Every finding on record at Oakview Terrace

Based on observation, interview, record review, and policy review, the provider failed to ensure a safe environment and supervision for one of one sampled resident (15), identified at risk for falling and with a fall prevention intervention that directed staff to not leave him in his wheelchair alone in his room, who fell from his wheelchair and sustained bruising and a laceration (a deep cut) above his left eyebrow when he was left in his room and his wheelchair alone by nursing staff. Findings include: 1. Observation and interview on 8/18/26 at 9:55 a.m. with resident 15 in his room revealed he was sitting in a recliner with his wheelchair folded up and tucked behind the bedroom door. He had a bruise under his left eye and steri-strips (thin, adhesive strips used to hold the edges of a cut or wound together as it heals) over his left eyebrow. He said that about a week ago in his room, he reached for something and fell out of his wheelchair, landed on his stomach, and bumped his face on the floor, which resulted in a bruised eye and lacerated eyebrow. 2. Review of resident 15's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His diagnoses included nontraumatic intracerebral hemorrhage (a sudden bleed inside the brain tissue, commonly referred to as a stroke, caused by a medical condition rather than an injury or accident), and polyneuropathy (a medical condition where multiple peripheral nerves throughout the body malfunction at the same time, causing numbness, tingling, burning pain, and muscle weakness). His 8/3/26 Brief Interview for Mental Status assessment score was 10, which indicated his cognition was moderately impaired. Resident 15's fall risk assessment scores on 5/4/26 and 8/3/26 were both 75, which indicated he had a high risk for falling. His 5/1/26 care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) indicated he tends to be impulsive and should be supervised while in his wheelchair. Progress notes in resident 15's EMR indicated that in addition to the fall he recalled on 8/8/26, he fell four more times since his admission to the facility, none of which required outside medical treatment. On 5/5/26, a progress note revealed resident 15 fell out of his wheelchair in the south television lounge and sustained a goose egg (a raised, swollen lump that forms on the head after a blunt impact), a small laceration to the right side of his forehead, and a small skin tear to his right upper forearm above his elbow. The intervention implemented to prevent subsequent falls was more frequent/closer monitoring. On 5/17/26, a progress note indicated resident 15 fell on the floor in front of his recliner in his room while trying to reach his TV remote. No injuries or interventions were documented. On 5/27/26, a progress note revealed resident 15's wheelchair cushion was not secured to his wheelchair and he slid out of his wheelchair while trying to turn off the television (TV) in his room, which resulted in a ping pong-sized hematoma (a localized collection of clotted or partially clotted blood outside of the blood vessels, caused by damage to an artery, vein, or capillary) to the right side of his forehead with a small cut in the middle. The intervention implemented to prevent subsequent falls was Resident is not to be left alone in his room while in [his] wheelchair. Make sure the [wheelchair] cushion is secured to the wheelchair. On 6/3/26, a progress note indicated resident 15 did not realize his call light was attached to his shirt. He attempted to get out of bed to get something without waiting for the staff's assistance and rolled out of bed and onto the floor, but did not sustain any injuries. The intervention implemented to prevent subsequent falls was to [lower the] bed to [the] floor, reminded resident to use call light. An 8/8/26 progress note revealed resident 15's most recent fall resulted in two 1-centimeter (cm) lacerations to his left eyebrow and a 1.2 cm by 1.6 cm skin tear and a hematoma to his left elbow. 3. Observation on 8/20/26 at 8:45 a.m. revealed resident 15 sitting in his wheelchair by a puzzle table in the south lounge area, near other residents being monitored by the staff. He remained there until 9:35 a.m., when activities assistant V wheeled him away to attend devotions in the dining room. 4. Interview on 8/20/26 at 8:55 a.m. with certified nursing assistant (CNA) K revealed that she knew resident 15 had a high risk for falling. To prevent him from falling in his room, the staff were to keep him out of his room when he was in his wheelchair so he did not try to get into his recliner or bed without the staff's assistance. They took him to the south lounge area to work on a puzzle or listen to music to keep a better eye on him. She said resident 15 knew he was not supposed to be alone in his room when he was in his wheelchair. 5. Interview on 8/20/26 at 9:10 a.m. with registered nurse (RN) F revealed she did not know whether any specific fall interventions were listed in resident 15's care plan, but she knew general interventions the staff used to prevent every resident from falling. We just check on him frequently and make sure his call light is within reach. She was not aware that specific interventions to prevent resident 15 from falling included making sure he was not in his wheelchair while in his room. 6. Interview on 8/20/26 at 9:41 a.m. with CNA J revealed that when resident 15 was in his room, he's supposed to be in his recliner, not his wheelchair. 7. Interview on 8/20/26 at 9:49 a.m. with director of nursing (DON) B revealed that while resident 15 knew he should not be in his wheelchair in his room alone, she said he could propel himself in his wheelchair to his room before the staff could assist him into his recliner. I don't believe [the] staff deliberately left him in his room alone, she said, and added that it was unacceptable that the staff left him alone in his room where he fell, since the intervention was noted. She considered every resident to be at risk for falling, and those who had an extreme risk had interventions in their care plan. Any updates regarding care plans or resident fall interventions were discussed among the staff during shift report and daily huddle (leadership team) meetings. She expected the charge nurses to ensure that the CNAs were following the residents' care plans. 8. Interview on 8/20/26 at 11:17 a.m. with administrator A revealed that she expected all staff to follow the residents' care plans. If the intervention was that we shouldn't leave him in his wheelchair alone, then we weren't following [his] care plan. 9. Review of the provider's July 2026 Baseline/Comprehensive Care Plans LTC [Long Term Care] Division Policy revealed the resident's comprehensive care plan was developed by an interdisciplinary team upon admission to the facility and updated quarterly and with a change in condition. It should address the resident and their safety concerns to prevent decline or injury and include interventions (actions, treatment, procedures, or activities designed to meet an objective) to help the resident attain or maintain their highest practicable physical, mental, and psychosocial well-being. 10. Review of the provider's April 2026 Falls and Accidents LTC Division Policy revealed that all staff were educated and have access to care plans, which were individualized for each resident and address potential hazards. B. Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the safety and supervision of two of two sampled residents (10 and 39) left the nursing home without the staff's knowledge (eloped) and entered the adjoining hospital. Findings include: 1. Review of the provider's 2/21/26 SD DOH report regarding resident 39's elopement revealed that on 2/21/26 at 8:10 p.m., the CNAs heard the nurses' station door alarm sound and responded to that alarm. They did not see any residents outside of that door. A different resident was in front of the door, and staff assisted the resident to a safe area. Resident 39 had received staff assistance at approximately 7:00 p.m. in her room. The hospital staff brought resident 39 back from the hospital at approximately 8:23 p.m. Resident 39 did not display any distress upon return to the nursing home. The RN was informed of that incident after the resident returned from the hospital but did not assess the resident. The staff assisted resident 39 with personal cares and put the resident to bed. 2. Interview on 8/20/26 at 12:15 p.m. with certified nursing assistant (CNA) S revealed she worked the day shift on 2/21/26 when resident 39 left the nursing home. She remembered assisting the resident that day, but she did not see the resident leave her room or the nursing home. She had heard the door alarm while she was providing care to another resident. She had looked out the nurses' station entrance door adjoining the nursing home and hospital, but did not see the resident. CNA S did not remember checking that all residents were accounted for after the door alarm had alarmed. Another resident was by the nurses' station entrance door, and she thought that resident had triggered that door alarm. The hospital staff brought resident 39 back to the nursing home, and the resident did not appear in distress and acted like her normal self. 3. Interview on 8/20/26 at 12:25 p.m. with DON B revealed that their camera footage was only available for seven days. The direct care staff did not have access to camera footage to check on the residents. She stated that by the time the hospital staff had brought back resident 39, and the nursing home staff realized the resident was not in her room, there was not enough time to do a head count on the residents. 4. Review of resident 39's record revealed she was admitted to the facility on [DATE]. Her care plan indicated she ambulated with assistance of one staff member with her walker, but for long distances she utilized a wheelchair and could self-propel. She was at risk for elopement and wandered at times related to being disoriented to place, and had impaired safety awareness and confusion related to dementia (a group of symptoms affecting memory, thinking, and social abilities). Her 12/3/24 elopement risk evaluation indicated she was not at risk for elopement. The staff was to distract her from wandering by offering diversions, structured activities, food, conversation, or television. 5. Following resident 39's elopement on 2/21/26, all staff were reeducated about the facility's elopement policy and procedure and that the time the door would alarm was shortened. The nurse assessment following resident 39's elopement was requested but was not provided by the end of the survey. 6. Review of the provider's 6/26/26 SD DOH FRI regarding resident 10 revealed that at 3:45 p.m. on 6/26/26, resident 10 was sitting in a chair by the nurse's station and the main entrance of the nursing home, which opened to an enclosed corridor that connected the nursing home to the hospital. Resident 10 had gotten out of the chair, exited the main door of the nursing home, and silenced the door alarm by pressing a bypass button next to the main entrance door. CNAs G and K heard the alarm before resident 10 silenced it, came to the main entrance door, and noticed that resident 10 was no longer seated near the nurse's station. Video surveillance showed that approximately 90 seconds after the door alarm sounded, CNAs G and K located resident 10 sitting in a chair in the enclosed corridor outside of the main entrance of the nursing home. They transferred him to his wheelchair and brought him back into the nursing home. RN F assessed resident 10 and found that his vital signs were all within normal limits. He had no injuries, pain, or discomfort. His physician and family member were notified of the incident. The elopement policy did not change between February and resident 10's 6/26/26 elopement, so assistant administrator D did not feel the staff needed to be reeducated on the policy in June. The staff hired between February and June received new employee orientation that covered emergency preparedness, wandering, and elopements, and were trained by existing CNAs to learn each resident's unique needs. Elopement drills were held following resident 10's 6/26/26 elopement, with opportunities identified for the staff to ensure that all current residents were accounted for after a door alarm sounded. Minimum data set (MDS) specialist/infection preventionist H reviewed elopement assessments for all current residents, and for those who identified as an elopement risk, she reviewed their assessments and care plans for accuracy. The facility's Care Plan policy was updated to include the results of the resident's elopement assessment. All residents' care plans were audited to ensure that they included the elopement assessment results, and ongoing audits are scheduled quarterly through the end of 2026. All audits were discussed at the facility's 7/13/26 Quality Assurance and Performance Improvement (QAPI) meeting. 7. Review of resident 10's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His diagnoses included unspecified psychosis (a state of losing touch with reality), dementia (a group of symptoms affecting memory, thinking, and social abilities), and neurosyphilis (when syphilis bacteria attack the brain and nervous system, causing delirium, mania, hallucinations, psychosis, and dementia). He had a 4/28/26 Brief Interview for Mental Status assessment score of 9, which indicated his cognition was moderately impaired. His 2/3/26 and 4/28/26 Elopement Risk Evaluations had scores of 3, which indicated he was at risk for eloping due to a history of wandering, attempting to leave the facility without informing the staff, and verbally expressing the desire to go home. Resident 10's progress notes indicated that the staff redirected him to his room or the nurse's station when he attempted to wander or leave the facility. An 8/18/25 progress revealed that resident 10 activated the door alarm when he opened the main entrance door of the nursing home at 4:30 a.m., and the staff redirected him back to his room. In January 2026 he moved to a room located closer to the nurse's station. His 5/5/26 care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) did not include any wandering or exit-seeking behaviors or any interventions related to those behaviors. His care plan indicated that he preferred to spend much of his day in his room reading his bible, watching television, and visiting with others. On 6/30/26, resident 10's care plan was updated to include his history of elopements on days when he demonstrates increased impulsivity/confusion and is seeking interaction with others. His care plan interventions were updated to include, Do not leave [resident 10] unattended when sitting at [the] nurse's station. Resident 10's care plan updated to include the results of his 2/3/26 and 4/28/26 Elopement Risk Evaluations, which indicated he was at risk for elopement due to a history of wandering, attempting to leave the facility without informing the staff, and verbally expressing a desire to go home. Resident 10's care plan updates were discussed at the staff huddle and shift report meetings from 7/1/26 through 7/8/26. On 7/29/26, the facility's interdisciplinary care team met and confirmed that resident 10 had made no additional attempts to exit the facility. 8. Interview on 8/19/26 at 3:04 p.m. with CNA G revealed that resident care plan updates were passed along during the staff huddle and shift report meetings by leadership staff and the charge nurses and were reflected on the care plan and Kardex (a report of the resident's care needs and interventions). The residents' EMR indicated if they wandered or were at risk for elopement, and the CNAs were to document their behaviors each shift. When residents wandered, the staff tried to distract or redirect them with an activity or a snack. 9. Interview on 8/20/26 at 8:55 a.m. with CNA K regarding resident 10's elopement revealed that she assumed a visitor or family member had left the nursing home when resident 10 eloped and activated the door alarm on 6/26/26. Since then, the staff no longer would leave resident 10 alone at the nurse's station, and the daily huddle and shift report meetings included updates on resident care plans and the residents who wandered. 10. Interview on 8/20/26 at 9:10 a.m. with RN F revealed that resident care plans were discussed at daily huddle and shift report meetings, then placed in a notebook at the nurse's station for the staff to review throughout the following week. She recalled that on 6/26/26, resident 10 was pretty antsy and probably just wanted a change in scenery. She said he frequently sat at the nurse's station to visit with the staff. 11. Interview on 8/20/26 at 9:49 a.m. with DON B revealed that all residents were to have an elopement assessment completed, and those who wandered or were at risk for eloping were to be discussed during the daily huddle and shift report meetings. She expected all nursing staff to familiarize themselves with all of the residents' care plans, which included individual interventions that helped prevent behaviors, including elopement. 12. Interview and record review on 8/20/26 at 10:10 a.m. with assistant administrator D revealed that following resident 10's elopement, director of facilities E disabled the bypass button next to the main entrance door, which previously allowed individuals to silence the door alarm after it sounded when the door was opened. Afte the bypass button was disabled, the staff had to enter a code on a keypad to turn off the door alarm. The staff placed a sign on the main entrance door that read, If you inadvertently sound the alarm, please remain right here until a staff member is able to connect with you. On 7/6/26, the bypass button was replaced with a keypad entry system that required a code to deactivate the door alarm. All staff were reeducated to perform a full count of current residents if they were unable to identify who activated the alarm. 13. Interview on 8/20/26 at 11:17 a.m. with administrator A revealed she expected the staff to interact with the residents who were at risk for eloping. 14. Review of the provider's July 2026 Elopement Policy and Procedure defines elopement as When a resident leaves the premises or a safe area unnoticed without the facility's knowledge and supervision or authorization, or when a resident breaches the door or walks or moves over the threshold. The procedure specified that, If no resident or person was observed setting off the alarm and no resident/person is visualized outside the nursing home: a. Notify the charge nurse, and b. account for all the residents and document that all residents were accounted for. 4. When a resident returns to the facility: a. Assess the resident's physical condition. b. Reassure of the resident's well-being/validate the resident's feelings.

Based on observation, interview, and policy review, the provider failed to ensure standard infection prevention practices were followed regarding one of one sampled resident (15) with a towel used for padding on the resident's wheelchair armrest that was not a cleanable surface. Findings include:1. Observation on 8/19/26 at 11:19 a.m. in the dining room revealed resident 15 sitting in his wheelchair at a table with two other residents. [NAME] Coban (a stretchy, self-adherent medical wrap that sticks only to itself and not to skin, hair, or clothing) was wrapped around the edges of a white towel that covered the right armrest of resident 15's wheelchair to provide a cushioned padding for the resident's right elbow and forearm. As resident 15 ate, his right arm alternated between resting in his lap, resting on the covered wheelchair armrest, and dangling over the wheelchair armrest with his hand touching the right wheel of his wheelchair. 2. Interview on 8/19/26 at 1:20 p.m. with resident 15 revealed that the therapy staff constructed the Coban and towel wheelchair armrest cushion to provide supportive padding for his right forearm and elbow. He did not know if it was ever cleaned. 3. Review of resident 15's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His diagnoses included nontraumatic intracerebral hemorrhage (a sudden bleed inside the brain tissue, commonly referred to as a stroke, caused by a medical condition rather than an injury or accident), and polyneuropathy (a medical condition where multiple peripheral nerves throughout the body malfunction at the same time, causing numbness, tingling, burning pain, and muscle weakness). He had an 8/3/26 Brief Interview for Mental Status score of 10, which indicated his cognition was moderately impaired. 4. Review of the Coban manufacturer's instructions for use (IFU) identified Coban as a single-use medical supply item made of porous material (a surface that physically traps bacteria inside tiny cracks, gaps, and pores) that absorbs liquids, sweat, and dirt, and loses its structural integrity when washed or sanitized. The manufacturer's IFU indicated that Coban was generally intended to be worn for 24 to 48 hours at a time, or until it became soiled or wet. 5. Interview on 8/19/26 at 1:30 p.m. with minimum data set (MDS) specialist/infection preventionist (IP) H revealed she did not know who put the Coban and towel padding on resident 15's wheelchair armrest, but she assumed it was the therapy staff. She did not know if the night-shift certified nursing assistants (CNAs) cleaned that padding when they cleaned the residents' wheelchairs. She thought the padding could be cleaned with Germicide (a brand of disposable wipes containing chemicals that destroy germs). If visibly soiled Coban wrap was on the resident's arm, rather than on his wheelchair, she expected the staff to replace it rather than clean it. 6. Interview on 8/19/26 at 2:30 p.m. with director of facilities E revealed he thought that the maintenance staff would repair the residents' wheelchairs with new parts, rather than tape them up. He assumed the nurses or CNAs put the Coban and towel on resident 15's wheelchair armrest to provide extra padding. If the staff had brought resident 15's wheelchair to the maintenance team to repair, he would have removed the Coban wrap and towel because it was an uncleanable surface. 7. Interview on 8/19/26 at 2:10 p.m. with physical therapist (PT) N revealed she tried several adaptive wheelchair armrest devices to relieve pressure on resident 15's right forearm and elbow. Most covered arm rests use Velcro straps to keep the armrest in place, which could be unstable if resident 15 leaned hard on the armrest. She monitored the resident 15's wheelchair armrest padding regularly and replaced the Coban and towel three times after they became visibly soiled. She agreed that Coban was a porous product that should be replaced rather than cleaned. 8. Interview on 8/19/26 at 3:04 p.m. with CNA G revealed the night shift CNAs were to clean the residents' wheelchairs. She thought the nurse or physical therapist changed the towel and Coban armrest padding on resident 15's wheelchair if it was dirty. 9. Interview on 8/20/26 at 8:55 a.m. with CNA K revealed she thought the therapy staff provided the towel and Coban armrest padding and were responsible for cleaning the padding. 10. Interview on 8/20/26 at 9:25 a.m. with PT and director of rehab M revealed he was not aware of the Coban and towel padding on resident 15's wheelchair armrest. He expected any adaptive device to be cleaned regularly and Coban to be removed and replaced regularly, rather than cleaned. He said, We should find something for him [to have on his wheelchair armrest] that is a washable or cleanable surface. 11. Interview on 8/20/26 at 9:49 a.m. with director of nursing (DON) B revealed she stated that a porous material like Coban only poses an infection control risk if it is visibly soiled. She expected the CNAs to clean resident 15's Coban and towel padding on his wheelchair armrest each night using Super Sani-Cloth Germicidal Disposable Wipes (disinfectant wipes used to clean, deodorize, and rapidly kill bacteria, viruses, and fungi on hard, non-porous environmental surfaces and medical equipment). When the Coban and towel padding became visibly soiled, she expected the CNAs to take the wheelchair into the shower room to clean and disinfect it. 12. Review of the provider's February 2026 Wheelchair Inspection and Maintenance policy revealed that the CNAs were to regularly clean resident wheelchairs, the maintenance staff were to repair them, and all staff were responsible for identifying proper wheelchair function, integrity, safety, and reliability. 13. Review of the provider's 11/22/22 infection control program policy revealed the policy was to prevent transmission of diseases within FRHS, to prevent healthcare-associated infections, to maintain a sanitary environment for patients, residents and staff, and to provide appropriate infection control education to staff. All personnel would determine infection control risks throughout the facility and ensure compliance with federal, state, and CDC infection control regulations.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to report a serious bodily injury from an unknown source to the SD DOH within two hours for one of one resident (38) when she was found with head trauma and deceased in her room by two of two certified nursing assistants (CNAs) (R and S).Findings include:1. Review of the provider's [DATE] SD DOH FRI received at 4:40 a.m. revealed that on [DATE] resident 38 was found unresponsive on her bedroom floor at 1:50 a.m. with severe trauma to her head by CNAs R and S.Resident 38 had a do-not-resuscitate (DNR) (a medical directive stating that if a person's heart stops or they stop breathing, healthcare staff should not perform CPR or other resuscitation measures) code status. CNA R and S notified RN T, who determined the resident had no respirations or pulse. RN T and CNA U lifted resident 38 off the floor with a total body lift (a mechanical lift and sling used to lift a person's full body) and placed her in her bed.CNA R and S last saw the resident at 10:00 p.m. to assist her with getting ready for bed and left her sitting in her recliner watching television (TV). Resident 38 was independent in her room, and she did not activate her call light for staff assistance. Resident 38 was wearing gripper (non-skid) socks. The lights and TV were on in the room. Her electric recliner was in a high position. The call light was on the right arm of her recliner, and her walker was positioned to the left side of the recliner, against the wall between the TV stands. The door was opened slightly.RN T called director of nursing (DON) B at 2:03 a.m. to inform her of the incident and requested directions due to the unusual nature of the event. DON B called system DON O at 2:10 a.m. to prepare to go into the facility to support the staff. Resident 38's family member was called at 2:15 a.m., and DON B called administrator A at 2:18 a.m. DON B and administrator A determined that they did not need to notify the coroner. DON B notified RN T that the coroner did not need to be notified and that resident 38 could be moved to her bed and be provided with postmortem (after death) care. RN T documented in the progress note that she notified the on call doctor, medical doctor P, at 3:39 a.m.2. Review of resident 38's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her [DATE] Brief Interview for Mental Status (BIMS) evaluation score was 9, which indicated her cognition was moderately impaired. Her diagnoses included unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities), type 2 diabetes mellitus (a condition involving disruptions in how the body regulates blood sugar), polyneuropathy (a symmetric peripheral nerve disorder resulting in varying degrees of sensory loss, pain, and weakness), and atrial flutter (an abnormal rapid and regular heart rhythm).Her [DATE] care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated that she was independent with repositioning herself in bed, eating, drinking, oral care, personal hygiene, transfers, going to the bathroom during the day, and using a bedside commode at night. She was independent with her walker in her room and wore incontinence (involuntary urine or bowel leakage) supplies. She required one staff member to assist with dressing, undressing, and propelling in her wheelchair outside of her room. She did not wear shoes, only gripper socks.Her [DATE] Morse Fall Scale (a tool used in healthcare to estimate a patient's risk of falling by scoring factors like history of falls, gait, and use of assistive devices) assessment score was 90, indicating she was at high risk for falling.Her [DATE] progress note indicated that resident 38 did not have respirations or a pulse and had severe facial trauma after her fall. RN T called resident 38's family member at 2:15 a.m., then called the funeral home at 2:58 a.m. and at 3:23 a.m., and then called medical doctor P at 3:39 a.m. The progress note did not indicate what information medical doctor P provided to the facility to pronounce her death.3. Interview on [DATE] at 9:20 a.m. with CNA R revealed that she worked the night shift on [DATE] and had assisted resident 38 with personal cares around 9:00 p.m. She passed fresh water to the residents around 3:00 a.m., and when she entered resident 38's room, she saw her lying in the middle of her room with blood around her face and head area. If the residents were independent, the staff would check on them at 3:00 a.m., when the staff passed out fresh water. If independent residents did not activate their call light, the staff did not check on them more often. After resident 38's incident, the staff checked on the residents when they went to bed and again at 1 a.m., 3 a.m., and 4 a.m.4. Interview on [DATE] at 9:30 a.m. with CNA S revealed that she worked the night shift on [DATE] and had assisted resident 38 with personal cares. The staff were told after resident 38's incident that they had to check all residents every two hours.5. Interview on [DATE] at 10:33 a.m. with RN T revealed that she worked the night shift on [DATE]. RN T contacted DON B via text message regarding resident 38's incident, and then DON B called system DON O to come in to help the staff. RN T called resident 38's family, the funeral home, and completed the paperwork regarding resident 38's incident.Since resident 38's incident, RN T stated she would check on every resident during rounds regardless of the resident's ability to care for themselves.6. Interview on [DATE] at 1:25 p.m. with DON B revealed that an incident such as resident 38's had never happened at the facility. She stated that the facility had 2 hours to notify the SD DOH of an unexpected death and acknowledged they failed to do so.7. Interview on [DATE] at 2:51 p.m. with administrator A and DON B revealed that on [DATE], system DON O started an investigation regarding 38's incident and completed the investigation on Monday ([DATE]). Administrator A said the facility had 2 hours to notify the SD DOH of an unexpected death and acknowledged they failed to do so.8. Interview on [DATE] at 8:15 a.m. with CNA J revealed that she was not sure of the reporting times for unexpected deaths, abuse, or neglect scenarios. She believed she had to notify DON B within 24-48 hours if she suspected or had seen abuse, neglect, or a resident had an injury.9. Interview on [DATE] at 8: 25 a.m. with CNA Q revealed that the staff had 48 hours to report any unexpected deaths, abuse, or neglect to DON B if she suspected or had seen abuse, neglect, or a resident had an injury.10. Interview on [DATE] at 9:14 a.m. with RN F revealed the facility had to notify DON B immediately of any suspected abuse or neglect, and the facility had two hours to notify the SD DOH of the incident and investigation regarding resident 38.

Based on observation, record review, and interview, the provider failed to post the required daily nursing staffing information that included the facility name, total number of staff hours. and the actual hours worked by nursing staff for 33 or 33 random days reviewed in March, April, and June of 2025. 1. Observation on 6/24/25 at 9:39 a.m. of the posted nurse staffing information revealed: *It was posted on a board near the nurses' station. *It did not contain the name of the facility as required. *There were six categories of staff listed on the sheet: RN (registered nurse), LPN (licensed practical nurse), CNA (certified nursing assistant), Medication aide, Restorative aide, and shift totals. *Within each of those categories the number of staff scheduled for the day was listed by shift. *There was one RN listed for each identified shift. *The CNA area under the 6:00 a.m. to 2:00 p.m. shift indicated there were six CNAs working within the facility during that time frame. *There were no documented actual or total hours worked on the form for nursing staff as required. 2. Review of the 6/24/25 nursing staff assignment sheet revealed: *There had been a staff member who was ILL for the 6:00 a.m. shift. *The staff member who had called in ill was not replaced by another CNA on the assignment sheet, which indicated there were only five CNAs present for that 6:00 a.m. shift. *Nurses in management roles were not listed on the assignment sheet. 3. Interview on 6/25/25 at 2:14 p.m. with RN H revealed: *The night nurse was responsible for completing the daily staffing sheet and posting it on the board near the nurses' station. *The numbers entered on the daily staffing sheet were gathered from the nursing staff assignment sheet, which listed the staff who were scheduled to work for the upcoming day. *She verified the CNA that was documented on the assignment sheet on 6/24/25 as ILL was not replaced by another staff member. *She verified the 6/24/25 daily staffing sheet was not updated to reflect the staff present during that shift. *She indicated if someone called in or did not show up for their shift, the daily staffing sheet would not be updated to reflect the actual number of staff present in the facility that day. *Nurses in management positions, such as the Minimum Data Set (MDS) nurse and the director of nursing (DON), were not included in the nursing staff numbers reflected on the daily staffing sheet. *The actual and total number of hours worked were not calculated and documented on the daily staffing sheet. 4. Interview on 6/26/25 at 12:09 p.m. with DON B revealed: *She expected the daily staffing form to be adjusted if there was a staff member call in to accurately reflect the number of staff working in the facility for the shift. *She verified there was no facility identification on the daily staffing form as required. *She agreed the daily staffing form did not reflect the actual staff hours worked, or the total number of staff hours worked as required. Review of the provider's June 2025 Nursing Daily Staffing Information Posting policy revealed: *The facility posts the following information on a daily basis: -1. Facility name -2. The current date -3. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. -4. Resident census. *The facility must post the nurse staffing data mentioned above on a daily basis at the beginning of each shift.

Based on record review, interview, and policy review, the provider failed to complete a baseline care plan and provide a written summary of the baseline care plan to the resident or their representative for seven of seven recently admitted sampled residents (11, 14, 17, 37, 38, 40 and 195) within 48 hours of their admission to the facility. Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her baseline care plan revealed her preferred wake time had been left blank. *There was no documentation that indicated the resident's baseline care plan was developed and reviewed with her, her representative, or that they had been provided or offered a copy of her baseline care plan within 48 hours of her admission. 2. Review of resident 37's EMR revealed: *He was admitted on [DATE]. *His baseline care plan did not include his dietary orders. His preferred wake time, sleep time, and bathing preferences had been left blank. *There was no documentation that indicated the resident's baseline care plan was developed and reviewed with her, her representative, or that they had been provided or offered a copy of her baseline care plan within 48 hours of her admission. 3. Review of resident 38's EMR revealed: *She was admitted on [DATE]. *Her baseline care plan did not include initial goals or a discharge plan, and her preferred wake time had been left blank. *There was no documentation that indicated the resident's baseline care plan was developed and reviewed with her, her representative, or that they had been provided or offered a copy of her baseline care plan within 48 hours of her admission. 4. Review of resident 40's EMR revealed: *She was admitted on [DATE]. *Her baseline care plan did not include initial goals or a discharge plan, and her preferred wake and sleep times had been left blank. *There was no documentation that indicated the resident's baseline care plan was developed and reviewed with her, her POA, or that they had been provided or offered a copy of her baseline care plan within 48 hours of her admission. 5. Review of resident 14's EMR revealed: *She was admitted on [DATE]. *Her baseline care plan did not include the date when the baseline care plan was completed, or by whom. *There was no documentation that indicated the resident's baseline care plan was developed with her, her representative, or that they had been provided or offered a copy of her baseline care plan within 48 hours of her admission. 6. Review of resident 17's EMR revealed: *She was admitted on [DATE]. *Her baseline care plan did not include her preferred wake time, sleep time preference, her bathing preference, her discharge goal, the date when the baseline care plan was completed, or by whom. *There was no documentation that indicated the resident's baseline care plan was developed with her, her representative, or that they had been provided or offered a copy of her baseline care plan within 48 hours of her admission. 7. Review of resident 195's EMR revealed: *She was admitted on [DATE]. *Her baseline care plan did not include the date when the baseline care plan was completed, or by whom. *There was no documentation that indicated the resident's baseline care plan was developed with her, her representative, or that they had been provided or offered a copy of her baseline care plan within 48 hours of her admission. 8. Interview on 6/25/25 at 2:31 p.m. with director of social services F regarding residents' baseline care plans revealed: *Nursing staff was responsible for completing the residents' baseline care plans when they admitted to the facility. *She expected that all areas within the baseline care plan to be completed. *It was not the provider's process to document when the resident's baseline care plan would have been completed or by whom. *It was not the provider's process to document on the resident's baseline care plan or in the resident's EMR if or when the baseline care plan was reviewed and offered to the resident or the resident's representative. *If the resident representative was not present to be able to review the resident's baseline care plan, the social services department would mail a copy of the baseline care plan to the resident's representative. *She had not documented when she mailed the resident's baseline care plan, or to whom. *She agreed that if she mailed the resident's baseline care plan to the resident's representative, it would not have been available for review within the first 48 hours of the resident's admission. 9. Interview on 6/25/25 at 2:31 p.m. with registered nurse (RN) H regarding residents' baseline care plans revealed: *The nurse was to complete the baseline care plans upon the resident's admission. *She stated the baseline care plans were usually completed within the first few hours of a resident's admission to provide direction for the resident's care needs and preferences, but the baseline care plan must be completed within 48 hours of their admission. *All areas of the baseline care plan were expected to be completed. *She did not review the baseline care plan with the resident or the resident's representative once it was completed. *She did not provide or offer a copy of the baseline care plan to the resident or the resident representative upon completion. *She verified there was no location on the baseline care plan to document when it was completed or by whom. *She did not document in the EMR when the resident's baseline care plan had been completed. 10. Interview on 6/26/25 12:09 p.m. with director of nursing (DON) B regarding baseline care plans revealed: *She expected all areas of the baseline care plan to be completed within 48 hours of a resident's admission. *She agreed without documentation of the date the baseline care plan was completed, there was no way to verify if it was completed within 48 hours of the resident's admission. *She was aware there was no documentation to support that the resident's baseline care plans were reviewed or if a copy was offered to the resident or the resident's representative. Review of the provider's June 2025 Baseline Care Plan policy revealed: *A baseline care plan will be developed within 48 hours of a resident's admission to promote continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable are informed of the initial plan of delivery of care and services by receiving a written summary of the baseline care plan. *The baseline care plan will include the minimum health care information necessary to properly care for a resident including, but not limited to: 1. Initial goals based on admission orders, 2. physician orders, 3. dietary orders, therapy services, 5. Social services, 6. PASRR [Pre-admission Screening and Resident Review] recommendations, if applicable, 7. Instructions needed to provide effective person-centered care that meets professional standards of quality of care, 8. Address resident safety concerns to prevent decline or injury, 9. Identify needs for supervision, behavioral interventions and assistance with ADL's [activities of daily living] as necessary. *There will be documentation in the clinical record that the baseline care plan was given to the resident and/or representative.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, observation, record review, interview, and policy review, the provider failed to follow resident's care plans to: *Provide adequate supervision for one of one sampled resident (40) who was left unsupervised in the whirlpool tub by two certified nursing assistants (CNA) (K and Q). *Provide adequate assistance by one of one CNA (S) for one of one sampled resident (38) who fell and sustained an injury and pain that required evaluation at the emergency room. Findings Include: 1. Review of the provider's 4/29/25 SD DOH FRI revealed: *On 4/28/25 at 4:15 p.m., CNAs O and P heard [resident 40] yell Hello from the [whirlpool] tub room, and went into [the whirlpool] tub room and noted [resident 40] sitting in the whirlpool [tub] without any staff member present. *CNA O immediately assisted resident 40 out of the [whirlpool] tub and back to her room. *The provider's investigation revealed that CNA K had initiated resident 40's bath and then had asked CNA Q to finish providing that bath. CNA Q then requested Charge Nurse [registered nurse (RN) R] tell CNA P to go into the [whirlpool] tub room to sit with [resident 40]. *CNA Q kept moving assuming she [RN R] had passed on that message [to CNA P]. *CNA O indicated she knew [CNA K] gave [resident 40] a bath and that [CNA K's] scheduled shift ended at 3:30 p.m. *When interviewed regarding that bath, resident 40 indicated, It was wonderful! I soaked and I enjoyed it! *When asked if she had to wait long after she called out, resident 40 stated, No, what [when] I was ready, I yelled Hello and a nice young lady came [in] right away. * .Poor communication and multiple assumptions amongst multiple staff impacted this situation. *CNA Q was the last staff member in the [whirlpool] tub room with [resident 40] and should not have left [resident 40] alone in the [whirlpool] tub room . 2. Interview on 6/24/25 3:40 p.m. with resident 40 and her power of attorney (POA) revealed: *Resident 40 recalled the above event when she was left alone in the whirlpool tub and stated, I loved it. *She indicated that she had been wearing a plastic safety strap and had not been worried or afraid when she was left alone. She had requested to soak in the whirlpool tub, and the staff had come into the room right away when she called out. *She knew CNA K had to leave that day while she was in the whirlpool tub, and that there had been a miscommunication between the staff about who was going to help her in getting out of the whirlpool tub. *She got herself washed and dressed each day, but was told after the incident on 4/28/25 that someone was supposed to have remained in the whirlpool tub room with her that day. *She had not been left alone in the whirlpool tub before the incident on 4/28/25 or since then. *She stated that she did not want anyone to get in trouble, she loved it there, and that the staff were my little angels. *Her POA stated that she had been informed of the incident, she had no concerns, and that resident 40 had shared with her it was the best bath. 3. Review of resident 40's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 2/20/25 Brief Interview of Mental Status (BIMS) assessment score was 9, which indicated she was moderately cognitively impaired. *Her 5/20/25 BIMS assessment score was 11, which indicated she was moderately cognitively impaired. *Her 2/26/25 revised care plan indicated she preferred a shower and required one staff member's assistance to get in and out of the shower, to wash her lower body, back, and hair. *Her 4/28/25 revised care plan indicated she preferred a shower and required one staff member's assistance to get in and out of the whirlpool tub, and to wash her lower body, back, and hair. *Her 5/28/25 revised care plan indicated she preferred a shower and required one staff member's assistance (SBA) [stand by assistance] to get in and out of the whirlpool tub. Once in the whirlpool [tub] [resident 40] is independent with bathing, staff [member] to stay in [the] room and assist as needed and requested by [resident 40]. 4. Observation on 6/25/25 at 9:00 a.m. of the nurses' station and whirlpool tub room revealed: *The whirlpool tub room was located directly across from the nurses' station. *While standing at the furthest point away from that whirlpool tub room, at the nurses' station, the conversation between the staff and the resident in that whirlpool tub room was able to be heard over the noise of the whirlpool jets. 5. Interview on 6/26/25 at 7:45 a.m. with director of nursing (DON) B revealed that CNA Q had resigned and was not available for an interview related to the 4/28/25 incident with resident 40. 6. Interview on 6/26/25 at 10:13 a.m. with CNA K revealed: *On 4/28/25, she had been asked by CNA Q to provide resident 40 with a whirlpool bath. She had started that whirlpool bath; however, her shift ended at 3:30 p.m., and she needed to leave. *CNA K requested that CNA Q finish resident 40's whirlpool bath, and CNA K provided CNA Q with a verbal report in the whirlpool room of what tasks needed to be finished, and that resident 40 had requested to soak in the tub. *CNA K knew that resident 40 liked to take a long bath and indicated that she should not have started a bath that she could not finish before the end of her shift. *CNA K indicated that when she left the whirlpool tub room on 4/28/25, resident 40 was in the whirlpool tub, and CNA Q had agreed to complete resident 40's whirlpool bath; however, CNA K saw CNA Q leave the whirlpool tub room and heard CNA Q state that she would be right back. *CNA K had not worked with CNA Q before that incident and thought that CNA Q would have finished resident 40's whirlpool bath. *CNA K stated that staff members carried walkie-talkies to communicate with each other, but resident 40 had no way to alert staff of her need for assistance, while in the whirlpool, except to yell for help. *CNA K thought that resident 40 was safe to be in the whirlpool tub unattended for a short period because resident 40 was independent with bathing and dressing, did not need physical assistance with bathing while in the whirlpool tub, and had requested to rinse herself off with the hand-held shower. *CNA K could not recall if she had been told before that incident that residents were not to be left alone in the whirlpool tub. 7. Interview on 6/26/25 at 11:40 a.m. with CNA O revealed: *On 4/28/25 she had heard CNA K tell CNA Q that she needed to leave at the end of her shift [3:30 p.m.] and that CNA Q had agreed to complete resident 40's whirlpool bath. *She did not know that CNA K and CNA Q had left resident 40 alone in the whirlpool tub. *She heard someone inside the whirlpool tub room say, Hello, I am done, from the nurses' station. -She stated that resident 40's voice was calm. *When CNA O entered the whirlpool tub room, resident 40 was in the tub and no staff were present. *Resident 40 indicated that she was finished soaking and was ready to get out of the whirlpool tub, and then CNA Q arrived and assisted resident 40 out of the whirlpool tub. *CNA O was trained that for the resident's safety, she was never to leave a resident alone in the whirlpool tub or the shower, even if they were independent or requested to be alone. 8. Interview on 6/26/25 at 12:24 p.m. with DON B and Minimum Data Set (MDS)/ registered nurse (RN) C regarding the incident with resident 40 on 4/28/25 revealed: *MDS/RN C had completed a skin assessment of resident 40 after that bath, and there were no concerns noted. Resident 40 stated she had enjoyed her bath. *DON B expected that the staff would remain in the whirlpool tub room for the entire time any resident was in the whirlpool tub for the resident's safety. *MDS/RN C stated no current resident was independent in the shower or the whirlpool tub. *Resident 40 should not have been left alone in the whirlpool tub. *CNAs were educated during their orientation that they needed to remain in the whirlpool tub room with a resident while they showered or took a bath, and that staff members could use the call light or walkie-talkies to call for help from other staff if needed. 9. Review of the provider's 3/13/25 SD DOH FRI revealed: *Resident 38 was standing at the foot of her bed in front of her dresser when CNA S entered her room. *CNA S walked to [the] head of the bed while resident [38] remained at the foot of the bed, to pull down the sheets. *Resident 38 fell backward without warning and hit the back of her head. *Resident 38 was sent to the emergency department (ED) to be evaluated as she hit the back of her head and edema [swelling] was present . *Resident 38 reported headache, and pain to her head, neck, back, chest and pelvis since falling. *While at the hospital ED resident 38 experienced an episode of hypoxia [low level of oxygen in the body] after IV [intravenous] Fentanyl [a pain medication] with oxygen levels in the 80s and required 5 liters (L) of oxygen by nasal cannula (NC) (a flexible tubing that delivers oxygen through the nose) and returned to the facility on 1L of oxygen by NC. *Resident 38 required SBA [standby assistance of one staff member] with a walker in and out of her room. *CNA [S] should have assisted the resident to a safe position prior to pulling down the sheets in the bed and should not have left resident [38] standing by the dresser . 10. Review of resident 38's EMR revealed: *She was admitted on [DATE]. *Her 3/11/25 BIMS assessment score was 0, which indicated she was severely cognitively impaired. *Her 12/16/24 revised care plan indicated she required the assistance of one staff member with her walker. Resident 38 does need extra assistance if she is having extra pain and other times she will forget that she needs assistance and [will] get up without assistance. *Her 3/20/25 revised care plan indicated she required SBA of one staff member with her walker . *Her 3/11/25 fall risk assessment indicated she was at high risk for falls and knew her own limits. *A 3/13/25 progress note indicated, Resident [38] was standing by her dresser and fell backwards hitting her head on her the bathroom door. Injuries: edema on the back of her head. 10/10 [ten on a zero to ten pain scale] generalized pain . Resident transferred to ED for evaluation. 11. Observation and interview on 6/24/25 4:08 p.m. with resident 38 revealed: *She was seated in her recliner with her call light next to her. *Her room was arranged as described in the FRI with her dresser at the foot of her bed. When the bathroom door was open, it aligned with the dresser. The room was uncluttered with both a wheelchair and a walker present. *She did not remember falling, did not know what she would use the call light for, and indicated that if she needed something, she would just get up and get it. *She was pleasant, answered basic questions, and denied having any pain. 12. Interview by phone on 6/26/25 at 10:00 a.m. with CNA S revealed: *On 3/13/25, resident 38 was in her room, standing at the foot of her bed, by her dresser with her walker, when CNA S arrived to assist her with getting ready for bed. The dresser drawer was open, and she thought that resident 38 was getting her pajamas from the dresser. *CNA S stated that she had gone to pull back the blankets on the bed when she heard resident 38 fall and hit her head. *Resident 38 was in a lot of pain and called out loudly after she fell. *The nurse came immediately after the resident fell that day and completed an assessment. Resident 38 was sent to the ED for further evaluation. *Resident 38 often got up unassisted. *She had been uncertain if resident 38 was allowed to stand independently at that time. -She had been educated after the resident's 3/13/25 fall that resident 38 required standby assistance and that staff were to remain within arm's reach of the resident when standing with or walking with her. *The level of staff assistance a resident required could be found in the resident's care plan in the EMR. 13. Interview on 6/26/25 at 11:40 a.m. with DON B revealed: *Resident 38 had required standby assistance of one staff member at the time of her 3/13/25 fall. *Resident 38 would often forget that she needed staff assistance and would get up independently. *She expected staff to assist resident 38 to her destination and to remain within arm's reach of her due to resident 38's fall risk. *CNA S should have assisted resident 38 to sit down before she turned back the bed linens that day. *She expected the CNAs to review the resident care plans and to know the level of assistance a resident required when standing or transferring to ensure their safety. 14. Review of the provider's June 2025 Bathing policy revealed: *Ensure the resident's safety during bathing. *Visit with the resident during bathing and keep conversation focused on his/her interests. *Do not leave the resident alone in the shower/tub room. Use the call light if you need assistance. Review of the provider's 10/31/24 LTC (Long Term Care) Falls and Accidents policy revealed: *Supervision/adequate supervision: This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. *All staff will be educated about and have access to care plans which are individualized for each resident . *Based on assessment of fall risk ., staff will implement appropriate individualized, resident-centered interventions to reduce the likelihood of falls . and communicate the risk and interventions to the staff through the plan of care.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed for: *The storage and handling of a catheter urine drainage bag for one of one sampled resident (11) with a catheter. *The cleaning and disinfecting of shared resident lift equipment by three of three observed certified nursing assistants (CNAs) (L, M, and T) Findings include: 1. Observation on 6/24/25 at 9:38 a.m. of resident 11's room revealed: *A sit-to-stand lift (mechanical lift used to assist from a seated to a standing position) was outside of resident 11's room with a safety sling draped over the top. *A small blue bag was attached to that lift. -There were no disinfectant wipes available to use in the bag. *Resident 11's uncovered catheter bag was hooked on the edge of her trash can which was on the right side of her recliner. 2. Observation on 6/24/25 at 10:32 a.m. outside of resident room [ROOM NUMBER] revealed: *There was a [NAME] Plus sit-to-stand lift with a purple sling draped over the top of it. -There were no disinfectant wipes available to use on that lift. 3. Observation on 6/24/25 at 2:16 p.m. of resident lifts parked in the 300-hall revealed: *The full body mechanical lift (a mechanical lift with a body sling used to lift a person's full body) labeled hoyer 1 had a container of glass cleaner wipes in the bag attached to the lift. -There were no disinfectant wipes available to use in that bag. *The EZ Stand sit-to-stand mechanical lift had a large sling draped over the lift while it was in the hallway -That lift did not have disinfectant wipes available to use on the lift or in the bag attached to it. 4. Observation and interview on 6/24/25 at 3:12 p.m. with resident 11 and CNA/certified medication aide (CMA) J, outside resident 11's room revealed: *There was an orange ribbon symbol under resident 11's nameplate outside her room. CMA/CNA J explained that the orange ribbon indicated that resident 11 had a urinary catheter. *Resident 11 was able to answer simple questions but was not aware of where her urinary catheter drainage bag was stored. *Resident 11's urinary catheter drainage bag was hanging from her trash can. The drainage spout was unhooked from its storage slot and was touching the floor. *CNA/CMA J confirmed that the resident's urinary catheter drainage bag was hanging from the trash can and that the spout was touching the floor. *Without performing hand hygiene (hand washing or the use of hand sanitizer) or putting on a gown CMA/CNA J put on a pair of gloves and, without using a disinfectant, placed the drainage spout back into the storage slot on the urinary catheter drainage bag. *She stated, It [the spout] must have come loose. *She stated that when resident 11 sat in her recliner, they would hang the urinary catheter drainage bag from the trash can to keep it off the floor. They did not use a catheter protective or privacy bag cover when resident 11 was in her room. *CMA/CNA J stated they used the privacy bag attached to the wheelchair to store resident 11's urinary catheter drainage bag when she left her room. *CMA/CNA J removed her gloves and, without completing hand hygiene, she left the residnet's room. 5. Review of resident 11's electronic medical record revealed: *She was admitted on [DATE]. *Her diagnosis included neuromuscular dysfunction of the bladder. *Her 5/27/25 Brief Interview of Mental Status (BIMS) assessment score was 2, which indicated she was severely cognitively impaired. *A 5/20/25 physician's order indicated Foley catheter .only change when compromised or leaking. 6. Observation on 6/25/25 at 7:52 a.m. of the soiled utility room revealed: *There was an EZ Stand sit-to-stand lift with a sling draped over it. *There was a Tollos Steady Aid sit-to-stand lift that did not have disinfectant wipes available to use n the lift. *There was a [NAME] Plus sit-to-stand lift with a sling draped over it. 7. Observation and interview on 6/25/25 at 11:00 a.m. of CNA M and CNA T and resident 11 revealed: *Resident 11's urinary catheter drainage bag was lying on the floor in front of her trash can. *The Tollos Steady Aid sit-to-stand lift was outside her room with the safety sling draped over the top of it. -There were no disinfectant wipes on that lift available to use. *CNA M and CNA T brought the Tollos Steady Aid sit-to stand lift with the sling draped over the top into resident 11's room and put on gowns and gloves. *CNA T confirmed that resident 11's urinary catheter drainage bag was lying on the floor, and with her gloved hands, she then hung the catheter bag on the edge of the trash can. *CNA T stated that when the catheter was attached to resident 11's right leg, they would hang the urinary catheter drainage bag from the trash can, and when the catheter was attached to resident 11's left leg, they would hang it from her chairside table. *CNA M emptied resident 11's urinary catheter drainage bag using a container with graduated measurements on it. *Without changing their gloves, CNA M and CNA T placed the lift safety sling around resident 11, attached that sling to the lift, and transferred resident 11 from her recliner to the wheelchair. *CNA M stated that each sit-to-stand lift had a safety sling that was to be kept with that lift. The safety sling would be used for transferring any resident who required the use of the lift, and any of the sit-to-stand lifts could be used with any resident. *CNA T stated that there were no disinfectant wipes on the lift, left, then returned with two wipes. She used one wipe to wipe the lift and a second to wipe the safety sling. *She stated those wipes were retrieved from the purple top container at the nurses' station. 8. Observation and interview on 6/26/25 at 8:52 a.m. with CNA L in the 200 hallway revealed: *She was cleaning the [NAME] Plus sit-to-stand lift with a wipe. *She stated that the sit-to-stand lifts were shared between all the residents who required that style of lift and that there was one safety sling for each sit-to-stand lift. Those safety slings were stored on the lift. *The shared lifts and safety slings were to be wiped down between each resident's use with a Sani-wipe [disinfectant]. *She used one wipe to wipe the surfaces of the lift and a second wipe to wipe the cloth safety sling. -She was unsure if there was a specific amount of time that the surface of the shared lift sling would need to remain wet to ensure that it had been disinfected between each resident use. *She left and then returned and stated there was no specific amount of time that the shared safety sling would need to remain wet, and as long as it was dry, it was ready to use with the next resident. *The full-body mechanical lifts were also shared by residents, however, each resident who used the full-body lift had individual lift slings because that sling was left under the resident in their chair for future use. 9. Interview on 6/25/25 at 5:19 p.m. with director of quality and infection control E and director of nursing (DON) B revealed: *Resident 11's urinary catheter drainage bag should not have been stored on the floor or hung on the trash can to prevent contamination. They had not considered where it should have hung, but they expected that there would have been a barrier between the bag and the floor or the trash can. *DON B confirmed that the resident's urinary catheter bag's drainage spout should have been cleaned with an alcohol pad after being in contact with the floor, before it was placed back in the catheter bag's holder. *DON B confirmed the CNAs should have changed their gloves and used hand hygiene after having emptied the catheter and having been in contact with the drainage spout before using the shared sit-to-stand lift and shared safety sling. *DON B confirmed that the lifts and the sit-to-stand safety slings were shared by all residents requiring the use of those lifts. The sit-to-stand safety slings were stored with those lifts in the hallway. *They expected that the purple top Sani-wipes would have been stored with each lift and used to clean and disinfect the lift and the cloth safety sling between each resident's use. *They were unaware that the shared cloth sit-to-stand safety lift slings may not have been adequately cleaned between each resident's use. *DON B confirmed that the sling's fabric surface would not be able to maintain a wet time to ensure that it had been cleaned or disinfected. 10. Review of the Super Sani-Cloth Germicidal Disposable Wipe product label revealed: *To disinfect and deodorize hard, nonporous surfaces: If present, use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface. Allow surface to remain wet for two [2] minutes. Let air dry . -There were no instructions for use to disinfect a cloth surface. 11. Review of the provider's April 2025 Perineal Care policy revealed: * Residents with an IUC [indwelling urinary catheter] . Hang [the] drainage bag . ensure bag is not touching the floor . *Prevent the drain spout from touching the floor . 12. Review of the provider's 11/14/24 Hand Hygiene policy revealed: *Hand Hygiene (HH) continues to be the primary means of preventing the transmission of infection .To provide a clean and healthy environment for residents, staff, and visitors. *HH, either with soap and water or with alcohol based hand rub (ABHR): .2. before a clean procedure or handling an invasive device . 5. After removing gloves. 13. Review of the manufacturer's [NAME] Plus Sling Cleaning Instructions revealed: *In order to obtain a sufficient level of disinfection, machine wash the sling at 158 degrees Fahrenheit (F). *If allowed according to product label, tumble dry at a low temperature, maximum 140 degrees F. 14. Review of the manufacturer's EZ Way Smart Stand Operator's Instructions did not include instructions for disinfecting the safety sling between resident uses. 15. Review of the manufacturer's Tollos Steady Aid safety sling instructions revealed: Reusable slings should be laundered between patients. 16. Review of the provider's April 2025 Disinfection of Non-Critical Resident Care Equipment policy revealed: *Cleaning, disinfecting and storing equipment and supplies is important in preventing the transmission of potential pathogens within the long-term care facility. *For the safety and comfort of residents, all reusable (non-critical) resident care items will be cleaned, disinfected and maintained in a safe manner between resident uses. *Noncritical resident care items .are cleaned between/after each resident use. They require Low level disinfection by cleaning following manufacturer instructions with an EPA [Environmental Protection Agency]-registered disinfectant detergent, or germicide that is approved for healthcare settings. *Disinfection Recommendations- Reusable resident care equipment: All applicable instructions on EPA-registered disinfectant products must be followed .Between each resident use and when soiled .Lifts & [and] slings.

Based on record review, interview, and policy review, the provider failed to ensure a Minimum Data Set (MDS) discharge tracking record assessment was completed within the required timeframe for one of one sampled resident (12) after her death in the facility. Findings include: 1. Review of resident 12's electronic medical record (EMR) revealed: *She died in the facility on [DATE]. *A significant change MDS had been completed on [DATE]. *A quarterly MDS had been completed on [DATE]. *No MDS tracking record had been completed when resident 12 died. 2. Interview on [DATE] at 2:14 p.m. with MDS/ registered nurse (RN) C revealed she: *Was responsible for completing and transmitting the MDS data for all residents. *Expected that resident 12 would have had an MDS tracking record assessment completed when she died, and confirmed that one had not been completed. *Tracked the MDS assessments that would need to have been completed by utilizing the dashboard alerts in the PointClickCare EMR system. *Stated it had been an oversight that resident 12's death in the facility tracking MDS had been missed. 3. Interview on [DATE] at 12:39 p.m. with director of nursing B revealed she expected one hundred percent compliance with the timely completion and submission of MDS data. 4. Review of the Resident Assessment Instrument (RAI) manual revealed that the death in facility tracking record assessment was to have been completed no later than seven days after a resident's death in the facility. Review of the provider's [DATE] LTC (Long Term Care) Resident-Assessment-Instrument (RAI)- System policy revealed: *The Assessment Coordinator is responsible for ensuring the Interdisciplinary Team (IDT) complete timely assessments and reviews in accordance with the CMS RAI Version 3.0 Manual. *Tracking Records - Must be completed for any resident in a Medicare or Medicaid certified facility regardless of payment source: . Death in Facility : Within 7 [seven] days after the resident's death. *The Assessment Coordinator is responsible for electronically transmitting encoded, accurate and complete MDS data . Review of the Centers for Medicare and Medicaid Services' [DATE] Version 1.18.1 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual revealed death in facility tracking records: *Must be completed when the resident dies in the facility or when on LOA [leave of absence]. *Must be completed within 7 days after the resident's death .

Based on interview, and record review, the provider failed to ensure one of one resident (7) who received an injectable diabetic medication had that medication coded accurately on the Minimum Data Set (MDS) assessment. 1. Interview on 6/24/25 at 2:45 p.m. with resident 7 revealed: *She had diabetes (a group of diseases that result in too much sugar in the blood). *She received an injectable medication weekly to treat her diabetes. *Her blood sugars were monitored by staff. 2. Review of resident 7's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated she was cognitively intact. *She had a diagnosis of diabetes. *Her blood sugars were monitored weekly by staff. *A 1/19/25 physician's order for Dulaglutide Subcutaneous Solution Auto-Injector Inject 0.5 ml [milliliters] subcutaneously one time a day every Sun. That order was discontinued on 3/23/25. *A 3/23/25 physician's order for, Dulaglutide Subcutaneous Solution Auto-Injector [an injectable medication to treat diabetes] Inject 0.75 ml [milliliters] subcutaneously one time a day every Sun [Sunday]. *Item N0350A of section N Medications of her 4/1/25 quarterly MDS (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment indicated she had received insulin injections seven times during the seven-day look-back period (the time period over which the resident's condition or status is captured by the MDS assessment) of that MDS. -Dulaglutide's medication classification was glucagon-like peptide-1 (GLP-1) agonists, which was not a form of insulin. It was administered weekly on Sundays, not daily. 3. Record review and interview on 6/26/25 at 8:51 a.m. with registered nurse (RN) I regarding resident 7 revealed: *The resident had a physician's order for dulaglutide to treat her diabetes, which was to be administered weekly on Sundays. *RN I verified that dulaglutide was not a form of insulin. *There were no current physician orders for insulin for resident 7. 4. Interview and record review on 6/26/25 at 12:05 p.m. with MDS/RN C revealed: *She had completed resident 7's most recent MDS assessment on 4/1/25. *She verified she had documented in that MDS that resident 7 had received an insulin injection seven times during the seven-day look-back period. *MDS/RN C stated she thought dulaglutide was a form of insulin. *MDS/RN C verified resident 7 had received one injection of dulaglutide in the seven-day look-back period. *She thought she entered dulaglutide as an insulin on the MDS because it was documented under the insulin administration tab in the medication administration record (MAR). She was unsure why she documented that resident 7 had received seven injections during that seven-day look-back period. *She agreed she had made an error in the resident's MDS assessment documentation. 5. Interview on 6/26/25 at 12:09 p.m. with director nursing (DON) B revealed: *She confirmed resident 7 was on dulaglutide injections weekly and had not been on insulin during the look-back period of her 4/1/25 MDS assessment. *She verified the above error in the documentation within resident 7's 4/1/25 quarterly MDS assessment. *She expected the MDS assessment documentation to be completely accurate upon submission. Review of the Centers for Medicare and Medicaid Services' October 2023 Version 1.18.1 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual regarding insulin documentation in section N revealed: *Review the resident's medication administration records for the 7-day look-back period. *Determine if the resident received insulin injections during the look-back period. *Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received. Review of the provider's 1/15/25 LTC [long-term care] Resident-Assessment-Instrument (RAI)-System Standard policy revealed: *[Provider name] will ensure 'the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strength and needs, as well as offering guidance for further assessment once problems have been identified.' *The quarterly review assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.

7. On 6/26/25 at 11:15 a.m., a request was made to DON B for the Northview and Southview refrigerator temperature logs for April, May, and June 2025. The logs for May 2025 were unavailable for review. 8. Review of the Southview Refrigerator/Freezer Temperature Forms revealed: *REPORT ALL OUT OF RANGE TEMPS [temperatures] TO THE DIETARY MANAGER AT TIME NOTED. *The refrigerator range was listed as 35-40 F, and the freezer range was 0 OR LESS. *In April 2025: -There were 15 days with no refrigerator or freezer AM temperatures recorded. -There were no PM temperatures recorded. -The form indicated the refrigerator was out of the range six days. *In June 2025: -There were 14 days with no refrigerator or freezer AM temperature recorded. -There were no PM temperatures recorded. -On 6/3/25, the refrigerator was out of the range indicated on the form. *There were no documented interventions for out-of-range temperatures documented on the form 9. Review of the Northview Refrigerator/Freezer Temperature Forms revealed: *In April 2025: -There were five days with no refrigerator or freezer AM temperatures documented. -There were 12 days with no refrigerator or freezer PM temperatures documented. -On 4/2/25, the refrigerator and freezer were documented as being over the temperature range indicated on the form. -All other documented refrigerator temperatures were below the refrigerator temperature range. *There were no interventions for the out-of-range temperatures documented on the form. *In June 2025: -On 6/19/25, no refrigerator or freezer AM temperature was documented. -There were eight days with no refrigerator or freezer PM temperatures documented. -On 6/2025, the freezer was documented as being over the temperature range indicated on the form. -There were 33 documented refrigerator temperatures below the refrigerator temperature range. *There were no interventions for out-of-range temperatures documented on the form. 10. Interview on 6/25/25 at 10:46 a.m. with food services supervisor G regarding the unit refrigerator and freezers revealed: *He expected the kitchenette refrigerator behind the nurses' station and the Northview refrigerator temperatures to have been monitored by the nursing staff. *The dietary staff provided snacks and beverages for the residents upon request. *Opened food items were to be dated and labeled by the dietary staff when they were removed from the kitchen. *He expected the nursing staff to date and label food items when they opened them on the unit. *He expected resident's food items not to be stored in the Southview refrigerator. 11. Interview on 6/25/25 at 4:20 p.m. with director of quality and infection control E regarding the unit refrigerators revealed: *She expected the Southview refrigerator and freezer not to have been used to store resident food. -That refrigerator had been put out of service and was to have been removed from the Southview unit. -She was unaware that the refrigerator contained an open applesauce dated Best by 2/26/25, and that the freezer contained an open ice cream container labeled with resident 38's name. *She expected the nursing staff to monitor and document the refrigerator and freezer temperatures of the Northview refrigerator and freezer twice daily. *Nursing staff were also responsible for dating and labeling food items when they were opened and discarding those items when they were spoiled. She was not sure how many days the food items could remain in the refrigerator safely. 12. Interview on 6/26/25 at 8:17 a.m. with certified nursing assistant (CNA) U regarding the Northview refrigerator revealed: *The Northview refrigerator and freezer were locked because they were in the memory care unit (an area where specialized care is provided in a structured, safe, and supportive environment to meet the unique needs of residents with significant memory and cognitive decline, that is secured to minimize unsafe wandering), and residents might have opened the refrigerator and taken items that did not belong to them. *The CNAs were responsible for monitoring and documenting the temperatures of the refrigerator and the freezer twice a day. *The kitchen delivered requested food items to the unit from the main kitchen. Those items were to be labeled and dated by the kitchen staff if they were already open. Nursing staff were to label and date food items when they opened them on the unit. *She would have notified the nurse if there was a problem with the refrigerator. 13. Interview on 6/26/25 at 12:09 p.m. with director of nursing (DON) B revealed: *The nursing staff was responsible for monitoring the unit refrigerator and freezer temperatures during the day, and the dietary staff was responsible for the temperature monitoring in the evening. *She expected that food placed in the unit refrigerators would be labeled with the resident's name and dated. *Food brought in for a resident was to be disposed of three days after opening. *She did not know the expectation for how food that was brought in for a resident was to be stored in the freezer. *She expected the nursing staff would have removed the food from the refrigerator that was not labeled with a resident identification, date, or was spoiled. *She expected maintenance be notified of temperatures that were out of range. *She expected an intervention to be documented on the temperature form if an out-of-range temperature was identified. *She verified there were multiple temperatures out of their policy's identified range between April 2025 and June 2025 with no documented interventions on the forms. Review of the provider's June 2025 Fridges policy revealed: *All refrigerators and freezers have thermometers and temperature is documented at least 1x [one time] daily. *Maintenance is to be notified if [the] refrigerator is above 40°F and freezer temperature is above 0°F. *Fridge temperatures should be between 40°F and 33°F. Freezer temperatures should be 0°F or below. *Food is served as soon as possible. All leftover food is discarded after three days (72 hours). Review of the provider's April 2025 Refrigerator Use policy revealed: *Food needing refrigeration will be labeled with the resident's name and dated and stored in the facility's refrigerator in the kitchenette behind the nurses station. Based on observation, record review, interview, and policy review, the provider failed to ensure: *Food was stored labeled, dated, and disposed of according to the provider's policy in three of three unit refrigerators and freezers. *Temperatures were monitored and addressed when out of range according to the provider's policy in three of three unit refrigerators and freezers. Findings include: 1. Observation on 6/24/25 at 8:58 a.m. of the Southview refrigerator and freezer revealed: *The posted June 2025 refrigerator and freezer temperature log was missing several temperature entries. *On the left side of the refrigerator was an external digital thermometer with an internal probe. The external digital display was not functional. *Inside the refrigerator, a thermometer read 42 degrees Fahrenheit (F). *The refrigerator contained: -A plastic tub with an open one-pound block of butter covered with tin foil, which was not labeled or dated. -An open container of applesauce dated Best by 2/26/25, that was labeled Act. *Inside the freezer, a thermometer read 22°F. *The freezer contained an open container of chocolate peanut butter ice cream labeled with resident 38's name and dated 6/22. 2. Observation on 6/24/25 at 10:10 a.m. of the Northview refrigerator and freezer revealed: *It contained two locks. The freezer was locked, but the refrigerator was not locked. *The posted June 2025 refrigerator and freezer temperature log was missing several entries. 3. Observation on 6/25/25 at 8:03 a.m. of the room behind the nurses' station labeled Clean Utility revealed: *There was an ice machine and a refrigerator in the room. *The June 2025 Kitchenette Refrigerator/Freezer Temperature form posted on the refrigerator door had areas for the temperatures of the refrigerator and freezer to be documented twice daily, once in the AM (morning), and once in the PM (evening). *The Refrigerator/Freezer Temperature form indicated the temperature range for the refrigerator was 35 to 40 [degrees] F and the range for the freezer was 0 [degrees] F or less. -There were no documented temperatures in the AM areas for the refrigerator or freezer on June 5, 7, 8, and 15. -The documented refrigerator temperatures were below 32 degrees Fahrenheit 14 times. -The refrigerator temperatures were documented above 41 degrees F on June 18 at 45 degrees F, 19 at 42 degrees F, 21 at 42 degrees F, and 23 at 42 degrees F. *Inside the refrigerator was: -A Ziploc bag of crumbled dry muffins that was not labeled with a name or a date. -A plastic container that was labeled with a resident's name but did not have a date on it. -A Cool Whip container that was labeled with resident 6's name and the date 6/12/25 that had mixed fruit with a layer of mold growing on the surface of the fruit. *Inside the freezer there was an unlabeled and undated partial 1.5-quart container of vanilla ice cream that had appeared to have been melted and refrozen due to the surface of the inside of the container was covered in clear crystals. *There were no interventions for the out-of-range temperatures documented on the form 4. Review of the April and May 2025 Kitchenette Refrigerator/Freezer Temperature forms revealed: *None of the documented refrigerator temperatures for the month of April 2025 were above 30 degrees F. *All but the 5/4/25 documented refrigerator temperatures in May 2025 were 32 degrees F or less. *There were no documented interventions for the out-of-range temperatures documented on the form. 5. Interview on 6/26/25 at 8:08 a.m. with registered nurse (RN) I revealed: *She was not sure who was responsible for monitoring the temperatures of the unit refrigerators and freezers. *She verified there were out of range temperatures documented for the kitchenette refrigerator freezer in June 2025. *She agreed there were items in the refrigerator and freezer that were not labeled with the resident's name and date when the item was opened or placed in the refrigerator. *She verified there was mold on the fruit in the refrigerator, indicated she would not serve that fruit, and that it should be disposed of, but did not dispose of it at that time. *She verified crystals had formed on the ice cream, and it appeared as the ice cream had been melted and refrozen. *She indicated she would notify maintenance if she was notified the refrigerator or freezer temperature was out-of-range. *She was not aware if maintenance had been notified there were documented out-of-range temperatures. 6. Interview on 6/26/25 at 8:41 a.m. with certified nursing assistant (CNA) M revealed: *She thought the kitchen staff was responsible for monitoring the unit refrigerator and freezers. *When residents had food brought in from an outside source, staff members were to label the food with the resident's name and date before placing it in the unit refrigerator freezers. *Both the CNAs and the kitchen staff were responsible for checking the food in the refrigerator for spoiled or outdated foods. *She did not know what she was to do if she noticed the refrigerator or freezer temperature was out of range.

Based on South Dakota Department of Health (SD DOH) event report review, medical record review, physical therapy evaluation review, care plan review, interview, and policy review, the provider failed to ensure one of one certified nursing assistant (CNA) (I) had followed one of one sampled resident's (7) care plan for using two staff persons to transfer resident 7 using a [NAME] Plus stand lift, resulting in a fall and a fractured hip. Findings include: 1. Review of the SD DOH event report received on 12/28/23 from the provider revealed at 12/19/23 at 7:30 p.m.: *Resident 7 was being transferred with the use of a [NAME] Plus stand lift from a wheelchair to his bed by CNA I when He slipped out of the lift. -CNA I had been supporting his upper body as he fell to the floor. *The lift had been removed from use, inspected by the physical therapist (PT), and found no fault in the lift. -The lift sling was new and in good repair. *Registered nurse (RN) L assessed resident 7 after the fall and transferred him to the hospital where he was diagnosed with a fractured hip requiring a total hip replacement. *The provider report indicated CNA I had followed the policy for using the [NAME] Plus stand lift because CNA I was eighteen years old or older so she could run a lift. Continued review of resident 7's 12/19/23 SD DOH event report revealed: *Director of Nursing (DON) B interviewed CNA I on 12/20/23 regarding resident 7's fall on 12/19/23 before her next scheduled shift revealed: *CNA I had confirmed: -She was using the [NAME] Plus stand lift independently on resident 7 at the time of his fall. -Resident 7 was in the [NAME] Plus stand lift, lifting him up to a standing position. -CNA I was standing behind him while cleaning his buttocks. -CNA I attempted to catch his fall by holding the top part of his body while protecting his head. *Review of RN L documentation confirmed his position when she entered his room. *A root cause analysis of the event completed by DON B, RN quality director P, Assistant administrator for senior living O noted that CNA I had not worked at the facility for several months because she had begun college in the fall of 2023 -She had not looked through the care plans before she stepped onto the unit to provide care for the residents she was assigned to on 12/19/23. 2. Review of resident 7's medical record revealed: *One 10/16/23 at 2:00 a.m. he was discovered on the floor beside his bed. -He had told a staff member he was attempting to retrieve his socks and shoes. *On 10/16/23 at 2:18 p.m. he was evaluated by a physician to check his injuries. *One 10/23/23 at 2:00 p.m. a nursing progress note indicated Minimum Data Set (MDS) coordinator/RN C and licensed social worker M had discussed his pain and that he had increased pain since that fall, requiring the use of a full-body mechanical lift. *He had a history of multiple sclerosis (MS), foot drop, and multiple falls, and was identified as a fall risk. *A 10/27/23 PT evaluation indicated PT N had encouraged charge nurses and CNAs to continue using the full-body mechanical lift. *A 10/30/23 PT evaluation indicated PT N recommended resident 7 to progress to the [NAME] Plus stand lift to help progress his lower extremity strength and tolerance. PT N educated the RN and CNA staff of the recommended changes. 3. Review of resident 7's care plan with a start date of 11/7/23, revealed: *For toileting he was to have had total assistance of two staff persons to transfer him with a full-body lift on and off the commode (toilet). *For transfers he was to have had two staff persons for using the [NAME] Plus stand lift. 4. Interview on 1/18/24 at 10:30 a.m. with DON B and MDS coordinator/RN C regarding resident 7's 12/19/23 fall revealed: *After a period of not working, CNA I had not reviewed the resident care plans before providing care for them on 12/19/23. *Resident 7 had been declining both physically and cognitively for the last several months. -He was care planned for two staff persons with him for all mechanical lift transfers. *When asked about a care plan specific for CNA's to use so they could carry it with them to refer to, MDS coordinator C stated she had provided a daily assignment sheet specific for each CNA to carry while working. -Resident 7's 12/19/23 daily assignment sheet provided to this surveyor had stated that he was supposed to use two staff members while using a stand lift. *DON B stated staff education was provided by her after the incident, including CNA I and all of the nursing staff. -She stated she had not kept the information provided to those staff members or a record of the attendance of the staff. *Observation at the same time, of the [NAME] Plus stand lift revealed: -MDS coordinator C was placed in the lift so that this surveyor could visualize how it worked. -A sling was placed on the person's abdomen and closed using the Velcro belt on the sling. -DON B stated the assessment after the 12/19/23 fall had determined: --The sling had been attached to the lift correctly and was tight enough to prevent him from falling through the sling. --The sling was still attached to the lift even after resident 7 fell . --CNA I stated in the SD DOH event report his legs just crumbled beneath him as he fell straight down. 5. Review of the provider's January 2024 Stand Lift Therapy Equipment Policy and Procedure revealed: *The policy for the lift was to be recommended for residents deemed appropriate by licensed PT's, in collaboration with PT assistants and nursing services. *All facility staff involved in resident care would have been assigned responsibility for ensuring compliance with the policy. *If variance from a care plan was necessary, the DON or PT staff would have been consulted. *Staff members would be provided with training initially and as needed to correct improper use or understanding of safe resident handling. *Use of the stand lift required manual operation of one staff member. *Staff is required to maintain direct line of sight supervision with all residents utilizing a stand lift. *Residents would have been required to maintain upright posture, and maintain satisfactory level of safety. Review of the undated [NAME] Plus Instructions For Use revealed the [NAME] Plus stand lift was to always be handled by a trained caregiver, continuously attending to the resident. Review of the provider's November 2021 Falls and Accidents policy revealed:*The determination of supervision was based on the resident's assessed needs and identified hazards in the residents environment. *All staff would have been educated about and have access to care plans which were initialized for each resident and address potential hazards. *Effective and modification of interventions was monitored on a regular basis through QAPI (Quality assurance and performance improvement) program. *The residents care plan would specifically address any risk factors that provided a benefit, such as a mobility device.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (27) was dressed in a Onesie (one-piece close-fitting garment with an opening in the back) restraint to prevent her from removing her clothing had the following: *Approval of the use of the Onesie restraint from resident 27's guardian. *An assessment to ensure the Onesie restraint was not used for staff convenience. *A physician's order for the use of the restraint. *Used the least restrictive restraint for the least amount of time. *Documented the use of the restraint in the care plan. *A routine re-evaluation to ensure the Onesie was appropriate and necessary. Findings include: 1. Observations of resident 27 revealed on: *On 1/16/24 at 5:30 p.m. she was wearing a flowered flannel Onesie with a zipper in the back. *On 1/17/24 at 10:30 a.m. she was wearing a denim Onesie with a zipper in the back. She continued to have that Onesie on through 4:30 p.m. *On 1/18/24 at 12:30 p.m. she was wearing a Onesie with a zipper in the back. Interview on 1/17/24 at 10:30 a.m. with resident 27's husband, who resided in the facility, revealed he was aware of the Onesie she wore. He stated she would remove her personal clothing if she wore regular clothing. Interview on 1/18/24 at 9:30 a.m. with certified nursing assistant (CNA) L regarding resident 27 revealed: *She wore the Onesie at all times otherwise she would remove her personal clothing, *As her dementia had progressed she started to remove her personal clothing. *She had been unable to be redirected when she took her clothing off. Interview on 1/18/24 at 2:30 p.m. with director of nursing B and Minimum Data Set coordinator C revealed: *They had not thought of the Onesie as a restraint. *Agreed there had been no assessments on the use of the Onesie. *They agreed it could have been a restraint as she had no access to her own body. Review of resident 27's undated care plan revealed: *Focus: [Resident] has a hx [history] of disrobing and aggressive behaviors towards others at times. *Goal: [Resident] will maintain current level of function through the next review date. The date was not listed. *Interventions: INDIVIDUALIZED STAFF APPROACHES: -utilize adaptive clothing when needed to prevent public disrobing. Review of resident 27's electronic and paper medical records revealed no assessments were completed to determine if the Onesie was needed as a restraint. Review of the provider's last revised September 1993 Physical Restraints policy revealed: *Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. *The provider will evaluate each resident for safety and provide adequate supervision and assistive devices to prevent avoidable accidents. *There was no guidance on what process was to have been completed to rule out a device as a restraint.

Based on observation, interview, and policy review, the provider failed to ensure staff interactions and services were provided in a manner that maintained a sense of dignity and respect for residents' that required assistance during one of two observed resident meal services. Findings include: 1. On 1/16/24 at 5:15 p.m. certified nursing assistant/certified medication aide (CNA/CMA) G was asked which dining tables were for the residents who required assistance with eating. She pointed to the last two tables at the north end of the dining room. She stated those were the feeder tables. There were other residents around when she stated that. Observation on 1/16/24 in the main dining room of the residents evening meal revealed at: *5:20 p.m. CNA E discussed with surveyors in the dining room that there were two feeder tables and one table for observation. *5:28 p.m. CNA F asked CNA E Do you want to feed? in the dining room in front of the residents while serving resident meals. *5:36 p.m. CNA E used resident 3's fork to bring food that had spilled out of her mouth onto her chin back into her mouth. *5:48 p.m. CNA F who was standing next to one of the assisted dining tables called across the dining room in a loud voice to registered nurse (RN) D, who was standing at the entrance to the dining room, [First name of RN D] do you want to assist with feeders at this table? *5:52 p.m. RN D used a spoon to scoop up food that had spilled onto resident 27's clothing protector and put it on her plate. She mixed the food that was scooped up from the clothing protector in with the other food and then gave resident 27 a bite of food. Interview on 1/18/24 at 3:00 p.m. with administrator A and director of nursing B revealed the above observations had not provided those residents with dignity when they were assisted with eating. The CNA's were given education on the use of the word feeder when they referred to residents who required assistance with dining. Review of the provider's policy on Dignity, last revised December 2021, revealed: *Staff would interact and carry out activities with residents that assisted in maintaining and enhancing each resident's self-esteem and self-worth. *Staff should address residents with the name or pronoun of the resident's choice, avoiding the use of labels for residents such as feeders.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Ongoing and timely skin assessments were conducted and documented by licensed nurses prior to the development of pressure ulcers for three of three sampled residents (9, 28, and 33) who had been identified as at risk for pressure ulcers. *Complete and accurate ongoing documentation of identified pressure ulcers for three of three sampled residents (9, 28, and 33) who developed pressure ulcers. Documentation to reflect: -Location and staging. -Size, depth, and presence, location and extent of any undermining g or tunneling. -Exudate, if present. -Pain, if present. -Wound bed, color and type of tissue/character, including evidence of healing. -Description of wound edges and surrounding tissues as appropriate. Findings include: 1. Observation and interview on 2/14/23 at 11:24 a.m. with resident 9 in his room revealed he: *Was sitting in a wheelchair on a ROHO pressure relieving cushion. There was a pressure relieving cushion in his recliner. *Had a prosthetic on his right leg and said the amputation above his knee happened in the past year due to his diabetes. *Received a whirlpool bath with staff assistance once a week. *Walked with staff three times a day in the hallway. *Had reported pain to his back side several months ago, and then the nurse looked and found a sore on his bottom. *Now, they were looking at it every day, they had placed a patch over it, and the pain was finally getting better. Review of resident 9's medical record revealed: *He was admitted on [DATE]. *His diagnoses included Type 2 diabetes with neuropathy, peripheral vascular disease, muscle weakness, right above the knee amputation, left toe amputation, malignant neoplasm of the bone and prostrate, and chronic kidney disease stage 3. *The Minimum Data Set (MDS) assessments dated 1/3/22 at admission and the significant change assessments dated 2/10/22, 6/8/22, 9/3/22, and 12/27/22 all coded him at risk for developing a pressure ulcer and he had a pressure reducing device for his bed and his chair. None of them coded the presence of a pressure ulcer until the 12/27/22 MDS that coded a Stage 2 pressure ulcer (top two layers of skin broken open, usually tender and painful, may also be an intact or broken open filled blister). *His Brief Interview for Mental Status (BIMS) score was 15 on all the above MDS assessments, and that indicated he was cognitively intact. *All eight Braden Scale assessment scores (used to determine the risk of developing a pressure ulcer) completed in 2022 indicated he was at risk for developing a pressure ulcer. *Skin/Wound Note documentation included: -On 12/28/21 00:12 a.m., No skin issues at this time noted other than recent amputation of right great toe with wound vac [vacuum] attached. dressing CDI [clean, dry, intact] with scheduled changes. -On 4/19/22 1:07 p.m., Resident has what appears to be a red welted area on his right buttock. Will continue to monitor and pass on to other shifts. -On 5/1/22 2:38 p.m., Resident has areas on inner coccyx that are deep red and look like they are about ready to open. Zinc spray applied and ROHO cushion placed in chair. Encourage resident to sleep with a pillow under one side and turn frequently when in bed to prevent further breakdown. -On 5/2/22 1:07 p.m., This RN [registered nurse] looked at resident bottom. Noted open area to left buttock with redness around the area. Area hard touch. No blanching. Resident does have scar tissue noted above open area. Area noted to have no s/sx [signs/symptoms] of infection and no odor. Noted edges to be wet. Resident did have pressure reducing air mattress and resident wanted to [the] air mattress taken off bed. Again this RN asked resident if he would think about air mattress told this RN to 'Keep thinking. I am not having that on my bed.' Resident does have pressure relieving cushion in recliner and wheelchair. Resident was cleaned up and area dried. Cream applied to area. This RN instructed staff and resident that he needs to relieve pressure off of bottom every two hours. Staff verbalized understanding. Resident also verbalized understanding. Will continue to monitor. -On 8/17/22 5:44 p.m., Resident has an area on buttocks that is very thin and has previously been open. This is currently being covered with a hydrocellular [silicone] foam dressing to protect the thin skin from shearing when resident slides forward in his w/c [wheelchair], recliner, or bed. -On 9/3/22 9:36 a.m., Resident has open areas on sacrum that are bleeding at this time. Area cleansed thoroughly and dressing applied. Will continue to monitor and update other staff. -On 9/16/22 11:07 a.m., Dressing removed from bottom area does have a foul smell however, suspect it could be from old drainage. dressing was not reapplied. would like to be able to monitor without dressing for a couple of days. nursing to utilize barrier cream at this time. -On 11/6/22 2:43 p.m., Resident's coccygeal area shows the fragile epithelialization to be opening up in two spots. Area was gently cleansed and Medihoney and a hydrocolloid dressing [two layers of beginning biodegradable, breathable, and adhesive material] was placed to cover. Will monitor closely. *His current medical orders included the following: -Juven nutritional supplement twice daily for wound healing. -Medihoney applied topically to the wound bed on his coccyx and then covered with a wound dressing every three days or sooner if the dressing became contaminated. -Nursing to check his coccyx wound/dressing daily and change it [the dressing] as needed until it [the wound] healed. Review of resident 9's care plan regarding skin integrity initiated on 1/14/22 and revised through 2/13/23 revealed: *Impairment of skin integrity at his coccyx related to peripheral vascular disease, type 2 diabetes, and stage 3 chronic kidney disease. *Interventions to prevent pressure ulcers and then to promote wound healing included: -A pressure reducing air mattress on his bed, that he refused, so after he was educated about the risks, the air mattress was replaced with a different pressure reducing mattress. -A pressure relieving cushion in his recliner and wheelchair. -Wound dressings to be completed as ordered by his physician. Observation and interview on 2/15/23 from 12:25 p.m. to 1:14 p.m. with RN B while performing wound care for resident 9 revealed: *Resident 9's stage 2 coccyx pressure ulcer was discovered when he complained about pain in his coccyx area. *They had placed a pressure reduction mattress on his bed, but he did not like it. He was educated on the risk versus benefits but still wanted it removed, so they honored his choice. *He had a gel cushion in his recliner and wheelchair until the pressure ulcer was discovered and then a ROHO cushion was placed in his recliner and wheelchair. *His stage 2 pressure ulcer was healing. 2. Observation and interview on 12/14/23 at 10:47 a.m. with resident 33 revealed he: *Was sitting in a wheelchair on a pressure relieving cushion. *Was able to move himself in his wheelchair using his arms and feet to his wife's room in a different location of the facility to visit her, and he did that several times a day. *Required assistance from staff for dressing and bathing. *Had compression stockings and shoes on his feet. *Denied any skin breakdown or skin concerns. Review of resident 33's medical record revealed: *He was admitted on [DATE]. *His diagnoses included: History of venous thrombosis and embolism, pulmonary embolism without acute cor pulmonale, cerebral infarction, and aphasia. *The MDS assessment dated [DATE] at admission and the 12/9/22 significant change MDS coded him as at risk for developing a pressure ulcer, and there was a pressure reducing device for his bed and chair. *His BIMS score on the 9/27/22 MDS was 15 and then 13 on the 12/9/22 MDS, both indicating he was cognitively intact. *All five Braden Scale assessment scores completed in 2022 indicated he was at risk for developing a pressure ulcer. *Skin/Wound Note documentation included: -On 11/7/22 6:12 a.m., Resident had scab/corn on left great toe in two spots. -On 2/10/23 9:00 a.m., This RN was informed of sore on resident left great toe. This RN assessed left great toe noted area to tip of left great toe with slight amount of drainage blood tint colored. Resident denies any pain to left foot or toe. After talking with staff noted that resident does wear TED [thromboembolism-deterrent] hose and the TED hose are tight to his toes. Right now resident just has gripper socks on and the socks are pulled away from his toes. Dressing was applied to left great toe. Order sent over to PCP [primary care physician] for Aquacel dressing for the great left toe. Resident son [name] notified of area on great left toe. Dietician notified of area on left great toe. Will continue to monitor. -On 2/11/23 4:12 p.m., CNA [certified nursing assistant] assessed resident's toe. He denied pain but stated he did feel some pain with cleansing of the wound. He states that he feels pressure and touching on his foot in general and his pedal pulses are palpable. His foot is normal temp [temperature] for his body. The wound bed is dark red granulation tissue with pale, hard tissue immediately surrounding, almost like an old blister. the periwound [sic] is dark red. Area cleansed and a hydrocolloid dressing applied. -On 2/13/23 2:00 p.m., This wound was rechecked as it did say right instead of left great toe. [physician] did see wound on Friday 2/10 and today 2/13. [resident 33] was started on antibiotics and he also will not wear TED hose as there is pressure from the TED hose. Also will talk with family about getting new shoes that are softer. Dressing continues to be foam to help keep moisture away from the wound. *His current medical orders included: -Juven nutritional supplement twice daily for wound healing. -A podiatry referral. -Bactrim antibiotic two times daily for left great toe infection for five days. -Routine wound care for left great toe. -An X-ray of left great toe. *The X-ray results were negative for any bone infection. Review of resident 33's care plan regarding skin integrity initiated on 10/3/22 and revised through 2/11/23 revealed: *He had impairment to skin integrity related to a left great toe pressure ulcer. *Interventions to prevent pressure ulcers and then to promote wound healing included: -A pressure reducing mattress on his bed. -A pressure relieving cushion in his recliner and wheelchair. -Physician orders for antibiotics, wound dressings, a podiatry referral, and an X-ray of his left great toe. Observation and interview on 2/15/23 from 12:25 p.m. to 1:14 p.m. with RN B while performing wound care for resident 33 revealed: *The stage 2 left great toe pressure ulcer was discovered when a CNA was putting on his TED compression stockings, and she alerted the nurse. *He wore TED compression stockings for his 3 plus pitting edema [fluid retention], and they attributed his ulcer to the TED compression stocking rubbing on his toe. *The CNAs had been educated to pull the TED compression stocking away from the toe when they put them on. *They had ordered toeless TED compression stockings for him. *He had an X-ray of the toe yesterday and there was no bone infection. *He moved himself in his wheelchair with his arms and feet. *He denied pain and said he did not feel the pressure ulcer on his toe, and it does not hurt me. *She further explained the process for identifying, reporting, and preventing the development of pressure ulcers included: -The charge nurse completed a comprehensive skin assessment for residents at admission. -Braden Scale assessments were completed by nursing at admission and quarterly with the MDS assessments and with significant changes. -Interventions such as cushions in chairs and wheelchairs, pressure reducing mattresses, and repositioning were put in place for residents at risk for skin breakdown. -Skin concerns or changes were identified and reported to nursing staff by CNA observations while assisting with personal care and bathing, or by residents reporting their concerns. -Once the nurse received a report of skin concerns or changes, the nurse would complete a skin assessment, decide on the plan of care and treatment, notify the physician for treatment orders, implement daily skin/wound checks, and complete weekly wound assessments with measurements. Interview on 2/15/23 at 3:49 p.m. with director of nursing (DON) A regarding nurses completing skin assessments revealed: *Braden Scale assessments were completed for residents by the nurse on admission, quarterly with the MDS and with any significant changes. *If the Braden score indicated a resident was at risk for pressure ulcers, interventions were put into place, such as pressure relieving devices, and repositioning programs. *A resident received a thorough skin assessment completed by the night charge nurse at admission. *CNAs observed resident's skin during personal cares and bathing and were to report to the charge nurse any skin concerns such as redness or bruising. *Outside of the CNA certification course that addressed dry skin, applying lotion etc . CNAs had no additional training for their delegated resident skin observations. *They held a daily huddle where staff were asked about any resident skin issues or observed skin changes. *When the charge nurse was notified of resident skin issues, she completed a skin assessment, notified the provider, and implemented a daily nurse skin/wound check. Interview on 2/15/23 at 6:12 p.m. with CNA D regarding skin observations revealed she: *Had worked at the facility for [AGE] years. *Had not received any additional training on observing residents' skin and/or wounds outside of her CNA certification course. *Completed skin observations when assisting residents with personal cares, activities of daily living and bathing. *Reported any observed resident skin concerns such as bruises, redness on the coccyx, under the breasts, armpits, skin folds or the feet to the charge nurse. *Had shared with the charge nurse any resident concerns voiced to her, such as redness or irritation in folds of skin or pain in pressure spots like bottoms or heels. *Attended the daily staff huddle and would bring up resident skin concerns at that time. *Had worked with residents who had skin concerns and had pressure ulcer prevention interventions in place such as, a gel or ROHO cushion, an alternating air mattress, a schedule to reposition every 2 hours, and/or a schedule to walk or go to the toilet depending on the resident's mobility. 47416 3. Observation on 2/13/23 at 4:15 p.m. of resident 28 revealed she was sitting in a reclining chair with a blood-stained incontinence pad under her. Observation on 2/14/23 at 10:10 a.m. of resident 28 revealed she was still sitting in a reclining chair. Observation and interview on 2/15/23 at 12:15 p.m. with of resident 28 revealed she: *Was in her bed lying on her left side. *Called a small black cushion in the seat of the reclining chair her special cushion. *Had a sore on her bottom. *Did not know exactly when she got it, but said that she did not have it before moving in. Review of resident 28's medical record revealed: *She was admitted on [DATE]. *The MDS assessment dated [DATE] at admission and the 1/10/23 significant change MDS coded her at risk for developing a pressure ulcer. She had a pressure reducing device for her bed and the chair. *The presence of one unstageable pressure ulcer and moisture associated skin damage were coded on the 1/10/23 MDS. *Her BIMS score on both the 3/24/22 and 1/10/23 MDS assessments were coded as 15 indicating she was cognitively intact. *The skin/wound section revealed: -No weekly skin assessments were documented after the initial screening on admission. -Photo documentation of four open areas had developed (coccyx, sacrum, left hip, and left ear). *The care plan was revised after the pressure ulcers had been identified with preventative measures implemented (gel and ROHO cushion). *She had become compliant with her treatments. Interview on 2/15/23 at 10:25 a.m. with RN B regarding resident 28 revealed: *She did not have pressure ulcers prior to her admission to the facility. *She had been noncompliant when first admitted to the facility, but she had been compliant with her treatment in the past few months. *She was supplied pressure relieving equipment (gel and ROHO cushion) but continued to get pressure ulcers. RN B was not sure why she kept getting ulcers. *CNAs look at residents' skin during bathing days and would let the nurse know of any concerns that were found. Interview on 2/15/23 at 12:21 p.m. with director of nursing A about resident 28's pressure ulcer revealed: *Resident 28 had obtained the pressure ulcers after her admission to the facility. *No skin assessments had been completed in the 11 months after resident 28 had been admitted . *CNAs were to check residents' skin during bathing and to notify the nurse of any identified issues. Interview on 2/15/23 at 6:15 p.m. with CNA C revealed only the CNAs would check the residents for skin issues during bathing and would inform the nurse if there were any identified skin issues. Review of the provider's 2/22 Skin Policy and Procedure revealed: *Full head-to-toe skin assessment was to be completed on admission and with significant changes to assess skin changes or breakdown. *The Braden Pressure Ulcer Risk Assessment tool was completed upon admission and with all MDS assessments. *Based on skin assessments, interventions were to be put into place. *Nurse Assistants were responsible to observe residents during daily care and especially during bathing and report concerns promptly to the charge nurse. *A nurse identifying a skin issue was to promptly document a thorough assessment in the medical record, determine treatment, and communicate the issue to staff. *The charge nurse was responsible to communicate skin concerns to physician and request treatment orders. *All skin injuries would receive daily monitoring by the charge nurses. *Documentation, at a minimum, of a weekly skin assessment would include skin injury location, type of injury, size, and integrity.

Based on record review, interview, and policy review, the provider failed to conduct monthly medication regimen reviews (MRR) each month for five of five sampled residents (7, 13, 15, 34, and 35). Findings include: 1. Review of resident 7's medical record revealed the MRR had not been completed for April 2021. 2. Review of resident 15's medical record revealed the MRR had not been completed for April 2021. 3. Review of resident 34's medical record revealed MRR had not been completed for March 2021 and June 2021. Surveyor 4. Review of resident 13's medical record revealed: *He: -Had diagnoses of [CONDITION(S)], agitation, depression, and mild cognitive impairment. -Received psychoactive medications. *There had not been a MMR completed for March 2021. 5. Review of resident 35's medical record revealed: *She had: -Diagnoses of [CONDITION(S)], dementia with behaviors, anxiety, and hallucinations. -Been followed by psychiatry. -Receiving psychoactive medications. *There had not been a MMR completed for March 2021. Surveyor 6. Interview on 7/29/2021 at 8:06 a.m. with administrator A and director of nursing B revealed: *MRRs had not been completed for all the residents in March 2021. *The consulting pharmacist responsible for completing the MRRs had resigned in March 2021. *The consulting pharmaceutical company had assigned a different pharmacist to complete MRRs in April 2021. *They did not know of any other months that might have been missed. 7. Telephone interview on 7/29/2021 at 10:00 a.m. with consulting pharmacist E revealed: *The previous pharmacist who had been completing the MRRs had unexpectedly resigned for health reasons in March 2021. *He had: -Not had another pharmacist available to complete the MRRs. -Completed the MRRs beginning in April 2021. 8. Review of the provider's February 2021 Medication Review policy and procedure revealed: *Procedure: -Medication Review Time Period: 1. Each resident's medication regiment will be reviewed at least monthly and with each significant change in status. -Medication Review Categories: 10. Review of each resident's chart to include at least the medication administration record, labs, physician orders, nursing progress notes, etc. -Reporting Findings: 1. Consultant pharmacist must report any irregularities to the primary physician and the DON [director of nursing].

Based on observation, interview, record review, and policy review, the provider failed to ensure side rail assessments for safety were routinely completed and documented for sixteen of sixteen sampled residents (3, 5, 7, 8, 9, 10, 11, 14, 17, 23, 24, 27, 29, 31, 35, and 38). Findings include: 1. Observation on 7/27/21 at 10:29 a.m. of resident 7 revealed: *Her bed had a side rail in the up position on the top right side of the bed. *She had been sleeping in her bed. Review of resident 7's care plan revealed she used a side rail on the right side of the bed for repositioning. Interview on 7/28/21 at 3:25 p.m. with registered nurse C and certified nursing assistant (CNA)/medication aide D regarding side rails revealed: *They had a couple of residents that had been using side rails for repositioning. *Through discussion, the interdisciplinary team would determine if a resident was able to use side rails. *They had not completed a safety assessment for side rail use for any resident. Interview on 7/29/21 at 7:57 a.m. with administrator A and director of nursing B regarding the use of side rails revealed: *Residents must request to use them. *The interdisciplinary team would then determine if a resident was able to use them. *They did not have a formal process for assessing the safety of the side rails. *They did not know safety assessments for side rails needed to be completed. *They thought the side rails had been care planned. *There had not been an initial or a routine safety assessment completed to determine or validate if a resident had the ability to use those side rails to reposition themselves or help them get in and out of bed. *Sixteen of the thirty-seven residents in the facility had been using side rails on their beds for repositioning. Review of the provider's July 2021 Side Rail Utilization policy revealed: *Policy: [Facility name] will not routinely use full or half side rails. Side rails may be requested only be [by] a resident who is capable of making decisions about their care. *Procedure: -Side rails will not be offered as part of routine care. -If a resident requests a side rail the interdisciplinary team will educate the resident on the risk associated with side rail use and alternatives such as a repositioning bar or assist bar. The April 2013 Food and Drug Administration Clinical Guidance For The Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings in part reads: *Creating a safe bed environment does not necessarily preclude the use of bed rails. However, a decision to use them should be based on a comprehensive assessment and identification of the patient 's needs, which include comparing the potential for injury or death associated with use or non-use of bed rails to the benefits for an individual patient. In creating a safe bed environment, the following general principles should be applied: -Avoid the automatic use of bed rails of any size or shape. -Restrict the use of physical restraints, including chest, abdominal, wrist, or ankle restraints of any kind on individuals in bed. -Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards and appropriately match the equipment to patient needs, considering all relevant risk factors. -Re-assess the patient's needs and re-evaluate the equipment if an episode of entrapment or near-entrapment occurs, with or without serious injury. This should be done immediately because fatal repeat events can occur within minutes of the first episode.

Based on observation, interview, and policy review, the provider failed to ensure infection control technique was maintained for: *One of one sampled resident (23) dressing change by one of one licensed practical nurse (LPN) (F). *Two of two observed sampled resident's (10 and 13) personal care by two of two observed certified nursing assistants (CNA) (G and H). *One of one whirlpool cleaning by one of one observed CNA/bath aide (G). Findings include: 1. Observation on 7/28/21 at 9:30 a.m. with LPN F in resident 23's room during a dressing change revealed: *Without performing hand hygiene or putting on gloves Nurse F: -Went to the medication (med) cart, removed a pill ([MEDICATION(S)]) from the cassette, placed it into a paper cup, and crushed it with the pill crusher. -Went to the treatment cart and removed the Optilock dressing, a few packages of 4x4 dressings, Chux, and a spray bottle that contained normal saline (NS). -Entered resident 23's room and had not performed hand hygiene or put on gloves. -Placed the: --Optilock dressing and 4x4 on the arm of her chair with out laying a barrier down. --NS spray and tape on the overbed table. -With her bare hands lifted the resident's right breast up. --The right breast had a soiled dressing that was light red and moist. -Placed a Chux folded in half under her right breast. -Tore pieces of tape and attached that tape to the overbed table -Opened the 4x4's and the Optilock dressing and placed them on the arm of chair. --There was not a barrier on the chair arm. -Without hand hygiene she put on gloves. -Removed the soiled dressing from her right breast and discarded it into the garbage. -With those same soiled gloves she: --Picked up the NS bottle and sprayed the right breast wound. --Wiped the right breast with a 4x4. -Removed her gloves and discarded the 4x4 and gloves into the garbage. -Went to the sink, used hand sanitizer, and put on new gloves. -Took a new 4x4, dabbed the right breast wound, and discarded the 4x4 with the soiled drainage on it into the garbage. -With the same soiled gloves picked up the paper cup with the [MEDICATION(S)] and sprinkled it on the right breast wound. -Placed the Optilock dressing and tape over the wound. -Removed her gloves and performed hand hygiene. Interview on 7/28/21 at 9:40 a.m. with LPN F regarding the above dressing change with resident 23 revealed she: *Agreed there were multiple missed opportunities for appropriate hand hygiene. *Should have placed a barrier down before placing supply items down. Interview on 7/29/21 at 9:00 a.m. with administrator A and director of nursing B regarding the above dressing change with resident 23 revealed they agreed there were several missed hand hygiene opportunities. Review of the provider's February 2021 Clean Wound Dressing Change policy and procedure revealed: *2. Wash hands upon entering residents room, (alcohol based hand sanitizer may be used.). *5. Wash hands prior to handling clean dressing supplies. *6. Establish clean field an flat surface with in reach of resident. *9. Wash hands. *26. Wash hands with soap and water. *30. Wash hands (alcohol based hand sanitizer may be used) when leaving residents room. 2. Observation on 7/27/21 at 10:29 a.m. with CNA/bath aide G with resident 13 revealed: *She put a gait belt on him and ambulated with him using a front wheeled walker (FWW) to his room. *Without performing hand hygiene and donning gloves she removed his brief and discarded it into the garbage can. *Without perfomring hand hygiene she put on gloves. She then: -Removed his socks and shoes. -Took a clean wash cloth and placed in on the floor under his left foot. --He had a suprapubic catheter. -Laid three alcohol wipe pads on the floor without a barrier. -Took an alcohol wipe and wiped the end of the catheter tubing with it. -Took a urinary container, opened the blue button on the end of the catheter tubing, and drained the urine into it. -Took another alcohol pad and wiped the end of the blue tip of the catheter tubing. -Discarded the urine into the toilet and had not rinsed the urinary container out. -Removed her gloves and had not performed hand hygiene. -Went into the hall and returned with clean clothing and a cover-up towel for the resident. -Placed the clean linen into the dresser. -Removed his shirt, discarded it onto the floor, and placed the cover-up on him. -Discarded the remainder of his soiled clothing onto the floor. -Covered him and pushed him to the whirlpool room. -Had not performed any hand hygiene throughout the above observation. Review of the provider's 2021 Catheter Care policy and procedure revealed Always wash your hands before and after handling the catheter, tube or bag, and wear gloves, following standard precautions for infection control. 3. Observation on 7/27/21 at 10:45 a.m. with CNA H with resident 10 revealed: *She assisted resident 10 to her room. *She performed hand hygiene and put on gloves. -Assisted resident 10 to hold onto the FWW and stand-up. -Removed the soiled brief and discarded it into the garbage. -Placed the commode behind the resident and assisted her to sit on it. -Went over to the sink and took a garbage bag and placed it onto the residents bed. -Went to the closet and took a package of wipes and a brief from the closet and placed them onto the bed. -Assisted the resident to stand-up. -Removed wet wipes from the package and wiped her front perineum area. --With the same wet wipes wiped her buttock area and discarded the wipes into the garbage bag on the bed. -Assisted the resident to sit in the wheelchair and removed her shoes, socks, and slacks. -Put on a clean brief, slacks, and shoes. -Pulled her slacks up. -Removed her gloves and with her bare hands she: -Took the bucket from the commode with her bare hands, rinsed the urine out of the bucket and placed it back into the commode. -Returned the clean supplies to the closet. -Opened the curtains. -Performed hand hygiene. Interview with CNA H following the above observation with resident 10 revealed she had: *Not performed hand hygiene after she removed her gloves and put on new gloves. *Asked the surveyor if she should have. -Missed some hand hygiene moments during the above observation. Review of the provider's July 2021 Perineal Care policy revealed: *Peri Care in the bathroom: -1. Wash hands. -2. Assemble equipment. -3. Explain procedure. Put on gloves. -4. Have resident stand if possible with feet apart. Gently remove brief. -5. Gently separate labia, with warm sudsy water wash cloth or peri wipes, cleanse from meatus to the back inside to outside. -6. Fold/turn cloth and wash groin areas (front to back). Use a clean portion of cloth with each wipe. -7. Rinse with clean disposable cloth, following the above pattern. -8. Gently dry. -10. Change gloves and apply peri cream if needed. -11. Remove gloves. -12. apply brief. Adjust resident's clothing. -13. Wash hands if resident is steady. -14. Assist resident with washing hands. 4. Observation and interview on 7/27/21 at 11:08 a.m. with CNA/bath aide G in the Southview whirlpool room revealed: *There was one whirlpool tub in the building. *Without performing hand hygiene she: -Put on gloves. -Took sanicloth wipes and wiped the arms and the seat of the whirlpool seat. -Took a spray bottle marked Virex Plus and sprayed the tub with it. -Filled the bottom of the whirlpool tub with the disinfectant located in the whirlpool tub unit. *She stated she would let the bottom of the whirlpool tub fill up with the solution until it was covered and then run the disinfectant in the whirlpool tub for thirty seconds. -Took a brush and wiped down the sides of the whirlpool tub, opened up the whirlpool tub door, and placed the chair unit into the whirlpool tub, and cleaned it with the brush and disinfectant solution in the bottom of the whirlpool tub. *She confirmed: -She let the disinfectant solution sit for fifteen minutes. -She would glance at the clock but but had not used a timer and there was no timer or clock on the wall in the whirlpool tub side of the bath house. -There had never been a problem with timeing the disinfectant solution because by the time she had gotten another resident ready for a bath the disinfectant solution had been in the whirlpool tub long enough. -After fifteen minutes she would go back into the whirlpool room and rinse the whirlpool tub off before she brought another resident in for a bath. *She had not monitored the contact time of the disinfectant solutin in the whirlpool tub. Interview on 7/28/21 at 3:00 p.m. with director of infection control I and director of nursing B regarding the above observations for resident's 10 and 13 and cleaning of the whirlpool tub revealed: *There were multiple missed hand hygiene opportunities. *Their expectations for hand hygiene was to have been completed: -Before and after donning and doffing gloves. -Going from a soiled to a clean procedure. *They: -Felt the whirlpool tub had been cleaned according to their policy. -Agreed there was no way to verify the contact time of the disinfectant in the whirlpool tub. Review of the provider's April 2020 Hand Washing/Hand Hygiene policy and procedure revealed: *Use an Alcohol-Based Hand Rub if hands are not visibly soiled and for routinely decontaminating hands in all other clinical situations: -Decontaminate hands before: --Having direct contact with patients/residents. --Donning gloves. -Decontaminate hands after contact: --With a patient's [resident] intact skin. --With body fluids or excretions, mucous membranes, non intact skin, and wound dressing if hands are not visibly soiled. -Decontaminate hands: --If moving from a contaminated body site to a clean body site during patient/resident care. --After contact with inanimate objects (including medical equipment. --After removing gloves. Review of the provider's Whirlpool Tub Disinfection policy revealed: *Procedure: -1. Drain the tub. -2. REPLACE THE TUB DRAIN Plug. -3. Push and Hold the Disinfect Jets button until there is approximately 1-1.5 gallons of water in the bottom of the tub. -4. Wet the brush with the disinfectant solution. Brush all tub and chair surfaces. Disinfectant needs 10 minutes before being rinsed off tub surface.

Based on observation, interview, record review, and policy review, the provider failed to follow physician's orders for one of one sampled resident (17) who was receiving oxygen. Findings include: 1. Observation on 7/27/21 at 10:15 a.m. in resident 17's room revealed: *She was sitting in a recliner with an oxygen nasal cannula on. *The oxygen concentrator flow rate was set at 5 liters. Observation and interview on 7/27/21 at 3:30 p.m. in resident 17's room revealed: *She was sitting in a recliner. *The oxygen concentrator flow rate was set at 5 liters. *She stated I am on 5 liters of oxygen. The staff would turn it up for me if needed, but I don't need them to, I can do it myself. Review of residents 17's medical record revealed: *diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *The 6/15/2021 medication review report signed by the physician stated Portable oxygen 2 liters with excertion (exertion) as needed for dyspnea and excertion (exertion). *The 2/16/2021 medication self-administration safety screen had not included oxygen. *The March 1, 2021 through July 28, 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . *The 5/24/21 quarterly Minimum Data Set assessment had been coded she used oxygen. *The revised 6/24/2021 care plan stated O2 (oxygen) as ordered to keep O2 above 90%. *There was no acknowledgement for self-administration of oxygen in the physician orders and dictation or nurse assessment. Interview and record review on 7/28/21 at 9:10 a.m. with registered nurse (RN) C regarding resident 17's oxygen revealed: *She confirmed resident 17 was on 5 liters of oxygen. *She was unable to find the physician's order for 5 liters of oxygen. *The only physician's order regarding oxygen use for her had been dated 3/8/2019. It had included: -Titrate oxygen 2-4 lpc (liter per cannula). -To keep sats (saturation) > (greater than) 90%. -Ok to titrate. Interview on 7/29/2021 at 9:00 a.m. with director of nursing B regarding resident 17's oxygen revealed: *The oxygen liter flow rate was to be at 5 liters. *She stated I just know from working with her how much oxygen she was to receive. Review of the provider's January 2021 Physicians's Order policy and procedure revealed: *1. All physicians' orders will be recorded on the Physicians's order sheet for each resident and signed or initialed by the attending/prescribing physician. *3. Physician's orders are reviewed every 30 to 60 days with resident recertification. *5. The verbal/telephone order will contain physician's instructions, date, signature, and title of the licensed nurse and physicians name. -a. The licensed nurse will read-back order to physicians and enter into Point Click Care. Review of the provider's February 2021 Care Plan policy and procedure revealed: *7. The care plan is reviewed, updated, and revised with change of resident condition. The care plan is reviewed, revised and updated at least quarterly at the scheduled care conference. Review of the provider's February 2021 Self-Administration of Medication policy and procedure revealed: *Purpose: -A resident may request to self-administer medication. Self administrations of medications and treatments by a resident is permitted with a physician order unless such practice for the resident is deemed unsafe. *Procedure: -2. The interdisciplinary team will assess the requesting residents ability to safely self-administer medication.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (18 and 28) with non-pressure related skin issues had received appropriate nursing assessments, complete documentation, proper communication between staff, and had received appropriate treatment for [REDACTED]. 1. Review of resident 28's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Restless leg syndrome. -Severe obesity. -[MEDICAL CONDITION]. -[MEDICAL CONDITION] of unspecified deep veins of unspecified lower extremity. -Hypertension. *He had [MEDICATION NAME] cream to be mixed with [MEDICATION NAME] cream ordered at the time of his admission for him to self-administer. -That cream was ordered for the left leg and groin areas only. *He was continent of bowel and bladder at the time of his admission but had recently become more incontinent. Refer to F690, finding 1. Observation and interview on 3/24/19 at 3:10 p.m. with resident 28 in his room revealed:*He complained of his brief frequently being wet. *That was a new problem that he did not have prior to admission. *His testicle was sore due to it rubbing on the side of his leg. *Had sore areas to his lower abdomen on both the left and right side. *Had to wait for two staff to assist him to stand when using the urinal. *Staff would put vaseline on his testicle. *Staff would apply a white cream to the abdomen. *When the vaseline and white cream were applied it would help. Interview on 3/25/19 at 7:49 a.m. with registered nurse (RN) G regarding resident 28 revealed: *He applied his own cream that was in his room. *The pharmacy mixed the creams and sent it to the facility. *There were no treatments completed by the nurses or certified nursing assistants (CNA). Interview on 3/25/19 at 8:34 a.m. with resident 28 in his room revealed: *Vaseline was sitting on the stand under his television. *There was also a white container with a pharmacy sticker on it that revealed: -Tac 0.1%/[MEDICATION NAME]. -To be applied to his groin two times a day. -It was filled on 2/19/19. -Was not to be used after 9/6/19. *He said the girls put it on him. *The girls also put the vaseline on his testicles. -He thought it was better. Observation on 3/25/19 at 8:41 a.m. with CNA D and CNA F when they moved him from his wheelchair to his recliner revealed: *They were using a Tollos standing aid lift to transition him from his wheelchair into his recliner. *The CNAs did not check for incontinence nor ask if he needed to use the bathroom. *No skin care was completed at that time. Observation and interview on 3/25/19 at 9:31 a.m. with resident 28 revealed: *At 9:31 a.m. his wife came out of his room and told CNA F he needed to use the bathroom. *CNA F said she would get someone. *At 9:37 a.m. the call light came on outside his room. *At 9:38 a.m. CNA D and CNA A came into assist him to use the urinal. -They used the standing lift to help him stand up to use the urinal. -CNA A held the urinal in place while he voided. *She was going to start dressing him, and he reminded her to apply his creams. *She used wipes to clean his groin and bottom. -When cleaning the area near his right testicle and upper, inner thigh he said ouch. *She applied vaseline to his bottom and to his right, upper, inner thigh near his groin. -There was a red area under his testicle on his right thigh. -That red area was about the size of his testicle. *She was going to put his brief on, and he reminded her to do the abdominal folds as well. *She applied the cream to the right abdominal fold. -That red area that looked raw. -There were two opened areas in the fold that were bleeding . *She applied cream to the left abdominal fold. -That area was reddened. -There was also a purple area about the size of a half of a dollar. *CNA A said CNAs usually put on the creams whenever he asked them to. *She said they were not medication certified. Refer to F658, finding 1. Interview on 3/25/19 at 10:19 a.m. with RN G revealed: *She went to assess his skin after the CNAs had told her about the above concerns. *He had an order to self-administer his creams but he was not doing it any more. *He had to ask staff for help when he needed to use the urinal or the bathroom. -When he was admitted he was able to take himself to the bathroom. *She had worked on 3/22/19, and those areas were not as bad as they were currently. -CNAs should have communicated the change in his skin to the nurses. Review of the last revised 2/19/19 care plan for resident 28 revealed: *He had an intervention that stated: Monitor skin in groin area and left leg for dematitis, he has ointment applied BID (two times day) to these areas. *There was no mention of the abdominal folds or the right upper inner thigh. Review of resident 28's interdisciplinary progress notes from admission on 2/6/19 through 3/25/19 revealed on: *3/20/19 at 12:47 p.m. a skin/wound note revealed: Resident has blood dripping from his testicles. cleansed testicles there is a dark red sore where the blood is coming from .patient (resident) states his testicles stick to his legs and 'rip' off. he has been utilizing PRN (as necessary) cream daily, 'some days several times' patient states his testicles itch a lot also. wil discuss with provider. *3/20/19 at 2:48 p.m.: physican ordered at vasoline guaze pad to area. *No notes about the condition of his skin from the above note through 3/24/19. *3/24/19 at 5:47 a.m. a physician's orders [REDACTED]. -There was no indication of the reason for that order or the condition of the abdominal folds. *There was no documentation to support the above observed concerns with his skin or when they had developed or worsened. Review of medication and treatment administration records (MAR/TAR) for (MONTH) 2019 for resident 28 revealed: *Interdry sheets to abdominal folds was ordered on [DATE]. *There were three documentations reflecting no supplies for that treatment. -The physican's orders had not been followed. *The documentation had reflected he had self-administered his [MEDICATION NAME] cream twice a day every day between 3/1/19 through 3/24/19. *The documentation had reflected he self-administered his [MEDICATION NAME] cream twice a day every day between 3/1/19 through 3/24/19. Interview on 3/25/19 at 5:29 p.m. with director of nursing (DON) and assistant director of nursing (ADON) revealed: *Surveyor requested all skin assessments for resident 28. -The DON stated there were no specific assessments or checks completed for moisture related skin issues. *There would be skilled charting for the two days he had been on skilled services. -Those would have included skin assessments but would have stopped when he was no longer on skilled services. *She had just been told his skin condition had worsened. *They just started an investigation to see when his skin condition had changed, since the nurse working today was not aware of it. Interview and record review on 3/26/19 at 10:56 a.m. with the DON and ADON regarding resident 28's skin issues revealed: *Upon admission he was self-administering his creams. -That had been appropriate at that time. -They were unsure when staff had started applying creams. *They confirmed there was a note on 3/20/19 about blood dripping from his testicle. -That was when they were first notified of his skin issues. *He was seen by his physician that day. -He ordered vaseline gauze to be applied to the area. *They typically only completed skin assessments for pressure ulcers. -His skin concerns were not pressure ulcers. -Documentation should have been in the progress notes. *They confirmed his skin had worsened significantly since his admission on 2/6/19. *They agreed communication between the CNAs and nurses was a concern. -The CNAs should have notified the nurse of any changes for a resident. 2. Review of resident 18's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Muscle weakness. -[DIAGNOSES REDACTED]. -Altered mental status. -Unspecified abnormalities of gait and mobility. -Type 2 diabetes. -[MEDICAL CONDITION]. Review of resident 18's 1/29/19 Minimum Data Set assessment revealed: *His Brief Interview for Mental Status score was fifteen indicating his cognition was intact. *He required extensive assistance of one staff person for bed mobility, transferring, walking, dressing, toilet use, and personal hygiene. *He was on a toileting program. *He was frequently incontinent of bladder. *He was always continent of bowel. Observation and interview on 3/25/19 at 10:35 a.m. with resident 18 revealed: *He had been sitting in his recliner in his room. *He was sitting on a gel cushion in his recliner. *He stated he had gotten a sore on his bottom recently, and it had hurt. *He stated it was better now. *They had put the gel cushion in his recliner after he had gotten the sore. Review of resident 18's nursing skin and wound progress notes from 12/1/18 through 3/25/19 revealed: *On 12/26/18: Resident noted to have 1cm (centimeter) X (by) 0.5 cm open area to upper right intergluteal cleft. Resident occasionally incontinent of urine, wears pull up incontinent product at all times. Resident states it is painful. Area blanches at this time, edges are well defined. PC applied to area, placed roho cushion in recliner. *On 1/3/19: Resident has open area to right inter gluteal cleft MASD (moisture associated skin damage) - area has increased in size and is painful for resident. Roho cushion placed in recliner last week and gel cushion is in place in wheelchair. Requesting [MEDICATION NAME] ointment from physician for current wound. *On 2/11/19: Resident has deep purple MASD area noted to upper left buttock, resident states it hurts a little. [MEDICATION NAME] ointment applied to area and resident and staff educated on re-positioning and keeping incontinent product clean and dry. Review of resident 18's assessments revealed: *There were no assessments for skin or pressure ulcers on 12/26/18, 1/3/19, or 2/11/19. *The Braden assessment done on 1/29/19 with a score of eighteen stated he was at risk for pressure ulcer development. *The prior Braden assessment done on 10/30/18 had a score of nineteen indicating he was not at risk. *There was no wound assessments. Review of resident 18's undated current care plan revealed it did not address the potential for skin breakdown other than for his feet. There had been no documentation of his MASD from the above dates. Interview on 3/26/19 at 1:02 p.m. with the DON and assistant director of nursing (ADON) regarding resident 18's skin concerns revealed: *The DON stated identifying MASD as deep purple was concerning. *She left to get RN G to answer some questions. *On 1/3/19 the skin and wound documentation stated it was worse, but there was no further notes until 2/11/19 regarding a different issue. *The ADON looked through his medical record and stated they had used [MEDICATION NAME] ointment from 1/3/19 through 1/23/19. -She assumed the wound had healed on 1/23/19, but there had been no documentation in his chart to reflect that. Interview on 3/26/19 at 1:06 p.m. with RN G and the ADON revealed: *RN G did not complete wound assessments on anything other then pressure ulcers. *The ADON stated they should have had notes from 1/3/19 through 1/23/19 to indicate improvement or worsening. *The ADON agreed documentation was not there to reflect the above mentioned MASD. *The ADON stated the care plan should have been updated to have included interventions for MASD. Surveyor: Review of the provider's 3/13/18 Skin policy revealed: *The purpose was: To provide guidelines and direction for healthcare professionals in assessing and providing care and intervention to patients with skin issues and to prevent the development of skin issues. *The procedure included: -A full head to toe skin assessment will be completed on admission or if there is a significant change in status, to assess skin changes/breakdown. --All skin issues present on admission will be documented. *Interventions for moisture included: -1. Ensure proper use of protective undergarment. --a. Recommended for use if incontinent of urine, not if having frequent stools. --b. Ensure right size. --c. Check every two hours for soiling and maintain a clean and dry surface. -2. Utilize a wicking cloth in moist skin folds (not to be used in conjunction with other topical treatments). -3. Ensure commode/urinal within reach. -4. Keep dressings clean dry and intact per physician orders. *There was no mention of: -How often assessments of resident's skin should have been done after admission to ensure there was no breakdown. -The process of documentation of skin concerns or treatments of those areas. -The process for direct care staff to communicate changes in skin condition to the nurses.

Based on observation, interview, and record review, the provider failed to have sufficient and competent nursing staff to ensure: *Two of two sampled residents (18 and 28) with non-pressure related skin issues had received appropriate nursing assessments, complete documentation, proper communication between staff, and had received appropriate treatment for [REDACTED]. *Two of two sampled residents (28 and 293) had not had a decline in their bowel and bladder continence. *One of two sampled residents (18) received restorative therapy. *Two of two randomly observed residents (5 and 42) had been toileted when needed. Findings include: 1a. Review of resident 28's medical record revealed he had skin breakdown and a decrease in continence. Refer to F684, finding 1. Refer to F690, finding 1. b. Review of resident 18's medical record revealed he had three episodes of moisture associated skin damage (MASD) from 12/1/18 through 3/1/19. There had been no assessments completed and documentation had not been thorough regarding treatment and interventions implemented. Refer to F684, finding 2. 2. Review of resident 293's medical record revealed she had a decline in her bowel continence. Refer to F690, finding 1. 3. Review of resident 18's medical record revealed he was to receive the following restorative therapy: *Nursing rehab (rehabilitation)/restorative: Transfer program - Nustep device quad (quadriceps) strengthening x (by) 15 min L3 resistance 6 days/week for 15 minutes each day. *Nursing rehab restorative: Active ROM (range of motion) program - bilat (bilateral) UE/LE (upper extremities/lower extremities) ROM activities 6 days/week for 15 minutes each day. *Nursing rehab/restorative: Walking program - Assisted Ambulation using FWW (front wheeled walker) with CGA (contact guard assist)/SBA (stand-by assist) of 1. (MONTH) ambulate up to 150'. Encourage (resident name) to walk to and from meals if able. *Documentation revealed he had not been getting therapy six days per week due to staffing issues. Refer to F676, finding 1. 4a. Observation on 3/25/19 at 8:12 a.m. of resident 42 revealed she stated she needed to go to the bathroom and was not taken until 9:05 a.m. after breakfast. Certified nursing assistant (CNA) N had told her she would have to wait until after breakfast. She had waited fifty-three minutes for staff to assist her with going to the bathroom. b. Observation on 3/25/19 at 9:03 a.m. of resident 5 revealed: *She had stated two times she had to use the bathroom. *CNA O told her she would have to wait until she was done assisting another resident with breakfast. *At 9:04 a.m. she asked again, and CNA O stated she would have to wait. *The resident stated I really need to have someone take me to the bathroom. *CNA O again told her she would have to wait. Interview with CNA O at that time revealed: *When asked if that was normal practice to have the resident wait she stated yes. -She would have to wait until she was done assisting the other resident. *When asked if there was someone she could call to assist the resident she stated No. Continued observation of resident 5 revealed: *She stated again: -I really have to get to the bathroom. -I really hope someone can get me to the bathroom. -Is anyone going to take me to the bathroom. *At 9:09 a.m. another staff person was called, and she came to assist the resident. 5. Interview on 3/26/19 at 4:03 p.m. with the director of nursing and the assistant director of nursing revealed they had been having some staffing issues. They would not expect the residents to be told they would have to wait to use the restroom. They had not made any changes to the restorative program staffing schedules at that time.

Based on observation, record review, interview, and policy review, the provider failed to identify food likes and dislikes, implement interventions, update care plan, and document usage of supplements for one of one sampled resident (8) with a significant weight loss. Findings include: 1. Review of resident 8's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She had been treated for [REDACTED]. *Her weight had declined since admission. *Her weight had been: -161.0 pounds (lb) on 12/8/16. -158.5 lb on 12/11/16. -157.0 lb on 12/18/16. -151.2 lb on 12/25/16. -150.5 lb on 1/1/17. -154.5 lb on 1/8/17. -155.0 lb on 1/15/17. -147.5 lb on 1/22/17. -147.0 lb on 1/29/17. -145.5 lb on 2/5/17. *There had been no documentation a re-weigh had occurred on 1/22/17 when she had a 7.5 lb weight loss. Review of resident 8's 12/15/16 Minimum Data Set assessment revealed: *Her Brief Interview for Mental Status (BIMS) score had been a three. -A score of zero to seven meant her thinking ability was severely impaired. *She required supervision from staff members for eating. *Nutritional status and dehydration were two care areas that had triggered based on the answers of the assessment. Review of resident 8's undated current care plan revealed the weight loss or nutritional status had not been addressed. They had one intervention for hydration. It was Encourage fluids at mealtimes et (and) with each resident contact. Observation on 2/7/17 at 8:00 a.m. of resident 8 revealed she had been in her room laying on the bed with her eyes closed covered with a blanket. Interview on 2/7/17 at 8:20 a.m. with certified nursing assistant (CNA) C regarding resident 8 revealed: *She had already been up, was dressed, and was washed up. *She had gone to her room and went back to bed. *CNA C stated she thought the resident was depressed. *She would refuse to eat sometimes. *They would offer her ice cream if she refused to eat. *She could not recall any other alternatives they would offer her if she did not eat her meal. Observation on 2/7/17 from 8:45 a.m. through 8:56 a.m. of resident 8 revealed: *At 8:45 a.m. she came out of her room ambulating with a walker. *She sat down at the table and was served cheerios, a muffin, and juice. -She had not attempted to eat. *CNAs C and D were assisting other residents with eating and had not attempted to help her. *She returned to her room without touching any of her food. Observation on 2/7/17 from 11:04 a.m. through 11:20 a.m. with registered nurse (RN) E in resident 8's room revealed: *She offered the resident sherbet after she had refused her antibiotic medication. *The resident ate the whole cup of sherbet before we had exited the room at 11:20 a.m. Observation on 2/7/17 at 11:50 a.m. of resident 8 revealed: *She had been in her room laying on her bed sleeping. *CNA D had been in her room, came out, and stated to CNA C the resident did not want to come out for lunch. *There had been no offers to get her any other food items or to provide assistance with eating. *They had left the food tray on the delivery cart from the kitchen and had not taken it to her room. Review of resident 8's diet card revealed it was blank. Interview with an unidentified dietary staff person revealed all the diet cards for residents in both memory care units were blank. She was not sure why they were that way. Review of resident 8's nursing interdisciplinary notes revealed on 2/4/17 Resident family states resident will not drink milk or the ensure, would like to try offering resident breeze juice for supplement. Review of resident 8's diet change form revealed on 1/5/17 they added Ensure 4 ounces (oz) with meals. On 2/4/17 the new diet was Breeze juice. It had not indicated an amount. The old diet section stated Ensure (refusing it). There had been no interventions documented on 12/25/16 when she had lost 5.8 lb from the previous week. A total of 9.8 lb since her admission on 12/8/16 to 12/25/16. Interview on 2/7/17 at 4:30 p.m. with the director of nursing (DON) regarding resident 8 revealed: *She was not aware the weight loss had not been addressed on the care plan. *She was unsure if or where staff documented supplement intake. -She stated she would have to contact the registered dietitian (RD) to learn that information. *All information regarding interventions implemented for the weight loss was requested at that time. Interview on 2/8/17 at 11:20 a.m. with resident 8's son revealed: *The staff had not asked him what foods she liked or disliked at admission or since she had been losing weight. *She was never a fan of milk. *His sister had told the staff she would not drink the Ensure because she had not liked milk. *She had always loved mashed potatoes and gravy. *She liked fried chicken, pizza burgers, roast beef, and corn. *She had told him once the food did not taste good. *When they had taken her out to eat in the past she would eat. *His sister had brought in Subway one day, and she ate that with no problem. Interview on 2/8/17 at 1:50 p.m. with the RD regarding resident 8 revealed: *The dietary manager (DM) had been on medical leave since November. -She could not provide the actual date she had gone on leave. *They had not assigned a person to complete the DM responsibilities when a new admission arrived. *On 12/25/16 the resident had a 6.1% weight loss that would have been considered a significant weight loss for one month. -She had completed her nutritional assessment on 12/20/16 and recommended adding the 4 oz Ensure at that time, but it had not been approved by the physician until 1/5/17. *Supplements were not documented or monitored until after the weight loss had become significant. -They had not started documenting supplements for resident 8 until February 2017. -They should have been documenting the consumption of the Ensure from when it had been started on 1/5/17. *She had read in the nursing interdisciplinary notes the family member had informed them the resident would not drink milk. -Staff had not informed her. *They had not gotten her food likes and dislikes at admission or since. *She was not aware the resident liked mashed potatoes and gravy. *Sometimes staff would offer her ice cream. *She added the weight loss to the care plan last night after the DON had called her. *No other interventions had been attempted. Interview on 2/8/17 at 2:00 p.m. with the DON regarding resident 8's weight loss revealed she had no other documentation regarding attempted interventions. Review of the provider's 1/2/14 Weights: Obtaining, Reweighs, Physician Orders, Care Plan policy revealed: *Weight loss of 5% in one month should have been reported to the DM. *The DM should have reported significant weight loss to the RD by the next visit or sooner. *The DM should have collaborated with the RD to address nutritional interventions related to weight loss. *In the absence of the DM the facility should have designated staff responsible for notifying the RD of weight issues. *The DM and RD were to have written an appropriate dietary care plan for each individual resident. *The charge nurse on duty when a new physician's orders [REDACTED].

Based on observation, record review, interview, and policy review, the provider failed to implement interventions for one of one sampled resident (8) who demonstrated continued behaviors related to a urinary tract infection [MEDICAL CONDITION], depressed mood, refusal to eat and take medications, and who had a significant weight loss. Findings include: 1. Review of resident 8's medical record revealed: *She had been admitted to the facility on [DATE]. *Her [DIAGNOSES REDACTED]. *She had been treated for [REDACTED]. *She had fallen on 12/15/16. *Her weight had declined since admission. *Her weight had gone from 161.0 pounds (lb) on 12/8/16 to 145.5 lb. on 2/5/17. Refer to F325, finding 1. Review of resident 8's 12/15/16 Minimum Data Set assessment revealed: *Her Brief Interview for Mental Status (BIMS) assessment score had been a three. -A score of zero to seven meant her thinking ability was severely impaired. *She had verbal behavioral symptoms that had occurred one-to-three days since her admission. *Rejection of care had occurred one-to-three days since her admission. *She had fallen once since her admission. *The care areas that had triggered based on the answers of the assessment were: -Cognitive loss. -Visual function. -Communication. -Urinary incontinence/catheter. -Behavioral symptoms. -Falls. -Nutritional status. -Dehydration, fluid maintenance. -Pressure ulcers. -[MEDICAL CONDITION] drug use. Review of resident 8's undated current care plan revealed: *A focus area of 'The resident has potential to be physically and verbally aggressive r/t (related to) dementia' with the following interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. -Give the resident as many choices as possible about care and activities. -Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of resident posing danger to self and others. -Presence of behaviors has historically been indicative of UTI in this resident. Report to nurse any changes in mood or behavior as resident may have UTI. -When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. *The weight loss had not been addressed on the care plan. Observation on 2/7/17 at 8:00 a.m. of resident 8 revealed she had been in her room laying on the bed with her eyes closed covered with a blanket. Interview on 2/7/17 at 8:20 a.m. with certified nursing assistant (CNA) C regarding resident 8 revealed: *She had already been up, was dressed, and was washed up. *She had gone to her room and went back to bed. *CNA C stated she thought the resident was depressed. Observation on 2/7/17 from 8:45 a.m. through 8:56 a.m. of resident 8 revealed: *At 8:45 a.m. she came out of her room ambulating with a walker. *She sat down at the table and was served cheerios, a muffin, and juice. -She had not attempted to eat. *CNAs C and D were assisting other residents with eating. *At 8:49 a.m. licensed practical nurse (LPN) B took a liquid medication to the resident. *The resident stated Is this the one that tastes so bad? *She went to pick-up the medicine cup and spilled part of the liquid on herself and onto the table. *LPN B had not refilled the medication cup to meet the amount needed to match the physician's orders [REDACTED].>*LPN B had attempted to give the resident what was left in the medicine cup, but she refused stating I don't like that. Interview on 2/7/17 at 8:55 a.m. with LPN B regarding resident 8 revealed: *The liquid medication was Bactrim an antibiotic. *The resident had a UTI they were treating. *She had refused the medication yesterday morning for her as well because she had not liked the taste. Observation, interview, and documentation review on 2/7/17 from 11:05 a.m. through 11:40 a.m. with registered nurse (RN) E regarding resident 8 revealed: *She stated the resident had been on Bactrim pill form in December 2016 for a UTI. *She had not liked the pills, because they were so big and got stuck in the back of her throat. *They thought she might take the liquid form better, but she did not like the taste and constantly refused to take it. *She had aggressive behaviors when she had a UTI. -She had defined the aggressive behaviors as combative with staff, uses her walker against staff, and tries to get out (of the memory care unit). *She had gone into the resident's room at 11:07 a.m. with another dose of Bactrim to see if she would take it for her. *She had a glass of juice and a cup of sherbet. *The resident had been sleeping, and RN E woke her up. *RN E asked her to take the medication again to help clear up her UTI. *The resident stated I don't like it. It tastes so bad. *The resident attempted to drink the liquid and took a sip. *She expressed facial grimacing and stated Yuck after taking a sip. *RN E gave her the juice to wash down the taste of the medication. *She asked the resident to finish the medication. *She stated I can't. I am not going to take that. *RN E offered the resident the sherbet, and she ate the whole cup before we had exited the room at 11:20 a.m. *She then layed back down and stated she was tired. *RN E had started with 20 ml in the medication cup and had 12.5 ml left. *At 11:35 a.m. this surveyor had asked RN E if there were different flavors of the liquid Bactrim. -She was unaware and stated she would have to call the pharmacist. *The pharmacist stated they were currently using the grape flavor, but they had cherry flavored liquid Bactrim as well. *RN E ordered the cherry flavor from the pharmacist for the resident at that time. Observation on 2/7/17 at 11:50 a.m. of resident 8 revealed: *She had been in her room laying on the bed sleeping. *CNA D had been in her room and came out and stated to CNA C that she did not want to come out for lunch. *There had been no offers to get her any other food items or to provide assistance. Review of resident 8's December 2016 Medication Administration Record [REDACTED] *She had an order for [REDACTED]. -Give one tablet by mouth two times a day for UTI. *On 12/17/16 she had refused the morning and supper medication for LPN B. -RN E had signed off that she had given them after LPN B had attempted. *On 12/19/16 she had spit out her supper medication of Bactrim. -There had been no signature or documentation they had re-attempted to give that dose of Bactrim. Review of resident 8's February 2017 MAR indicated [REDACTED]. Review of faxes and notifications sent to the physician from 12/15/16 through 2/7/17 revealed they had not notified the physician of the following: *She had not liked taking the Bactrim pill as it was so large. *She had refused her medications on 12/17/16. *She spit out her medications on 12/19/16. *She had not liked the taste of the liquid Bactrim medication. *She had refused the Bactrim on 2/6/17 and missed that dose. *They had not notified the physician until after this issue had been addressed with them on 2/7/17. Review of resident 8's interdisciplinary notes from 12/8/16 to 2/7/17 revealed on: *12/9/16, a note by the licensed social worker stated the Resident was pleasant and interacting well with family and residents. *12/12/16, the physical therapist stated she was Pleasant and cooperative. *12/14/16, staff reported Resident is pleasant and cooperative with occasional irritability but no significant behaviors. *12/15/16, documented aggressive behaviors, exit seeking, combativeness, and anger on the overnight shift. They had received orders for [MEDICATION NAME] 0.5 mg IM for anxiety and agitation. *12/15/16 at 8:03 a.m., they had documented they had contacted the residents son. (Son's name) was concerned about the turn around in his mother's behaviors .Son wondering if we can check mother for UTI, as this was the cause of her behaviors prior to admission to (facility name). *12/15/16 at 3:02 p.m., the physician had ordered To check U/A (urine analysis) on resident r/t increased behaviors and hx (history) of UTI with behaviors. *12/15/16 at 10:00 p.m., she had a fall in her room. *12/16/16, she had continued to be uncooperative. *12/17/16 at 9:39 p.m., Resident refusing assistance from staff, refusing medications, refusing meals. C/o (complained of) sore throat but refuses to let this nurse look at it. Resident does have UTI and is scheduled to take Bactrim and this could be the reason for behaviors at this time. *12/17/16 at 6:11 p.m., Resident very resistive with staff, meals, and family today. Did not take medications all day, was able to get resident to take Bactrim and [MEDICATION NAME] at 1400 (2:00 p.m.). Resident ate some Kuchen that daughter brought. Also did eat Subway sandwich daughter brought. Resident did take her Bactrim, [MEDICATION NAME], and [MEDICATION NAME] this evening. Was upset staff were trying to help her, did talk resident into getting into PJ's for the night. *12/17/16 at 6:16 p.m., they had received an order from the on-call physician To use [MEDICATION NAME] 0.5 mg IM (intramuscularly) Q6 (every 6) hours PRN as needed for agitation. Resident has had some behaviors today that are leading towards possible aggression later, an the order was obtained for the weekend if needed. Will talk to primary physician on Monday 12/19/16. *12/17/16, the daughter had requested she be on Tylenol, as she had always been on it even when she was at home. *12/19/16, they had identified the UTI could be impacting her behavior as well as her cares. *12/19/16 at 4:24 p.m., they had administered [MEDICATION NAME] 0.5 mg IM for aggressive behaviors. -At 7:06 p.m. they had documented the [MEDICATION NAME] had been ineffective. *12/22/16, they Obtained U/A for analysis and reflux to culture. Resident has aggressive behaviors that are likely linked to the UTI with orders for PRN [MEDICATION NAME]. *1/5/17, the physician had been to see her. He documented Since admission, there have been a few instances where the patient's behavior was aggressive. The nursing staff needed to utilize IM [MEDICATION NAME] on two occasions, on 12/15 and 12/19. She was checked for UTI twice, completed one course of Bactrim DS, as prior to her admission here, the patient had increased aggressiveness and agitation secondary to a UTI at the Behavioral Health Facility .It is very difficult to convince the patient to take her regular medications. -He added quetiapine 25 mg at bedtime because her Uncontrolled behavior is quite problematic with the surrounding staff and surrounding residents. -There had been no documentation staff had informed him of her spitting out her pills on 12/19/16. -There had been no documentation of discussion of continuing to treat for the UTI, as she was still demonstrating behaviors. *1/20/17 at 7:00 p.m., they had administered [MEDICATION NAME] 0.5 mg IM for Res (resident) was very anxious and weepy, also was hitting and pushing residents and staff. *1/22/17 at 2:40 a.m., they had administered [MEDICATION NAME] 0.5 mg IM for agitated. *1/27/17 at 4:07 p.m., they had administered [MEDICATION NAME] 0.5 mg IM for aggressive behaviors. *1/30/17 at 11:15 a.m., they had notified the physician of her behaviors and the use of the IM [MEDICATION NAME]. They were waiting to see if he wanted a U/A done. *2/1/17, they Received order to obtain a U/A with reflex to culture per (physician name) r/t residents increase in aggressive behaviors towards others and hx (history) of UTI with behaviors. *2/2/17, they received an order to start Bactrim DS BID x 7 days for UTI. *There had been no documentation by LPN B of her refusing the Bactrim on 2/6/17. *There had been no documentation notifying her primary physician of the continued behaviors from 1/5/17 through 1/30/17. *There had been no documentation they had discussed continued treatment for [REDACTED]. *There had been no documentation they were addressing or monitoring for dehydration. Review of resident 8's 12/15/16, 1/3/17, 2/1/17, and 2/3/17 U/A laboratory reports revealed she was not resistant to any of the sixteen antibiotic medications listed. Observation on 2/7/17 at 2:00 p.m. of resident 8 revealed she had not been in her room or in the Northview memory care unit. Interview on 2/7/17 at 4:15 p.m. with CNA C regarding resident 8 revealed her son and daughter-in-law had come to visit at 2:00 p.m. They were able to get her up and had taken her to the beauty shop to get her hair done. Interview on 2/7/17 at 4:30 p.m. and again on 2/8/17 at 2:00 p.m. with the director of nursing (DON) regarding resident 8 revealed: *Her first week in the facility she was quiet and friendly. -She had not demonstrated any behaviors. *The physician should have been notified the resident had spit out her pills on 12/19/16 and refused the dose of Bactrim on 2/6/17. *She would not have gotten the correct treatment for [REDACTED]. *The behaviors she was demonstrating could have been due to a chronic UTI. *They had started [MEDICATION NAME] PRN and [MEDICATION NAME] due to those behaviors. *She was unsure where to locate the CNA behavior documentation. *On 2/7/17 this surveyor asked her to provide any other information regarding interventions for the behaviors, weight loss, and overall decline. Interview on 2/8/17 at 11:20 a.m. with resident 8's son revealed: *She had a history of [REDACTED]. *She had been at a different nursing home prior to being admitted here. *She had demonstrated aggressive behaviors and was sent to the local hospital. *They had done a UA and not found a UTI. *The hospital transferred her to a behavioral health facility where they found a UTI. *They treated the UTI, and her behaviors went away. *He listed the specific behaviors as being upset with everything and being angry. *They had seen a pattern with behaviors related to UTIs, and If we can get the UTI under control behaviors get better. *Once the UTI is resolved we see improvement in her behaviors. *They had learned from a psychiatrist that a UTI could cause behaviors in a person. *They had called him when they wanted to start the [MEDICATION NAME] and told him it was to help her return to a normal sleeping pattern. *He stated even when she was at home she did not have a normal sleeping pattern. She had not slept through the night. Interview on 2/8/17 at 1:10 p.m. with the social service designee/assistant regarding resident 8 revealed: *The licensed social worker was currently on leave. *The residents first week in the facility she had no behaviors. She was calm and had no issues. *She had come from behavioral health and had been treated for [REDACTED]. *She suspected the behaviors she was demonstrating since after admission might have been related to a UTI. *They discussed her in the weekly quality assurance meetings, and she pushed to look at the UTI not being resolved. *She was not providing one-to-one interventions for her. *She had no documentation of interventions or collaboration with nursing or dietary departments regarding adjustment to the new facility, the behaviors, refusal to eat or take medications, potential depressed mood, or the weight loss. A policy on treatment of [REDACTED]. Review of the provider's 1/2/14 Weights: Obtaining, Reweighs, Physician Orders, Care Plan policy revealed: *Weight loss of 5% in one month should have been reported to the DM. *The DM should have reported significant weight loss to the RD by their next visit or sooner. *The DM should have collaborated with the RD to address nutritional interventions related to weight loss. *In the absence of the DM the facility should have designated staff responsible for notifying the RD of weight issues. *The DM and RD were to have written an appropriate dietary care plan for each individual resident. *The charge nurse on duty when a new physician's orders [REDACTED]. Review of the provider's 2/15/13 Administration of Medications policy revealed: *All medications and biologicals administered must be ordered in writing by the resident's attending physician. *The person administering the medication must chart on the MAR indicated [REDACTED] *The MAR indicated [REDACTED]. *Should there be any doubt concerning the physician's orders [REDACTED].

Based on record review, interview, and policy review, the provider failed to ensure nutritional interventions for one of three sampled residents (6) with a significant weight loss. Findings include: 1. Review of resident 6's nursing progress notes revealed her initial admission was on 8/29/11. Review of resident 6's following Minimum Data Sets revealed: *11/22/11: -Her weight was 157 pounds (lb). -She had a weight loss of 5% (percent) or more in the last month or a loss of 10% or more in the last six months. -She was on a physician prescribed weight loss regimen. *12/15/11: -Her weight was 154 lb. -She had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months. -She was not on a physician prescribed weight loss regimen. Review of resident 6's nutritional assessments by the consulting dietitian revealed: *On 8/30/11: -Her weight was 169.5 lb. -The goal was "No wt (weight) gain. Keep 165-170 # (lb) Maintain /improve hgb/hct (hemoglobin/hematocrit). -The recommended diet was "regular." -She was to receive dietary counseling prn (as needed). *On 9/27/11: -"Weight 155.6 BMI (Body Mass Index) - overwt (overweight) but down 13-1/2 # (lb) since admit." -"Estimated that every "point' of [MEDICAL CONDITION] is ~ (approximately) 10# of fluid - cont. (continue) on regular diet; p.o. (oral intake) 40-70% overall." -"Wt (weight) loss likely r/t (related to) fluid. Will monitor next round of wts before making interventions as the fluid reason." *10/4/11: -"readmitted from hospital for [MEDICAL CONDITION] - had a bleed, + (positive) [MEDICAL CONDITION], UTI (urinary tract infection)." -Soft, regular diet. -"P.O. (oral intake) 90-100% per records. -Weight 169.6 lb. *1/3/12: -Labs were noted. -There was no mention of the resident's 29 lb weight loss since admission. Review of a 12/20/11 nutritional status update revealed "Resident is on a regular diet and her weight is stable at this time." That was signed by the dietary manager (DM). Review of resident 6's graphic chart revealed she had the following weights: *September 2011 -Week 1: 169 lb. -Week 2: 155.6 lb. -Week 3: Nothing recorded. -Week 4: Hospital *October 2011: -Week 1: 166.2 lb. -Week 2: Nothing recorded. -Week 3: Nothing recorded. -Week 4: 168.5 lb. *November 2011: -Weeks 1 and 2: Nothing recorded. -Week 3-156.5 lb. -Week 4-153.4 lb. *December 2011: -Week 1: Hospital -Week 2 and 3: nothing recorded. -Week 4: 132.5 lb. *January 2012: -Week 1: 140 lb. *There were no further weights recorded. Review of resident 6's 1/11/12 physician's visit revealed: *"Current weight-140 lb. The last weight was 168.5 lb." *The physician wrote "appetite good." *There was no other acknowledgement of the weight loss. Review of resident 6's entire medical record revealed: *The physician had not ordered: -A diuretic (a medication that prevents fluid retention) since admission. -Any type of diet restriction to promote weight loss. Review of resident 6's 12/21/11 care plan revealed it did not address her weight loss. Interview on 1/24/12 at 11:00 a.m. with the DM revealed: *She was notified by the nursing department when a resident had a weight change. *She did not keep a log of weekly weights. *She was unaware resident 6 had lost so much weight. *She confirmed the dietitian should have re-evaluated her but had not. Interview on 1/24/12 at 3:10 p.m. with the consulting dietitian revealed she: *Relied on nursing or the DM to inform her of weight losses or changes. *Would not go through every resident's chart to see if they had lost weight. *Had not been informed of resident 6's weight loss. *Agreed resident 6 had lost a significant amount of weight, and there had been no nutritional interventions put in place. *Was unaware the DM did not keep a record of weights. Review of the provider's 3/19/04 abnormal nutritional conditions policy revealed: *"Residents who have abnormal nutritional conditions will have alterations in their diet made to promote good nutritional status. If the DM or consulting dietitian discovers that a client's nutritional condition is altered, the following intervention is implemented and individualized according to the needs of the client." *"Excessive Weight loss: Excessive weight loss is considered to be a decrease of more than 5 % (percent) of the body weight within one month or decrease of more than 10 % of body weight within 6 months." *"All residents are weighted each week. Residents at risk for weight loss are weighed each week The DM and consulting dietitian will review the weight chart monthly. The DM will check weekly weights and report any concerns to the consulting dietitian." *The DM will begin an intake study if there is a significant change including weight loss. She will observe the client eating and discuss the problem with nursing assistants and nurses who may have additional clues to the causes of the change." *"The DM will discuss the problem and the resident's intake with the consultant who will develop an appropriate plan of action." *"Resident may be offered fortified foods, increased calorie supplements and foods with addition fats and calories. Six smaller meals per day may be needed." *"Record problem, goals, intervention in the care plan, and medical record. Monitor weight changes monthly and revise intervention as necessary."