's treatment administration records (TAR) revealed: *May 2023 TAR: -0.25 ml of morphine had been administered one time (5/7/23) for mild pain rated as a 6. -0.5 ml of morphine had been administered five times (5/7/23, 5/8/23, 5/12/23, 5/14/23, and 5/28/23) for moderate pain rated between 4 and 8. *June 2023 TAR: -.25 ml of morphine had not been administered that month for mild pain. -0.5 ml of morphine had been administered five times (6/1/23, 6/13/23, 6/19/23, 6/22/23, and 6/26/23) for moderate pain levels rated between 3 and 7. Interview on 7/19/23 at 9:30 a.m. with LPN F regarding the numerical pain ratings for resident 49 and his May 2023 and June 2023 TARs revealed: *The physician's morphine orders had not included numerical pain scale parameters that had defined what constituted mild and moderate pain. *She completed a PAINAD (Pain Assessment in Advanced Dementia) assessment tool to determine a numerical pain value for the resident based on a pain score between 0 and 10. -A pain score between 1 and 6 was mild and a pain score over 6 was moderate pain. *She was unable to provide a copy of the PAINAD tool she referred to or any references to support the PAINAD scoring system that she had used. Review of the PAINAD assessment tool revealed: *It was an observational tool with numerical equivalents for each of five behavioral items. -Each of those items was scored between 0 to 2 for a maximum score of 10. *Scoring guidelines: -1 to 3=mild pain. -4 to 6=moderate pain. -7 to 10=severe pain. Interview on 7/20/23 at 11:30 a.m. with DON B regarding resident 49's PRN morphine order revealed: *Nursing supervisors C and D should have completed the following: -Established with the ordering physician a pain scale to have been used in conjunction with the morphine order. -Identified what score based on that scale constituted mild pain and what score based on that scale constituted moderate pain. -Entered that physician's order information on resident 49's TAR. *LPN F had not used the PAINAD assessment tool correctly. *There was no consistency between the amount of morphine that had been administered to the resident according to the pain level because there was no pain scale to reference.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of four sampled residents (6) had received the appropriate care and service to prevent a stage two pressure ulcer from developing while receiving care in the facility. Findings include: 1. Interview on 8/22/17 at 9:35 a.m. with certified nursing assistant (CNA) Q regarding resident 6 revealed: *He had: -Been alert and oriented. -Required staff assistance with personal care. -Been independent with walking in the past but was declining and required staff assistance for safety. *She had stated He has been getting kind of shaky. Observation on 8/22/17 at 4:12 p.m. of CNA E with resident 6 revealed: *The resident had been in his room sitting in a recliner with a wheeled walker (w/w) placed in front of him. *CNA E had prepared to assist the resident to the bathroom. *He had: -Required her assistance to help him with transferring and walking to the bathroom. -Needed her assistance with personal care and dressing. Review of resident 6's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He currently had required the staff to: -Assist him with all of his mobility needs for transferring from place-to-place, moving in bed, and activities of daily living. -Implement any preventative interventions to ensure skin breakdown would not have occurred. *His capabilities and level of independence had fluctuated depending upon his level of alertness and pain. *He had no nursing physical assessment to support an area of concern on his right buttocks at the time of his admission. *His Braden pressure ulcer risk assessment scores from 12/12/16 through 5/30/17 ranged from twenty to twenty-two. -Those scores indicated he had not been at risk for skin breakdown. *He had required physical therapy services from 2/2/17 through 3/14/17 to assist him with weakness, poor balance, and a decrease in activity tolerance. *He had frequent episodes of decreased alertness and severe back pain starting in March 2017. *He had occasional episodes of unresponsiveness and had been sent to the emergency room (ER) for evaluation. -During those ER visits he had been given intravenous fluids for complications with dehydration and hematuria in his urine. *He had frequent coughing episodes with a decline in fluid intake. *On 4/25/17 he had started speech therapy (ST) to assist him with swallowing difficulties. *His level of care fluctuated daily, and at times he required two staff members to assist him with transfers, bed mobility, and personal care. *On 5/30/17 he had acquired a stage two pressure ulcer. -That pressure ulcer had been located on his right buttocks. *No documentation to support preventative measures had been put in place: -Prior to the skin breakdown. -After the skin breakdown had occurred and to ensure proper healing. *No documentation to support: -The dietician had reviewed the chart to ensure his current nutritional status was sufficient enough to support the healing of an opened wound. -When that stage two pressure ulcer had been healed. Review of resident 6's current comprehensive care plan revealed: *It had several different and random revision dates for all the focus areas of concern. *A focus area: I have potential for impairment to skin integrity r/t (related to) bladder and/or bowel incontinence, need for assistance with toileting and transfers, psoriasis. -Initiated 12/22/16. -Revised 12/26/16. -That focus area had not supported a recent stage two pressure ulcer to his right buttock. *Goal under that focus area I will no have impairment to my skin r/t pressure and/or incontinence through the next review. -Initiated 12/22/16. -Revised 6/7/17. -That goal had not supported his history of skin breakdown. *Interventions under that focus area had not identified: -How often he should have been repositioned. -What had been put in place for the staff to follow to ensure no further skin breakdown occurred. *A focus area: I have the potential for a nutritional problem r/t limited fluid intake. -Initiated 1/5/17. -Revised 6/2/17. *The goal and interventions for the above focus area had not identified any current or past skin concerns. Review of resident 6's 5/30/17 physician's orders [REDACTED].>*Pressure ulcer stage II (two) Rt (right) buttock. *Cleanse with wound cleanser - apply [MEDICATION NAME] dressing to Rt buttock wound. *Change Q (every) 7 days and PRN (as needed) until resolved. Review of the 6/2/17 registered dietician's quarterly progress note for resident 6 revealed: *She had completed a chart review on the resident. -That chart review had been four days after an opened area had been identified. *No documentation to support she had reviewed the resident's medical record for a stage two pressure ulcer. Interview on 8/23/17 at 2:00 p.m. with the registered dietician regarding resident 6 revealed: *She confirmed the above dietary note for the resident. *She had documentation on her resident nutrition at risk sheet identifying a pressure ulcer for the resident. -That documentation was not a part of the resident's chart and had been for her own personal use. *She could not remember reviewing his current nutritional status at that time to ensure it was sufficient to promote healing of an opened wound. *The resident's status and wound concerns would have been discussed every Tuesday, Wednesday, and Friday in their morning meeting. -She would have attended all of those meetings. *She agreed: -No documentation confirmed no review had occurred for a stage two pressure ulcer by her. -The care plan should have been updated to support a wound to his right buttock and to ensure proper healing of that wound. Review of resident 6's 5/30/17 through 8/14/17 weekly skin integrity assessment record revealed: *On 5/30/17 and 5/31/17 the documentation supported an opened area to his right buttocks. -Those assessments had not described what preventative measures or plan were put in place to ensure no further skin breakdown. *From 6/5/17 through 8/14/17 there was no documentation to support: -An issue or skin concern to his right buttock. -When the stage two pressure ulcer had been resolved. Interview on 8/24/17 at 8:00 a.m. with the director of nursing regarding resident 6 revealed: *There was no current wound nurse. *The unit managers would have completed oversight of wound management for the residents. *All of the interdisciplinary care team and herself were responsible to ensure appropriate interventions were in place to ensure no skin breakdown would have occurred. -She stated We work as a team here. *She confirmed: -The above medical record review. -He had experienced a decline in condition after his admission and had required increased staff assistance during that time. -That decline had placed him at a high risk for skin breakdown. *She agreed: -His Braden pressure ulcer risk assessment scores did not support a high risk for skin breakdown. -They should have recognized a decline in his health status would have placed him at risk. -He had acquired the stage two pressure ulcer while under the care of the facility. -No pressure relieving measures had been put in place to ensure he did not have any skin breakdown. -The skin assessment should have identified interventions to ensure no further skin breakdown had occurred and promote healing. -The skin assessments should have identified when a wound was healed. -They failed to be proactive with preventative interventions in a timely manner to ensure no skin breakdown had occurred. -The staff followed the care plan to ensure appropriate care had been provided. -The care plan was not updated, reviewed, and revised to ensure he had received the necessary care and services he required. -The dietician should have reviewed his chart to ensure he had adequate nutritional support and interventions to promote healing of an open wound. Review of the provider's 8/7/05 Assessment and Documentation of Pressure Ulcer policy revealed: *Purpose To screen, assess, plan, and implement appropriate skin care. *Policy: -Residents will be assessed for risk of pressure ulcers upon admission and ongoing throughout their stay. -Based on assessment findings, interventions will be implemented to reduce and/or prevent the risk of pressure ulcer development. *Procedure: -The Braden Scale will be completed on admission, then quarterly in conjunction with each MDS and/or significant change. An acute change in condition may warrant additional evaluation. -The residents care plan will be updated to identify if they are at risk for pressure ulcers, interventions, and treatment. -Interventions to reduce pressure ulcers will be implemented and may include but not be limited to: --Nutrition. --Hydration. --Repositioning. --Support surfaces. --Pressure redistribution. --Resident education. -Pressure ulcers will be treated as ordered by the physician and documented in the medical record. -Measurements and wound characteristics will be documented weekly.

Based on observation, record review, interview, and policy review, the provider failed to ensure one of three sampled residents (7) with pain had it adequately managed. Findings include: 1. Random observations of resident 7 on 8/22/17 from 8:00 a.m. until 7:00 p.m., and on 8/23/17 from 7:15 a.m. until 5:00 p.m. revealed she spent the entire day in her bed, primarily on her back. Review of resident 7's 8/22/17 physician's orders [REDACTED].>*Her [DIAGNOSES REDACTED]. *She had orders for the following medications for pain: -[MEDICATION NAME] tablet 20 milligrams (mg) by mouth three times a day for muscle spasms. -[MEDICATION NAME] HCl tablets 5 mg by mouth every 6 hours as needed for pain as needed. -[MEDICATION NAME] HCl tablet 50 mg give 2 tablet by mouth every 6 hours as needed for pain. Review of resident 7's Minimum Data Set (MDS) assessments revealed: *On 2/28/17 she had occasional pain she rated a seven. -She received an as needed pain medication. *On 5/25/17 she had received a scheduled and a PRN pain medication. -She had rated her frequent pain an eight. *On both of the above assessments she was alert and oriented to person, place, time, and had good recall. Review of the resident's August 2017 Medication Administration Record [REDACTED] *Had received the [MEDICATION NAME] eight of the ninety-two times she could have had it. *Had never received the PRN [MEDICATION NAME] for breakthrough pain. Interview of resident 7 on 8/22/17 at 2:00 p.m. and on 8/24/17 at 11:00 a.m. revealed: *She spent a lot of time in her bed. *She frequently refused to get out of bed because of pain. *She did receive a medication for her pain but continued to have pain. *It especially hurt whenever they moved her. *She had foam blocks that were supposed to be placed under her knees to prevent pressure to her feet and toes. -She refused to use it because it hurt her knees. Observation on 8/23/17 at 5:00 p.m. of certified nursing assistant (CNA) C and licensed practical nurse LPN (F) with resident 7 revealed: *They emptied her catheter. *They rolled her to her side when they were going to clean her up following an incontinent bowel movement. *The resident repeatedly stated Ow. That hurts. I hope you are done with this soon. Ow that hurts. -Her breathing was labored, and she made a groaning sound. *She acknowledged she had pain in her legs when asked. Review of resident 7's pain documentation on 8/23/17 revealed there had been no pain documented by the nurse or CNA following the above observation. Interview on 8/23/17 at 4:30 p.m. with CNA P regarding resident 7 revealed she: *Had pain a lot. *Complained of pain whenever she was repositioned. *Did not come out of her room for meals or activities because of the pain. Interview on 8/23/17 at 4:45 p.m. with LPN F regarding resident 7 revealed: *She confirmed the resident was noncompliant with care. *If the resident had pain they would give her something for pain. *No one had told her the resident was having pain. -She did not equate the repeated comments during the above observation with the resident having pain. Interview of resident 7 on 8/23/17 at 11:00 .am. revealed: *She always had pain in her leg. *She stated I would rate it an 8.5 to 9 on a scale of 1 to 10. *She thought she needed to tell the nurse when she had pain in order to get some medication for it. Interview on 8/23/17 at 1:50 p.m. of nursing supervisor B regarding pain assessments revealed: *They were completed on a quarterly basis with the MDS assessment. *They had not assessed the resident's pain level on a daily basis. Review of the provider's 4/6/09 Pain Management policy revealed *(Facility name) believes that all residents have the right to have their pain assessed, accepted, and acted upon by health care professionals. Effective pain management enhances resident comfort, health, and participation in his/her plan of care. (Facility name) believes it is our obligation to manage pain using an interdisciplinary approach. *All residents will be assessed for pain upon admission or readmission. *The Hierarchy of Pain assessment -1) Resident Self-Report. --a) A 0-10 numeric scale or the Wong/Baker faces will be utilized to assess intensity. -3) Observe for resident behaviors --a) Facial expressions --b) Physical movements --c) Vocalizations *2. Implementation of interventions: a. Interventions are indicated and expected for pain which is unacceptable to the patient, often a pain scale rating greater than 4 on a 1-10 pain scale.

Based on observation, interview, record review, job profile review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being of all seventy-four current residents. Findings include: 1. Interviews, observations, record reviews, and policy reviews, throughout the course of the survey revealed the administrator had not ensured the safe and complete management and overall well-being of the residents. Interview on 8/24/17 at 10:30 a.m. with the administrator and with executive management fell ow H present revealed he: *Agreed he did not regularly make rounds on or visit the long term care units. *Had not been aware of the grievance resolution process. *Had not known what the expectation of the social service designees was in assisting with grievances. *Had not known there had been times over fourteen days before grievances had been resolved. *Was aware the activity director had been working on the floor many days. -Agreed that caused the resident activities to have been very limited. *Thought the director of nurses (DON) did all incident investigations. Stated I think (DON name) just takes them all. *Was aware there were family members and some residents that thought the DON was difficult to approach and talk to. -Had not addressed that concern with the residents, family members, or DON. -Thought the lack of relationship building between the DON with residents, families, and staff had been because she had to address some specific areas of concerns when she first started as their DON. Refer to: F166, F248, F280, F281, F309, F314, F431, and F441. Review of the provider's last revised 5/30/17 President of Sturgis Market job profile revealed he: *Was responsible for providing strategic leadership for the organization and its related entities. *Creates an environment in which people feel valued, respected, and energized to explore new methods of doing business. *Ensured employees were competent to manage change. *Cultivated strategic customer relationships and ensured the customer perspective was considered. *Developed methods so that the strategic plan was cascaded to the facilities, and the management team was held accountable for implementation of the plans.

Based on observation, testing, record review, interview, manufacturer's recommendation review, and policy review, the provider failed to: *Prevent a fracture injury for 1 of 1 sampled resident (1) who had a repositioning bar on her bed. *Ensure the mattress and assistive device did not create an entrapment zone for 8 of 17 sampled residents (3, 4, 5, 6, 7, 8, 9, and 10). *Ensure 1 of 1 sampled resident (2) who had her bed raised in high position had received safety education and her care plan reflected her choice. Findings include: 1. Record review on 1/31/17 of resident 1's electronic medical record revealed: *She had been admitted on [DATE]. *Physician's admission orders [REDACTED]. *Repositioning bars had not been recommended for the resident according to the Repositioning Bar Assessment/Screen completed and signed by physical therapist B on 12/22/16. *The Minimum Data Set assessment dated [DATE] indicated: -Her cognitive or thinking ability had been severely impaired. -She required extensive assistance of two staff members for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. *Her admission care plan of 12/22/16 and completed care plan dated 1/2/17 had no mention of positioning bars. *Progress notes dated 1/11/17 at 10:30 p.m. by licensed practical nurse C stated During hourly rounds, resident was found with right arm folded up, hand behind head and wedged between positioning bar and mattress. Left arm folded between chest and floor. Rest of body on floor with left leg crossed over right. Assisted by 2 to unwedge arm and eased the rest of the way to the floor. Arm red with ~2cm ST (skin tear) with minimal bleeding. Right hand painful and floppy at wrist. Stabilized and wrapped with 2 ACE wraps. C/O left hip tenderness. Logrolled onto backboard. Left foot slightly adducted. Lifted onto gurney by 4 staff members. The resident was then taken to the ER (emergency room ). *An emergency room report dated 1/12/17 at 12:16 a.m. signed by the emergency room nurse stated X-rays had been negative. *A FAX (facsimile) dated 1/12/17 at 12:00 noon to the resident's physician stated: -A call had been received from the physician at the emergency room . -The resident had a fracture to her right wrist. -Orders had been received for a splint to keep the resident's wrist immobile. Interview on 2/1/17 at 9:18 a.m. with the director of nurses (DON) confirmed the above findings regarding resident 1. She stated the positioning bar had not been removed from the bed from the previous resident. Surveyor 2. Random observations on 1/31/17 from 9:00 a.m. through 4:00 p.m. and on 2/1/17 from 8:15 a.m. through 10:00 a.m. revealed seventeen resident beds with one or two assistive devices applied to the side of the bed at the top one-third of the bed. Random testing of resident's 3, 4, 5, 6, 7, 8, 9, and 10's bed revealed the mattresses moved around while sitting down on them or when the surveyor's knee bumped them. The mattresses slid easily on the bed frame causing gaps between the mattress and the assistive device creating an entrapment zone. Interview on 2/1/17 at 9:18 a.m. with the DON confirmed she was not aware of the mattresses and assistive device gap that was easily created with the above testing. Review of the provider's 2008 NOA Medical Industries, Inc., Operation and Maintenance Manual for the bed, on page 21 revealed a heading of Periodic Inspection and listed 2. Review 'REDUCING THE RISK OF ENTRAPMENT' listed in this manual. (The capitalized words were also bolded.) 3. Random observations on 1/31/17 from 9:00 a.m. through 4:00 p.m. and on 2/1/17 from 8:15 a.m. through 10:00 a.m. revealed resident 2's bed was in the high position. The resident was either sitting on the edge of the bed with her feet swinging or laying flat in the bed. Review of resident 2's medical record revealed no physician's order, no education completed for safety concerns, and no care planning for the bed being in the high positron per the resident's preference. Interview on 1/31/17 at 1:30 p.m. with resident 2 revealed she put the bed in the high position. However staff would place the bed in the low position. Interview on 2/1/17 at 9:18 a.m. with the DON confirmed she expected the bed to be in the low position when staff were not assisting the residents. Confirmed the care plan did not indicate the resident's preference to have the bed in the high position, and education on bed safety had not been done. Review of the provider's 2008 NOA Medical Industries, Inc., Operation and Maintenance Manual for the bed, revealed on page 3 The bed should be left in its lowest position when unattended to reduce the risk of injury to the resident due to falls while getting into or out of bed or while lying in the bed. Surveyor Review of the provider's last revised 12/12/16 Repositioning Bars policy revealed: *Residents had the right to be free from accident hazards as much as possible. *The provider would assess and identify assistive devices that were potential hazards to the resident and remove them when possible. *All residents were to have been assessed for the use of a repositioning bar upon admission or re-entry and then quarterly thereafter. *Residents would not have repositioning bars placed prior to the completion of the assessment process.

A. Based on observation, interview, record review, policy review, job description review, and pamphlet review, the provider failed to ensure nutritional interventions were in place by one of one registered dietician (RD): *For 1 of 1 sampled resident (4) who had been admitted with a stage I pressure ulcer to her coccyx. *For 1 of 1 sampled resident (4) who developed two unstageable pressure ulcers while under the care of the facility. *For 9 of 13 sampled residents (1, 3, 4, 5, 7, 8, 10, 12, and 13) who had significant weight loss. Findings include: 1. Observation on 7/19/16 at 8:20 a.m. of resident 4 revealed: *She had been laying in bed sleeping. *She had pressure relieving devices: -In her bed. -On both of her feet. -In her wheelchair. *She appeared to be very thin and weak. *Her bones were easily noticed through her skin. Interview on 7/19/16 at 9:10 a.m. with licensed practical nurse (LPN) C regarding resident 4 revealed: *She had good memory recall. *She had a history of [REDACTED]. Those pressure ulcers had been acquired during her stay in the facility. *She currently had an unstageable pressure ulcer to her right heel. *She had a poor appetite and would occasionally refuse meals. *The LPN had been unsure if the resident had been monitored for weight loss. Review of resident 4's medical record revealed: *An admission date of [DATE]. *She was admitted with a right lower leg fracture sustained from a fall and a pressure ulcer to her coccyx. *She had a history of [REDACTED]. *She had a stage I pressure ulcer to her coccyx upon admission. *She had received facility acquired unstageable pressure ulcers to both her left and right heels. *Her admission weight had been 100.6 pounds (lb). *A significant weight loss within six months of admission. Her weight had decreased to 89 lb. That weight loss had been 11% since admission. *She had been ordered a regular diet with thin consistency liquids. *She was to have been weighed weekly. *She had incomplete nutritional risk assessments documented on 12/23/15, 1/6/16, 1/16/16, 2/10/16, and 6/16/16 . -There were no risk factors, goals, or interventions recorded for her weight loss, skin breakdown, and poor nutritional intake. Observation and interview on 7/19/16 at 11:30 a.m. with certified nursing assistant E regarding resident 4 revealed: *She had prepared to assist the resident to get out of her bed. *She had stated: She does not always get up for every meal. If she was up for breakfast she probably will refuse to eat lunch. *The staff were to have offered the resident a glass of Ensure when she had refused a meal. *The resident frequently refused to drink the Ensure. Review of resident 4's Minimum Data Set (MDS) assessments revealed: *A 12/21/15 admission MDS assessment revealed: -A weight of 100 lb. -A stage I pressure ulcer to her coccyx. *A 6/6/16 quarterly MDS assessment revealed: -A weight of 89 lb. -Weight loss of 5% or more in last month or loss of 10% or more in the last six months indicated Yes, not on physician-prescribed weight-loss regimen. -She had one unstageable pressure ulcer. Review of resident 4's physician's orders [REDACTED].>*On 12/28/15: -No weight changes; no nutritional concerns. -Skin: wound care issues. *On 2/19/16: -Supplements offered but refuses; weight loss. No documentation to support any further nutritional recommendations. -Skin: wound care issues, pressure area of coccyx stage 2, not open and pink; pressure area of left heel greatly improved, right heel suspected deep tissue wound. *On 3/18/16 the physician's documentation and assessment regarding weight loss had been the same as 2/19/16. The pressure ulcers had been reviewed with no changes. *On 5/23/16: -Problems not reviewed (last reviewed 3/18/16) abnormal weight loss. -The pressure ulcers had been reviewed with no further changes recommended. *On 7/11/16: -She had been seen by the physician for a sixty day review. -Weight: No weight changes; no nutritional concerns. -No documentation to support the physician had been aware of the resident's 11% weight loss within six months. -Skin: wound care issues (right heel). *No documentation to support the RD had made any recommendations to the physicians for nutritional support during and in-between the above visits. Review of resident 4's 12/15/15 initial admit care plan revealed no documentation to support the RD had made any nutritional recommendations for weight gain and wound healing. Review of resident 4's current care plan revealed: *A focus area: -I have potential/actual impairment to skin integrity r/t (related to) [MEDICAL CONDITION], fragile skin. -The focus area had not been initiated until 7/1/16. *Goal for the above focus area: -I will be free from pressure related skin breakdown with current interventions through the next review date. -The goal had not been initiated until 7/1/16. *Interventions for the above focus area: -Encourage good nutrition and hydration in order to promote healthier skin. -No documentation to support what good nutrition the staff were to have provided for the resident. *She had required assistance from the staff to ensure all of her activities of daily living needs had been met. That had included offering her nutritional supplements when she refused to eat a meal. The focus area and intervention had been initiated on 12/22/15. No documentation to support the RD or staff had reviewed that intervention for appropriateness between 12/22/15 and 7/20/16. *A focus area: -I have the potential for a nutritional problem of under nutrition r/t limited meal intake. -The focus area had not been initiated until 6/16/16 after the resident had experienced a 11% weight loss. Review of the provider's nutrition at risk meetings documentation from 2/2/16 through 6/7/16 regarding resident 4 revealed: *She had: -Been identified as nutritionally at risk. -Been reviewed for meal intake, fluid intake, snack intake, therapy concerns, medical concerns, and skin issues on 2/2/16 and 4/5/16. -Not been reviewed during the months of March, May, and June. -Not been reviewed for weight changes or additional concerns during any of those monthly meetings. *No documentation to support the RD had any further recommendations or concerns regarding the results of her nutritional intake, weight loss, and current skin issues. Interview on 7/20/16 at 5:50 p.m. with the director of nursing revealed: *She was aware of resident 4's weight loss and skin concerns. *She confirmed resident 4's weight loss and skin concerns had not been addressed as to risk factors, goals, or interventions. *She confirmed: -The above observations, interviews, and medical record review. -Resident 4's weight loss and skin breakdown was a continual issue for her and should have been addressed upon admission and ongoing. *She had been informed several times the RD was behind with her nutritional assessments and documentation. *She was aware the RD had: -Failed to complete her nutritional assessments. -Not initiated a nutritional care plan on resident 4 until 6/16/16. -Not made recommendations to the physician and staff regarding the resident's weight loss and skin breakdown concerns. Interview on 7/21/16 at 8:00 a.m. with the administrator revealed: *He had not been aware resident 4 had identified as nutritionally at risk for weight loss and skin breakdown. *He would have expected: -Any resident who was admitted under a compromised state to have been appropriately assessed by the RD in a timely manner. -The nutritional assessments to have been fully completed. -Resident 4 to have been reviewed monthly at the nutrition at risk committee meetings. -Recommendations made to the physicians from the RD as deemed appropriate. Interview on 7/21/16 at 9:15 a.m. with the RD revealed: *She confirmed resident 4 was nutritionally at risk for weight loss and skin breakdown. *She stated resident 4 was discussed at the weekly nutritional risk committee meetings and care conferences. *She had been behind in completing her nutritional risk assessments. *She confirmed none of the nutritional risk assessments had contained documentation to support risk factors, goals, and interventions for resident 4. *She confirmed: -The above medical record review. -She completed section K of the MDS. -She completed the nutritional section for the care plans. -She had not made any recommendations to the physicians or staff as to how to address her weight loss and skin concerns. *She stated: I guess I dropped the ball on her. She just fell through the hoops. *She had no comment to offer when asked what her expectations of an RD were. Review of the provider's 2/24/2000 Comprehensive Care Plan policy revealed: *A comprehensive care plan is developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment (MDS). *The RD had been considered a part of the interdisciplinary care plan team. *Each resident's care plan has been designed to: -Identify problem areas. -Incorporate risk factors associated with identified problems. -Reflect treatment goals in measurable outcomes. -Identify the professional services responsible for each element of care. *The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS). *It is the responsibility of all staff involved in the resident's care to review and update the care plan on an ongoing basis. A complete care plan review will be performed at least quarterly. Review of the provider's 1/8/11 Skin Care Protocol policy revealed: *To define treatment and monitoring methods used for pressure ulcers. *To provide education, in-service, continuous quality management and care plan guidelines for prevention and treatment of [REDACTED]. *Prevention of Pressure Ulcers: -A Nutritional assessment is completed when a resident is identified at risk for skin breakdown. The assessment will be completed by the dietary manager or the facility dietician. -Weights will be monitored for weight loss/gain. The weights will be monitored monthly for residents that are high risk on the nutritional assessment and for a score of 18 or less on the Braden scale and for residents with actual pressure ulcers present. -Review of current dietary plan and any recommendations for appropriate changes in meal plan and/or supplement. -Reassess, reevaluate, and revise interventions when progress is not noted. Review of the provider's undated and unsigned Clinical Dietitian Job Description revealed: *Responsible for providing high quality nutritional care to LTC (long term care) residents. *Assess, plans, coordinates and provides safe and appropriate nutritional care assigned. This includes teaching and consulting. *Completes nutritional assessment/Minimum Data Set /Care Plans for Senior Care Resident on admission, quarterly, and as necessary with a change in condition. *Actively initiates evidence-based interventions with interdisciplinary collaborations to promote optimal patient care and outcomes. Review of the provider's undated Welcome pamphlet given to the residents and family upon admission revealed Facility Services: Attention to changing medical or psychosocial needs such as weight loss. 2. Record review, observation, and interview throughout the survey revealed residents 1, 2, 5, 7, 8, 10, 12, and 13 had significant weight losses. There were no RD assessments to identify risk factors, goals, or interventions for those residents. Refer to F325, findings 1, 2, 3, 4, and 5. B. Based on observation, interview, and policy review, the provider failed to ensure two of two unlicensed assistive personnel (UAP) (N and O) and one of one licensed practical nurse (LPN) (B) accounted for narcotic medications administered to three random residents at the time of administration. Findings include: 1. Observation on 7/19/16 at 12:05 p.m. of UAP N after she had administered [MEDICATION NAME] 50 milligrams (mg) to resident 21 revealed she did not sign for the medication in the narcotic accountability register. 2. Observation on 7/19/16 at 12:15 p.m. of UAP O after she had administered [MEDICATION NAME]/APAP 5/325 mg to resident 22 revealed she did not sign for the medication in the narcotic accountability register. 3. Observation on 7/20/16 at 11:30 a.m. of LPN B revealed after she had administered [MEDICATION NAME] 5/325 mg resident 23 revealed she did not sign for the medication in the narcotic accountability register. 4. Interview on 7/20/16 at 11:00 a.m. with UAPs N and O revealed: *They did not sign the narcotic accountability register for any narcotics they administered until after the midday medication pass. *The narcotic registers were kept at the nurses' desk. *They signed for all narcotics they had administered during their shift at one time. Interview on 7/20/16 at 4:40 p.m. with the director of nursing revealed her expectation had been for narcotics to have been signed out at the time of administration. Review of the provider's last revised 11/22/05 Controlled Substance Administration & Control policy revealed the signature of the nurse administering the narcotic medications was to have been recorded on the control sheet. Review of Patricia A. Potter et al., Fundamentals of Nursing, 8th Ed., Televise, St. Louis, Mo., 2013, page 566, revealed: *The nurse is responsible for following legal provisions when administering controlled substances such as opioids, which are carefully controlled through federal and state guidelines. *Hospitals and other health care agencies have policies for the proper storage and distribution of narcotics. *Use a special inventory record each time a narcotic is dispensed. Use the record to document the patient's name, date, time of medication administration, name of medication, dose, and signature of nurse dispensing the medication.

Based on observation, interview, record review, policy review, job description review, and pamphlet review, the provider failed to assess, develop, and implement interventions for: *One of one sampled resident (4) who had been admitted with a stage I pressure ulcer to her coccyx. *One of one sampled resident (4) who developed two unstageable pressure ulcers while under the care of the facility. *One of one sampled resident (4) who experienced a significant weight loss within six months of her stay in the facility. Findings include: 1a. Observation on 7/19/16 at 8:20 a.m. of resident 4 revealed: *She had been laying in bed sleeping. *She had pressure relieving devices: -In her bed. -On both of her feet. -In her wheelchair. *She appeared to be very thin and weak. *Her bones were easily noticed through her skin. *Her back had been curved causing her head to bend forward and to the right. Review of resident 4's medical record revealed: *An admission date of [DATE]. *She was admitted with: -A right tibia fracture sustained from a fall. -An immobilizer on her right leg/knee upon admission. -A stage I pressure ulcer to her coccyx. -A weakened and compromised health condition. *She had a history of [REDACTED]. *She had received two facility acquired unstageable pressure ulcers to both her left and right heels. -Those pressure ulcers had been acquired within thirty days of her stay in the facility. *She had been dependent upon the staff to assist her with all of her mobility and activities of daily living (ADL) *On 12/14/15, 3/12/16, and 6/6/16 her Braden pressure ulcer risk assessment scores ranged from 12 to 13. Those scores had indicated she was at high risk for developing pressure ulcers. b. Continued review of resident 4's medical record revealed: *Her admission weight had been 100.6 pounds (lb). *She had a significant weight loss within six months of admission. Her weight had decreased to 89 lb by the 6/6/16 Minimum Data Set (MDS) quarterly assessment. That weight loss had been calculated to 11%. *She had been ordered a regular diet with thin consistency liquids. *She was to have been weighed weekly. *She had incomplete nutritional risk assessments documented on 12/23/15, 1/6/16, 1/16/16, 2/10/16, and 6/16/16 . -There were no risk factors, goals, or interventions recorded for her weight loss, skin breakdown, and poor nutritional intake. c. Interview on 7/19/16 at 9:10 a.m. with licensed practical nurse (LPN) C regarding resident 4 revealed: *She had good memory recall. *She had a history of [REDACTED]. Those pressure ulcers had been acquired during her stay in the facility. *She currently had an unstageable pressure ulcer to her right heel. *She had a poor appetite and would occasionally refuse meal services. The LPN had been unsure if the resident had been monitored for weight loss. Refer to F281, finding 1. Refer to F314, finding 2.

Based on observation, interview, record review, pamphlet review, job description review, and policy review, the provider failed to: *Reposition one of two sampled residents (2) with a history of pressure ulcers according to his care plan and individual needs. *Implement interventions to promote healing and prevent pressure ulcers from developing for one of one sampled resident (4) who had acquired two unstageable pressure ulcers while in the facility. Findings include: 1. Interview on 7/19/16 at 9:10 a.m. with licensed practical nurse (LPN) C regarding resident 2 revealed: *He had: -Required staff assistance with all activities of daily living (ADL) including transferring him in and out of his wheelchair (w/c). -A urinary catheter to drain his bladder. -A history of pressure ulcers to his penis from the urinary catheter tubing. Review of resident 2's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *On 9/11/15, 12/10/15, 3/4/16, and 5/29/16 his Braden pressure ulcer risk assessment score ranged from 15 to 17. Those scores indicated he was at high risk for developing pressure ulcers. *On 5/27/16 a stage I pressure ulcer had been assessed on his penis. *He had required one to two staff members to assist him with all ADL. -That had included transfers and bed mobility. Observation and interview on 7/19/16 from 10:45 a.m. through 2:30 p.m. with certified nursing assistant (CNA) F regarding resident 2 revealed: *He: -Had a urinary catheter to drain his bladder. -Was incontinent of bowel. -Had received assistance with perineal care earlier in the morning before he got out of bed for the day. -Would not require perineal care the rest of the day unless he had to have a bowel movement. *She would let the surveyor know if and when she assisted him with perineal care. -Her shift ended at 2:30 p.m. *The CNA had not informed the surveyor of any perineal care for the resident during the above time frame. Random observations on 7/19/16 from 2:30 p.m. through 7:00 p.m. of resident 2 revealed he: *Had been sitting in his wheelchair on a pressure relieving cushion in the(NAME)unit activity room. *Did not leave the room. *Was assisted to the dining room for supper at 6:45 p.m. by an unidentified staff member. *Had been served his supper at 7:00 p.m. *Was not observed being repositioned in his w/c during the above time frame. Review of resident 2's current care plan revealed: *A focus of area: I have potential impairment to skin integrity r/t (related to) bowel incontinence, decreased mobility, need for assistance with toileting and transfers. -Revision date of 6/9/16. *A focus area: I am frequently incontinent of bowels r/t impaired mobility and dementia. -Interventions for the above focus area: Check me every two hours and as required for incontinence. -Revision date of 3/19/16. Interview on 7/20/16 at 5:50 p.m. with the director of nursing (DON) and the Minimum Data Set (MDS) assessment nurse regarding resident 2 revealed: *They had confirmed: -The above medical review for the resident. -He had acquired a pressure ulcer from his catheter tubing. -He required staff assistance with all ADLs. *They would have expected the staff to have repositioned him at a minimum of every two hours. 2. Observation on 7/19/16 at 8:20 a.m. of resident 4 revealed: *She had been laying in bed sleeping. *She had pressure relieving devices: -In her bed. -On both of her feet. -In her wheelchair. *She appeared to be very thin and weak. *Her bones were easily noticed through her skin. Interview on 7/19/16 at 9:10 a.m. with licensed practical nurse (LPN) C regarding resident 4 revealed: *She had good memory recall. *She had a history of [REDACTED]. Those pressure ulcers had been acquired during her stay in the facility. *She currently had an unstageable pressure ulcer to her right heel. *She had a poor appetite and would occasionally refuse meal. Observation on 7/19/16 at 10:53 a.m. with LPN C regarding resident 4 revealed: *She had prepared to apply [MEDICATION NAME] to her right heel. *The right heel had a hard, black, and thickened area attached to it. -That area measured approximately 2 centimeters (cm) by 2 cm. Review of resident 4's medical record revealed: *An admission date of [DATE]. *She was admitted with a right tibia fracture sustained from a fall. *She had: -A history of [MEDICAL CONDITION] reflux disease, depression, anxiety, [MEDICAL CONDITION], and pressure ulcers. -An immobilizer on her right leg/knee upon admission. -Acquired a stage I pressure ulcer to her coccyx during her stay at the hospital. -Acquired two facility acquired unstageable pressure ulcers to both of her heels within 30 days. -Been dependent upon staff to assist her with all her mobility and ADL needs. *On 12/14/15, 3/12/16, and 6/6/16 her Braden pressure ulcer risk assessment score ranged from 12 to 13. Those scores had indicated she was at high risk for developing pressure ulcers. Review of resident 4's 12/14/15 physician's admission orders [REDACTED] *She had a right tibia fracture with a knee immobilizer in place for support and stability. *The therapy department was to have weaned her out of the immobilizer. *Complete weekly skin assessment every Friday. *No documentation to support: -The staff should not perform skin checks underneath of the immobilizer. -A stage I pressure ulcer to her coccyx. -The resident was at high risk for pressure ulcers and required preventative interventions to ensure no further skin breakdown occurred. Review of resident 4's physicians' orders revealed on: *12/28/15: -She had been assessed by the physician. That physician confirmed she had a stage I pressure ulcer to her coccyx. -No documentation to support the resident required any specialized treatment for [REDACTED]. -No documentation to support the necessity for additional preventative skin break down interventions. *1/27/16 an order for [REDACTED]. -No documentation to support she had required the use of a specialized air mattress prior to 1/27/16. *1/29/16 an order for [REDACTED]. -No documentation to support why she needed those heel lift boots. *4/15/16 an order to Complete daily pressure assessment on right heel and document in assessments. May DC (discontinue) when healed. Review of resident 4's Skin Integrity Assessment records from 12/14/15 through 7/8/16 revealed: *On 12/14/15: -A stage I pressure ulcer had been identified on her coccyx. -No documentation to support her heels had been identified as an area of concern. *On 12/18/15 both heels had been identified as having dry skin attached to them. -That skin integrity change to both of her heels had occurred four days after admission. *On 12/31/15 her right heel had a 3.1 cm to 4.0 cm black area. -That area on her heel remained unhealed as of 7/20/16. *On 1/15/16 a 1.5 cm x 1.0 cm reddened area had been identified to her left heel. *On 1/29/16 that left heel area had increased in size to 2.0 cm by 1.8 cm. The area had been documented as deep purple/black in color. *On 2/12/16 both the left and right heels had been documented as Suspected deep tissue injury. *From 2/14/16 through 4/8/16: -The left heel showed progression towards healing with a decrease in size and improvement in color. -There was no documentation on the left heel after 4/8/16 to support when the wound had healed. *From 4/8/16 through 7/15/16 the right heel remained unhealed and unstageable. *No documentation to support: -The treatment, goals, and interventions put in place and utilized by the staff to ensure healing had occurred for all the areas of concern. -When the stage I coccyx pressure ulcer had healed. Review of resident 4's 12/15/15 initial care plan revealed: *Skin care had been identified as an area of concern. *She was to have received pressure ulcer care. -Staff had been directed to See TAR for orders. *She had a brace on her right lower extremity. *No documentation to support: -What type of pressure ulcer care she was to have received. -What interventions had been put in place for the staff to follow to ensure no further skin break down had occurred. -The staff should have performed skin checks underneath of her right leg brace to ensure no skin break down occurred. -How often she should have been repositioned. -She required staff assistance with transfers, bed mobility, and repositioning. -She had been at high risk for skin break down. Review of resident 4's current care plan revealed on 12/22/15: *A Focus area: I have a pressure ulcer to my right heel and am at high risk for pressure related skin breakdown r/t immobility. -That focus area had been revised on 3/19/16. *The interventions for the above focus area had not identified: -The use of a pressure relieving air mattress. -The use of pressure relieving foam boots to both of her feet. -Heel protectors and/or pillow to keep heels off the bed. -How often the staff should have checked the skin underneath the brace on her right leg. -What the facility policies/protocols for the prevention of skin breakdown were. -If the staff had reviewed and revised those interventions to ensure appropriateness since 12/22/15. Interview on 7/20/16 at 6:00 p.m. with the DON and MDS assessment coordinator regarding resident 4 revealed: *They confirmed: -The above medical record review. -She had been admitted in a weakened and compromised state. That condition had placed her at high risk for skin breakdown. -She had been admitted with a stage I pressure ulcer to her coccyx. -She had acquired the unstageable pressure ulcers to both of her heels while under the care of the facility. -There had been no documentation to support the staff had done skin checks underneath of her right leg brace. -No pressure relieving devices had been put in place prior to the physician's orders [REDACTED]. -The skin assessments should have identified interventions to ensure no further skin breakdown had occurred. -The skin assessments should have identified when a wound was healed. -The staff failed to be proactive with preventative interventions in a timely manner to ensure no further skin breakdown had occurred. -The staff followed the care plan to ensure appropriate care had been provided. -The care plan was not updated, reviewed, and revised to ensure she had received the necessary care and services she required. Review of the provider's 1/8/11 Skin Care Protocol policy revealed: *The goal is to identify residents at risk for developing pressure ulcers and to ensure that a treatment plan is in place for residents with pressure ulcers. *The Braden Scale protocol will be used to implement the appropriate prevention devices for all risk areas. *Bed and chair bound individuals with impaired ability to reposition will be assessed for additional factors increasing risk for pressure ulcers. These factors include immobility, incontinence, and inadequate nutritional intake. *Reposition bed bound and chair bound residents at least every 2 hours. *Utilize pressure reducing mattress or pressure reducing overlays (air or gel). *Heel protector's and/or pillows under legs/ankles to keep heels off of the bed. *Observe skin daily especially bony prominence's. Refer to F281, finding 1.

Based on record review, interview, and policy review, the provider failed to ensure: *Appropriate physical assessment, mental assessment, and psychosocial care had been conducted for one of one sampled resident (1) abused by one of one certified nurse assistant (CNA) (E). *The physical, mental, and psychosocial needs were met regarding the possible physical and/or verbal abuse by one of one CNA (E) for five of five identified residents (2, 3, 4, 5, and 6). Findings include: 1. Review of the initial internal investigation report review dated 1/7/16 by the director of nursing (DON) revealed: *At 1645 (4:45 p.m.) ___ (South Dakota Department of Social Services Specialist) came to the facility to talk to ____ (social services designee) the social worker and I about an anonymous complaint that they had that came in on a hotline. These were serious allegations against a male CNA in our facility that took care of ______ (resident 1). According to the DSS worker this male CNA had lifted this resident who is care planned as a hoyer lift, and he lifted her by hand and threw her into bed, covered her mouth with his hand to make her shut up, stated a camera was placed in the room and there is proof to these allegations as well as the resident having multiple broken bones. There have been no broken bones since this writer has been employed to the facility since 2013, May. *1-8-2016 0930 (9:30 a.m.) a call came in from the lawyer for the ____ facility and it was then stated that more allegations of slapping the resident hitting the resident and threats to hit her if she didn't be quiet were made, these also were not DSS allegations, and that the video that was obtained by the family was going to be given to us today and we would determine from these what to do. Phone interview on 1/12/16 at 3:57 p.m. between the complaint coordinator for the South Dakota Department of Health Office of Licensure and Certification and the DON revealed the DON had viewed the five video clips ____ (resident 1's)family attorney shared with the facility today. The five video clips showed CNA E's interactions with the resident as follows: a.Clip one and clip two dated 10/4/15 revealed CNA E pulling ____ (resident 1) head backwards, leaning her forwards, and throwing her legs into bed. *Note: Resident 1 was care planned to use a lift. -CNA E started perineal (peri)-care (hygienic care of personal areas), resident 1 'trills' (rapid fluttering of two tones together), and CNA E slaps her hard enough to be heard on the video. -CNA E resumes peri-care roughly, ___ (resident 1) 'trills', CNA E covers her mouth and possibly her nose, while pushing her head down onto the bed. b. Clip three dated November 18th reveals CNA E 'ripping' off ___ (resident 1) shirt, leaves her with not shirt on, before he leaves he places his fist to the side of her face in a 'warning stance'. *Pulled her into the bed naked, and left her there uncovered for a period of time. *Was rough with her while placing her legs onto the bed. c. Clip four dated October 18th revealed ___ (CNA E) and a new hire (CNA F) transferring the resident without a lift under the arm pits. It looks like she was dropped, but she was not it was an awkward transfer. *___ (CNA E) is then alone with ___ (resident 1), covers her mouth again while she is lying in bed. *___ (CNA E) also grabs ___ (resident 1) L (left) arm which is contracted, twists it and hold it off to the side. d. The last clip, no date given, he pulls her forward and hits her on the back hard with his fist. Review of resident 1's medical record and care plan revealed: *No interdisciplinary progress notes (IPN) regarding the above physical and verbal abuse. *No IPN that indicated her primary physician had been notified of the physical abuse. *No IPN of any physical assessment for any injuries. *Her care plan had not been updated to include monitoring for any signs or symptoms of emotional distress or a change or increase in any behaviors. Review of the CNA schedules for the Massa unit from 7/19/15 through 1/7/16 revealed: *CNA E worked Monday through Thursday evenings (2:00 p.m. to 10:00 p.m.) and then the week-end for one week. *Then Tuesday through Friday evenings with the week-end off on the next week. *That schedule rotated every two weeks. Interviews on 1/14/16 from 8:30 a.m. through 2:30 p.m. with CNA's A, B, C, F, G, and licensed practical nurse D revealed they had all worked with CNA E. None of them revealed any knowledge of abuse by any staff to any residents. Interview on 1/14/16 at 3:43 p.m. with the long term care supervisor revealed: *The provider had not interviewed other employees who had worked with or had interaction with CNA E. *The provider had not interviewed resident 1 or any other resident who had interaction with CNA E. *The licensed nurses and CNAs did not have a set schedule. Although some of the CNAs who had been at the facility for some time, such as CNA E, might have had a set working pattern during the week. *She tried to watch and audit CNAs and other employees on her shift. But was busy and did not audit resident care behind closed doors all the time. *It was policy that two staff must attend to a resident when using a lift. But she may not always catch everyone to do a two person. *The charge nurse would delegate where the CNAs would work on a particular unit. *The provider had put no monitoring of resident care in place for staff or residents. *The CNAs in training worked under the RNs and licensed practical nurses. But would work one-on-one with other CNAs while in a resident's room. *There was a resident who shied away from male staff due to one instance with a male CNA a while ago. But she had not noticed anything since that time. Interview on 1/14/16 at 3:55 p.m. with the DON revealed: *On 1/7/16 a 4:45 p.m. she and the SSD were notified by the DSS specialist of the alleged abuse of resident 1 by a male CNA. At that time she and the president had let CNA E work with supervision on the same unit in the skilled nursing facility, but on a different wing of that unit as advised by the provider's counsel. The DON confirmed CNA E was the only male CNA on the Massa unit. *Only she and the provider's counsel had viewed the video clips and interviewed CNA E on the alleged complaint. -She stated CNA E had admitted to the following regarding resident 1: --Twisting her contracted arm. --He had been losing his patience with her and five other residents (2, 3, 4, 5, and 6) for the past six months. --Putting her to bed in a rough manner. --He would forget what he was doing during her care. He would leave her in bed naked and leave the room. *After the interview with CNA E and his admittance to the abuse of resident 1 and others you could see a pattern with the residents he chose to abuse. -They all had some type of dementia. -All but one or two: --Could not display emotions. --Were non-verbal. --Had very little to zero family involvement. *She confirmed there were no progress notes to indicate resident 1's physician had been notified. She stated she had not had time to do a late entry. She stated the on-call physician at the hospital had been notified of the incident with resident 1. *There had been no physical examination of resident 1 by a physician. *The SSD had not spoken with resident 1 or any other residents. The SSD felt it would interfere with the police department's investigation. *She had not interviewed any other employees, as she was told it would interfere with the police department's investigation. She felt CNA E's admittance to the abuse was enough. *She had started mandatory training regarding abuse and neglect as of today, 1/13/16. *Neither she nor the president had considered the idea of counseling for resident 1 or the other residents. She was told they needed to see to what extent we need to talk with her (resident 1) after the police investigation. *Neither she nor the president had implemented monitoring of staff on various shifts and with various types of care. 2. Continued interview with the DON confirmed after CNA E had admitted to losing his patience with five other residents: *There were no progress notes to indicate other physicians had been notified after CNA E had admitted to the abuse of another five residents (2, 3, 4, 5, and 6). *She had not interviewed resident's 2, 3, 4, 5, and 6. Review of the Brief Interview of Mental Status scores revealed: *Resident 1 was zero (could not respond). *Resident 2 was zero. *Resident 3 was fifteen (highest score to understand). *Resident 4 was eleven. *Resident 5 was three. *Resident 6 was three. Review of resident's 2, 3, 4, 5, and 6's medical records revealed: *No IPN regarding any possible physical and verbal abuse. *No IPN that indicated their primary physicians had been notified of possible physical abuse. *No IPN of any physical assessments for any injuries. *Their care plans had not been updated to include monitoring for any signs or symptoms of emotional distress or a change or increase in any behaviors. 3. Exit interview on 1/14/16 at 5:30 p.m. with the facility president revealed: *He was made aware of the incident and complaint on 1/7/15. On that same day the provider's counsel advised the DON and himself to let CNA E work on another unit, away from resident 1, and with supervision. *He had not viewed the video clips. *He was not present when CNA E admitted to the abuse nor present for the termination of CNA E. *CNA E had been suspended since Friday 1/8/16 and relieved of duties as of 1/12/16 at 4:00 p.m. *He had relied on updates from the DON. *Neither he nor the DON had conducted any employee or resident interviews, as they might interfere with the police investigation. *He had not implemented any internal or outside resources to aide in psychosocial well-being counseling for resident 1 or the other five residents. Review of provider's final internal investigation report review by the DON revealed: * .on January 12th this writer was asked to go view the videos of the complaint and validate that it was indeed one of our staff members. *At that time I witnesses several counts of abuse on the videos and was able to identity the person doing the assaulting as one of our staff member, ____ (CNA E). *This writer and another staff nurse are going thru all of the files of the residents that CNA E had cared for and area looking for any other signs of further abuse. None have been found at this time. *___ (CNA E) did state in the meeting at the time of his termination that there were four other residents that he 'might' have lost his patience with. these residents files have been looked over and nothing found to indicate abuse occurred, such as bruises or falls unexplained etc. *The allegations of abuse have been found to be true and the videos have been viewed by this writer and the staff member involved has been terminated. *All of the residents named are unable to speak for themselves in any way to confirm or deny the abuse. *___ (DSS specialist) has been contacted to receive advise on how to proceed with the follow up with the resident involved from a social worker view as well as our social worker involvement to proceed with talking with the resident to assure she is ok, as well as the other residents. Review of the provider's 7/20/11 Suspected Abuse or Neglect of Elderly or Disabled Adults policy revealed: *1. Abuse, physical harm, bodily injury, or attempt to cause physical harm or injury, or the infliction of fear or imminent physical harm or bodily injury on an elder or disabled adult. *A. 5. The social work/discharge planning staff will coordinate with the Department of Social Services, the state's attorney's office or law enforcement during the investigative process. *A. 6. Contact and plans will be documented in the Ancillary Progress Notes of the patient's chart. *D. 3. Psychological (Emotional): -The person may exhibit these behaviors but of themselves they do not indicate psychological abuse or neglect. However, there may be clues to staff to ask more questions and look beyond the obvious . Review of the provider's 7/20/11 Reporting of Suspected Abuse or Neglect of Elderly or Disabled Adults policy revealed 4. The investigative report must include approaches put in place for prevention. Review of the provider's April 2009 Abuse Investigations, Protection of Residents During policy revealed: *Policy Statement: Residents will be protected form harm or retaliation during an abuse investigation. *A. 1. employees accused of participating in the alleged abuse may be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the administrator or designee. Review of the provider's undated Social Service Department and Care Planning policy revealed: *The social service department was primarily responsible for helping the residents manage social and emotional concerns. *The social service department should have focused on problems and needs that included emotional adjustment for expression of feelings, problems, and concerns.

Based on record review, interview, and policy review, the provider failed to identify and ensure one of one sampled resident (1) had been kept free from physical and verbal abuse by one of one certified nursing assistant (CNA) (E). Findings include: 1. Review of the initial internal investigation report dated 1/7/16 by the director of nursing revealed resident 1 had been physically and verbally abused by CNA E. Refer to F309, findings 1 and 3.

Based on observation, record review, and interview, the provider failed to ensure repositioning bars had been used in a safe manner to prevent potential injury for seven of seven sampled residents (1, 2, 3, 4, 5, 6, and 8) and actual injury for one of one sampled resident (9). Findings include: 1. Observation on 2/25/15 from 10:00 a.m. through 11:30 a.m. revealed seven residents (1, 2, 3, 4, 5, 6, and 8) had one or two repositioning bars on their beds. Interview on 2/25/15 at 3:15 p.m. with the director of nursing (DON) and the Minimum Data Set (MDS) assessment nurse confirmed: *No assessments had been completed for the safe use of repositioning bars for residents 1, 2, 3, 4, 5, 6, and 8, or for any of the residents with repositioning bars attached to their beds at this time. *The use of the repositioning bars had not been documented in the care plans or on the residents' cardexes. *Each resident's cardex was used by the certified nursing assistants to provide individualized care specific to that resident. 2. Review of the provider's incident reports for the past six months revealed a report dated 12/2/14 for resident 9. That report dated 12/2/14 for resident 9 revealed: *The resident had slid out of bed that morning. *She had caught her right arm in the repositioning bar. *There had been no injury identified for the following: bruising, loss of range of motion, or pain upon examination. *A slight redness had been present on the inner upper arm from the repositioning bar. *The repositioning bar was removed from the resident's bed at that time. Interview on 2/25/15 at 4:00 p.m. with the DON regarding the above incident for resident 9 confirmed: *No assessment or care planning had been completed for the safe use of the repositioning bar by the resident. *The use of the repositioning bar had not been documented on her cardex for the CNAs use. *It had not been reported to the State of South Dakota Department of Health when the resident had caught her arm in the repositioning bar. *She did not think the care plan had been revised after the resident had caught her arm in the repositioning bar. Further interview on 2/25/15 at 4:40 p.m. with the DON confirmed: *There had been no staff training that had addressed the use of the repositioning bars since the last survey on 6/12/14. *The quality assurance committee had not addressed the use of the repositioning bars since the last survey on 6/12/14. *After reviewing her notes from that survey she agreed the survey team had given technical assistance in regards to the repositioning bars. *That technical assistance had directed the provider to complete assessments and care planning for the need and safety for the use of the repositioning bars. *There had been no policy for the assessment and use of the repositioning bars.

Based on record review and interview, the provider failed to ensure: *One of six sampled residents (6) had psychoactive medications administered in an appropriate manner. *Three of six sampled residents (2, 7, and 11) had a gradual dose reduction (GDR) completed for the use of psychoactive (affects the mind) medications. Findings include: 1. Review of resident 6's physician's orders [REDACTED]. *On 6/15/12 an order for [REDACTED]. *On 6/20/12 the following medications had been discontinued: -[MEDICATION NAME] ([MEDICATION NAME]) (anti-psychotic). -[MEDICATION NAME] (anti-psychotic). *On 6/20/12 the following medications had been ordered: -[MEDICATION NAME] (anti-psychotic) 1.0 mg two times a day. -[MEDICATION NAME] (anti-anxiety and sedative) 25 mg at bedtime. -[MEDICATION NAME] (anti-psychotic) 20 mg IM (intramuscular) injection daily as needed (PRN). -[MEDICATION NAME] (anti-anxiety) 1.0 mg IM injection two times a day PRN. *On 7/10/12 an order for [REDACTED]. *Resident 6's most current [MEDICAL CONDITION] medications dated April 2013 included: -[MEDICATION NAME] 0.5 mg twice daily. -[MEDICATION NAME] 0.5 mg once daily. -[MEDICATION NAME] 0.5 mg IM injection twice daily PRN. -[MEDICATION NAME] 20 mg IM injection once daily PRN. -[MEDICATION NAME] 0.5 mg twice daily PRN. That had been reordered on [DATE]. Review of resident 6's June 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the 6/20/12 physician's encounter summary notes revealed "She does have some PRN [MEDICATION NAME], but staff states that does not even phase her. She is not hitting them but she is often agitated and requires a lot of care from the staff." Review of a 11/20/12 physician assistant's note revealed: *She had been observed by nursing staff having occasional breakthrough agitation that did not respond to PRN [MEDICATION NAME]. *"I recommend we trial [MEDICATION NAME] 0.5 mg two times daily PRN for breakthrough agitation." Review of the 7/27/12 significant change Minimum Data Set (MDS) assessment revealed "Her physician has attempted to assist in medication management of behaviors to increase quality of life, but resident had increased lethargy with some of the medication changes...As her lethargy increased, her behaviors decreased or resolved, but then she was not eating or drinking adequately and required more assist with cares. She is currently requiring extensive assist of one with all activities of daily living tasks including during meals. At times she will hold a glass or utensil, but falls asleep holding it. Some meals staff is not able to awaken her and she is not able to eat...Resident has had five falls since her previous assessment in June 2012. Due to her continued lethargy and low blood pressure, her physician discontinued her [MEDICATION NAME], her [MEDICATION NAME] was decreased from 1 mg to 0.5 mg, her [MEDICATION NAME] was held for two days and then resumed at half the dose...Due to decreased intake, resident does have signs and symptoms of dehydration including dry oral mucous membranes, dry lips and decreased skin turgor." A nursing progress note dated 7/5/12 by registered nurse (RN) M revealed she had relayed concerns to resident 6's physician of "Being extremely groggy and having low blood pressure. New medication orders made." Review of resident 6's 7/6/12 dietary assessment revealed: *Her weight had decreased thirteen pounds from 6/3/12 through 7/2/12. *From 6/1/12 through 6/18/12 her average recorded meal intake was 50 (%). *From 6/19/12 through 6/22/12 her average recorded meal intake was 21.3 (%). *From 6/23/12 through 6/30/12 her average recorded meal intake was less than 15 (%). *She had been recorded as "unable to wake up", "trying to swat Ensure away", "sleeping", and "refused." Random review of resident 6's MAR from 11/15/12 through 5/1/13 revealed "she had refused", "meds not offered" or had been "sleeping" forty-one times. Interview on 5/15/13 at 10:30 a.m. with RN L, one of the MDS coordinators, confirmed resident 6 had been lethargic (drowsy) from her [MEDICAL CONDITION] medications and had a significant weight loss as a result. 2. Review of resident 2's 4/3/13 physician's orders [REDACTED]. Review of resident 2's 5/1/3 through 5/31/13 MAR indicated [REDACTED]. Review of resident 2's pharmacy review notes from 4/26/12 through 4/29/13 revealed a note had been sent to the physician in January 2012 regarding a GDR. No response to that note had been documented until 7/23/12. No other documentation had been entered that had addressed a GDR or the continued use of the [MEDICATION NAME]. Review of resident 2's mood and behavior documentation record from 8/1/12 through 5/11/13 revealed only one behavior had been documented during that time frame. That documentation stated the resident had been very difficult to arouse or keep aroused on 9/6/12 during the day shift. Review of resident 2's 6/27/12 through 10/3/12 medication management meeting review sheets revealed the [MEDICATION NAME] orders and GDR was considered appropriate. The resident was on [MEDICATION NAME], and it was on the Beer's list of medications (medications considered potentially inappropriate for the elderly). The resident's current behaviors had been stable, and a GDR was contraindicated. Those sheets had been signed by nursing staff and the pharmacist. Review of resident 2's nursing progress notes from 1/3/13 through 5/11/13 revealed: *On 3/14/13 the resident's daughter had requested she be allowed to remain in bed until she had awakened. *The daughter had observed her mother had been awake two to three days per week. *Those days would be followed by one to two days when she had been very sleepy. *On 3/21/13 the resident was noted to be on bed rest related to a left leg fracture. *She had been treated with medication for restlessness on 3/24/13 and 3/25/13 after her leg fracture. *On 4/1/13 a significant change assessment had been completed from 3/21/13 through 3/27/13. *Her physician had met with the family and stated the prognosis had been poor. *The family had chosen comfort care at that time. *No behaviors had been documented during the above time frame. Review of resident 2's per requested need (PRN) medication record from 3/18/13 through 5/10/13 revealed ten times she had been too sleepy to take her scheduled medications. Review of a 7/23/12 physician's telephone order audit sheet signed by the physician's assistant (PA) revealed the current dose of [MEDICATION NAME] was to have been continued. It further stated any further GDR were clinically contraindicated due to behaviors. No further documentation had been included to support the behaviors or other indications that had contraindicated a GDR or the continued use of the medication. Interview on 5/14/13 at 2:50 p.m. with the pharmacist confirmed there had been delays in the past in receiving a response from the physicians in regards to GDRs. When a physician had not responded in a timely manner it had not been brought to the medical director's attention. Now that a PA had been hired last April 2012 it had been better. The PA had addressed those concerns now. Interview on 5/15/13 at 9:00 a.m. with the PA confirmed: *Interviews with nursing back in July 2012 had led her to believe the [MEDICATION NAME] should have been continued. *She had not reviewed the use of the [MEDICATION NAME] since that time. *She would not have expected nursing to have contacted her even with the significant change in status. Interview on 5/15/13 at 11:00 a.m. with licensed practical nurse H confirmed she had provided care to resident 2 over the past year that she had worked at the facility. She had not observed the resident to have behaviors that had endangered her or others. She had not refused care. She had refused her medications at times for up to two or three days at a time. She would get verbally short or snappy with staff at times. Interview on 5/15/13 at 2:30 p.m. with the DON confirmed: *All of a resident's medications were looked at every quarter when completing the Minimum Data Set (MDS) assessment. *She would not have expected that to have been done if a significant change in status MDS had been completed. The provider had no policy that addressed GDRs or the use of antipsychotic medications. 3. Review of resident 7's medical record revealed an order for [REDACTED]. There had been no documentation of an attempted GDR or contraindication of a GDR for the continued use of the [MEDICATION NAME]. 4. Review of resident 11's PRN Medication Record from 4/15/13 through 5/15/13 revealed he received [MEDICATION NAME] (for itching) 25 mg ten times. Two times he had requested the [MEDICATION NAME] for anxiety pre-[MEDICAL TREATMENT] (for kidney failure). Five times he had requested it prior to [MEDICAL TREATMENT]. Three times he had requested it there had been no reason recorded. The indicated use of the [MEDICATION NAME] had been for itching not for anxiety or pre-[MEDICAL TREATMENT]. 5. Interview on 5/15/13 at 12:45 p.m. with the director of nurses confirmed there had not been an attempted GDR for resident 7. She agreed there had not been any physician documentation to support the continued use of the [MEDICATION NAME]. She agreed pre-[MEDICAL TREATMENT] and anxiety had not been indicated as a use for [MEDICATION NAME] for resident 11.

Based on interview and record review, the provider failed to ensure one of one sampled resident (6) did not have an avoidable significant weight loss. Findings include: 1. Review of resident 6's medical record revealed she had an avoidable significant weight loss of thirteen pounds from 6/3/12 - 7/2/12 related to the use of psychoactive medications. Refer F329, Finding1.