Every finding on record at Palisade Healthcare Center

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, document review, observation, interview, and policy review, the provider failed to protect the resident's right to be free from neglect for three of three sampled residents (1, 2, and 3) whose incontinence (involuntary urine or bowel leakage) products were not changed timely and the residents were not repositioned per leadership expectations by three of three CNAs (C, E, and P), for one of one sampled resident (4) who reported an unidentified staff member did not change resident 4 for a long period of time and he developed skin irritation and open sores to his perineal area, from abuse for one of one sampled resident (3) whose perineal area (genital area) was cleaned roughly by one of one certified nursing assistant (CNA) (Q) and developed an open sore, from neglect for two of two sampled residents (1 and 5) who requested staff to assist them with care and they did not, and for one of one anonymous resident (15) who reported she was not changed when requested during the night shift by one of one CNA (H). Findings include:1. Review of the provider's 2/1/26 SD DOH FRI report revealed that during the night shift on 2/1/26, resident 1 reported that CNA P refused to give her a pillow and a blanket, was rude to her when she asked to be repositioned, and CNA P was on the phone talking in a different language while providing her care. Resident 1 reported to the staff that CNA P was afraid of CNA P because she was unsure when CNA P might lose her temper. Resident 1 reported feeling comfortable with the other staff. The report indicated that on 2/1/26, resident 2 reported that night shift staff, CNA P, did not change her incontinence product overnight, and she did not have her call light device to alert the staff that she needed assistance. She reported to the staff that she was not afraid that night and felt comfortable with the other staff. The provider's final investigation stated that they interviewed other residents who resided down the same hallway, and no other residents had concerns and felt safe at the nursing home. They interviewed a staff member, and he reported that CNA P was sleeping while at work on either 1/31/26 or 2/1/26. The facility terminated CNA P's employment. 2. Review of resident 1's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 2/12/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. Her 2/10/26 Braden scale (a tool used to assess the risk of developing pressure ulcers) assessment score was 12, which indicated she had a high risk for developing pressure ulcers. She had diagnoses including type two diabetes (a condition involving disruptions in how the body regulates blood sugar), spinal stenosis (narrowing of the spaces in the spine, putting pressure on the nerves and spinal cord), pain, muscle weakness, morbid obesity (excessive weight that significantly impacts health and well being), major depressive disorder (a mood disorder characterized by persistent feeling of sadness, emptiness, or loss of interest in activities that lasts for at least two weeks), and conversion disorder with motor symptoms or deficit (involuntary, distressing motor issues such as paralysis, weakness, tremor, gait problems that are incompatible with known neurological diseases). She had physician's orders on 12/14/25 for Furosemide (a diuretic), 8/25/25 for Spironolactone (a diuretic), and 10/7/25 for Duloxetine (for depression). Her 2/2/26 care plan indicated she required staff assistance with her care due to activity intolerance and weakness. She required one to two staff members to move her in bed and one staff member for her personal hygiene needs. Her care plan indicated her skin was at risk for impairment, and she was to have her heels propped on pillows, a pressure-reducing mattress, a wheelchair pressure-reducing cushion, use of a total body lift (a mechanical lift and sling used to lift a person's full body) for transfers between surfaces, and required two staff members for transfers. She had a history of having a pressure ulcer on her bottom. The staff were to follow facility policies and protocols for the prevention and treatment of skin breakdown and to reposition her frequently while she was resting. With each incontinence episode, she was to have her perineal area cleaned and a barrier cream (an ointment that protects skin from urine and feces) applied. The CNA urinary incontinence documentation from 3/30/26 to 4/13/26 revealed that she was incontinent of urine. Her incontinent product was documented as changed three times on 3/30/26, once on 3/31/26, twice on 4/1/26, three times on 4/2/26, twice on 4/3/26, once on 4/4/26, twice on 4/5/26, twice on 4/6/26, twice on 4/7/26, twice on 4/8/26, twice on 4/9/26, twice on 4/10/26, once on 4/11/26, three times on 4/12/26, and twice on 4/13/26. 3. Review of the 4/13/26 report sheet (a document that indicated whether the resident was continent or incontinent, how they transferred, and any other special notes) indicated that resident 1 was incontinent of bladder and bowel, used the total body lift for transfers, and required two staff members for all of her care. 4. Observation and interview on 4/14/26 at 9:10 a.m. with resident 1 in her room revealed she was lying on her bed and positioned her back, was tired, and wanted to rest. 5. Observation at 1:11 p.m. of resident 1 in her room revealed she was lying on her bed and positioned her back. Her lunch tray was sitting on her bedside table. 6. Observation and interview on 4/14/26 at 2:06 p.m. with resident 1 revealed she felt really tired, which was not normal for her. She had a pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) in the past, but currently did not have one. She had a bariatric bed and mattress, which is wider for comfort and to enable ease with positioning. 7. Interview on 4/14/26 at 2:32 p.m. with CNA D revealed resident 1 required staff assistance for repositioning and changing her incontinent product. She usually activated her call light when her incontinence product was wet and needed to be changed, but if she did not alert the staff, then the staff would check on her. She was more tired today so she may not alert the staff when she became incontinent. Staff were to document every time residents were taken to the bathroom or their incontinence product was changed. 8. Observation on 4/14/26 at 3:28 p.m. of resident 1 in her room revealed she was lying on her bed and positioned on her back. 9. Interview review on 4/14/26 at 4:08 p.m. with CNA C revealed resident 1 was to be changed and repositioned every two hours. CNA C stated resident 1's incontinence product was last changed around 12:00 p.m. and that she usually allowed the staff to change and reposition her. CNA C verified that resident 1 was not changed or repositioned for four hours. She did not document that in the resident's EMR. 10. Observation on 4/14/26 at 4:28 p.m. of CNAs C and E providing care to resident 1 in her room revealed that resident 1 was lying on her bed and positioned on her back. The CNAs provided incontinence care and applied a barrier cream to resident 1's slightly red groin and buttocks. Her incontinence brief and lift sheet (a specialized fabric placed across the middle of a bed used to safely reposition a person), which was underneath her, appeared wet. The CNAs changed resident 1's hospital gown, lift sheet, and incontinence brief, and repositioned her on her right side. The CNAs did not prop her heels up on pillows. 11. Interview on 4/14/26 at 4:40 p.m. with CNA C revealed that resident 1 was more tired today. She applied barrier cream for residents during incontinence care and was not sure which cream she was supposed to use, so she applied whatever cream the resident had in their room. CNA C verified resident 1 was not changed or repositioned for almost four and a half hours. 12. Interview on 4/16/26 at 5:38 a.m. with CNA H revealed that resident 1 was last changed and repositioned on her back at 4:00 a.m. 13. Continued observations on 4/16/26 from 5:42 a.m. through 6:28 a.m. revealed that resident 1 was lying in her bed and positioned on her back. 14. Interview on 4/16/26 at 11:30 a.m. with registered nurse (RN) M revealed that on 2/1/26, resident 1 told her that resident 1 did not want CNA P to assist her anymore because CNA P was on her phone during resident 1's personal care and would not talk to her while providing the care. Resident 1 filled out a grievance form with the help of CNA E. 15. Interview on 4/16/26 at 12:30 p.m. with CNA E regarding the incident with resident 1 on 2/1/26 revealed that resident 1 told her that the night shift CNA P came into resident 1's room during rounds (checking on residents' status and assistance needs), she asked CNA P for a blanket, and CNA P did not acknowledge her. CNA P appeared rushed and was on a phone call, speaking in a different language. CNA E then helped resident 1 file a grievance regarding the incident. 16. Review of resident 2's EMR revealed she was admitted to the facility on [DATE]. Her 3/5/26 BIMS assessment score was 9, which indicated her cognition was moderately impaired. Her 2/22/26 Braden assessment score was 15, which indicated she had a risk for developing pressure ulcers. Her diagnoses included urinary tract infection, Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), major depressive disorder, stage IV pressure ulcer, type two diabetes, and pain. She had 1/28/25 physician orders to wear heel boots (specialized, cushioned protective coverings worn on the feet to help prevent bed sores) when in bed and 2/14/25 physician orders for a weekly skin audit. Her medication administration record (MAR) indicated that she had a 4/30/25 physician order for Venlafaxine 112.5 mg to be given daily (used to treat depression), a 3/13/26 physician order for Spironolactone 25 mg to be given daily, a 3/15/26 physician order for Furosemide 20 milligrams (mg) to be given daily, a 4/3/26 physician order Doxycycline 100 mg (antibiotic) to be given twice daily for ten days and on 4/14/26 to be given twice daily for eight days for her infected wound on her right buttock, and a 4/4/26 physician order for an intramuscular (IM) injection of ceftriaxone 1 gram (antibiotic) to be given daily for five days for an infected wound on her right buttock. Her treatment administration record (TAR) indicated she had physician's orders from 3/19/26 through 4/6/26 for the staff to paint resident 2's left heel blister with betadine (antiseptic used to kill germs) and wrap it with kerlix (gauze wrap) daily. She had a 3/27/26 physician's order for the staff to apply a wet-to-dry dressing twice a day to a wound on her right buttock. On 4/7/26 the physician ordered for the staff to paint resident 2's left heel blister with betadine and apply a foam dressing daily and as needed until the blister resolved. Her 1/29/26 weekly skin evaluation indicated that her right buttock pressure ulcer was 3.5 centimeters (cm) x (by) 3 cm. There was no depth documented on the assessment. The wound bed was black, did not have any drainage, had a slight odor, and there was no undermining (when tissue destruction happens under the skin at the edges of a wound, creating a pocket) or tunneling (narrow, deep channels or passageways that extend a wound bed into surrounding tissues). It indicated it was worsening, and new wound care orders were received when she was at the wound clinic. Her 2/3/26 weekly skin evaluation indicated that her right buttock pressure ulcer was 4.5 cm x 3 cm, and the depth was 1.2 cm with no undermining or tunneling and a slight odor. The wound bed was black and was described as now open, draining black, green slime. It indicated it was worsening. Resident 2's 2/16/26 care plan indicated she required a full body lift for transfers, needed one staff member to help her with getting dressed, her call light was to be left within her reach, and the staff were to monitor her for pain. She was to be repositioned from side to side routinely by one staff member, have her heels elevated when lying in bed, have an air mattress on her bed, and have frequent toileting and barrier cream applied. When she was incontinent, the staff were to wash, rinse, and dry her perineal area. The CNA urinary incontinence documentation from 3/30/26 through 4/13/26 indicated resident 2 was incontinent of urine. Her incontinence product was documented as changed twice on 3/30/26, once on 3/31/26, twice on 4/1/26, three times on 4/2/26, twice on 4/3/26, once on 4/4/26, twice on 4/5/26, twice on 4/6/26, twice on 4/7/26, twice on 4/8/26, twice on 4/9/26, twice on 4/10/26, once on 4/11/26, and twice on 4/12/26 and 4/13/26. 17. Review of the 4/13/26 report sheet indicated that resident 2 was incontinent of bladder and bowel and required a full body lift for transfers. 18. Observation on 4/14/26 at 9:11 a.m. of resident 2 in her room revealed she was in her bed sleeping, she had an air mattress, and was lying on her left side. 19. Observation and interview on 4/14/26 at 10:35 a.m. with CNA C and D while they were providing care to resident 2 in her room revealed that resident 2 had heel boots on, and there was a dressing on her left heel and her coccyx (tailbone). Resident 2 declined to have her bath, and the CNAs changed her incontinence product, repositioned her onto her left side, and gave her the call light. 20. Observation on 4/14/26 at 1:10 p.m. of resident 2 in her room revealed she was lying on her bed and was positioned on her left side. 21. Observation on 4/14/26 at 2:31 p.m. of resident 2 in her room revealed she was lying on her bed and was positioned on her left side. 22. Interview on 4/14/26 at 2:32 p.m. with CNA D revealed that resident 2 was usually dressed by this time, but they were waiting to get her dressed until after her bath, and she still did not want one. CNA D was planning on transferring resident 2 to her wheelchair once CNA C came back from lunch. 23. Observation on 4/14/26 at 2:56 p.m. of resident 2 in her room revealed she was lying on her bed and was positioned on her back. 24. Interview on 4/14/26 at 4:08 p.m. with CNA C revealed resident 2 was to be repositioned and her incontinence product was to be changed every two hours. She was repositioned and her incontinence product was changed around 2:40 p.m. She verified that she was not changed or repositioned from 10:35 a.m. until 2:56 p.m. 25. Observation and interview on 4/15/26 at 10:30 a.m. of licensed practical nurse (LPN) F, providing wound care for resident 2 in her room revealed the pressure ulcer on her left heel was calloused and dry and her pressure ulcer on her coccyx was a stage IV (4;open wound with full-thickness skin and tissue loss. bone, tendon, or muscle may be visible). Resident 2 was not to be positioned on her back due to her pressure ulcer. 26. Interview on 4/16/26 at 5:38 a.m. with CNA H revealed resident 2 was repositioned and her incontinence brief was changed around 4:20 a.m. 27. Continued observations on 4/16/26 from 5:41 a.m. through 8:40 a.m. revealed that resident 2 was lying in her bed and positioned on her right side. 28. Observation and Interview on 4/16/26 at 8:40 a.m. revealed CNA E went into resident 2's room to get her ready for the day. Resident 2 had the same shirt on from the previous day. Resident 2 stated she requested her shirt to be changed last night and that CNA H would not change it. She stated that CNA H was rough with her and did not talk to her when CNA H repositioned her during the night. When resident 2's blankets were pulled back, her heel boots were sliding off her feet, and her heels were resting on the bed. She stated her left heel hurt. 29. Interview on 4/16/26 at 12:30 p.m. with CNA E regarding the incident involving resident 2 on 2/1/26 revealed that resident 2 was tearful when she told CNA E about the incident and resident 2 asked CNA E not to leave her alone because she was afraid. CNA E thought resident 2 was afraid because she did not have her call light that night to alert the staff for help. Resident 2 had described CNA P as the CNA that night. 30. Review of the providers 4/12/26 SD DOH FRI report revealed that on 4/12/26, resident 3 obtained an open area on her coccyx when CNA Q was cleaning her roughly. CNA E had to physically stop CNA Q from continuing to clean her. The provider's investigation regarding this incident was ongoing during the survey. 31. Review of resident 3's EMR revealed she was admitted to the facility on [DATE]. Her 3/18/26 BIMS assessment score was 5, which indicated her cognition was severely impaired. Her 10/10/25 Braden assessment score was 12, which indicated she had a high risk for developing pressure ulcers. Her diagnoses included Alzheimer's disease, weakness, and type two diabetes. She had 7/23/25 physician's order for furosemide, and a 1/9/26 physician's order for a protective foam dressing to her coccyx and to the middle back of her back. The dressing was to be changed on her bath days, Tuesday and Friday, for her skin integrity. Resident 3's 1/19/26 care plan indicated she required the assistance of one staff member for bed mobility, getting dressed, and for her personal hygiene care. She was incontinent of bladder and bowel, and required the staff to assist her with frequent toileting and barrier cream application, including when she woke up, before and after her meals, at bedtime, during the night shift rounds, and as needed. She required two staff members to pull her up in bed using a lift sheet to prevent her skin from tearing, and for transfers using a total body lift. Resident 3 had a pressure injury to her coccyx from immobility and incontinence. She had an air mattress on her bed, a pressure-reducing cushion in her wheelchair, was to always wear heel boots, and have her call light within her reach. The CNA urinary incontinence documentation from 3/30/26 to 4/13/26 indicated that she was incontinent of urine. Her incontinence product was documented as changed twice on 3/30/26 and 3/31/26, three times on 4/1/26, twice on 4/2/26 and 4/3/26, once on 4/4/26, twice on 4/5/26, three times on 4/6/26, twice on 4/7/26, 4/8/26, 4/9/26, and 4/10/26, once on 4/11/26 and 4/12/26, and three times on 4/13/26. 32. Review of the 4/13/26 report sheet indicated resident 3 was incontinent of bladder and bowel, required a total body lift for transfers, and was on hospice. 33. Observation on 4/14/26 at 9:26 a.m. of resident 3 in her room revealed she had an air mattress on her bed, and she was sitting in a high-back wheelchair that had a pressure-reducing cushion. 34. Observation on 4/14/26 at 2:04 p.m. of resident 3 in her room revealed she was sitting in her wheelchair. 35. Observation and interview on 4/14/26 at 2:40 p.m. in resident 3's room revealed resident 3 was sitting in her wheelchair. She stated she did not like to stay in her wheelchair all day and was unable to use the toilet in the bathroom. She felt her incontinence brief was flooded and her bottom was sore, but the cover on her bottom helped. She indicated that some staff members were rough while providing her care, but they were not mean. 36. Observation and interview on 4/14/26 at 3:43 p.m. with activity aid/CNA L and CNA C providing care for resident 3 in her room revealed that CNA C last changed resident 3's incontinence brief before lunch. Activity aid/CNA L and CNA C changed her incontinence brief and applied Remedy Moisturize skin cream to her bottom. 37. Interview and Kardex (a report of the resident's care needs and interventions) review on 4/14/26 at 4:08 p.m. with CNA C revealed resident 3 was to be repositioned and her incontinence brief was to be changed every two hours. She was last changed and repositioned around 11:00 a.m. If a resident had a pressure sore, they were to be repositioned every two hours. She knew that because it would be in the resident's Kardex. Resident 3's Kardex did not indicate how often she needed to be repositioned or changed. 38. Observation and interview on 4/15/26 at 10:10 a.m. of LPN F providing wound care to resident 3 in her room revealed she had a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer on her coccyx, and had a foam dressing covering it. She did not have a dressing on the middle of her upper back, or have any other open areas. LPN F changed the foam dressing on resident 3's coccyx. 39. Observation and interview on 4/16/26 at 5:38 a.m. with CNA H revealed that resident 3 had a sore on her bottom, and she changed the dressing on her coccyx when it was wet and applied a barrier cream to her bottom when it was a little red. Resident 3 was repositioned and her incontinence brief was changed at 4:30 a.m. 40. Observation and interview on 4/16/26 at 6:54 a.m. with CNA E providing care to resident 3 in her room revealed that resident 3 was wearing the same shirt from the day before, had a foam dressing to her coccyx, and did not have a foam dressing to her upper back. CNA E stated that after CNA H worked, she noticed that residents in CNA H's care did not appear to have received appropriate resident care. 41. Interview and EMR review on 4/16/26 at 11:30 a.m. with RN M revealed resident 3 was supposed to have the foam dressing on the middle of her back and coccyx. 42. Interview on 4/16/26 at 12:00 p.m. with RN K regarding the incident involving resident 3 on 4/12/26 revealed that CNA E reported that CNA Q was cleaning her too hard and caused an open area on her coccyx. RN K completed a full skin assessment, measured the wound, cleaned it, and applied a barrier cream to it. She did not apply a dressing to it. She classified the wound as a stage II pressure ulcer and notified resident 3's hospice team, physician, and family. 43. Interview on 4/16/26 at 12:30 p.m. with CNA E regarding the incident involving resident 3 on 4/12/26 revealed she and CNA Q were assisting resident 3 with personal hygiene care while changing her incontinent brief. CNA Q cleaned resident 3's bottom using a dry wipe and a cleansing spray, and caused her healed pressure ulcer area to reopen. CNA E verbally tried to get him to stop, and when he did not listen, she physically positioned her arms and hands in front of the resident to stop him from cleaning her bottom. Resident 3 was quiet during the incident and CNA E reported the incident to RN K. CNA E stated that before this incident happened with CNA Q, she had reported to LPN G and RN M, her concerns that CNA Q was not nice to the residents, he was rough with them, and he did not consistently provide incontinence care to them, but she felt they did not listen to her. 44. Interview on 4/16/26 at 3:42 p.m. with hospice RN N revealed that she expected the facility staff to reposition resident 3 every two hours, and provide incontinence care every two hours or sooner if needed. Resident 3 was to have the foam dressing on her upper back for the prevention of pressure ulcers. She had a previous pressure ulcer to her coccyx that healed, but the skin was still fragile. After the incident on 4/12/26, the skin on her coccyx opened back up. 45. Observation and interview on 4/14/26 at 9:27 a.m. with resident 4 revealed he was lying in his bed that had an air mattress, had one heel boot sitting on his wheelchair, and was positioned on his back. He stated his call light was consistently not answered by the staff for two hours, and sometimes it was not answered for four hours. He stated his incontinence brief was not changed a week or two ago for a long period of time, and he sat in urine for so long that he developed skin irritation and open sores to his perineal area. He stated that the staff applied a barrier cream to his skin when they changed his incontinence brief. He did not want to wear heel boots, and he felt he could reposition himself sometimes. 46. Observation and interview on 4/15/26 at 9:53 a.m. with LPN F providing wound care for resident 4 in his room revealed that his perineal area, inner upper thighs, and rectal area were bright red and had superficial open areas. Resident 4 stated he had had the sores for a few weeks. LPN F stated he had skin irritation and open sores to his perineal area, cleaned the area, applied nystatin (antifungal) powder, and a barrier cream with zinc in it. She educated him to notify the staff when he was wet. He stated he was not always able to feel when he urinated or was wet. LPN F stated the CNAs were supposed to check on him every two hours. 47. Interview on 4/16/26 at 5:38 a.m. with CNA H revealed that resident 4 needed assistance with repositioning and changing his incontinence brief every two hours. 48. Review of resident 4's EMR revealed he was admitted to the facility on [DATE]. His 3/2/26 BIMS assessment score was 12, which indicated his cognition was moderately impaired. His 10/16/25 Braden assessment score was 12, which indicated he had a high risk for pressure injuries. His diagnoses included a stroke (when blood flow to part of the brain is interrupted either by blockage or a burst blood vessel) affecting his right side, quadriplegia (paralysis caused by a spinal cord injury resulting in partial or total loss of movement and sensation in all four limbs, and the torso), major depressive disorder, overactive bladder (involuntary bladder muscle contractions, creating a sudden, uncontrollable urge to urinate), and urinary incontinence. He had physician orders on 4/6/26 for nystatin powder to be applied to the perineal area twice daily and as needed, on 1/20/26 for Sertraline (an antidepressant), and on 10/6/25 for lactulose for constipation. Resident 4's 4/6/26 care plan revealed he required two staff members to transfer him with a full body lift, and one staff member to assist him with bed mobility, and personal hygiene care. His skin was at risk for impairment, and the staff was to turn and reposition him routinely. The staff was to ensure he was clean and dry, to check and change his incontinence brief, and use a barrier cream for protection as needed for incontinence. He required an air mattress on his bed and a cushion in his wheelchair. The CNA urinary incontinence documentation from 3/30/26 to 4/13/26 indicated that he was incontinent of urine. His incontinence product was documented as being changed twice on 3/30/26 and 3/31/26, three times on 4/1/26, twice on 4/2/26 and 4/3/26, once on 4/4/26 and 4/5/26, three times on 4/6/26, twice on 4/7/26, 4/8/26, 4/9/26, and 4/10/26, once on 4/11/26 and 4/12/26, and three times on 4/13/26. 49. Review of the 4/13/26 report sheet indicated he was incontinent of bowel and bladder, and required a full body lift for transfers. 50. Observation and interview on 4/16/26 at 5:38 a.m. with CNA H revealed she was sitting on a chair in the [NAME] resident hall. Resident 5 was calling out for help, and she entered and exited resident 5's room and stated that resident 5 wanted to get up for the day. She stated that she sometimes helps residents get up in the morning, but typically, the day staff would help get them up. At night, she would check on the residents every two hours and would change their incontinent product, assist them to use the toilet, or reposition them at that time. She documented every time a resident was assisted to the bathroom or if she changed their incontinent product. 51. Observation on 4/16/26 at 6:03 a.m. revealed that resident 5 was again calling out for help. CNA H entered and exited her room and then stated that resident 5 needed to go to the bathroom. CNA H indicated she was going to find someone to help her with that. 52. Observation and interview on 4/16/26 at 6:13 a.m. with CNA E assisting resident 5 revealed she appeared restless, and her incontinence brief was wet. Resident 5 stated she needed to use the bathroom and that no one would help her. CNA E assisted her with getting on the bedpan and stated resident 5 was typically continent of urine and bowel. Her call light was at the foot of her bed, and CNA E stated that resident 5 could use her call light appropriately. There were two signs on her wall by her bed that stated that her call light was to be attached to her bed because she was at high risk for falling. 53. Review of resident 5's EMR revealed she was admitted to the facility on [DATE]. Her 2/24/26 BIMS assessment score was 11, which indicated her cognition was moderately impaired. Her diagnoses included a stroke affecting her left side, Alzheimer's disease, anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and depression. She had a 2/24/26 physician's order for escitalopram (a medication for anxiety and depression) and a 3/23/26 physician's order for physical therapy and occupational therapy (PT/OT)/speech therapy (ST). Review of resident 5's 4/8/26 care plan indicated she needed one staff to assist her with bed mobility, dressing, and personal hygiene care. She used a bedpan for her toileting needs. Her perineal area was to be cleansed after each incontinent episode. Staff were to follow facility policies and protocols for the prevention and treatment of skin breakdown. She needed a pressure-reducing mattress on her bed and a cushion in her wheelchair. She was to be transferred with the assistance of two staff members and a full body lift. Staff were to be sure the resident's call light was within reach and encourage her to use it for assistance. S

Based on observation and interview the provider failed to ensure call lights (a communication tool that enabled residents to alert staff for assistance) were within reach for 10 of 10 sampled residents (3, 5, 6, 8, 9, 10, 11, 12, 13, and 14) that would allow the residents to request assistance from staff promptly. Findings included: 1. Observation and interview on 4/14/26 at 9:04 a.m. revealed that resident 9 was slid down in her bed and needed help. Resident 9 stated she did not know where her call light was and never had access to it. Social Services Director (SSD) S entered the room and acknowledged that the call light was hung over the resident's headboard, not within reach of the resident. She moved the call light next to the resident, but thought she could have reached it when it was over the headboard. 2. Observation on 4/14/26 at 9:06 a.m. revealed resident 10 was in bed, and her call light was clipped to its own cord at the wall, not within reach of the resident. SSD S came to the doorway, acknowledged that the call light was not within the resident's reach, and moved it closer to the resident. 4. Observation on 4/16/26 at 6:10 a.m. revealed Resident 13 was in bed sleeping, and her call light was hanging off her bed near the floor and was not within reach. 5. Observation on 4/16/26 at 6:10 a.m. revealed Resident 14 was in his bed. His call light was over his overbed table, which was pushed away from his bed and out of reach. 6. Interview on 4/16/26 at 6:10 a.m. Certified nursing assistant (CNA) U acknowledged that both residents' 13 and 14 call lights were out of reach. 7. Observation and interview on 4/16/26 at 6:13 a.m. revealed that resident 5 was calling out for help. CNA E went into her room to assist her. Resident 5 stated that no one would answer her call, and she needed to go to the bathroom. Her call light was lying at the foot of her bed. Two signs near her bed stated she was a high fall risk and that her call light was to be attached to her at all times. CNA E stated that resident 5 was able to use her call light appropriately, and she should have it within her reach. When she found call lights that were not left within a resident's reach, she reported it to the nurse. 8. Observation on 4/16/26 at 6:29 a.m. with certified medication aide (CMA) R revealed resident 11 was in his bed, asleep. His call light was lying over a basin on his bedside table, not in reach. CMA R acknowledged that the call light was not within reach and that it was a concern. 9. Observation and interview on 4/16/26 at 6:29 a.m. with CMA R revealed that resident 12 was in bed and his call light was clipped to his recliner, not within his reach. He acknowledged that the call light was not within reach and that it was a concern. 10. Observation on 4/16/26 at 6:46 a.m. revealed resident 8 was lying in her bed, and her call light was on the bedside table in front of her television, out of reach. 11. Interview on 4/16/26 at 6:47 a.m. with registered nurse (RN) T revealed he completed his first rounds on his residents during his initial med pass. He expected residents to always have their call lights within reach and the CNAs to look in on each resident at least every 2 hours. 12. Observation on 4/16/26 at 6:47 a.m. revealed resident 6 was lying in her bed, and her call light was on the bedside table that was pushed away from her bed, out of reach. 13. Observation on 4/16/26 at 6:54 a.m. revealed resident 3 was lying in her bed, and her call light was on her end table, out of reach. 14. Interview on 4/16/26 at 7:11 a.m. with LPN I revealed that residents were to have their call lights left within their reach. 15. Interview on 4/16/26 at 4:40 p.m. with administrator A revealed she expected residents' call lights to be within their reach.

Based on observation, interview, record review, and policy review the provider failed to ensure 1 of 1 resident (7) supra pubic catheter (a tube placed in the bladder to remove urine from the body) was irrigated (flushed) using a sterile graduated cylinder for the saline and vinegar solution that was used to flush her supra pubic catheter by licensed practical nurse (LPN) I.Findings include:1. Observation and interview on 4/16/26 at 9:07 a.m. with licensed practical nurse (LPN) I revealed that resident 7's supra pubic catheter was flushed twice a day. She stated she reused the graduated cylinder, but that she would get a new syringe each time she flushed the catheter. She was trained that way but could not remember who trained her. The cylinder had been written on with a Sharpie, sterile only for vinegar and water, not to empty urine from the catheter. 2. Interview on 4/16/26 at 2:34 p.m. with director of nursing (DON) B revealed she been the at the facility since 4/13/26. She understood that the container should be changed every single time. She was aware that resident 7 has had urinary tract infections. She stated they should have been using sterile technique and sterile supplies. 3. Interview on 4/16/26 at 3:11 p.m. with RN M revealed she was a nurse manager and was training for the infection preventionist position. She was not aware that the nurses were using a non-sterile graduated cylinder for resident 7's supra pubic catheter flushes. She was not sure where that had come from and stated LPN I knew that it was not sterile and that they had sterile catheter kits that should have been used. She stated and showed this surveyor that the urinary catheter kits that should have been used were sterile and available to the nurses. 4. Review of resident 7's record electronic medical record (EMR) revealed she had a physician's order from 4/10/26 to flush her catheter with 100 cc (cubic centimeters) of normal saline and 20 cc 5% (percent) vinegar twice daily and as needed related to a bladder disorder. The physician's order indicated to instill the saline and vinegar 60 ml (milliliters) and allow that to drain, and then instill the remaining 60 ml to drain.Resident 7's diagnoses were urinary retention, bladder disorder, overactive bladder, proteinuria, and bladder-neck obstruction.Resident 7's medications included cranberry capsules for urinary tract infection (UTI) prevention and methenamine Hippurate for UTIs. 5. Interview on 4/16/26 at 5:23 p.m. with administrator A revealed LPN I had been educated regarding the urine catheter kits and stated nurses should know what a sterile field was. 6. Review of the providers' undated indwelling catheter irrigation revealed to use the prescribed irrigation solutions and a sterile basin. Commercially packaged kits containing sterile irrigation solutions and a graduated receptacle, and a 50 milliliter (ML) catheter tip syringe may be available in some facilities.

Based on South Dakota Department of Health (SD DOH) complaint intake report review, record review, interview, and policy review, the provider failed to ensure staff provided quality care related to skin injury prevention and skin management processes including completing skin evaluations, accurate communication, accurate documentation, and implementing interventions and treatment orders for one of one sampled resident (1) who developed skin injuries to his left lower leg, left foot, and right lower leg and was hospitalized related to those wounds. Those failures put all residents at potential risk for serious injury or harm. Immediate Jeopardy (IJ) at F684 began on 11/18/25 when the provider failed to evaluate resident 1's left lower leg, left foot, and right lower leg wounds and implement appropriate follow-up procedures. *Administrator A was notified of the IJ on 11/18/25 at 4:03 p.m., and a removal plan was requested.*The IJ was removed on 11/19/25 at 1:00 p.m. as confirmed by onsite verification by the survey team. *After the IJ removal, the severity of non-compliance remained at a E.*Current census was 46. Findings include: 1. Review of the 11/12/25 SD DOH complaint intake report regarding resident 1 revealed:*Resident 1 went to his scheduled wound clinic appointment for treatment of his pressure ulcer (skin and/or underlying tissue injury caused by prolonged pressure) on his coccyx (tailbone), where it was determined that he needed to be transferred to the emergency room for further evaluation because of the condition of his left foot and left and right lower leg wounds. *The nursing home where resident 1 resided was aware and concerned of the left foot and both leg wounds and planned to move up his wound care treatment appointment to be seen earlier, but that did not occur. *The vascular physician indicated that resident 1's left foot and both leg wounds should have been treated sooner.*Resident 1 was admitted to the hospital on [DATE] with wounds to his left lower leg, left foot, and right lower leg. 2. Review of resident 1's electronic medical record (EMR) revealed: *He admitted to the nursing home on 8/29/25 with a pressure ulcer on his coccyx. That pressure ulcer was categorized as unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed) by licensed practical nurse (LPN) D on 9/2/25. *His 8/29/25 Brief Interview for Mental Status (BIMS) assessment score was 7 which indicated his cognition was severely impaired. *His diagnosis included chronic diastolic (congestive) heart failure, peripheral vascular disease (arteries narrow, restricting blood flow to the limbs), unspecified protein calorie malnutrition, and Brown-Sequard syndrome (damage to one half of the spinal cord that causes weakness and paralysis). Resident 1's current care plan (personalized plan that addresses a resident's care needs, goals, and interventions) revealed: *He was dependent on staff members to reposition him.*He required the use of a full body lift (a mechanical lift and sling used to lift a person's full body) for transferring. *He had actual impaired skin integrity related to his pressure injury to his coccyx and wounds (revised on 10/30/25) on his left heel, left inner ankle, left medial foot, and bilateral shins.Interventions last updated on 9/30/25 in that impaired skin integrity care plan area included:* Administer treatments as ordered and monitor for effectiveness.* Air mattress to bed.* [Name redacted] wound clinic as scheduled or as needed.* Inspect skin while providing care, notify nurse of any new skin conditions.* Pressure reducing cushion to wheelchair.* Use draw sheet to pull resident up in bed with two staff to prevent shearing.* Wound vac [a device that uses negative pressure to remove excess fluid and debris from a wound to promote wound healing]. Make sure this keeps a charge and is running at 125 mmHg. Review of resident 1's physician's orders included: *On 8/29/25, Heel boots on while in bed. Reposition frequently with wedge. Every day and night shift.*On 9/3/25, Weekly Skin Audit every day shift every Wed [Wednesday] Nurse initials = Head to Toe Skin Evaluation completed. If new skin impairment is found, document in Progress Notes, notify Medical Provider, and initiate Weekly Skin Evaluation. *On 9/26/25, Wound vac dressing changes every MWF [Monday, Wednesday, and Friday] to coccyx.*On 10/28/25, Wound treatment to left foot. Apply foam dressing to left heel, left lateral foot and inner ankle. Change every 3 days and prn [as needed] if loose/soiled.*On 10/30/25, Wound care to bilateral shins: Cleanse with Vashe [skin cleanser], cover with dry dressing, change every day. Do until healed.Review of resident 1's treatment administration record (TAR) indicated:*His weekly skin audit was completed every Wednesday from 9/1/25 through 11/4/25. *LPN F completed resident 1's left foot treatment on 10/28/25 and his bilateral shin treatment on 11/1/25, 11/2/25, and 11/3/25. *LPN D completed resident 1's left foot and bilateral shin treatment on 10/31/25. *Registered nurse (RN) L completed resident 1's left foot and bilateral shin treatment on 11/3/25. Resident 1's nursing progress notes indicated:*A late entry note created on 11/6/25 by LPN D for 10/22/25 stated, Charge nurse [RN K] brought this writer in to see resident's left inner ankle. Pressure wound noted. Upon evaluation of foot noted there also to be a SDTI [Suspected Deep Tissue Injury] to left heel and left medial foot. Risk management completed and fax sent to MD for foam dressing treatment. Charge nurse stated that the Wound/Wound Vac smelled so bad we need air freshener or peppermint oil to put in his room. She asked why he wasn't on IV antibiotics. I asked her to call the wound clinic to get an appointment sooner than 11/4. She stated she called [name redacted] wound clinic but they have not returned call yet. Son [name redacted] is here visiting and he was notified of new wounds on left foot.*On 10/26/26 RN/MDS coordinator C documented, Resident noticed to have an open [area] on his left medial [inside] ankle. Looks to be a stage 2 [open wound or blister with partial-thickness skin loss] pressure ulcer. Also has a open area to inner medial foot. Son and PCP [primary care provider] notified nurse treated with betadine [topical antiseptic], foam dressing, and kerlix [gauze bandage].On 10/22/25 LPN D faxed resident 1's physician that resident 1 had three wounds on his right foot, he had an appointment at the wound clinic next week, and requested orders to cover the wound with foam for protection and change it every three days.*The physician replied yes to those requested orders on 10/22/25. On 10/28/25 LPN D faxed resident 1's physician that the previous order was incorrect, and it was resident 1's left foot that had wounds. *She requested to change the ordered wound dressing to be completed daily due to increased drainage. *She informed the physician that resident 1 also had wounds to his right and left shins and requested orders to cleanse those with Vashe brand wound cleanser, and cover with a dry dressing daily. *The physician replied yes to the requested order on 10/29/25. Resident 1's weekly skin evaluations indicated:*On 8/29/25 resident 1 had a pressure ulcer on his coccyx, a skin tear on his right and left forearms, and red areas on his right and left heels that staff were to monitor. *On 9/23/25 the wound care nurse documented that resident 1's right and left heel wounds had healed and his pressure ulcer on his coccyx was a Stage IV (open wound with full-thickness skin and tissue loss that may have visible bone, muscle, or tendon). *From 9/30/25 through 10/21/25, resident 1's Stage IV pressure ulcer on his coccyx was his only documented skin injury. *On 10/27/25, his Stage IV pressure ulcer was evaluated and no other skin concerns were included in that evaluation. *On 10/28/25, resident 1's wounds on his left foot were evaluated. The wound to his left outer foot was 8.5 cm long, 3.0 cm wide, and was slightly open in the center of the wound. The wound to his left inner ankle was open, 4.0 cm long, 4.0 cm wide, and had heavy drainage. The wound on his left heel had purple intact tissue, was 4.5 cm long, and 3.7 cm wide. He was bathed on 8/29/25, 9/3/25, 9/10/25, 9/17/25, 9/24/25, 10/1/25, 10/8/25, 10/15/25, 10/22/25, 10/29/25, and 11/4/25 with no documented skin concerns.Resident 1 went to the wound clinic on 9/10/25, 9/24/25, and 10/7/25 for care of his coccyx pressure ulcer and his next wound clinic appointment was scheduled for 11/4/25. 3. Review of the 11/4/25 wound clinic appointment notes regarding resident 1 indicated:*The nursing home asked the wound clinic to examine resident 1's left foot due to a new ulcer on that foot. *Resident 1's skin wounds were labeled as: Wound #1 coccyx, Wound #2 left foot, Wound #3 left lower leg, and Wound #4 right, medial lower leg. *Wound #2's (left foot) measurements and observations were: 8 cm [centimeters] length x 13 cm width x 0.2 cm depth, with an area of 104 sq [square] cm and a volume of 20.8 cubic cm. Adipose [fat tissue] is exposed. There is a small amount of sero-sanguineous [both blood and the liquid part of blood (serum)] drainage noted which has a mild odor.*Wound #3's (left lower leg) measurements and observations were: 12 cm length x 3.5 cm width x 0.2 cm depth, with an area of 49 sq cm and a volume of 9.8 cubic cm. Adipose is exposed. There is a small amount of sero-sanguineous drainage noted which has no odor.The periwound (area of skin immediately surrounding a wound) skin exhibited edema [swelling] and erythema [redness]. The temperature of the periwound skin is warm. Periwound skin presents with s/s [signs and symptoms] of infection. Local pulse is absent. *Wound #4's (right, medial lower leg) measurements and observations were: 1.5cm length x 1 cm width x 0.2 cm depth, with an area of 1.5 sq cm and a volume of 0.3 cubic cm. Adipose is exposed. There is a small amount of sero-sanguinous drainage noted. *The wound clinic called the nursing home and inquired about resident 1's new left foot, left lower leg, and right lower leg wounds. The nursing home was unsure when those wounds developed, but believed they were caused by how resident 1 positioned his legs. *The wound clinic consulted with podiatry who agreed resident 1 should be admitted to the hospital for the severity of his left foot, left leg, and right leg wounds. 4. Interview on 11/17/25 at 8:45 a.m. with certified medication aide (CNA) G revealed: *If she saw a new skin impairment on a resident, she would alert a nurse.*Resident skin audits were scheduled on the TAR, and some residents' audits were to be completed daily. *LPN D was the wound care nurse, and she evaluated residents skin impairments once a week. *If a resident had a skin wound, it was checked daily. 5. Interview on 11/17/25 at 2:15 p.m. with director of nursing (DON) B revealed:*LPN D was the facility's designated wound care nurse. *Weekly skin evaluations were to be completed by the floor nurses on duty on residents' bath days. *She expected the bath aides to notify the nurse if they saw something unusual about a resident's skin or noticed if a wound appeared worse. *She expected the nurse to notify the physician, family, and the wound care nurse about a new or worsening wound.*She expected that the nursing staff would have continued to follow up with the physician or wound care clinic to arrange for resident 1 to be seen sooner. *She believed there was an oversight in care because there were policies and procedures in place, but something was missed, as there were four days which nothing was done for resident 1's leg wounds. *She verified that LPN D had incorrect information in the fax sent to the provider on 10/22/25 and had not implemented treatment for resident 1's left foot and both leg wounds until 10/28/25. 6. Interview on 11/18/25 at 9:35 a.m. with LPN F revealed: *He remembered resident 1 had a wound on his tailbone where the bone was visible. *Resident 1 had a wound vac for the majority of his time at the facility. *LPN D was the nurse who showed him how to change resident 1's wound vac, and he had changed it many times.*He did not know how resident 1 had got the wounds on his legs. *He did not remember performing wound care treatment on resident 1's left foot or both legs. 7. Interview on 11/18/25 at 10:02 a.m. with CNA I revealed: *She was a bath aide and knew resident 1 had skin wounds on his left foot and both legs. *Bath aides did not document skin changes on bath days. If the staff saw a new skin impairment, they would inform LPN D or the floor nurse on duty. *The wounds on resident 1's left foot were always covered, and the wounds on his shins looked scabbed over. *Resident 1's left foot and both legs were covered with bandages when she bathed him on 11/4/25 before he left for his wound clinic appointment. 8. Interview on 11/18/25 at 10:28 a.m. with administrator A revealed: *She believed there was a breakdown in their processes because RN K did not document resident 1's new skin impairment on his left foot and both legs on 10/22/25 and should have completed a skin evaluation, contacted the family and the resident's healthcare provider, and made efforts for him to be seen at the wound clinic sooner. *She thought they could have addressed his left foot leg wounds sooner and prevented them from worsening. *She expected the nursing staff to follow physicians' orders. 9. Interview on 11/18/25 at 11:10 a.m. with LPN D revealed:*She confirmed she was the facility's designated wound care nurse. *She expected RN K to take care of resident 1's left foot and both leg wounds when they were discovered on 10/22/25 and complete a skin evaluation. *A weekly skin assessment was to be completed every Wednesday for residents by the floor nurse on duty, and resident 1's skin wounds on his left foot, left lower leg, and right lower leg was not identified until 10/22/25. *RN K did not document about resident 1's new skin wounds on his left foot or both legs, so she (LPN D) created a late entry note on 11/6/25 to document that the resident's new skin wounds was identified. *She believed there was a communication breakdown and that more should have been done for resident 1's skin wounds. *She completed all her skin/wound evaluations on Tuesdays for residents who had current skin impairments. *She verified that she entered the physician's 10/29/25 order regarding resident 1's wound treatment incorrectly in the EMR system. 10. Interview on 11/18/25 at 12:00 p.m. with RN E revealed:*If a resident was observed with a new skin impairment, the nurse would place a checkmark in the resident's EMR under skin audit. *The nurse was to document the new skin impairment in a progress note, and perform a skin evaluation, but many staff just informed LPN D. 11. Interview on 11/18/25 at 12:19 p.m. with RN/MDS coordinator C revealed: *A floor nurse notified her on 10/26/25 about resident 1's new left foot and both leg wounds. *RN/MDS coordinator C documented what she observed and did for resident 1 in a nursing progress note. *Every day, management held an early morning meeting to review residents' progress notes, and identify new skin impairments. LPN D would be notified of any new skin impairments to add them to her list to complete those residents' skin evaluations. *She felt all staff knew that LPN D completed the skin evaluations and that the staff were expected to alert LPN D if they saw a new skin impairment. 12. Interview on 11/18/25 at 12:29 p.m. with DON B revealed: *She expected that the nurse who identified a new skin impairment was to complete a skin evaluation that day and document in the resident's nursing progress notes, any actions taken, and who was notified. *In any of the resident's EMR with weekly skin audits, the EMR would prompt a nurse who found a new skin impairment to complete a skin evaluation. 13. Interview on 11/18/25 at 3:46 p.m. with RN K revealed: *She noticed resident 1 had missing skin with yellow or white discharge on his left foot wound.*She did not document anything about his foot wound because she did not work at the facility often and did not know where to document about wounds, so she alerted the wound care nurse, LPN D. *RN K stated she dressed resident 1's wounds on his left foot with a foam dressing and ensured his pressure ulcer prevention boots were on all day on 10/22/25. *She explained that she called and faxed the wound care clinic that day (10/22/25), but never heard back, and felt she did not work at the facility often enough to follow up on that. 14. Interview on 11/19/25 at 10:53 a.m. with resident 1's son revealed:*He visited his father on 10/18/25 and left early on 10/22/25, so he had not seen him that day. *When he arrived, his father's left ankle was wrapped up, and there were visible red areas on the skin of his legs.*He notified the nurse, who told him they were monitoring it and planned to move up his wound care appointment. *The wound clinic called him on 11/4/25, informing him that resident 1's wounds were a potential amputation situation. *The vascular surgeon, had taken care of his father for years, informed him that if the facility had acted sooner, the situation could have been corrected. 15. Review of the provider's updated July 2025 Skin Integrity policy revealed:* In an effort to maintain the resident's optimal level of skin integrity and promote healing of skin ulcers/pressure ulcers/wounds, the facility has a systemic approach and monitoring process for evaluating and documenting skin integrity. In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds.* The resident's skin is inspected daily with completion of ADL's [activities of daily living] (unless [the] resident is independent in ADL completion). Changes in the resident's skin are reported to the Licensed Nurse (LN).* Ongoing evaluation continues weekly with the LN completing a full body skin audit. Completion of the skin audit is documented on the treatment administration record (TAR) with their initials.* If skin impairment is noted after admission (in addition to the above steps), the LN:a. Initiates alert charting.b. Completes (and documents) notifications to the medical provider and resident or resident representative.c. Implements new interventions as needed. Documents on the resident's care plan. d. Notified Food and Nutrition Services Manager (FANS) and/or Registered Dietitian of new pressure injury or worsening wound condition for nutritional needs evaluation.e. Notifies Director of Nursing Services (DNS) of skin impairments that indicate a potential significant change in condition (Stage II or greater Pressure Ulcer, surgical wound dehiscence, hematoma, or bruise on an area of the body not usually vulnerable to trauma (e.g. head, breasts, inner thighs, groin). f. The DNS and/or designee complete a comprehensive review of the resident's medical record to evaluate if the pressure injury was avoidable or unavoidable. This evaluation is documented in the nurse's notes.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and manufacturer's operator's instructions review, the provider failed to ensure:*The safety of one of one sampled resident (1) who fell from a total body lift (a mechanical lift and sling used to lift a person's full body) and sustained a hematoma (an injury that causes a localized collection of blood under the skin) while being transferred by one of one licensed practical nurse (LPN) (C) and one of one certified medication aide/certified nursing assistant (CMA/CNA) (F).*The sling sizes for eight of eight sampled residents (1, 2, 3, 4, 5, 6, 7, and 8) who used a total body lift for transfers were assigned according to the sling's manufacturer's instructions. Findings Include:1. Review of the provider's 9/12/25 SD DOH FRI regarding resident 1 revealed:*On 9/12/25 at 11:20 a.m. LPN C and CMA/CNA F had been transferring resident 1 from her wheelchair to her bed.*CMA/CNA F had reported that resident [1] fell out of the [full-body lift] sling, and stated all 4 [four] sides of the sling were hooked up to the metal bar of the mechanical lift.*LPN C had stated that he didn't know how the sling slipped off the hook.*Resident 1 had stated, I was in the sling. I was being lifted up and the next thing I knew I was cracking my head but not from hitting it on the bar from hitting it really hard on the floor.*LPN C reported that resident 1 had a hematoma behind her left ear.*Resident 1 had neck pain and was transferred to the hospital for evaluation and returned later that same day. A hematoma to the back of the left ear was noted on the evaluation at the hospital. *The sling [used during that transfer] was noted to be an XL [size extra-large].*[An] Audit was done 9/12/2025, to assess all sizes of slings to those residents who utilize them, and appropriate sizes are in place. 2. Review of resident 1's electronic medical record revealed:*Resident 1 was admitted on [DATE].*Her diagnosis included osteochondrodysplasia (a genetic condition where there is a defect in the development of cartilage and bone, leading to skeletal abnormalities and disproportionate growth), anterior displaced Type II dens fracture (a fracture of the second cervical vertebra where the fractured fragment is moved forward), and quadriplegia (partial or complete loss of movement and/or sensation in the upper and lower parts of the body).*Her 9/3/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact.*Her 9/3/25 care plan indicated that she required the assistance of two staff members and the use of a full-body mechanical lift for transfers.-There was no documentation of what size lift sling she used at that time.-A care plan intervention added on 9/14/25 indicated: I require a full body small sling for transfers with the mechanical lay down lift. I have one assigned to me with my room number on the tag. Ensure the loops [of the sling] are completely inside of the metal rings on the lift bar.*A 9/13/25 physician's order indicated wear the [cervical] collar whenever up out of bed.*Her 9/15/25 weight was 147.9 pounds (lbs). Review of resident 1's 9/4/25 Physical Therapy Evaluation revealed:*Resident 1 requires the Hoyer lift [a brand of full-body mechanical lift] for all transfers, and included that transfers with resident 1 using that lift had not been tested during that evaluation.*There was no documentation that the full-body lift sling size had been assessed during that evaluation. Review of resident 1's 9/12/25 hospital discharge summary indicated:*On 9/12/25, resident 1 sustained a head injury when she was transferred with the full-body mechanical lift, and she hit her head on the bed frame and then on the floor.*She reported mild discomfort.*A 9/12/25 Computed Tomography (CT) scan (a medical imaging test) showed an occipital scalp [back of the head] hematoma without underlying fracture, and changes since February 2025 though [the changes] may have been present on the August 2025 MRI (MRI) (a medical test to create highly detailed images inside the body).*There is clinical concern for new cord injury. Consider MRI.*Neurosurgery (a medical specialty focusing on the brain and spinal cord) did review and thought no acute recommendations aside from the collar to be worn while out of bed. 3. On 9/16/25 at 10:00 a.m., a resident census list, indicating which residents used mechanical and non-mechanical transfer lifts, a transfer policy, a resident safety policy, and instruction manuals or policies regarding the use of mechanical lifts and their slings was requested. Review of the facility provided documentation revealed:*The provider indicated they did not have policies regarding resident safety, resident transferring, or mechanical lift sling use.*The provider referred to the EZWay Classic Lift Operator's Instructions for all guidance on the use of the full-body mechanical lifts and the lift slings.*The provider's census indicated 12 residents required the use of a full-body mechanical lift. 4. Observation and interview on 9/16/25 at 11:36 a.m. with resident care manager (RCM)/registered nurse (RN) D and CNA J while assisting resident 7 to transfer using the full-body mechanical lift revealed:*Each resident who used a full-body mechanical lift for transferring was to have their own sling that remained in the resident's room or wheelchair.*There were different-sized slings, and they would know which sling size was to be used for each resident by checking the resident's weight in their EMR and referencing that with the size chart in the manual attached to the EZWay full-body mechanical lift.*That size chart was the EZWay Sling Sizing Chart.*They thought that resident 7 used an extra-large sling, because it was in his room. RCM/RN D and CNA J transferred resident 7 with that extra-large sling and the full-body mechanical lift. Observation and interview on 9/16/25 at 11:55 a.m. and again on 9/17/25 at 7:48 a.m. with resident 1 and her husband revealed:*On 9/12/25, LPN C and CMA/CNA F were assisting her to transfer from her wheelchair onto her bed with the full-body mechanical lift and sling. They had raised her in the sling and had begun to turn her in the sling to align her body to the bed when she fell onto the floor.*Resident 1 thought the lift strap had come unhooked and caused her to fall.*When she fell, she hit her head on the floor, had pain in the back of her head and in her neck, and waited on the floor for the ambulance to arrive because she was afraid that if staff moved her, she would have had a more serious neck injury.*She was told at the hospital that she had a hematoma on the back of her head, and she was relieved that the hospital tests showed that there was no more serious injury.*She had constant pain before the fall and since, but she did not think that she had more pain than she did before the fall as long as she avoided lying on one specific spot on the back of her head.*The staff used the same lift sling that she fell out of since she was admitted on [DATE].*After that fall on 9/12/25, the staff used a smaller lift sling.*The sling in her room was a blue, Direct Supply full-body size small. That sling was marked with the date 9/12/25 and her room number.*Resident 1 chose not to wear the physician-ordered neck collar unless she was in therapy. Observation and Interview on 9/16/25 at 2:36 p.m. with LPN C regarding resident 1's 9/12/25 falling incident revealed:*CMA/CNA F was assisting him in transferring resident 1 from her wheelchair to the bed with the mechanical full-body lift and a yellow-colored sling.*He thought that the sling strap had come unhooked from the lift and caused resident 1 to fall from the lift when the resident was raised above her wheelchair.*He demonstrated with the mechanical full-body lift and a sling what he thought had occurred that day. He did not think that the sling used for resident 1 when she fell was the wrong size.*He thought resident 1 hit her head on the bed, and then her body hit the floor.*After resident 1 fell, he immediately assessed resident 1's vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) and pain, had the staff call the ambulance, and remained with resident 1 until the ambulance arrived because resident 1 had a previous neck injury and she was scared.*Resident 1's husband was outside of the room when resident 1 fell and was very upset about what had happened. Observation and interview on 9/16/25 at 2:50 p.m. with LPN/RCM E regarding resident 1's 9/12/25 fall revealed:*CMA/CNA F alerted LPN/RCM E that resident 1 fell out of the lift sling when CMA/CNA F and LPN C transferred the resident.*LPN/RMC E went to resident 1's room to assist, notified resident 1's husband, and called the ambulance.*LPN/RMC E confirmed that a yellow-colored sling had been used to transfer resident 1 the day resident 1 fell, and that sling was too large for resident 1.*Education had been conducted with all nursing staff on 9/12/25, after resident 1's fall, which included that staff were to check the resident's weight in the EMR and to determine the correct sling size to use by referencing the EZWay sling size guide that was located on the mechanical full-body lift.*Any nursing staff, including CNAs, were able to look up the resident's weight and determine the correct sling size to use by referring to the EZWay sling size guide. Interview by phone on 9/16/25 at 2:59 p.m. with CMA/CNA F regarding resident 1's 9/12/25 fall revealed:*She was assisting LPN C in transferring resident 1 from her wheelchair to the bed with the mechanical full-body lift and a yellow-colored sling.*She fastened the bottom two straps to the mechanical full-body lift, and LPN C fastened the top two sling straps that were closest to resident 1's head.*Resident 1 fell out of the left side of the sling. She thought that all four straps remained fastened after resident 1 fell from the sling.*She thought that the sling used to transfer resident 1 had been a size large.*That yellow-colored sling was in resident 1's room, and she thought that was the right sling size because the staff person who brought it to resident 1's room should have checked that it was the right size.*When she would bring a sling to a resident's room, she would check the resident's weight in the EMR and pick the sling size that the EZWay manual on the lift indicated the resident would need. Observation and interview on 9/16/25 at 3:07 p.m. with resident 1, LPN C, and CMA/CNA I revealed:*LPN C and CMA/CNA I used the mechanical full-body lift and a blue size small Direct Supply sling to transfer resident 1 from her bed to her wheelchair.*CMA/CNA I indicated that she had used resident 1's weight and the EZWay sling size guide to determine which size sling resident 1 needed.*She confirmed that the sling she had used was not an EZWay sling and was unsure if the Direct Supply sling had a different sizing guide. She was unsure if the Direct Supply sling size could be correctly determined using the EZWay sling size guide. Observation and interview on 3/16/25 at 3:10 p.m. with director of nursing (DON) B in the laundry room revealed:*Slings were washed and stored in the laundry room between resident uses.*The provider had at least four different brands and different sizes of mechanical lift slings.*She was unaware if there were size guides for the four brands of mechanical lift slings found in the laundry room.*She expected the CNAs to use the residents' weights found in the EMR to select the correct sling size for all of the different brand lift slings based on the EZWay sling size guide, and to ensure the resident fit between the top and bottom of the sling and that the sling was not too narrow for the resident's body. Interview on 9/16/25 at 3:27 p.m. with CMA/CNA I regarding the lift slings revealed:*She ordered the facility's resident care supplies and ordered the size small Direct Supply sling about a year ago for a previous resident. She thought it would be the correct size sling for resident 1 because she was a tiny gal, and it was the only size small sling that the facility had in stock.*She would look to see if she could locate a sling sizing guide for the Direct Supply lift sling that she had ordered last year.*There was an EZWay sling size chart taped to the nurses' station counter to help the CNAs when selecting the correct size slings to use. Interview on 9/16/25 at 3:40 p.m. with administrator A regarding the use of mechanical lift slings revealed:*The provider had several different brands and sizes of mechanical lift slings.*She thought that the lift sling sizing was universal and that all slings could be used with the EZWay brand lifts.*She expected the nursing staff to use the EZWay lift sling size guide when they determined which size sling the resident required for all of the brands of slings.*She did not have sling size guides for the four brands of slings that were in the laundry room and available for use.*She confirmed that the lift slings were stored in the laundry room between resident uses, and she expected the CNAs to select the correct size lift sling based on the resident's weight using the EZWay lift slings. Interview on 9/17/25 at 7:15 a.m. with administrator A revealed she:*Printed the sling size guides for three of the most commonly used brands of slings that they used.*Had been unaware that each brand of sling had its own sizing guide and that not all of them used the resident's weight as a basis for the size sling a resident required.*Ordered seven EZWay brand slings on 9/16/25 that were recommended for use with the EZWay mechanical full-body lift that they used.*Spoke with the EZWay representative when she purchased those full-body mechanical lifts several years ago and had been told she could use any brand sling with the lifts.*Was considering discontinuing the use of the yellow Guldmann lift slings because those slings used three different resident body measurements in determining the sling size a resident would require, and not the resident's weight.*She agreed that they had not completed a resident assessment of those body measurements. Observations on 9/17/25 of the resident's mechanical full-body lift slings revealed:*At 7:38 a.m., resident 2 had a Direct Supply size large split-leg mechanical lift sling in her wheelchair.*At 7:45 a.m. LPN/RCM E and CMA/CNA G confirmed that resident 3 had used a blue mesh lift sling with a green trim on the edge for showering that morning. The label on the sling was illegible, and LPN/RCM E confirmed that she did not know the size of the sling. LPN/RCM E and CMA/CNA G had used the Guldmann size large sling to transfer resident 3 from his bed to his wheelchair.*At 7:57 a.m. CNA H confirmed that she used a Guldmann size large sling to transfer resident 8 from her bed to her wheelchair.*At 8:07 a.m., CNA K confirmed that resident 4 was seated in her wheelchair on a Guldmann size large sling*At 8:47 a.m., LPN/RCM E confirmed that resident 6 had used a Guldmann sling to get out of bed for breakfast, and that sling was removed from resident 6's wheelchair while she was up and was on her bed. The lift sling on her bed was a Guldmann size large.*At 8:52 a.m., resident 5 stated that staff used the lift sling in her wheelchair to get out of bed for breakfast. That lift sling was a Guldmann size extra-large. Interview on 9/17/25 at 9:09 a.m. with administrator A revealed:*She had been unaware that each mechanical lift sling manufacturer had a different size guide to determine the correct size sling a resident required for the use of the full-body mechanical lifts.*The therapy department assessed the resident for their correct transfer status and the equipment they required for transferring. The therapy department did not assess the resident for the correct size lift sling.*Administrator A conducted an investigation and interviews with staff on 9/12/25, and determined that resident 1 was not placed in the correct lift sling size when she fell on 9/12/25, but she felt that the correct sling size the staff were currently using to assist her with transferring was correct.*The provider primarily used the yellow Guldmann brand lift sling that required three body measurements to determine the correct size. Those measurements had not been completed when determining the correct lift sling size to use when transferring residents.*She was unaware that six of the eight residents would have been on the wrong size lift sling using the EZWay size chart. The lift sling size for those residents could not be determined because the three body measurements had not been completed.*She agreed that the Direct Supply, Guldmann, and SMT Volaro lift slings could not be accurately determined using the EZWay lift sling size guide.*A licensed staff member had not completed a resident assessment to determine the correct size lift sling that residents 1, 2, 3, 4, 5, 6, 7, and 8 would need when transferring with the mechanical full-body lift. 4. A request was made to administrator A and DON B on 9/17/25 at 7:34 a.m. for policies related to resident assessment, resident care planning, resident equipment, and resident falls. Review of the policies provided revealed they did not include assessing a resident for the use of the mechanical full-body lift or sling, who was responsible for completing that task, or what resident information was expected to be included in the resident's comprehensive care plan related to the use of mechanical lifts. 5. Review of the 11/28/18 EZWay Classic Lift Operator's Instructions revealed: EZWay slings are made specifically for the EZWay Lifts. For the safety of the patient and caregiver, only EZWay slings should be used with EZWay lifts.*As patients [residents] do vary in size, shape, weight and temperament, these conditions must be taken into consideration when deciding which EZWay Sling is suitable for each patient's needs.*There are a variety of slings available in various sizes.*Attaching the sling to the lift.Make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook of the hanger bars.*Lifting the patient.Push the UP button on the hand control to initiate the upward motion of the lift. Continue the upward motion until there is tension on the legs of the sling, make sure all the loops on the sling are securely hooked on the hanger bars.*Users must accept full responsibility for checking the condition of all slings and harnesses before each and every use on the patient.*It is recommended that slings be replaced after one year or if the sling shows any sign of damage or wear.*The Sling Sizing Chart had a color-coded chart that indicated which color correlated to which size. There was also a guide that correlated sling size with Weight of Patient and Maximum distance from patient's tailbone to base of neck. **Does not apply to Belted Mesh or Multi-Purpose slings**. That chart indicated:-Gray was size S (small), for patients 70 - 100 lbs. (pounds) with a maximum distance from tailbone to base of neck of 21 (inches).-Beige was size M (medium), for patients 90 - 220 lbs. with a maximum distance from tailbone to base of neck of 24.-Burgundy was size L (large), for patients 190 - 320 lbs. with a maximum distance from tailbone to base of neck of 26.-Green was size XL (extra-large), for patients 280 - 450 lbs. with a maximum distance from tailbone to base of neck of 29.-Black was size XXL (extra, extra-large), for patients 400-600 lbs. with a maximum distance from tailbone to base of neck of 36.-Brown was size XXXL (extra, extra, extra-large), for patients 600+ lbs. with a maximum distance from tailbone to base of neck of 37.*NOTE! The size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of the patient. A proper fit will involve the judgement of the caregiver.Review of the requested Direct Supply Slings size guide revealed:*There were five different total body lift sling models, each had a different size and Recommended user weight.-Some sling models came in five sizes, extra small through extra-large, and others came in three sizes, one model size was indicated by weight only, 125-200 lbs., 175-300 lbs., and 275 - 500lbs.*Our multi-brand slings have passed rigorous compatibility testing standards for use with leading models of lift equipment. So even if you have multiple brands of lifting equipment in your community, you can depend on one affordable sling brand to help keep your staff and residents safe during transfers. Review of the requested Guldmann full body lift sling size guide revealed:*There were 12 different total body sling models.*The sling sizes were determined by the measurement of the residents' hip width, chest width, and seated height from the bone to the top of their head. The resident's weight was not considered.*There were five Kids sizes and nine additional sizes that ranged from XS (extra small) to 5XL. 6. Review of the provider's March 2025 Charge Nurse Job Description revealed:*Evaluates resident care as related to individual resident needs, family involvement, and the physician's plan of care for the resident.*Provides clinical supervision to nursing assistants. Review of the Certified Nursing Assistant Job Description revealed:*Under general supervision performs a combination of following duties in caring for residents.consistent with.established long-term care standards.*Reports to the Licensed Nurse directing and overseeing resident care on assigned unit. 7. Review of a 9/16/25 email communication between administrator A and the EZWay Safety Program Coordinator revealed, If an item is purchased to be used with another brand product, EZWay will not be held liable for any issues resulting from usage with non-EZWay equipment.

Based on observation, interview, record review, and policy review the provider failed to adequately identify and effectively implement pressure ulcer (skin and/or underlying tissue injury due to prolong pressure) preventative interventions for residents identified at risk for developing pressure ulcers for:*One of one sampled resident (3) who developed a pressure ulcer to her heel.*One of one sampled resident (27) who developed a pressure ulcer to her coccyx (tailbone).Findings include: 1. Observation on 8/5/25 at 9:10 a.m. of resident 3 in her room revealed: *There was a sign on the wall beside the entrance to resident 3’s room that indicated she was on enhanced barrier precautions (personal protective equipment, such as gloves and a gown was to be worn with all close contact resident care). *She was sitting in a wheelchair near her bed. *She was wearing a Prevalon boot (a cushioned boot that floats the heel off the surface of the mattress, to help reduce pressure) on her left foot. *There was a second Prevalon boot on a chair at the foot of her bed. *She had an air mattress on her bed. *On the wall beside her bed was a sign that said, “heel boots on at all times while in bed.” 2. Interview on 8/6/25 at 4:45 p.m. with certified nursing assistant (CNA)/certified medication aide (CMA) M revealed: *Resident 3 used Prevalon boots and an air mattress because she had a pressure ulcer on her heel. *Those interventions were put into place after resident 3’s had developed that pressure ulcer. *Prior to the pressure ulcer being identified on resident 3’s left heel, CNA/CMA M stated resident 3 had complained of pain to her heels. -When resident 3 reported the pain to CNA/CMA M she placed a pillow under resident 3’s legs to float her heels off the mattress. *CNA/CMA M stated she was off for a few days after resident 3 reported pain to her heels. *When CNA/CMA M returned to work, she found blood on resident 3’s bed sheet and the open area to the resident’s heel was identified. 3. Review of resident 3’s electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 7/23/25 Brief Interview for Mental Status (BIMS) assessment score was 4, which indicated she had severe cognitive impairment. *Her 6/16/25 and 6/30/25 Braden Scale for Predicting Pressure Score Risk assessment was 15, which indicated she was at risk [low risk] for the development of pressure ulcers. *Physician Y was notified of resident 3’s left heel pressure ulcer on 7/21/25 and ordered the wound to be cleansed with a wound cleanser twice weekly and covered with a foam dressing until healed. *“Pro Heal Liquid Protein [a supplement that promotes wound healing] two times a day 30 cc [cubic centimeters] to aid in wound healing” was added on 7/24/25. Review of resident 3’s 8/5/25 care plan revealed: *She did not ambulate. *She was dependent on the assistance of one staff for dressing and bed mobility. *She required assistance from two staff members and a mechanical lift for transfers. *The pressure ulcer was added to her care plan as a problem area on 7/21/25. -The heel boots and the air mattress were added to her care plan as interventions for the pressure ulcer on 7/29/25. *Prior to the identification of the pressure ulcer, resident 3’s care plan the skin integrity interventions were, -“Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning.” -“Follow facility policies/protocols for the prevention/treatment of skin breakdown.” -“Pressure Ulcer risk evaluation quarterly and as indicated.” -“Weekly skin observations by charge nurse per protocol.” *Within the 8/6/25 Clinically Unavoidable Review and Acknowledgement assessment licensed practical nurse (LPN)/ resident care manager (RCM) wound nurse I documented, “Based on the above clinical review of medical conditions and individual high risk factors in combination with all defined and implemented interventions the center has put forth, this IDT [interdisciplinary team] and Provider agree the specified skin impairment is determined to be unavoidable.” -The assessment indicated the documentation was to be, “Defined and Implemented Interventions PRIOR to the Skin Impairment or Pressure Injury Development”. --This assessment indicated interventions initiated after the pressure ulcer was identified included the medication review and recommendation on 7/22/25, the staff education on individual care planned skin prevention needs on 7/22/25, the nutritional supplement ordered on 7/24/25, and the registered dietician review and recommendation on 7/24/25, -Lab results were not included in the portion labeled Lab Results in that assessment. *A 7/15/25 at 5:50 a.m. progress note indicated, “Called to [the] residents [resident’s] room during the night to look at her heels. Both heels are pink and spongy. Heel protectors [were] placed [on the resident] and will monitor. Will pass onto [the] oncoming nurse.” *There was no documentation that the pressure ulcer had been identified in the progress notes. *There was no documentation that the resident’s representative was notified of the change in her heel condition. *Resident 3’s weekly skin evaluation on 7/22/25 at 2:11 p.m. indicated the area to resident 3’s left heel measured 0.6 centimeters (cm) X (by) 0.6 cm and was identified as a stage II (2: open skin wound with partial thickness skin loss) pressure ulcer without drainage. *Resident 3’s 7/28/25 Weekly Skin Evaluation indicated the pressure ulcer was “improving” and measured 0.8 cm X 0.7cm and was 0.1cm deep. -The stage of the pressure ulcer had advanced from a stage II to a stage III (3: open skin with full thickness skin loss. Fatty tissue may be visible). -The base of the wound was 100% slough (tissue that was not alive and could hinder the healing process) and moderate drainage. *On 7/29/25 at 2:36 p.m. an air mattress was placed on resident 3’s bed. *Resident 3’s 8/4/25 Weekly Skin Evaluation indicated the pressure ulcer was “improving” and measured, 1 cm X 1 cm and was 0.1 cm in depth. -It remained at a stage III. -It was 75 % slough and 25 % granulation tissue (new tissue formed in the healing process) without drainage. 4. Interview on 8/7/25 at 2:35 p.m. with LPN/RCM wound nurse I revealed: *She had received specialized training in wound care. *She was primarily responsible for residents’ wound care and wound assessment documentation. *When asked what interventions were in place to prevent the development of pressure ulcers for resident 3, she stated she received skin checks weekly by the nurses, she had a Braden Scale assessment completed on admission which indicated she was at risk (low risk), and she was admitted from the hospital with heel protector boots. *Upon review of resident 3’s progress notes LPN/ RCM wound nurse I verified the heel protector boots had not been provided to resident 3 until 7/15/25. *LPN/ RCM wound nurse I was not aware there was concern related to resident 3’s heels prior to the identification of the pressure ulcer documented on the resident’s 7/22/25 weekly skin evaluation assessment. * LPN/RCM wound nurse I completed the Clinically Unavoidable Review and Acknowledgement assessments and used her clinical judgement to determine whether a pressure ulcer was clinically avoidable or unavoidable. *She stated she had determined resident 3’s pressure ulcer to her left heel was unavoidable due to resident 3’s immobility, poor positioning related to her torticollis (muscle contractions causing the head to lean to one side), and having been dependent on one or two staff members for most of her care needs. * LPN/RCM wound nurse I agreed she had included interventions on the resident 3’s clinically unavoidable review and acknowledgement assessment that were not implemented until after the development of the pressure ulcer. *She stated it was not her usual practice to include interventions on those assessments that were implemented after the pressure ulcer was identified. *She verified resident 3’s heel pressure ulcer had been identified on 7/22/25 but the Clinically Unavoidable Review and Acknowledgement assessment was not completed until 8/6/25. *She stated she had not identified whether resident 3’s shoe or the mattress that may have caused the pressure ulcer. Resident 3 was not to wear her shoes until the pressure ulcer had resolved and she had an air mattress. *LPN/RCM wound nurse I would document whether a pressure ulcer was improving or not based on a decrease in the size of the pressure ulcer or a decrease in exudate (drainage). *She agreed resident 3’s weekly skin assessments indicated each the size of the pressure ulcer had increased each week. *LPN/RCM wound nurse I stated she had documented on resident 3’s 7/28/25 weekly skin assessment the pressure ulcer was improving because there was no longer any exudate, even though the size of the wound had increased, and she advanced the pressure ulcer from a stage II to a stage III with 100% slough. *LPN/RCM wound nurse I stated she had documented on the 8/4/25 weekly skin assessment that the pressure ulcer was improving because there was granulation tissue present, even though the size of the wound had increased. *She verified she had not notified the physician of the increased size of the pressure ulcer. 5. Observation of resident 27’s room on 8/5/25 at 11:39 AM revealed: *She was not in her room *Her heel boots were lying on the floor by her bed. *She had a sign on the wall located by the foot of her bed that stated she needed to wear heel boots in bed. *Her mattress appeared to be the facility's standard mattress. 6. Review of resident 27’s EMR revealed: *She was admitted on [DATE]. *Her most recent Braden scale score, completed on 5/1/25, was 13, which indicated she was at moderate risk of developing pressure ulcers. *Her 5/30/25 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact. *She had diagnoses of spinal stenosis (narrowing of the spinal cord), spondylosis (age-related wear and tear on the spinal discs (cushion between vertebrae) and bones), radiculopathy (disease of the nerve root in the spine), disease of the spinal cord, weakness, diabetes, and morbid obesity (excessive body weight that significantly impacts health and well-being). *Her 7/29/25, weekly skin evaluation indicated she had a new pressure ulcer on her coccyx (tailbone). It listed the measurements as 0.6cm long by 1.1cm wide by 0.1cm in depth. The pressure-reducing interventions in place included: a cushion in her chair, a pressure-reducing mattress, and heel boots. *A 7/30/25 physician’s order instructed to: “clean open wound at coccyx with wound cleaner, pat dry, and apply foam dressing twice per week & PRN [as needed].” *Her 7/30/25 Clinically Unavoidable Review and Acknowledgement assessment was blank. *An 8/2/25 Nutrition Hydration Skin Committee review progress note indicated the interdisciplinary team (IDT) met about the resident’s pressure ulcer discovered on 7/29/25. The pressure ulcer was a stage II the measurements noted in the 7/29/25 weekly skin evaluation were listed. The registered dietitian recommended adding the ProHeal supplement daily to aid in wound healing. The IDT staff members included regional dietitian G, DON B, and LPN/RCM, wound care nurse I. *8/3/25, she had received a doctor’s orders for ProHealth, a liquid protein supplement. Take one ounce daily to aid in pressure ulcer healing. *Her 8/5/25, weekly skin evaluation noted the wound had improved and was smaller in size. 7. Observation of resident 27 on 08/05/2025 at 3:16 p.m. revealed: *She was lying in bed on her back. *Her heel boots were on the floor by her bed. *A pressure relief cushion was in her wheelchair. 8. Observation and interview with resident 27 on 8/5/25 at 3:20 p.m. revealed: *She had an open sore on her left buttock that sometimes caused her pain. -The nurse puts a patch on it. *The staff did not reposition her, and she would have liked to have been repositioned more. *She tried to reposition herself in bed sometimes, but would then slide. *The provider’s staff had told her they did not want side rails used, but she thought she would be able to move herself more if she had them. *An air mattress was not on her bed. 9. Observation of resident 27 on 8/6/25 at 2:55 p.m., 4:24 p.m., and again at 4:54 p.m. revealed she had been lying in her bed, position on her back. 10. Interview on 8/6/2025 at 4:40 p.m. with certified nursing assistant (CNA) Q revealed: *To prevent pressure ulcers, the staff repositioned residents from side to side and placed heel boots on the residents. If the resident did not have boots, staff used a pillow or blanket to lift their feet off the bed. The staff would check on those residents more frequently. *For resident 27, the staff tried to reposition her every two hours. She stated resident 27 had “kinda” moved on her own, so they would ask her if she had repositioned herself. If resident 27 had said yes, they would not have repositioned the resident at that time. *Resident 27 was not physically able to reposition herself in bed from side to side. She had not refused to be repositioned. *They were not able to use side rails because they were considered a restraint. *The mattress type on resident 27’s bed had been the facility's standard mattress that everyone used, except for the hospice residents. The hospice residents usually used an air mattress. 11. Review of her current care plan on 8/7/2025 indicated: *She needed one staff member to assist her with bathing or showering, repositioning in bed, and two staff members to assist her with transferring. *She had been incontinent of bowel and bladder. *She was to have a pressure-reducing mattress on her bed. 12. Further review of resident 27’s EMR revealed her 7/30/25 Clinically Unavoidable Review and Acknowledgement assessment was signed as completed by LPN/RCM, wound care nurse I on 8/7/25. *The assessment indicated she was at risk for developing pressure ulcers due to her history of pressure ulcers, poor alignment, impaired functional mobility, diabetes, incontinence, behavioral disturbances, and pain. *The assessment conclusion note stated: “Based on the above clinical review of medical conditions and individual high-risk factors in combination with all defined and implemented interventions the center has put forth, this IDT and Provider agree the specified skin impairment is determined to be unavoidable.” 13. Interview on 8/7/25 at 11:51 a.m. with LPN/RCM wound nurse I revealed: *Resident 27 liked to lie in the same position in bed, and staff have reported they cannot get her to lie on her side. *She had a pressure ulcer in the past on her coccyx that had healed. *She shifted frequently in her wheelchair to get comfortable, which increased her risk for pressure ulcers related to friction. *After the development of a pressure ulcer, she expected the Clinically Unavoidable Review and Acknowledgement assessment was to have been done within 24 hours. *She was not sure why resident 27’s 7/30/25 initial Clinically Unavoidable Review and Acknowledgement assessment was blank. She confirmed she completed the assessment today. *Resident 27 had been on and off the ProHeal supplement. She received it again when her coccyx pressure ulcer re-opened. *She stated resident 27 should have been repositioned routinely, every two to three hours. *She denied that resident 27 had declined being repositioned but stated the resident had preferred to be on her back. She confirmed that information was not included in her care plan. *She expected CNAs to document on the repositioning task intervention in the EMR each time the resident was repositioned. *She reviewed the resident 27’s repositioning documentation for the past 14 days, which indicated resident 27 had only been repositioned one to three times each day. *She confirmed resident 27 was not repositioned as expected to help prevent her from developing a pressure ulcer. *She stated her mattress was the facility's standard mattress, which was considered pressure-reducing. *She would consider using an air mattress if her wound did not improve within two weeks. *The provider was a side rail-free building, and hers were zip-tied down. She was updated on the residents' request for grab bars. *She stated that, even with the resident not being repositioned routinely and based on her clinical judgment, she thought resident 27’s pressure ulcer was unavoidable. 14. Interview with DON B on 8/7/25 at 6:08 p.m. revealed: *She expected pressure ulcer prevention interventions to be implemented for residents at high risk for developing pressure ulcers or if they had a history of pressure ulcers. -Those interventions included the use of heel boots and repositioning every two hours. *She stated the standard mattresses were pressure-reducing and she did not expect a resident to have an air mattress unless the resident’s pressure ulcer was a stage III or IV (open wound with full-thickness skin and tissue loss. Bone, tendon, or muscle may be visible), depending on its severity. *She expected resident 27 not to be frequently lying on her back if she had a pressure ulcer on her coccyx. *She expected the Clinically Unavoidable Review and Acknowledgement assessment to be completed within 24 hours. *She stated she thought Resident 27’s pressure ulcer was unavoidable, even though she was not repositioned as expected, and was frequently placed on her back. 15. Review of the provider’s July 2025 Skin Integrity policy revealed: *“In an effort to maintain the resident’s optimal level of skin integrity and promote healing of skin ulcers/pressure ulcers/wounds, the facility has a systemic approach and monitoring process for evaluating and documenting skin integrity. In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds.” *“The nurse completed the Braden Scale/Skin Integrity Evaluation on admission, weekly for three weeks, and then annually.” *“The nurse establishes a plan of care based on risk factors in an effort to limit their potential effects.” *“If skin impairment is noted after admission (in addition to the above steps), the LN [licensed nurse]: -a. Initiates alert charting. -b. Completes (and documents) notifications to the medical provider and resident or resident representative. -c. Implements new interventions as needed. Documents on the resident’s care plan. -d. Notified Food and Nutrition Services Manager (FANS) and/ or Registered Dietician of [the] new pressure injury or worsening wound condition for nutritional needs evaluation. -e. Notified Director of Nursing [DON] Services (DNS) of skin impairments that indicate a potential significant change in condition (Stage II or greater Pressure Ulcer, surgical wound dehiscence, hematoma, or bruise on an area of the body not usually vulnerable to trauma (e.g. head, breast, inner thighs, groin). -f. The DNS and/ or designee complete a comprehensive review of the resident’s medical record to evaluate if the pressure injury was avoidable or unavoidable. This evaluation is documented in the nurse’s notes. *“If a wound condition fails to improve after 2 weeks of treatment or the condition of the wound deteriorates, the Medical provider and Resident’s Representative are notified. If a new treatment order is obtained the LN: - a. Re-evaluates [the] plan of care and resident’s condition (e.g. off-loading pressure from [the] skin impairment area, nutritional intake, blood sugars, and lab values).”

Based on observation, interview, record review, and policy review, the provider failed to follow infection prevention and control processes to ensure:*Proper hand hygiene, glove use, and gown use, was performed by eight of eight observed staff members (certified nursing assistant (CNA) R, K, L, and O, licensed practical nurse (LPN) I, housekeeper Z, and registered nurse (RN) H) during resident care for four of four sampled residents (1, 3, 5 and 27). *Contact precaution protocols were followed by one of one observed LPN (C) during resident care activities and medication administration for one of one sampled resident (52) related to an infectious bacterial infection in her stool.*The mechanical lift was cleaned between resident use by four of four observed staff members (CNAs L, O, and P, and LPN N) during two of three missed opportunities. 1.Observation on 8/5/25 at 10:24 a.m. of RN H and LPN I while providing resident 1‘s wound care revealed: *RN H and LPN I performed hand hygiene then put on a pair of gloves and a gown. *They cleaned off the designated wound care table with a sanitizing wipe, placed a towel down as a barrier, and removed wound dressings from a plastic bag with the resident 1’s name handwritten on it in marker. *With those same gloved hands, LPN I then removed a towel from under the resident's leg. That towel had visible blood on it. She removed the soiled gloves, performed hand hygiene (washed her hands), and put on a new pair of gloves. *LPN I then used a ruler to measure the wounds. She touched the resident’s legs and wounds with the ruler. She then set the ruler down on the clean wound care table, removed her gloves, did not perform hand hygiene, and put on a new pair of gloves. *With those gloved hands, LPN I cut the clean dressing supplies to the wound size. She cleansed the wounds with a wound cleanser, then reached into the clean supply bag with those same gloved hands. She touched her personal glasses with the back of those gloved hands. LPN I then covered resident 1’s leg with wound dressings. *LPN I then removed a roll of tape from the clean wound supply table with those same gloved hands. She wrote the date on the tape with a marker, then placed the marker on the clean dressing supplies. She then applied the dressing to the resident’s leg. *RN H opened the bedside dresser drawer with gloved hands and pulled out a compression leg wrap. She gave the wrap to LPN I. That wrap was then applied to the resident’s leg by LPN I with her same soiled gloved hands while RN H held that leg. RN H then removed her gloves, performed hand hygiene, and put on new gloves. *With those new gloves on, LPN I removed a dressing from the resident’s left index finger and threw it away. A tube of bacitracin antibiotic ointment fell onto the floor. With her gloved hands, RN H picked up the ointment tube off the floor. LPN I opened a new wound dressing, then RN H applied the ointment to the dressing that was being held in LPN I’s hand. LPN I then placed the wound dressing to resident H's index finger. LPN I and RN H did not perform hand hygiene or put on new gloves before the clean dressing was applied to resident 1’s index finger. *With those same gloved hands, RN H picked up the unused supplies from the table and put them back into the plastic treatment bag labeled with resident 1’s name. She removed her gloves and gown then threw them away. She performed hand hygiene. She then returned to the hallway and placed that bag of supplies into the treatment cart with other residents' treatment bags. Interview with LPN I on 8/5/25 at 11:04 a.m. regarding the above wound care observation revealed - she: *Acknowledged she had missed several opportunities to remove her gloves and to perform hand hygiene. *Agreed that caring for the resident’s wounds then retrieving supplies from the clean supply field contaminated the clean supply field. *Acknowledged that placing the contaminated wound/treatment supply bag into the treatment cart with other residents' (wound/treatment) supplies may have contaminated the treatment cart and the supplies stored in it. 2.Observation on 8/5/25 at 4:46 p.m. with resident 5 in her room revealed: * CNA R and CNA K were at the bedside to help resident 5 off the bedpan. They both performed hand hygiene, then put on new gowns and gloves. *CNA R helped resident 5 roll onto her left side in bed. She removed the bedpan from under the resident. She then tied the plastic bedpan covering, and handed the bedpan to CNA K. CNA K then went into the bathroom and disposed of it. *CNA R and CNA K removed their gloves, performed hand hygiene, then put on new gloves. *CNA K placed a clean incontinence brief on the resident, assisted her in pulling up her pants, and placed a sling under the resident. CNA K then wiped her forehead with the back of her gloved hand. *With those same gloved hands, CNA K transferred resident 5 to her wheelchair with CNA R's assistance and the use of a mechanical lift. They removed the sling from behind resident 5. They took off their gloves and performed hand hygiene. 3. Observation on 8/6/25 starting at 8:09 a.m. during medication pass in the 300 hallway with LPN C revealed: *LPN C prepared medications at the medication cart for resident 52 at 8:09 a.m. *He entered residnet 52's room without performing hand hygiene (handwashing) or wearing gloves and a gown. There was a sign next to her door that read “CONTACT PRECAUTIONS”. LPN C assisted resident 52 from the toilet to the recliner. He checked her vital signs (the body's basic functions such as temperature, blood pressure, pulse, and respiration rate) and gave her her medications. He did not perform hand hygiene when he left the resident's room. LPN C did not wear a gown or gloves at any time while in resident 52’s room. *LPN C prepared medications for resident 36 at 8:25 a.m. He entered the resident's room without performing hand hygiene, gave the resident his medications, and did not perform hand hygiene after exiting the room. *LPN C prepared medications for resident 54 at 8:30 a.m. He performed hand hygiene at the medication cart. He entered the room, gave the medications to resident 54, then left the room without performing hand hygiene. Interview with LPN C on 8/6/25 at 8:44 a.m. revealed he: *Thought he did not have to wear any PPE if he did not have any direct contact with the resident. *Was aware that resident 52 has a diagnosis of Clostridium difficile (a contagious infection of the intestines and colon). He stated he did not wear a gown or gloves because “it’s on all of our skin”. *Was aware of the policy to wear a gown and gloves while assisting a resident on contact precautions when providing direct care. Record review of resident 5’s chart revealed: *She was admitted on [DATE]. *Her diagnoses included C. Diff and a stage IV 4 (4; an open wound with full thickness skin and tissue loss. Bone, muscle, or tendon may be visible) pressure ulcer (a wound that resulted from pressure to an area) to her sacral area (low back to buttocks region). *She had been in the hospital, where she was diagnosed with a recurrent C. Diff infection prior to her admission to the facility. *She had a current physician’s order for “Fidaxomicin (an antibiotic used to treat C. Diff) Oral Tablet (Fidaxomicin) Give 200 mg [milligrams] by mouth one time a day every other day” that was to be administered until 8/10/25. *She had a wound vac (a medical device used to promote healing of wounds) that was to cover her stage IV 4 pressure ulcer. Review of resident 5’s current care plan revealed: *She required the assistance of one staff member for bathing, repositioning in bed, dressing, personal hygiene, transfers, and toilet use. *She was on enhanced barrier precautions (EBP) (gown and gloves use when providing close contact cares) related to her stage IV 4 pressure ulcer She was on contact precautions (gown and gloves were to be worn when entering the resident's room to prevent the spread of infection through direct or indirect contact) related to her C. Diff. 4. Interview with RN H on 8/7/25 at 3:29 p.m. revealed: *She was the facility's designated infection preventionist. *She was aware that the hand sanitizer dispensers in the resident’s shared bathrooms were not filled with hand sanitizer. She was told this is against the fire code, so they stopped refilling the dispensers. *Infection rates were tracked on a quarterly report by RN H. If a resident would get an infection, the resident’s room would be highlighted on her report. The resident’s antibiotics and lab cultures were discussed in the daily morning meeting. *She acknowledged that if a clean field was touched with a soiled glove, that field would be contaminated. *Clostridium difficile infection (C.Diff) rooms with a contact precautions sign would require staff to wear a gown and gloves at all times while in the room. *She acknowledged that their policy for regarding resident rooms where a resident with C. Diff infection resided indicated staff were to perform hand hygiene with soap and water before and after providing resident care and between glove changes. *Staff only need to wear a gown and gloves while in a resident's room who was on enhanced barrier precautions (EBP) room if they were providing any resident contact care. *Staff should be assisting residents to perform hand hygiene after using the bathroom and before eating. 5. Interview with DON B on 8/7/25 at 5:49 p.m. revealed her expectation was for staff members to follow all policies regarding hand hygiene, contact precautions including enhanced barrier precautions (EBP), personal protective equipment (PPE), and wound care practices. 6. Observation on 8/5/25 at 9:04 a.m. of resident 27’s room revealed: An enhanced barrier precautions (glove and gown use when providing contact care) (EBP) sign from the Centers for Disease Control and Prevention (CDC), was hung outside the residents' door frame. That sign: *It had two stop signs at the top of the sign. *It stated, “EVERYONE MUST: -Clean their hands, including before entering and when leaving the room.” *It stated, “PROVIDERS AND STAFF MUST ALSO: -Wear gloves and a gown for the following High-Contact Resident Care Activities. -Dressing -Bathing/Showering -Transferring -Changing Linens -Providing Hygiene -Changing briefs or assisting with toileting -Device care or use…. -Wound Care: any skin opening requiring a dressing.” *At the bottom of the sign, it indicated, “Do not wear the same gown and gloves for the care of more than one person.” *There were no gowns available for use observed inside or outside of the room. Review of resident 27’s electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 5/30/25 BIMS assessment score was 14, which indicated her cognition was intact. *She had diagnoses of spinal stenosis (narrowing of the spinal cord), spondylosis (age-related wear and tear on the spinal discs (cushion between vertebrae) and bones), radiculopathy (disease of the nerve root in the spine), disease of the spinal cord, weakness, diabetes, and morbid obesity (excessive body weight that significantly impacts health and well-being). *She needed assistance from staff members for repositioning in bed, dressing, changing of incontinence products, and transferring. *She was incontinent of bowel and bladder. *She had a pressure ulcer on her coccyx. *She was required to be on EBP, and gowns and gloves should be worn by staff members while providing her personal hygiene incontinent care and any direct, prolonged contact care. Observation and Interview on 8/5/25 at 3:38 p.m. with certified nursing assistant (CNA) L revealed: *She applied resident 27’s heel protectors without wearing a gown or gloves, and she did not perform any hand hygiene. *Sometimes she would wear gowns and gloves when working with resident 27, but she did not work in that hallway very often. *Resident 27 was on EBP, but she was not sure why, as she thought EBP was only for residents who had catheters. *She had worked here at the facility for about a year. Observation on 8/5/25 at 4:15 pm in residents 27 and 29’s room revealed: *Resident 29 was sitting in her room, slouched in her wheelchair. *CNAs L and O placed a sling under resident 27 without wearing gowns or gloves. *Without performing hand hygiene, CNA O repositioned resident 29 in her wheelchair. She failed to perform hand hygiene after assisting her. *CNAs L and O then transferred resident 27 with a mechanical lift (a mechanical lift and sling used to lift a person’s full body) without wearing gowns and gloves. *CNAs L and O left the room without performing hand hygiene and did not sanitize the mechanical lift. 7. Observation on 8/5/25 at 9:55 a.m. between the 100 and 200 hallways revealed: *Resident 1 was sitting in a bath chair covered in a blanket with a liquid dripping on the floor beneath him. *He was missing the toes on his right foot. *CNA K wrapped a towel around the resident’s right foot and held up the foot while the resident 1 was pushed in the bathchair to his room. *CNAs K and R then transferred the resident to his bed using a mechanical lift, and did not wear gowns. *CNA K took her gloves off, did not perform hand hygiene, and pushed the mechanical lift into the hallway. *Without performing hand hygiene, she put on one glove and sanitized the lift. 8. Interview on 8/5/25 at 10:04 a.m. with CNA K revealed: *She had worked at the facility for about a year. *Resident 1 had just finished with a shower, and he had a towel on his leg covering a wound. *Resident 1 did not need to be on EBP anymore because his wounds were closed. 9. Interview on 8/5/25 at 4:36 p.m. with CNAs L and O revealed: *They stated that gowns and gloves were supposed to be worn when changing resident 27’s incontinence product, and if they came in contact with the open wound. *They did not know where the gowns were stored and stated they thought they were in the rooms of residents who were on EBP. *They would perform hand hygiene before and after providing resident care and when moving from a dirty to a clean task. *They stated there was no hand sanitizer in the resident 27’s room, but there was soap and water. 10. Observation and Interview on 8/7/25 at 9:29 a.m. with CNA P revealed: *There was a mechanical lift in the utility room in front of the hopper (a specialized sink flushing device used to rinse soiled items and linens of bodily fluids) that was plugged into the outlet near the hopper. *CNA P stated the room was a utility room, and she used this room to charge the mechanical lift. *She reported using the hopper at times. *She stated the mechanical lift should be sanitized after it is taken out of this room before it is used for a resident. She stated the lift also needed to be sanitized after it was used on a resident. 11. Observation on 8/7/25 at 9:53 a.m. in resident 3’s room revealed: * CNAs were seen in resident 3’s room, who was on EBP. * They turned on the call light and LPN N answered the call light. * LPN N took the mechanical lift out of the utility room and brought it to that room without sanitizing it first. 12. Observation on 8/7/25 at 2:21 p.m. revealed housekeeper Z cleaned resident 3’s room, who was on EBP, without wearing a gown. 13. Interview with DON B on 8/7/25 at 6:08 p.m. revealed: *If a resident was on EBP, they would have a sign on the outside of their doorway. *Staff had been trained on the policy and procedures of EBP. *She expected gowns and gloves to be worn when staff had high contact with a resident in his or her room who was on EBP, which included transferring the resident. *She expected staff to use the rolling personal protective equipment (PPE) storage cart, which was shared between two hallways, when they cared for a resident who was on EBP. She stated the third hallway had its own PPE rolling cart. *She expected hand hygiene to be performed before working with a resident and when they left the room, when moving from a dirty to clean task during resident care, and after removing PPE. *Staff do not have hand sanitizer available in the residents' room, but it was available in the residents’ bathrooms. *She expected the hand sanitizers in resident bathrooms to work and the soap to be available in the residents' rooms. *She expected the mechanical lift to be stored and plugged in in an empty room or the utility room. *She expected the mechanical lift to be sanitized before using it for a resident. *She stated a performance improvement project (PIP) on staff performing hand hygiene had been started in June. 14. Observation on 8/5/25 at 9:10 a.m. of resident 3 revealed: *Near the entrance of her room there was a sign that indicated she was on EBP. *She had a Prevalon boot (a cushioned boot used to float the heel off the mattress) on her left foot. *There was no alcohol-based hand sanitizer (ABHS) dispenser in her room. *There was an ABHS dispenser in her bathroom that would not dispense ABHS. 15. Observation and interview on 8/5/25 at 11:14 a.m. with resident 4 in her room revealed: *Near the entrance of her room there was a sign that indicated she was on EBP. *She had a urinary catheter. *She stated staff wore a gown when they assisted her with her care needs, but she had not seen them wear a gown. *There was no alcohol-based hand sanitizer (ABHS) dispenser in her room. *There was an ABHS dispenser in her bathroom that would not dispense ABHS. 16. Observations on 8/5/25 from 11:44 a.m. through 11:49 a.m. of the 100-hallway revealed: *There were seven of thirteen observed resident rooms (105, 106, 108, 110, 111, 112, and 115) that did not have ABHS available in the residents’ rooms or bathrooms to use to perform hand hygiene. *There was one resident room, 104, that did not have soap available in the resident room to perform hand hygiene. 17. Interview on 8/6/25 at 11:39 a.m. with environmental services account manager AA and environmental service district manager BB revealed: *Cleaning of a room with a resident who was positive for C-Diff would require the use of bleach to clean all surfaces. *The housekeeping staff were to clean the rooms of residents who have C-Diff for the last. *It was their expectation for housekeeping staff to wear a gown and gloves while in the room of a resident who had C-Diff. *The expectation for the cleaning of a resident’s room who was on EBP was the same but did not require the use of bleach to clean environmental surfaces. *All staff members were responsible for replacing hand sanitizers and soap when empty or if they were not functioning properly. *It was on the list of daily duties for housekeepers to check if the hand sanitizers or soap dispensers needed refilling and to refill them as needed. *Verified that the hand sanitizers had not been refilled in seven rooms in the 100-hallway, and the soap dispenser had not been refilled in one room in the 100-hallway. *Environmental services account manager AA and environmental service district manager BB agreed that the housekeepers had not been routinely checking the soap and hand sanitizer dispensers due to the dispensers having remained empty throughout the survey since first observed on 8/5/25. 18. Interview on 8/7/25 at 9:33 a.m. with CNA/CMA/medical records U revealed: *She was aware that there was no ABHS available in the residents’ rooms at times. *She stated that sometimes there was ABHS in the dispenser, but the dispenser did work. *She stated if she noticed an ABHS or soap dispenser was empty in a resident’s room she would refill it or notify housekeeping staff. Review of the provider’s May 2025s Handwashing/Hand Hygiene policy revealed: *”Policy statement: The facility encourages and facilitates compliance with hand hygiene practices in alignment with standard precautions and standard of practice as outlined by the…CDC. *Procedure: 1. Personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. Personnel follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soaps, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use. 3. Residents…. 4. Hand washing with alcohol-based hand rub (ABHR) is preferential to soap and water in most clinical situations. Wash hands with soap (…) and water for the following situations: a…. b. after provision of care for residents with known or suspected with infectious diarrhea including…c. difficile…. 5. Hand hygiene is performed… c. Before and after direct contact with residents…. d. Before and after assisting a resident with personal care activities…. I. Before and after dressing change/wound care. m… (e.g. when moving from potentially contaminated sites to clean sites). O…after contact with a resident with infectious diarrhea (soap and water). p. after handling common use equipment (ie…mechanical lifts, etc.) r…after removing gloves. t…Before and after entering transmission-based precaution settings…. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. 7.The use of gloves does not replace hand washing/hand hygiene…. *Washing Hands:…. *Using Alcohol-Based Hand Rubs:….” Review of the provider’s 3/26/24 Enhanced Barrier Precautions policy revealed: *”Policy statement: Enhanced Barrier Precautions (EBP) are initiated to reduce transmission of multidrug resistant organisms (MDRO’s) employing targeted gown and glove use during high contact resident care activities. Initiated for residents known to be colonized or infected with MDRO or have open wound or indwelling medical devices.” *” Procedure: -…1. Enhanced barrier precautions are used in conjunction with standard precautions and expand the use of PPE to donning [putting on] of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO’s to staff hands and clothing. -…2. EBP are indicated for residents with any of the following: --…b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. -…6. Enhanced barrier precautions requires use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDRO’s to hand and clothing of healthcare professionals. -…12. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: --…a. Dressing --…b. Bathing/showering --…c. Transferring --…d. Providing hygiene --…h. Wound care: any skin opening requiring a dressing -…14. When enhanced barrier precautions are implements, the infection preventionist or designee: --…a. Validates protective equipment is maintained near the resident’s room so that everyone entering the room can access what they need. --…b. Posts the appropriate notice on the room entrance door and in the front of the resident’s chart so that all personnel will be aware of precautions or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. --…e. Ensures that an adequate supply of antiseptic soap and paper towels is maintained in the room during the isolation period.” Review of the provider’s 3/2025 Transmission-Based Precautions (Isolation) policy revealed: *”Policy statement: Transmission-based precautions (previously referred to as isolation precautions) are implemented for residents known to be, or suspected of being, infected with infectious agents.” *”Procedure: -…1. Use transmission-based precautions in addition to standard precautions -…5. Communication of transmission-based precautions is accomplished with pertinent signage and verbal reports to personnel and visitors” *”Contact Isolation Procedures -…1. Contact, or touch, is the most common and most significant mode of transmission of infectious agents. Contact transmission can occur by directly touching the resident, through contact with the resident’s environment, or by using contaminated gloves or equipment. --…a. Personnel having contact with the infected resident should wear gloves and a gown. --…b. Prior to leaving the resident’s room, gown and gloves are removed and hand hygiene performed. --…d. Residents with wound drainage, fecal incontinence, or diarrhea, that cannot be contained, should be placed on contact precautions until a specific organism for the origin of the medical issue is identified.” Review of the provider’s 5/2025 Clostridiodes Difficile (CDI) policy revealed: *”Policy statement: Preventative measures are taken to prevent the occurrence of Clostridiodes difficile among residents and precautions are taken while caring for residents with C. difficile Infection (CDI) to prevent transmission.” *”Procedure: -…1. Clostridiodes difficile (C.diff) is a spore-forming, Gram-positive anaerobic bacillus that is often the source of antibiotic-associated diarrhea and C.diff infection. -…6. Contact precautions are implemented when CDI is suspected or confirmed. --…a. Transmission-based precautions are implemented for symptomatic residents while evaluating the cause of their symptoms. --…b. Contact precautions for confirmed CDI are maintained until 48 hours after resolution of diarrhea at minimum.“ Review of the provider’s 5/2025 Handwashing/Hand Hygiene policy revealed: *”Policy statement: The facility encourages and facilitates compliance with hand hygiene practices in alignment with standard precautions and standards of practice as outlined by the Centers for Disease Control and Prevention”. *”Procedure: - .2. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff to use. - .4. Hand washing with alcohol-based hand rub is preferential to soap and water in most clinical situations. Wash hands with soap and water for the following situations: -- .b. After provision of care for residents with known or suspected with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile. - .5. Hand hygiene is performed as soon as feasible, after hands become contaminated and frequently during the working day/ Examples of situations include but are not limited to: -- .e. Before and after meal assistance. -- .l. Before and after dressing change/wound care.

Based on interview, observation, record review, and policy review, the facility failed to ensure:*The food was appetizing and served at a satisfactory temperature.*Accurate menus were provided to residents.Findings include: 1. Interview on 8/5/26 at 9:06 a.m. with resident 2 revealed: *She stated the facility’s food service was fair to poor and unorganized. *If she did not like the food being served her alternate meal option was soup and a sandwich. *She felt it took a long time for her to be served her meal in the dining room. *She thought her table was always the last table to be served and by the time she received her meal the food was cold. 2. Interview on 8/5/25 at 10:58 a.m. with resident 18 revealed: *He ate all of his meals in his room. *He did not like the food he was served. *When he received his food, it was cold at times. *Staff used to bring a menu to his room, so he knew what was being served but that no longer happened. *He stated he would need to go down to the dining room to see what was on the menu. 3. Interview on 8/5/25 at 11:17 p.m. with resident 19 revealed: *He ate all of his meals in his room. *He stated the quality of his meals were “sub-par”. *He felt his food was cold about 75 percent of the time. *Staff used to bring him a menu of the meals, but he no longer received one. 4. Interview on 8/5/25 at 11:36 a.m. with resident 37 revealed: *She stated the food was terrible. *She usually ate her meals in the dining room. *When she ate meals in her room the food was cold. Occasionally when she ate in the dining room, the meals were cold. *She used to receive a menu, but that no longer happened. *The food items listed on the menus often changed because those food items were unavailable. 5. Observation and interview with resident 2 during the meal service on 8/5/25 starting at 12:12 p.m. revealed: *Cook T was serving drinks to the residents, and stated there was no grape juice available for those residents who wanted it. *The staff began to serve the residents’ meals at 12:35 p.m. *At 12:53 p.m. meals were served to the residents seated at resident 2’s table. That was the last table to be served their meals. *Resident 2 stated the temperature of her meal was “medium”. *At 12:54 p.m. with meal trays were sent to the 100-hallway followed by the 200-hallway. -The trays were brought into each hallway on an uninsulated cart with open shelves by the dietary staff, and left there until a nursing staff member passed the meal trays to the residents in their rooms. -The plates on the meal trays were covered by a plastic insulated plate cover. *All meal trays were delivered to the residents’ rooms in the 100 and 200 hallways by 1:04 p.m. 6. Interview on 8/5/25 at 3:12 p.m. with resident 28 revealed: *He ate his meals in the dining room. *When he received his food, it was generally cold, so he would eat fast to prevent the food from becoming colder. 7. Interview on 8/5/25 at 3:40 p.m. with dietary manager S revealed: *He had a copy of the weekly menu available for the residents that wanted one on Fridays. *The residents were to come and ask him for the menu if they wanted one. 8. A test tray of the lunch meal served on 8/6/25 requested by the surveyors revealed: *It was delivered to the survey team at 1:25 p.m. *The meal tray was the last tray served off the steam table for that meal. *The temperature of the cubed potatoes was 132 degrees Fahrenheit (F). *The cubed potatoes felt cool when eaten. *The meat of the pulled pork sandwich was 135 degrees, and the bun felt cool to the touch. *The pulled pork was dry. *The temperature of the mixed vegetables was 147 degrees F. *The mixed vegetables were mushy, and overcooked. 9. Interview on 8/7/25 at 9:33 a.m. with certified nursing assistant (CNA)/ certified medication aide (CMA)/ medical records staff member U revealed: *Residents expressed frustration regarding the food to her at least weekly. *Most often those frustrations were about how the food tasted, but occasionally they had reported to her that the food was cold. *The facility used to pass out menus to all the residents but since a new contracted food service company started in the dietary department the menus are no longer passed out to the residents. *Residents have expressed to her that they would like to receive the menus. *She had witnessed times when the food items written on the menu board in the dining room were crossed out and substituted with another food item. 10. Review of the provider’s July 2025 menu substitution record revealed: *On 7/2/25 for the dinner meal turkey was added to replace the baked potato taco with the reason for the change documented as “not enough potatoes”. *On 7/7/25, for dinner, hot dogs, and green beans were added to replace the 4-cheese bake with the reason for the change documented as “short staffing due to no show”. *On 7/8/25 for lunch BBQ, baked beans, and peas were added to replace hot dogs, tater tots, and a salad with the reason for the change documented as “did not have”. *On 7/10/25 for lunch goulash and peas were added to replace turkey and Swiss sandwiches, chips and beets with the reason for the change documented as “did not have”. Review of the provider’s August 2025 menu substitution record revealed: *On 8/4/25 “changed but forgot to write down” was documented in the margin. *On 8/5/25 for breakfast bacon was added to replace sausage with the reason for the change documented as “running low”. *On 8/5/25 for breakfast toast was added to replace pancakes with the reason for the change documented as “not enough mix”. *On 8/5/25 for lunch chicken was added to replace turkey with the reason for the change documented as “do not have”. *On 8/5/25 for lunch, macaroni and cheese was added to replace potatoes with the reason for the change documented as “not enough.” *On 8/6/25 for breakfast, ham was added to replace bacon with the reason for the change documented as “not enough for everyone”. *8/7/25 for lunch, turkey was added to replace smoked sausage with the reason for the change documented as the “delivery company did not have”. 11. Review of the provider’s resident council meeting minutes from November 2024 through July 2025 revealed: *On 11/18/24 the notes stated, “need to follow recipes” and “food not tasting good”. *On 12/23/25 a resident requested the meal portions be increased and was told the facility needed to “go by cooperates [corporates] guidelines”. *On 2/17/25 the dietary department received feedback from the residents that it had “slow service” and “short staffed”. *On 4/14/25 the residents requested that menus be passed out on Fridays, and they wanted condiments on the tables and on the room trays. *On 4/14/25 the resident council minutes included a portion identified as Administrator session which revealed: -“Administrator reeducated on mealtimes and there have been complaints that the room trays are later and later due to residents slowly trickling in the dining room late. The expectation is that the dining staff serve at mealtimes and are completed with serving the dining room in 30 minutes and then room trays are done. Anyone who comes in late and did not request a room tray, will have their food served on a tray and aides can reheat the food if needed.” -“Hard veggies” -“Likes/Dislikes are updated per residents’ request”. -“To spicy/salty/peppery”. -“[residents] Like week 1 and 2 menus and now week 3, 4, 5 are not good”. 12. Review of the provider’s grievances from May 2025 through July 2025 revealed: *On 6/12/25 resident 32 reported she was unable to eat in the dining room because there was no room. -Residents 7, 32, and 37 asked to be provided a weekly menu. *Grievances filed by staff on 6/15/25 and 6/16/25 indicated there were no condiments for the food and on 6/16/25 the “meals were not out on time, slow staff”. *On 6/28/25 a grievance was filed by residents 20 and 37 reporting that the meat was hard. *On 6/30/25 resident 5 was not served lunch. *On 7/9/25 resident 12 reported the meal was not what she ordered. 13. Interview with resident 23 on 8/7/25 at 10:48 a.m. in his room revealed: *The menu he was given for week 8/4/25 to 8/8/25 had the dates “15-21” written on it. Resident 23 states he got the menu from the “head guy”. *He used to get menus on a regular basis and stated he had to “beg” for this menu. *He said that the kitchen has all new staff and they are inexperienced. *He likes to have a copy of the menu in his room to refer to, so that he can bring his own seasonings to the dining room. *Tuesday’s menu was listed as roast turkey and mashed potatoes. 14.Observation and interview on 8/7/25 at 10:48 a.m. with resident 23 revealed: *He stated that for the Tuesday lunch meal he was served macaroni and cheese with chicken strips. He did not eat the chicken strips. -He asked his table mate for some milk to add to the macaroni and cheese because it was too dry. *He stated, “Often the noodles are served tough and unchewable.” *Resident 23 stated on Wednesday they were served mixed vegetables instead of broccoli. *He said the vegetables were served in warm water and not flavored. 15.Interview on 8/7/25 at 11:24 a.m. with dietary manager (DM) S revealed: *He was aware of the resident frustrations with the changing menu. *He attended the monthly resident council meetings where this has been discussed. *He tries to have the menu for the next week available to residents on the Friday before. *He expects the trays that are delivered to residents to be the same temperature as the plates that are served to the residents in the dining hall. 16.Interview on 8/5/25 at 9:02 a.m. with resident 14 revealed she: *Did not always eat because she did not like the food she was given. *Did not know she could request something else if she did not like the food. *Was not asked by the staff what foods she liked. 17.Review of resident 14’s EMR revealed: *She was admitted on [DATE]. *Her 5/23/25 Brief Interview for Mental Status (BIMS) Assessment score was 15, which indicated she was cognitively intact. 18.Review of resident 14’s August 7, 2025, care plan revealed: *She liked Pepsi and popcorn. *Staff were to monitor her for symptoms of low blood sugar. *Staff were to encourage her to eat 50 percent of her meals or more. If she ate less than that, the staff were to offer her a substitute or supplement. *She ate breakfast in her room, otherwise, she ate in the main dining room. 19.Review of the provider’s October 2017 Food Temperatures policy revealed: *“Food Temperatures are taken and documented daily prior to meal service and monitored periodically throughout meal service.” *“Corrective action is taken for food temperature outside of regulatory standard (hot food should be 140 degrees F or above, cold foods 41 degrees F or less). It is suggested hot foods not exceed 180 degrees F in the kitchen.” Review of the providers' 2025 Facility Assessment revealed, “Build a relationship with [the] resident/get to know him/her, then engage [the] resident/representatives in conversation to find out what makes a good day for the resident, and what upsets him/her. Incorporate this information into the care planning process, ensure staff caring for the resident/representative have this information, and record and discuss treatment and care preferences… stay open to requests and preferences and work to support those as appropriate.”

Based on observation, interview, and policy review, the provider failed to ensure: *Three of three medication carts were free from medications beyond the use by date after opening for six of six residents sampled. *Two of three shower rooms were free from medications that were intended for individual resident use and without access to staff that were not qualified to administer medications. *Drugs and biologicals are stored according to the facilities policy in two of three shower rooms and one of three medication carts. *Drugs and biologicals are free from access and administration by staff other than trained nurses and certified medication aides (CMAs). Findings include: 1.Observation on 8/6/25 at 2:53 p.m. of the 200 hallway medication cart revealed:*Resident 26s Lantus (long-acting insulin for blood sugar control) insulin pen did not have an open date listed.*Resident 7's Lantus insulin pen and Semglee (long-acting insulin) insulin pen did not have open dates listed on them.*Resident 5's Lispro insulin vial had an open date of 6/28/25 written on it. Review of the facility's Medications with Shortened Expiration Dates reference sheet revealed Lispro's expiration date was 28 days after the vial was opened. Residnet 5's Lispro vial that was opened on 6/28/25 expired 28 days later, on 7/26/25. 2. Observation on 8/6/25 at 3:00 p.m. of the 100 hallway medication cart revealed resident 28's two boxes of Lanaprost eyedrops (used to treat high pressure in eyes) did not have open dates documented on them. 3. Observation on 8/6/25 at 3:27 p.m. of the 300 hallway medication cart revealed:*Two boxes of Lanaprost eye drops. One was resident 53's and one was resident 24's. Neither eyedrop boxes had an open date documented on them. *Psyllium powder (for constipation) that is administered by mouth was being stored in the same plastic storage container as triad cream (wound healing product), meta honey (wound healing product), and nystatin powder (antifungal) that are administered topically. 4. Observation on 8/7/25 at 2:13 p.m. of the shower room in the 200 hallway revealed:*An open shelving unit with plastic storage bins on the shelves.*Each bin had a resident's room number labeled on it. There were two bins labeled STOCK. The STOCK bin contained one bottle of nystatin cream with an open date of 4/2/25 documented on it, one tube of bacitracin (antibiotic) ointment with an open date of 2/15/25 documented on it, and one tube of bacitracin ointment with an open date of 2/18/25 documented on it. 5. Interview on 8/6/25 at 3:12 p.m. with licensed practical nurse (LPN) N revealed:*She was not aware that some medications had shortened expiration dates after opening.*She acknowledged that all medications needed to have an open date listed on the container and opened medications should be thrown away if the open date could not be found. 6. Interview with LPN C revealed he was aware that some medications have short expiration dates. He stated if he would find a medication without an open date, he would not know when it would expire. He would discard the medication. 7. Interview on 8/7/25 at 5:49 p.m. with director of nursing (DON) B revealed: *She expected all staff to follow policy and procedures for medication storage and labeling, including documenting the open dates on all opened medications.*She was aware of medications with shortened expiration dates and recieved an updated list from the pharmacy. She tried to keep a current updated medication expiration dates list in the medication storage room.*Staff qualified to give medications included licensed nurses and certified medication aides.-That included physician ordered medicated creams such as antifungal, zinc, and antibiotic creams.*She acknowledged that licensed nurses or medication aides were the only ones who should have access to the medicated creams. 8. Review of the provider's January 2021 Medication Storage policy revealed:*Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe [and] effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication.*In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed to access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access.*Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments, and suppositories.*Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in [a] refrigerator or at room temperature.*Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. 9. Review of the provider's January 2021 Medication Administration General Guidelines policy regarding medication administration revealed:*Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. *Check expiration date on package/container. No expired medications will be administered to a resident.*Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date.*The nurse shall place a ‘date opened' sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened.*Certain products or package types such as multi-dose vials and ophthalmic drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. 10. Review of the provider's 2005 Medications with Shortened Expiration Dates list revealed:*Lispro insulin vials expire 28 days after opening.*Lantus insulin pens expire 28 days after opening.*Lanaprost eyedrop bottles expire 42 days after opening.

Based on observation, interview, and record review the provider failed to ensure staff responded timely to residents' call lights for 7 of 18 residents (3, 6, 8, 14, 19, 28, and 54) who expressed complaints regarding staff not responding timely to their call lights to address the residents' needs.Findings include: 1. Observation and interview on 8/5/25 starting at 11:00 a.m. with resident 19 in his room revealed: *At 11:00 a.m. resident 19’s call light was on. *He stated he had turned his call light on about 10:30 a.m. *He stated there were times his call light was on for two hours before it was answered by the staff. *At 11:29 a.m. his call light was answered. Follow-up interview on 8/7/25 at 9:20 a.m. with resident 19 revealed: *At times he had felt like he was going to die by the time his call light was answered. *When he had to wait long periods of time for assistance, he felt degraded. Review of resident 19’s electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 6/23/25 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated he was cognitively intact. *He was a quadriplegic (paralysis that affects all four limbs) and required the assistance of one staff member for bed mobility, dressing, and eating, and the assistance of two staff members with the use of a mechanical lift for transfers. *He had a history of pressure ulcers related to his immobility. *He was incontinent of bowel and bladder. Review of resident 19’s call light times between 7/24/25 and 8/7/25 for response wait times that were longer than 15 minutes revealed: *The call light was used in that resident’s room [ROOM NUMBER] times. *Forty-two of those times were indicated as “Needs Improvement” according to the system selected filters. *On 7/24/25 the call light wait times were, 31 minutes and 25 seconds, 21minutes and 15 seconds, 33 minutes and 44 seconds, 23 minutes and 48 seconds, and 29 minutes and 26 seconds. *On 7/25/25 the call light wait times were, 27 minutes and 12 seconds, and 38 minutes and 31 seconds. *On 7/26/25 the call light wait times were, 18 minutes and 13 seconds, 20 minutes and 30 seconds, 21 minutes and 32 seconds, 44 minutes and 1 second, 36 minutes and 29 seconds, 20 minutes and 17 seconds, 40 minutes and 19 seconds, 37 minutes and 13 seconds. *On 7/27/25 the call light wait times were, 42 minutes and 34 seconds, 16 minutes and 49 seconds, and 28 minutes and 29 seconds. *On 7/28/25 the call light wait times were, 28 minutes and 15 seconds, and 16 minutes and 25 seconds. *On 7/29/25 the call light wait times were, 19 minutes and 31 seconds, and 25 minutes and 27 seconds. *On 7/30/25 the call light wait times were, 17 minutes and three seconds, 27 minutes and 15 seconds, and 24 minutes and 21 seconds. *On 7/31/25 the call light wait times were 33 minutes and 37 seconds, 16 minutes and 18 seconds, and 18 minutes and 4 seconds. *On 8/1/25 the call light wait times were 34 minutes and 28 seconds, and 16 minutes and 20 seconds. *On 8/2/25 the call light wait time was 30 minutes and 27 seconds. *On 8/3/25 the call light wait times were, 20 minutes and 54 seconds, and 33 minutes and 4 seconds. *On 8/5/25 the call light wait times were 16 minutes and 59 seconds, and 31 minutes and 50 seconds. *On 8/7/25 the call light wait time was 18 minutes and 37 seconds. 2. Interview on 8/5/25 at 3:12 p.m. with resident 28 revealed: *He stated that he had consistently waited about 45 minutes after he turned on his call light before he received assistance. *At times he wheeled himself out into the hallway and hollered for assistance because no one had answered his call light. *He stated that he could do most things by himself, but there were times he used his call light or hollered for staff assistance for his roommate, resident 19. Review of resident 28’s call light times audit from 7/24/25 and 8/7/25 for call light response wait times that were greater than 15 minutes revealed on: *On 7/24/25 resident 28 used his call light one time with a wait time of 25 minutes and 38 seconds. *On 7/25/25 resident 28 used his call light two times. Those call light response wait times were 38 minutes and one second, and 26 minutes and 50 seconds. 3. Observation on 8/7/25 starting at 9:20 a.m. outside resident 3’s room revealed: *Her call light was on at 9:20 a.m. *Housekeeper Z walked by the room multiple times and did not respond to the call light. *At 9:49 a.m. certified nursing assistant (CNA) P responded to resident 3’s call light and told her she would return shortly. *CNA P returned to the resident 3’s room with a gown and gloves at 9:50 a.m. Review of resident 3’s electronic EMR revealed: *She was admitted on [DATE]. *Her 7/23/25 Brief Interview for Mental Status (BIMS) assessment score was 4, which indicated severe cognitive impairment. *She did not ambulate. *She depended on assistance from one staff member for dressing and bed mobility and two staff members with the use of a mechanical lift for transfers. *She had a pressure ulcer on her left heel. 4. Review of the resident council meeting minutes from November 2024 through July 2025 revealed: *On 2/17/25 the documented resident concern communicated during resident council meeting was “CNA’s-lack of respect and short staffed”. *On 4/14/25 the documented concern communicated during the resident council meeting related to a long call light response time from a resident who was no longer in the facility. 5. Review of grievances from May 2025 through July 2025 revealed: *On 5/7/25 resident 6 reported having waited a long time for staff to respond to her call light. *On 5/8/25 a grievance was filed regarding a resident who waited a long time for staff to respond to her call light and her medications. That resident had discharged from the facility. *On 5/14/25 resident 8 reported she waited a long time for her call light to be answered. *On 5/19/25 a grievance was filed regarding a resident’s call light not having been answered. That resident had discharged from the facility. *On 6/19/25 resident 54 reported having waited a long time for staff to respond to the resident’s call light. 6. Interview on 8/6/25 at 4:46 p.m. with certified nursing assistant (CNA)/certified medication aide (CMA) M and licensed practical nurse (LPN) N revealed: *The expectation was for resident call lights to be acknowledged by a staff member within three to five minutes to determine what the resident needed and to communicate with the resident if there was going be a delay in providing what the resident needed. *Call light response times were generally longer after the breakfast meal. *CNA/CMA M stated all staff members were able to answer call lights, LPN N did not think the housekeepers could answer call lights. 7. Interview on 8/7/25 at 6:12 p.m. with administrator A revealed she did not know what system selected filters were used for the call light audits that determined if the timeliness of the staff’s response to a call light was excellent, acceptable, or needs improvement. 8. Observation and interview with resident 14 on 8/5/25 9:44 a.m. revealed she: *Had to wait a couple of hours for help at times when she turned on her call light. *Stated she had wet her pants when she had to wait a long time for staff to help her, and that made her feel like she was abandoned. *Had a “call don’t fall” sign taped to her wall to remind her to use her call light for assistance. *She stated she had fallen, but that had been a while ago. Review of resident 14’s electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 5/23/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. *She had a diagnosis of depression, anxiety, diabetes, and irritable bowel syndrome (a bowel disorder that causes constipation or diarrhea). *She required extensive assistance from one staff member to use the bathroom and to transfer out of her wheelchair. *She had a history of falls. -A fall prevention intervention on her 8/7/25 care plan indicated staff were to “Be sure my call light is within reach and encourage the resident to use it for assistance. Staff [will] be prompt [in] response to all [of the residents’] requests for assistance.” Review of resident 14’s call light times between 7/24/25 and 8/7/25 for call light response wait times that were longer than 15 minutes revealed: *The call light was used in that resident's room [ROOM NUMBER] times. *Twenty-three of those times were indicated as “needs improvement” according to the system-selected filters. *On 7/24/25, call light wait times were 38 minutes and 2 seconds and 27 minutes and 14 seconds. *On 7/25/25, call light wait times were 18 minutes and 32 seconds, 16 minutes and 55 seconds, 21 minutes and 36 seconds, 43 minutes and 20 seconds, and 26 minutes and 42 seconds. *On 7/26/25, call light wait times were 25 minutes and 50 seconds, 1 hour and 37 seconds, 22 minutes and 15 seconds, and 16 minutes and 20 seconds. *On 7/27/25, call light wait time was 18 minutes and 54 seconds. *On 7/28/25, call light wait time was 15 minutes and 48 seconds. *On 7/29/25, call light wait times were 18 minutes and 46 seconds and 21minutes and 51 seconds *On 7/30/25, call light wait times were 24 minutes and 24 seconds, 1 hour 5 minutes and 3 seconds, and 1 hour 31 minutes and 54 seconds. *On 7/31/25, call light wait times were 25 minutes and 44 seconds, and 1 hour 58 minutes and 24 seconds. *On 8/1/25, the call light wait time was 21 minutes and 13 seconds. *On 8/2/25, the call light wait times were 16 minutes and 41 seconds and 21minutes and 22 seconds. 9. On 8/6/2025 at 1:30 p.m., a request for a call light response policy was made to director of nursing (DON) B. DON B stated they did not have a policy regarding call lights. 10. Interview on 8/6/2025 at 4:40 p.m. with CNA Q revealed she felt it was hard to answer the call lights in a “timely manner” with only one CNA working in each hall. 11. Interview on 08/07/2025 at 6:08 PM with the director of nursing services (DON) B revealed: *She expected call lights to be answered within five minutes and stated that ten minutes would be too long. *She completed call light audits weekly or more often if there were complaints or concerns. *When completing the audits, she reviewed the timeliness of staff response to the call lights, who was working, and which residents were involved to identify trends.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, and policy review, the provider failed to report an allegation of suspected neglect for one of one sampled resident (56). This citation is considered past non-compliance based on the corrective actions the provider implemented immediately following the incident. Findings include:1.Review of the provider's 4/10/25 SD DOH FRI revealed:*On 4/3/25 certified nursing assistant (CNA)/certified medication aide (CMA)/activities director J reported via a grievance form that resident 56's incontinence product had not been changed on the night shift.*Resident 56 was noted to be very incontinent of urine.*Resident 56's diagnoses included: -Dementia (a group of symptoms affecting memory, thinking, and social abilities).-Congestive heart failure (heart does not pump blood as well as it should).-Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe).-Agitation (feeling of restlessness or nervous excitement).*Resident 56 was receiving end-of-life hospice care services.*On 4/9/25 a skin review was completed for resident 56, with no new identified areas of concern noted.*Resident 56's care plan was reviewed and updated.*Resident 56's family and primary care provider was notified of incident.*Staff education was started.*CNA X was suspended pending investigation. 2. Interview on 8/6/25 at 8:26 a.m. with CNA/CMA/activity director J regarding the reported 4/3/25 incident revealed:*She started her shift at 6:00 a.m. on 4/3/25.*Resident 56 was in her recliner in the same clothes she had worn the day before.*Resident 56 was wet with urine from her waist down.*She was told by CNA X that resident 56 had behavioral episodes during the night shift and had refused to get changed.*When she provided resident 56's incontinence care, she did not observe any skin areas that were open.*She had filled out a grievance form later that day on 4/3/25 and turned it in. Interview on 8/6/25 at 4:12 p.m. with licensed practical nurse (LPN)/resident care manager (RCM) I revealed:*CNA/CMA/activities director J had given her a grievance form regarding resident 56 on 4/3/25.*She reviewed CNA documentation and behavior documentation for resident 56.*She had notified director of nursing (DON) B and was unsure if it was neglect due to resident 56's behaviors of refusing toileting when she asked CNA X.*Resident 56's skin evaluation had been completed on 4/9/25 and there were no new areas of concern noted.*She had given the grievance form to either DNS B or administrator A after completing her investigation on 4/4/25. Interview on 8/7/25 at 9:48 a.m. with DON B revealed:*She was notified of the grievance form on 4/7/25 by LPN/RCM I.*Based on the information shared with her she did not consider the 4/3/25 incident to have been a neglect issue.*She was unsure when administrator A was made aware of the 4/3/25 incident.*She was aware that allegations or incidents of neglect or abuse of a resident DOH needs to be notified within two hours. Interview on 8/7/25 at 10:01 a.m. with administrator A revealed:*She was notified of resident 56's incident on 4/10/25 at approximately 10:00 a.m.*CNA X had worked shifts on 4/3/25, 4/5/25, 4/6/25 and 4/8/25.*She identified the incident on 4/3/25 as a neglect issue and reported it to DOH on 4/10/25.*She had been out to a conference when the incident happened, no one notified her until 4/10/25.*CNA X was suspended on 4/10/25 and an investigation was initiated.*CNA X's employment was terminated on 4/11/25 after being interviewed and admitting to not changing resident 56's incontinence products. Review of the provider's updated September 2017 Grievance procedure Policy revealed:*8. If the grievance involves abuse, neglect, exploitation, or misappropriation of resident property, the ED [Administrator] is notified immediately, and an investigation begins. Review of the provider's published September 2017 Abuse Reporting and Response Policy revealed:*Policy statement: The center immediately reports all suspected and /or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law.*4. The Executive Director or designee reports alleged violations to the state survey agency and other officials in accordance with state law (such as Adult Protective Services and local law enforcement) as follows:a. Immediately but no later than 2 hours-All allegations of abuse, neglect.b. Immediately but not later than 24 hours- All allegations, if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The provider's implemented systemic changes to ensure the deficient practice does not reoccur was confirmed after record review revealed the facility had followed their quality assurance process, education was provided to all direct care staff regarding reporting abuse and neglect, what to do when residents reject cares and how to deal with refusals such as incontinence cares and toileting, what is a reportable incident and who needs to be contacted and within what time frame they need to be contacted. Continued monitoring on all residents through clinical alert monitoring was being completed daily which advises the Interdisciplinary team of resident concerns, such as refusals of care, behaviors, self-transfers and falls. Audits were being completed on incidents that would be reportable to the SD DOH and brought to monthly QAPI meetings for review. Based on the above information, non-compliance at F609 occurred on 4/3/25, and based on the provider's 4/25/25 implemented corrective actions for the deficient practice confirmed on 8/7/25, the non-compliance is considered past non-compliance.

Based on record review and interview, the provider failed to ensure the Medicare notice given to the resident and/or the representative was:*Provided on the current form and completed according to the form's instructions for one of two sampled resident (1) who had discharged from Medicare skilled part A services and remained in the facility.*Completed according to the form's instructions for one of two sampled resident (22) who had discharged from Medicare part A services and remained in the facility.Findings include:1. Review of the Entrance Conference Worksheet completed by the provider on 8/6/25 revealed that two sampled residents (1 and 22) had been discharged from Medicare Part A skilled services and remained in the facility. 2. Review of the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123, with a revision date of July 2022, for resident 1 revealed: *His last covered day on Medicare Part A Skilled Service was 4/4/25. *The required information of You have the right to get your information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY [teletypewriter for people with hearing or speech difficulties] users can call [PHONE NUMBER]” was not included on the form. 3. Interview on 8/7/25 at 3:05 p.m. with MDS/RN coordinator F regarding the NOMNC form for resident 1 revealed that she confirmed the form was outdated and did not include the non-discrimination clause above. 4. Review of the NOMNC with a revision date of December 2024, for resident 22 revealed: *Her last covered day for Medicare Part A Skilled Service was 2/19/25. *The Sign below to show you received and understood this notice” was not signed or dated by the resident or the resident’s representative. 5. Review of resident 22's 2024 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055, with verbal notification given to resident 22’s representative by telephone that was documented on 2/17/25 revealed: *The Reason Medicare May Not Pay section, which required a brief explanation to help understand why Medicare may deny payment, was marked as “Custodial Care” and did not include what Medicare services she had been receiving, as required. There was no signature of who had provided that verbal notice to her representative. 6. Interview on 8/7/25 at 2:20 p.m. with Minimum Data Set (MDS) coordinator/registered nurse (RN) F regarding SNF Beneficiary Notices for resident 22 revealed: *She agreed that the NOMNC provided was not signed or dated by the resident or their representative. *She agreed the SNF ABN form should have included the skilled nursing service that Medicare may deny payment for, and there was no identification of who had provided the verbal notice. *She was not available when that notification was given and was unable to determine who had given that notice. 7. Review of the January 2025 Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 and Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed: *The SNF ABN Form Instructions included: -Completing the SNF ABN indicated in the Reason Medicare May Not Pay section, the SNF must give . a brief explanation of why the beneficiary's medical needs or condition do not meet Medicare coverage guidelines. The reason must be sufficient and specific enough to enable the beneficiary to understand why Medicare may deny payment. -Signature and Date indicated If an authorized representative signs for the patient, write (rep) or (representative) next to the signature. -“Disclosure Statement: The disclosure statements in the footer of the notice are required to be included on the document.” *The NOMNC Form's Instructions included: -{Insert type}: Insert the kind of service being terminated, i.e., skilled nursing, home health, comprehensive outpatient rehabilitation service, or hospice.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review and policy review, the provider failed to ensure one of one resident (1) had an antiroll back bracket on his wheelchair to prevent it from rolling backwards when he attempted to stand up and self-transfer after he fell on [DATE] sustaining a laceration to his head and going to the hospital for sutures to that area. Findings include: 1.Review of the provider's SD DOH facility online report revealed: *On 1/17/25 Resident 1 had been sitting in his wheelchair in the common area near the nurses' station watching television. -The nurse heard a crash and resident 1 yelled. -The nurse noted resident 1 had tipped forward in his wheelchair and hit his head on the floor. -Resident 1 was assessed and had a laceration to his left eyebrow that needed repair and the resident was sent to the hospital. -Resident 1 was able to ambulate short distances with staff. -He used the wheelchair for locomotion and was able to propel himself in the wheelchair or staff would propel him for longer distances. -He was known to self-transfer and was forgetful. -He had diagnoses of dementia, diabetes, memory deficit, delirium, cerebral infarction and psychosis disorder with hallucinations. -The fall was investigated, and it appeared resident 1's wheelchair brakes were not locked when he attempted to self-transfer. -A maintenance ticket had been placed to add an anti-roll back bracket on his wheelchair to prevent his wheelchair from rolling backwards if he attempted to self-transfer. -Resident 1's care plan be updated to include that intervention. 2. Interview on 3/11/25 at 10:44 a.m. with resident 1's family revealed: *Resident 1 liked to sit near the nurse's station and watch television. *Resident 1 had a fall a few months ago and had hit his head, and went to the hospital for stitches to his head. *They stated he would attempt to get up by himself. 3. Observation on 3/12/25 at 11:37 a.m. of resident 1 revealed: *He was sitting in his wheelchair in the common area near the nurses' watching television. -That wheelchair did not have an anti-roll back bracket on it. 4. Interview on 3/12/25 at 11:38 a.m. with certified nursing assistant (CNA) C regarding resident 1's wheelchair revealed the wheelchair resident 1 was sitting in was not his wheelchair and it did not have an anti-roll back bracket on it. 5. Observation and interview on 3/12/25 at 11:45 a.m. with administrator A of resident 1's wheelchair revealed: *She confirmed that resident 1 was not in his wheelchair and the one he was in did not have the anti-rollback bracket. *She then left the area to look for resident 1's wheelchair. 6. Review of resident 1's care plan dated 1/2025 revealed: *His problems list indicated: -He was at high risk for falls related to confusion, deconditioning, gait and balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs and history of falls. -He had multiple falls since admission due to cognition and impulsiveness. -He had a fall on 1/17/25 and had sutures above his left eye. *His interventions and tasks indicated staff to ensure: -A bedside commode be placed by his bedside at night to ensure that his toileting needs were met. -He had on appropriate nonskid footwear when walking or mobilizing in his wheelchair. -He had his call light within reach and encourage him to use it for assistance as needed. -Followed facility fall protocol. -Followed medical doctors orders for treatment of laceration above his left eye. -Provided a safe environment with even floors free from spills and/or clutter, adequate, glare-free light at night. -Placed his bed in low position at night. -He had handrails on walls. -He had personal items within reach. -His bed was kept in lowest position while he was in bed. -His room was kept free of clutter. -Purposeful staff rounded to ensure his needs are met. -Toileting assistance was offered to him upon rising, before and after meals, and a night and as needed. -His wheelchair would be placed next to his bed and in a locked position. -Included his wheelchair had an antiroll back bracket intervention. 7. Interview on 3/12/25 at 12:00 p.m. with director of nursing (DON) B regarding resident 1 revealed: *Resident 1's wheelchair was found in another resident's room. -She stated someone must have used his wheelchair for different resident or he may have been walking and they grabbed a different chair for him. -Resident 1 had been assisted to his wheelchair that had the anti-rollback on it. *DON B stated each nurse manager had a group of residents they were responsible for updating their care plans, but resident 1's wheelchair anti-rollback bracket intervention had been missed and was not on his care plan. 8. Review of the provider's Fall Management and Neurological check policy dated 1/2025 revealed: *Procedure: -3. The Minimum Data Set (MDS), including Care Area Assessment (DAA) is utilized to further evaluate resident risk of falls and the development of the comprehensive care plan. -'5. The licensed nurse (LN) updates care plans reflecting individualized intervention in an attempt to reduce or prevent falls. -7. The residents care plan is reviewed quarterly and after a fall to determine effectiveness of current intervention and considers the residents goals, choices and preferences.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and record review the provider failed to ensure one of one sampled resident's (1) care plan had been updated to reflect his current needs regarding the fall intervention for his use of a wheelchair with an anti-rollback bracket (to prevent it from rolling backward) as indicated in the provider's SD DOH FRI following the residents fall on 1/17/25 when he sustained a head laceration that required evaluation and stitches at a hospital. Findings include: 1. Review of the provider's SD DOH facility online report revealed: *On 1/17/25 Resident 1 had been sitting in his wheelchair in the common area near the nurses' station watching television. -The nurse heard a crash and resident 1 yelled. -The nurse noted resident 1 had tipped forward in his wheelchair and hit his head on the floor. -Resident 1 was assessed and had a laceration to his left eyebrow that needed repair and the resident was sent to the hospital. -Resident 1 was able to ambulate short distances with staff. -He used the wheelchair for locomotion and was able to propel himself in the wheelchair or staff would propel him for longer distances. -He was known to self-transfer and was forgetful. -He had diagnoses of dementia, diabetes, memory deficit, delirium, cerebral infarction and psychosis disorder with hallucinations. -The fall was investigated, and it appeared resident 1's wheelchair brakes were not locked when he attempted to self-transfer. -A maintenance ticket had been placed to add an anti-roll back bracket on his wheelchair to prevent his wheelchair from rolling backwards if he attempted to self-transfer. -Resident 1's care plan be updated to include that intervention. 2. Review of resident 1's care plan dated 1/2025 revealed: *His problems list indicated: -He was at high risk for falls related to confusion, deconditioning, gait and balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs and history of falls. -He had multiple falls since admission due to cognition and impulsiveness. -He had a fall on 1/17/25 and had sutures above his left eye. *His interventions and tasks indicated staff to ensure: -A bedside commode be placed by his bedside at night to ensure that his toileting needs were met. -He had on appropriate nonskid footwear when walking or mobilizing in his wheelchair. -He had his call light within reach and encourage him to use it for assistance as needed. -Followed facility fall protocol. -Followed medical doctors orders for treatment of laceration above his left eye. -Provided a safe environment with even floors free from spills and/or clutter, adequate, glare-free light at night. -Placed his bed in low position at night. -He had handrails on walls. -He had personal items within reach. -His bed was kept in lowest position while he was in bed. -His room was kept free of clutter. -Purposeful staff rounded to ensure his needs are met. -Toileting assistance was offered to him upon rising, before and after meals, and a night and as needed. -His wheelchair would be placed next to his bed and in a locked position. -Included his wheelchair had an antiroll back bracket intervention. 3. Interview and observation on 3/12/25 at 12:00 p.m. with director of nursing (DON) B regarding resident 1's wheelchair revealed: *Resident one was sitting in the incorrect chair. *His wheelchair was found in another resident's room. *She stated someone must have used his wheelchair for a different resident and had not returned it to resident 1. *Resident 1 was assisted into his correct wheelchair. *DON B stated each nurse manager had a group of residents they were responsible for to update their care plans, but this intervention had been missed. *The provider did not have a specific care plan policy to review. 4. Review of the provider's Fall Management and Neurological check policy dated 1/2025 revealed: *Procedure: -3. The Minimum Data Set (MDS), including Care Area Assessment (CAA) is utilized to further evaluate resident risk of falls and the development of the comprehensive care plan. -'5. The licensed nurse (LN) updates care plans reflecting individualized intervention in an attempt to reduce or prevent falls. -7. The residents care plan is reviewed quarterly and after a fall to determine effectiveness of current intervention and considers the residents goals, choices and preferences.

Based on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the provider failed to protect one of one (1) resident from neglect due to failure to provide physician-ordered care. Findings include: 1. Review of the provider's SD DOH FRI report submitted on 10/28/24 at 7:27 p.m. revealed: *Resident 1 had a diagnosis of psoriasis (a skin disease that causes a rash and itchy, scaly patches). * On 10/27/24 a family member of resident 1 visited the facility and reported care concerns to another family member. -The room had a foul odor. -The resident's sock was very dirty and saturated. -Maggots were found on his feet. *The family member went to the nurse on duty on 10/27/24 with her concerns. -The nurse sent a certified nursing assistant (CNA) to help clean up the resident. *On 10/28/24 a different family member brought these concerns to administrator A and director of nursing (DON) B: *An assessment of resident 1's legs completed by DON B and the facility wound nurse indicated: -His socks were saturated with drainage from his legs. -He had reddened lower extremities with patches of dry skin from his knees to his toes. -His legs appeared edematous (swollen with fluid). -Nurses cleaned his legs with soap and warm water. -No evidence of maggots were present. *DON B asked resident 1 when he last had lotion applied to his legs per his physician's orders. -He reported that did it last night and put clean socks on. -He stated prior to that it had been a few days during the day. -He reported no treatment was done that day prior to when DON B and the wound care nurse assessed him. *His ordered leg treatment was documented in his electronic medical record (EMR) as completed every shift including that day by licensed practical nurse (LPN} C. *On 10/28/24 DON B interviewed LPN C regarding the care concerns reported by resident 1's spouse on 10/27/24. -When asked what resident 1's legs looked like on 10/27/24, LPN C stated I didn't look at them yesterday. -She sent a CNA to clean up his legs and feet after the family member came to her with concerns. -LPN C stated she again didn't do his treatment and stated that was on me. *DON B asked LPN C about the documentation that indicated his leg care had been completed on 10/27/24 and 10/28/24. -LPN C stated, I haven't done it yet. *DON B immediately placed LPN C on suspension while a further investigation was done related to suspected neglect. *LPN C was terminated on 10/28/24 due to false documentation of treatment completion. -DON B notified the Board of Nursing in the state where LPN C's license was issued. -The South Dakota Board of Nursing contacted DON B after being notified by that state's Board of Nursing. Review of resident 1's EMR revealed: *Resident 1 was admitted on [DATE]. *There were current orders for bilateral lower extremity care including: -Aquaphor External Ointment (moisturizer) apply to dry skin topically every shift for dry skin related to Psoriasis Vulgaris. -LPN C initialed that she completed that treatment on 10/25/24, 10/26/24, 10/27/24, and 10/28/24. Interview on 11/26/24 at 11:10 a.m. with DON B revealed: -Resident 1 was admitted on [DATE] with orders for skin care by applying Aquaphor ointment to his bilateral lower extremities. *His family member came to her on 10/28/24 with concerns of resident 1's care that were expressed to her by another family member who had visited resident 1 on 10/27/24. -She was provided with pictures taken on 10/27/24 of resident 1's foot that showed heavily saturated stained socks and clearly visible maggots near his toes. -DON B confirmed that the picture background was of resident 1's room at the facility when showing the pictures to this surveyor. *She would have expected nursing staff to follow doctor's order and to document appropriately. *She agreed that wound care not provided daily as ordered would be considered neglect if it could cause harm. *During the 10/28/24 investigation, LPN C admitted to DON B that she had been using vinegar to wash Resident 1's legs. -There was no order to use vinegar as a skin wash on resident 1's legs in his EMR. *There was a physician's order dated 11/14/24 to stop using vinegar for skin cleaning. Just use warm soapy water. -The order was in response to a contact by family member who was concerned that LPN C was washing resident 1's legs with vinegar. Interview on 11/26/24 at 1:45 p.m. with administrator A revealed: *She was approached on 10/28/24 by a family member of resident 1 with concerns about his care. -She was shown pictures of resident 1's feet with maggots visible. *She immediately brought in DON B who provided care to resident 1 and began the investigation. *Her expectations regarding wound care were for the nursing staff to follow the doctor's orders, if you're signing something off it had better be done. *She agreed that maggots in a wound would be considered harmful to some extent, definitely neglect. *She directed DON B to report LPN C to the Board of Nursing. Review of the provider's updated October 2022 Abuse, Neglect, and Misappropriation of Resident Property Prohibition Policy revealed: *Each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, mistreatment, neglect . *Definition of Deprivation of Goods or Services by Staff: The deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff has the knowledge and ability to provide care and service, but choose not to do it, or acknowledge the request for assistance3 from a resident(s), which result in care deficits to a resident. *Definition of Neglect: Failure of the Center, its employees or service providers to provide goods and eservices to a resident that are necessary to avoid physical harm pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), resulting in physical harm, pain, mental anguish, or emotional distress.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review and interview the provider failed to ensure the care plan reflected the current individualized care needs for one of one sampled resident (1) with physician-ordered skin treatments. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: *He had physician orders dated 10/31/24 for skin care to lower extremities (LE) every day shift. -LE were to be washed daily with warm soapy water. -Pat dry. -Apply Aquaphor external ointment. -Apply ABD pads to areas that are weeping. -Wrap with Kerlix. -Apply Ace wraps (compression wraps) from toes to knees. -Aquaphor external ointment was discontinued on 11/7/24. -Vaseline was started on 11/7/24. -An order dated 10/31/24 for Ace wraps to be removed every night shift. *His diagnoses included: -Psoriasis Vulgaris (skin cells build up and form scales and itch dry patches of skin). -Vascular Dementia (brain damage caused by multiple strokes). -Diabetes Mellitus type two with other specified complications. -Peripheral vascular disease (blood flow is reduced to extremities). -Chronic Kidney Disease. -Bipolar disorder (mood swings from depressive lows to manic highs). -Localized edema. *He had a Brief Interview for Mental Status (BIMS) assessment score of 14 which indicated he was cognitively intact. *He had weekly skin observations completed on 10/16/24, 10/23/24, 11/4/24, 11/6/24,11/13/24 and 11/20/24. All noting no new area of concern. *Behavior charting documenting refusal of bathing care and leg treatment care. *Resident 1's current care plan revealed: *He had a focus area of activities of daily living (ADL) self-care performance deficit due to Dementia, Disease process: seizure activity initiated on 10/22/24. -He was Diabetic and had Psoriasis. *Interventions for his skin at risk were initiated on 10/22/24. -Barrier cream. -Lotion to dry skin. -Wheelchair cushion. -Pressure-reducing mattress to bed. -Resident requires skin inspection weekly. *His care plan did not indicate any other focus areas regarding skin condition/care. *Did not indicate dressing changes order by physician 10/31/24 to be completed every day shift. *His 11/5/24 comprehensive care conference meeting notes revealed: -He had a skin integrity issue. -He had skin care to LE's. -Wash with warm soapy water, pat dry, apply ABD's to areas that are weeping. -Wrap with Kerlix. -Apply ACE wraps from toe to knee. As needed. -Remove Ace wraps every night. 2. Interview on 11/26/24 at 1:45 p.m. with administrator A revealed: *They did not have a care plan policy. *Director of nursing (DON) B or resident care manager (RCM)/licensed practical nurse (LPN) D would update care plans if there were changes regarding residents' skin issues or care needs.

Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure one of one certified medication aide (CMA) (C) administered a medication (med) according to pharmacy directions for one of one sampled resident (1) who required the use of the med to stabilize phosphorus levels in his blood. Findings include: 1. Review of the 6/24/24 SD DOH FRI regarding resident 1 revealed: *Facility staff found dozens of medications stored in a [NAME] Bay Packers mug and loose medications sitting on the top of the night stand drawer . *The Facility has a standing order to crush medications in applesauce and [the] physician was notified that this was implemented and why (after the medications were found). Review of resident 1's electronic medical record revealed: *His diagnoses included end-stage renal disease, dependence on renal dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood), Marfan Syndrome, other disorders of phosphorus metabolism, and diabetes mellitus. *He received dialysis three times per week. *A 6/24/24 physician's order indicated, Crush all medications in applesauce. Ensure resident takes medications prior to leaving resident. every day and night shift. Observation and interview on 8/6/24 at 2:15 p.m. with resident 1 revealed: *He had opened the top drawer of his bedside table to remove a video game. *There were three small medication cups in the top drawer of that bedside table with a light-yellow substance and one white plastic spoon containing the same-colored substance. *He stated, I don't know what that is, when asked what was in the corner of the drawer. *He quickly shut the drawer. Observation and interview on 8/6/24 at 3:19 p.m. with administrator A regarding resident 1 revealed: *A physician's order was obtained on 6/24/24 to crush all medications for the resident after a staff member had found medications in his room. -That was implemented to ensure he had taken the medications. *Interventions implemented after the 6/24/24 FRI included educating the resident and the personnel who administered his medications that his medications were to have been crushed and that the personnel were to stay while he takes the medication. *The facility had not completed any audits to ensure his compliance with taking the medications as ordered. Observation and interview on 8/6/24 at 4:24 p.m. with CMA C revealed she: *Removed two white tablets from the medication card. *Confirmed the medication she was preparing was Sevelamer HCL (medication used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis) Oral Tablet. *Placed the two tablets into a plastic sleeve and proceeded to crush the medication. *Put a glove on her right hand and removed several small white pieces from the plastic sleeve. -She placed the white pieces in the trash can on the med cart. *Poured the remaining contents of the sleeve into a medication cup and continued to remove small white pieces from it. *Showed one of the pieces to the surveyor that contained the letter A. *Mixed the remaining white powder in the medication cup with apple sauce. *Placed the medication cup on the top of resident 1's bedside table, waited for him to place the mixture in his mouth, and then exited the room. -The resident had not swallowed the medication before she exited the room. Continued observation and interview on 8/6/24 at 4:31 p.m. with CMA C at the medication cart after administering the medication revealed: *A medication card for Sevelamer Carbonate 800 MG (milligram) TAB (tablet) with the instruction GIVE 2 TABLETS BY MOUTH THREE TIMES DAILY WITH MEALS (AM, NOON, PM). *She read out loud the blue sticker on the top left corner of the medication card that stated Do not chew or crush. Contact pharmacist if you have questions related to this med. -She confirmed she had crushed all his medications including the Sevelamer. -She stated It is ok as long as you do it carefully. That is why I picked out the coating. *She confirmed that she had not discussed that direction with her supervisor. Interview on 8/6/24 at 5:04 p.m. with director of nursing (DON) B revealed she: *Confirmed that resident 1 took his medication crushed to make sure he is taking them. *Was unaware that staff were crushing the Sevelamer. *Expected medications that contained a label stating do not crush would not have been crushed. *Explained that Sevelamer was a medication prescribed for resident 1 because he was on dialysis. -He had been prescribed the medication because his phosphorus levels had been too high. *Considered crushing a medication that should not have been crushed as a significant medication error. Review of the provider's January 2021 Medication Administration General Guidelines Policy revealed: *Medications are administered as prescribed in accordance with manufacturer's specifications . *Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. *Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. *Medications are administered in accordance with written orders of the prescriber. *The resident is always observed after administration to ensure that the dose was completely ingested.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of one refrigerator in the kitchen storage room used for storing resident foods: -Was maintained for cleanliness. -The food stored in the refrigerator was monitored for outdated food items consistently. *Groceries delivered in cardboard boxes were not left on the floor of the pantry and the walk-in freezer. *Food items set up on kitchen carts for the next meal were covered until they were brought to the dinner table. *The following kitchen equipment and the surrounding environment was maintained in a clean and sanitary manner: -Two of two ovens, one convection, and one oven/range. -One-of-one stove hood filter panels. -One of one steam table. -One of one vegetable sink. -One stainless steel counter on the back wall holding a large mixer on the counter. -One of one shelf holding pans under a steel table in the serving area. -One of one toaster. *Two of two large ceiling vents *All kitchen area floors, including the following: -Kitchen storage room. -Serving and cooking areas. -Pantry. -Dishwasher area. -Below and behind the ice machine *The kitchen area walls: -Above and below the dishwasher table. -The walls and floors of one walk-in cooler and one of one walk-in freezer. -Behind the ovens. -Behind and below the stainless-steel counter on the back wall. -Behind and below the three-compartment sink and the hand sink. -All walls in the kitchen storage room. Findings include: 1. Observation on [DATE] at 3:15 p.m. during the initial tour of the kitchen revealed: *The dietary cook's daily cleaning list for [DATE] through [DATE] revealed the dates of [DATE] and [DATE] had no documentation of any cleaning on those dates. *The dietary aide's daily cleaning list for [DATE] through [DATE] revealed the date of [DATE] had no documentation for any cleaning on that day. *The toaster, tray, and the surrounding shelf had crumbs of bread. *One-of-one oven/range and one-of-one convection oven had: -Dark brown and black unidentified build-up on the walls, ceiling, and inside of the oven door. -The floors of the ovens were lined with aluminum foil that was covered with dark unidentified stains and food particles. -Both ovens had dark brown and black unidentified streaks of food on the inside walls and doors. -The outside of the ovens were covered in grime that was sticky to the touch. *Above the ovens was one large ceiling vent. -The grate covering the vent was covered with grease, grime, and dust. *The kitchen floors: -Had heavy dust and dirt build-up under the ovens, the counter and vegetable sink at the back of the kitchen, and a heavy amount of dirt and brown/black stains at the back door (adjacent to the pantry). -The floor under the back counter had a plastic bag and papers left under the counter. -The floor under the three-compartment sink had dust and dirt build-up. Interview at the above time with cook O and dietary aide N. When dietary aide N had been asked why the kitchen had not been cleaned she stated only two employees were working in the kitchen and there was no time for cleaning. Cook O stated that was the third day on her job. Continued observation of the kitchen on [DATE] at 4:00 p.m. revealed the walk-in cooler had: *Two food carts holding thirty-five uncovered fruit cups. -There was no date indicating how long the food had been dished and left uncovered. *One plastic container on a shelf. -The container appeared to have some kind of deli meat. -The container was not identified what it was or when it was placed in the cooler or a use-by-date. Continued observation on [DATE] at 4:15 p.m. of the kitchen storeroom next door to the kitchen revealed: *The floor was littered with pieces of paper and a heavy amount of dust, dirt, and lint. -Two small containers of applesauce were sitting on the floor. *Two meal tray carts. -One of the carts had been placed under a large ceiling vent. -An opened cardboard box was placed under that vent. -The box contained plastic disposable glasses, bowls, and small containers with lids. -The ceiling vent contained a large amount of lint and dust. -Some of the vent dust was visible on top of the tray cart. *The window at the end of the room revealed: -The window screen had been placed inside the window. -The screen, windowsill, and trim had an accumulation of dirt, dust, grime, and cobwebs. -A metal shelving unit to one side of the window held the nursing department items for medication passes, such as supplement drinks, and applesauce. -The other side of the window there was a metal shelving unit holding the emergency supply of food. *A sign on the refrigerator in that room indicated it was to have been used for storing resident food items. -The thermometer indicated the temperature in the refrigerator was 40 degrees Fahrenheit. The temperature was to have been documented daily. The temperatures for the dates of [DATE] and [DATE] had not been documented. *The refrigerator was full of food, with the resident's food stacked on top of other resident food. -Some foods were in bags, while other foods were in take-out boxes. *The inside of the resident's refrigerator had old, dried food stuck to the shelving and the door. Observation and interview with dietary manager (DM) P regarding the kitchen on [DATE] at 10:30 a.m. through 12:50 p.m. revealed: *When dietary manager P was asked about the unclean vegetable sink she stated the sink had not been used in three to four months because they rarely used fresh fruits or vegetables. -She served baked potatoes for lunch on [DATE]. *Observation of the metal counter at the back of the room held the vegetable sink, and large mixer revealed: -A window above the vegetable sink had a screen on the inside of the window. --The screen was coated with dust, brown grit, leaf parts, and cobwebs. --The windowsill, and window trim also had brown grit, dust, and greasy grime. -A food processor sat on a shelf below the sink covered with dust. --When DM P was asked why the food processor was under the sink, she did not respond. -Beside the sink was an opened cardboard container holding paper baking sheets used for food going into the oven. -The countertop had grit, and dust, and was sticky to the touch. -Beside the container was a large, covered mixer. -The rest of the counter held random items not used for cooking or baking. *When asked about the counter area and lack of cleaning DM P stated: -The area was not used. -They did not use the mixer. --They used a large spoon and bowl to mix the food. -The mixer had flour on its base. *The wall behind the back counter revealed brown and black stains and was sticky to the touch. *The oven hood filter panels inside the hood area and the fire suppression pipes on the hood had a build-up of greasy grime and thick dust. -DM P stated she had never cleaned the panels attached to the hood because she was told not to touch the hood. *The dishwasher area had brown and dark black stains: -On the wall against the dish table. -Below the dish table next to the floor. -The dishwasher had a heavy build-up of white mineral deposits sitting on the top. -The table beside the dishwasher had rust on the legs. Continued observation on [DATE] at 12:10 p.m. with DM P of the steam table area revealed: *A large flour bin with flour sat on a shelf below the coffee maker and beside the steam table. -The lid had been covered with dust that could be wiped away. *An approximately five-inch by two-inch piece of ceiling that was coming away from the wall in front of the steam table. *An electrical outlet on the wall in front of the steam table was missing the cover plate. -The sides of the table including the area with knobs used to turn it on and off were sticky to the touch from grease. Observation on [DATE] at 12:40 p.m. of the walk-in cooler and walk-in freezer revealed: *Five metal shelving units in the cooler and freezer had heavy rust. *A metal pipe attached to the wall of the cooler had left rust stains on the wall. *Both the cooler and freezer floors had dirt, juice spills, and food particles on the floors with sticky build-up, especially in the doorways. Observation on [DATE] at 1:30 p.m. of the ice machine in the dining room revealed: *The ice chute had built-up mineral deposits as well as a build-up of juice splashes from drinks in their glasses when adding ice to their glasses. *The area behind and below the ice machine had dust, dirt, and papers on the floor. *The walk-in freezer and pantry had two towers of cardboard boxes filled with groceries. -The groceries were delivered on [DATE]. -They remained on the floor of the walk-in freezer and pantry until [DATE]. Observation and interview on [DATE] at 9:30 a.m. with DM P revealed: *When asked who was responsible for keeping the residents' refrigerator clean and monitoring the food DM P stated: -The residents or family were to take care of the food in the refrigerator. -She did not state who was responsible for keeping the refrigerator and the kitchen storage room clean and sanitary. Observation on [DATE] at 9:30 a.m. of the resident's food in the resident's refrigerator with DM P revealed the following foods were either beyond the expiration date or had no date to indicate how old the food was. *A burrito or sandwich wrap had no date on the container. *An undated container of Braunschweiger had no date on the container. *One sandwich wrap had expired on [DATE]. *One pancake and sausage meal had no date on the container. *Three containers of yogurt had expired on [DATE]. *Several bags of shrunken blueberries in juice had no date. *One piece of bologna had no date. *One piece of cheese with no date. *Onion dip with no identified date. Interview on [DATE] at 10:15 a.m. with registered dietitian (RD) Q regarding the above kitchen findings revealed: *RD Q had only been consulting with the provider for one month. *He had been in the building on [DATE]. *He had told DM P the area in front of the steam table needed to be cleaned. *RD Q discussed the findings from the survey and the lack of a sanitary environment and expired or undated food. *RD Q confirmed: -Kitchen and kitchen storage areas had not been maintained in a sanitary manner. -Opened items were to have use by dates. -Food items should have been covered until they were served. Interview on [DATE] at 2:15 p.m. with DM P regarding maintaining the kitchen in a sanitary manner confirmed: *The resident refrigerator: -Was not clean. -Had not been monitored for expired food or missing dates on food items. *Opened foods should have a use by date. *Prepared foods should have been covered until it was served. *The cardboard boxes that held food items should not have been left on the floor of the pantry and walk-in freezer floor. *The ceiling vents in the kitchen and kitchen storage room were not cleaned. *The kitchen and kitchen storage room walls, floors, and windows had not been cleaned. -Metal shelves in the walk-in cooler and freezer, one wall of the cooler, and the legs of the dish table had rust. *Kitchen equipment (ovens, stove hood filter panels, steam table, vegetable sink, stainless steel countertop, and shelf, large mixer, shelf holding pans, tray carts, and a toaster should have been cleaned and maintained. DM P stated: *The provider had lost two cooks. *She had been working as a cook after they lost two cooks. *She normally did not work in the kitchen, spending her time in her office. *She was not aware that the kitchen had been so dirty. I couldn't believe how bad it was. Review of the provider's [DATE] Resident Personal Refrigerators and Foods Brought into Center by Family/Visitors policy revealed: *Foods brought to a resident by family by family, or visitors may be stored in their refrigerator or designated refrigerator/freezer in the Center. *Non-perishable foods in the resident's room were dated and stored in containers with tight-fitting lids or sealable bags, except fresh fruit. *There was a designated refrigerator in the building to store resident foods. *The refrigerator containing the resident food items had thermometers and daily temperature logs with temperatures documented. -Temperature standards for the refrigerator were ,d+[DATE] degrees Fahrenheit. -Temperatures outside of those standards were to have been reported to [DM P] or the Person in Charge. *Perishable foods were to have been covered, labeled, dated, and discarded following use-by-date guidelines. -Provider staff were responsible for educating the resident and family on food/fluid labeling and dating. -Provider staff, at their discretion, could discard food items that were not safe to eat, nor labeled after verbally notifying the resident or then responsible party. Review of the provider's [DATE] Sanitation Policy revealed: *The food service was to have been maintained in a clean and sanitary manner. *Kitchens, kitchen areas, and dining areas were to have been kept clean and free from litter and rubbish. *Utensils, counters, shelves, and equipment were to have been kept clean, and maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chips. *Ice used in connection with food and drink was expected to come from a sanitary source and was to have been handled and dispensed in a sanitary manner. *Cleaning schedules were developed by the [DM P] or the person in charge. *The registered dietitian was to complete comprehensive summary reports. Review of the provider's [DATE] Food Storage Policy revealed: *Food storage areas were to have been maintained in a clean, safe, and sanitary environment. * Food storage areas were to have been kept clean at all times. *Food or food items not requiring refrigeration were to have been stored on surfaces (shelves, racks, dollies, etc. a minimum of six inches above the floor to facilitate thorough cleaning, in a ventilated room, not subject to sewage or contamination. *Packaged food, canned foods, or food items stored were to have been kept clean and dry. *Dry bulk foods, such as flour were to have been stored in seamless metal or plastic containers with tight-fitting covers or bins. *Remove food from packing boxes upon delivery to minimize pests. *Foods were to have been dated with the month and year of delivery. *Cold foods were to be maintained at 41 degrees Fahrenheit. *Foods that were stored in walk-in refrigerators and freezers were to have been stored above the floor on shelves, racks, dollies, or other surfaces to facilitate a thorough cleaning. Do not line the shelving. *Opened items were to have use-by-dates. The use-by-date. The provider may indicate the date opened or the date prepared, if required from the survey agency. *The manufacturer's expiration date, when available, was the use-by-date for unopened items.

Based on observation, interview, record review, and policy review, the provider failed to provide a homelike environment that was free from excessive foul odors and large amounts of dust, dirt, debris, rust, and other cosmetic issues for all 49 residents living at the facility. Findings include: 1. Observation and interview on 3/11/24 at 4:22 p.m. with resident 40 revealed: *The wall-mounted heating unit under the window was not attached to the wall and had fallen forward. *There was a box fan sitting on the floor in her room, and it was blowing air out the door. -She said her room is too hot and is very noisy. *The bottom of the toilet was missing portions of caulking. The remaining caulking was brown in color. The original color was white. There was a foul odor in the bathroom. -She said her room smells like poop and pee every morning and I can barely stand it. *She stated maintenance worker I looked at the toilet but didn't do anything. Observation on the following dates and times of the 200 hall-way room revealed: *3/11/24 at 2:53 p.m. there was a strong odor of urine around rooms 205 to 208. *3/11/24 at 3:02 p.m. the exterior door outside room [ROOM NUMBER] was missing the lower portion of the door molding on the right side. The foundation was crumbling. -The door glass had a cloudy film between the layers of glass. -There were sharp rusty edges exposed. *3/12/24 at 1:26 p.m. the exterior door on 200 hallway was not closed tightly allowing visible gaps between the door and the door frame. *3/12/24 at 2:43 p.m. there was a strong odor of urine around resident rooms 206 to 208. *3/13/24 at 10:59 a.m. there was a strong odor of urine outside of resident room [ROOM NUMBER]. Observation on 3/11/24 at 6:05 p.m. in the front men's public restroom revealed: *Four tiles were missing from the wall behind the toilet. -Plumbing pipes were exposed. -The tiles were sitting on the edge of the sink. *There was a package of opened wet wipes in the sink. *There was evidence of rusty water streaks in the sink basin and around the faucet. Interview on 3/12/24 at 9:10 a.m. with resident 7 revealed she stated: *They have been cleaning the heck out of this place since you walked in. They were checking the rooms at 7:00 a.m. and looking at the bathrooms. *Her bathroom smells of urine from the toilet. -She had questioned maintenance worker I and had asked if the seal was broken. -They [maintenance] are aware of the problem, but they haven't fixed it. *It's funny how corners of the building that haven't been touched in months are finally getting cleaned. *They were even polishing the floors at 6 a.m. Observation on 3/12/24 at 1:28 p.m. in resident room [ROOM NUMBER] revealed: *The toilet seal at the base of the toilet was missing in the front. -There was a brown substance around the base of the toilet. *The baseboard molding in the bathroom was cracked and not a cleanable surface. *There was a bedpan sitting on the floor. Observation on 3/12/24 at 1:35 p.m. in the entry lobby revealed: *The sitting room was to the east of the entrance. *There were unidentified brown stains in the carpet in the sitting room. *There was a puzzle area to the west of the entrance. *There was a layer of dust covering the bookshelves, an oxygen concentrator, and a table near the puzzle area. *Some of the plants had dropped dead leaves on the tables and carpet. Observation on 3/12/24 at 1:39 p.m. in the resident smoking area revealed: *Cigarette butts were lying on the ground and in the trash can. *The windows were covered with dirt and cobwebs *The overhead soffit (the material beneath the eave that connects the far edge of the roof to the exterior wall of the building) was peeling and dropping down. That was located directly above the resident smoking area. *The exterior door had peeling paint and was missing portions of the weather strip molding. Observation on 3/12/24 at 2:12 p.m. in the dining room revealed there was: *Salt and plant material on top of the piano. *A vent next to the piano that was rusted. *A layer of dust covering the stereo. *Five of the twelve dining room tables had areas where the surface had worn off. *An entanglement of extension cords between the stereo and the television. *Dust, dirt, and Nerf gun darts located under items on the north wall. *Food debris, dirt, dust, and paper items under the ice machine on the south wall. Observation on 3/12/24 between 4:15 p.m. and 4:31 p.m. in the 100-hallway revealed: *Resident rooms [ROOM NUMBERS] had chipped paint on the walls and chipped wood on the doors. *The far exit door was unable to be opened by one person. -It required both administrator A and regional nurse consultant K to push together quite hard to open it. --The bronze push bar was tarnished to a green color. *There were cobwebs above the door. *The air vent in front of the activities desk was not completely attached to the ceiling. *The large ceiling vent in front of resident's room [ROOM NUMBER] had a thick layer of dust. *The vent in front of resident room [ROOM NUMBER] was not completely attached to the ceiling on two sides with at least a one-half-inch gap. Observation on 3/12/24 at 4:41 p.m. in the 300-hallway revealed: 301: *There was a metal pole of a toilet arm (used to provide support for the residents) next to the back of the toilet tank and the toilet seat. -The rest of the safety rail was not present or connected to the arm. -The metal pole extended up approximately ten inches and was uncovered, there was a concern of a resident falling backward and causing skin harm. *The bathroom door had two gouges of unvarnished wood exposed. *A metal heater under the window beside the bed had fallen to the floor. 303: *A one-by-one-foot area of the ceiling close to the ceiling light in the middle of the room was pulling away from the ceiling. *A corner by the closet had wall edging coming loose from the wall. *Paint was peeling from both sides of the bathroom door frame. *Chunks of missing wood and varnish were missing from the door. 304: *Paint was peeling off the bathroom door frame. *The entry door to room [ROOM NUMBER] had chunks of missing wood and varnish. 305: *The bathroom door was missing chunks of wood and varnish. *Paint was peeling off the bathroom door frame. *There were scrapes and scratches on the wall behind the recliner. *The bathroom heater had areas of missing paint. 307: *There was approximately 20-inch-by-three-inch area of the wall beside the bed where something had scraped the sheetrock away. *The north tub room had a sink with heavy rust on the faucet, levers, and drain. *Four holes had been placed in tiles beside the toilet. -They had not been filled. Observation on 3/13/24 at 10:08 a.m. in the 300-hallway revealed: *The skylight located between resident rooms [ROOM NUMBERS] contained dirt, evidence of a water ring approximately five inches wide and 15 inches in length, and plant debris. *The ceiling vent across from 309 was coated with a significant dust build-up. *The door to resident room [ROOM NUMBER] was open and contained the following: -An air mattress was lying on the floor. -A hospital bed was positioned on its side. -A second hospital bed without a mattress. -The bathroom contained the following: --An opened and used container of skin cleanser, a bottle of lotion, toothpaste, barrier cream, deodorant, and a toothbrush in a travel protector. --On the back of the toilet was an opened package of wet wipes. --There was no paper towels or toilet paper. *The door to resident room [ROOM NUMBER] was open, the light was on, and it contained the following: -A bed piled with a combination of what appeared to be resident belongings including: --Two suitcases, a plastic bag containing clothes, and boxes. -A bin containing wheelchair foot pedals. -Two mechanical lifts. -A furniture [NAME]. -A set of wall cabinets were sitting on the floor. -The bathroom contained a minimum of 15 cardboard boxes piled on the floor, sink and toilet and a resident four wheeled walker. -The closet contained over 25 boxes including COVID-19 tests, a continuous positive airway pressure (CPAP) cleaner, and gowns piled to the ceiling. *The door to resident room [ROOM NUMBER] was open and it contained the following: -Two unmade resident beds -A full trash can. -A room chair and a high-back wheelchair. -The bathroom was missing the toilet paper holder and there was no toilet paper. *The door to resident room [ROOM NUMBER] was labeled This room is clean and ready for our new resident. It contained the following: -A toilet with no back lid. -There were ceramic pieces located in the trash. -Personal care products unlabeled in the bathroom included a yellow plastic bin located in the sink. Observation on 3/13/24 at 10:40 a.m. of the therapy room revealed: *The hard folding divider curtain between the therapy room and the conference room had a large area of a dry white substance beneath it. The substance extended into both rooms. *There was a cloth chair with three nickel-sized red stains and a larger discolored stained area surrounding the red stains. *There were two mouse traps sitting on the floor in the far corner on both sides of the exit door. *There were five ceiling vents with darkened stained areas surrounding them. Interview on 3/14/24 at 9:53 a.m. with maintenance worker I and maintenance director J revealed: *Staff would notify them about something that needed fixing in person. *They confirmed there were maintenance request books at each nurse's station. -Staff usually wrote the requests in those binders if he was not able to address the concerns right away. *Maintenance worker I checked the maintenance request binders about once per week. *The management team discussed maintenance requests at the morning meetings. *Maintenance worker I performed rounds each morning around the building to check for leaks and any damages to the building such as holes in walls and broken doors. *Maintenance director J explained tiles were missing in the men's bathroom due to recent plumbing work that had been completed. The tiles were replaced. *They explained that the nursing staff were responsible for keeping the resident's mechanical lift equipment clean. *They confirmed they did not keep track of all the maintenance fixes they performed throughout each day. Observation and interview on 3/14/24 from 10:18 a.m. to 10:40 a.m. with administrator A revealed: *The survey team walked her through the building to inform her of the identified concerns. *The bathroom door in room [ROOM NUMBER] was off its bottom hinge. The wood paneling was chipping away. -She was not aware of that. *It was her expectation that the dietary department should have kept the dining room clean. *She was aware of: -The state of the skylights. -The issues with the foundation crumbling. -The concerns with the deteriorating caulking around resident toilets. 2. Review of the provider's July 2015 Homelike Environment policy revealed: *Policy Statement: Resident rooms are personalized and organized in a manner that promotes independence through a homelike environment. *There was nothing in the policy about shared resident spaces. Review of the provider's resident handbook, last updated December 2023, revealed: *Page 24, 3 - Community Life - .Heating and Lighting. Staff members maintain the heating and overall lighting throughout the center. - .Room Cleanliness and Maintenance. Our goal is to provide a clean environment in good working order for our residents. We replace light bulbs and repair plumbing issues as needed. If you have any concerns about the cleanliness of your room or working order of your bathroom, please alert center staff.

Based on observation, interview, record review, policy review, and manufacturer's guideline review, the provider failed to ensure: *Four of four sampled resident's (6, 11, 34, and 38) oxygen concentrator machines were free from dust buildup. *One of one shared resident oxygen concentrator machine was free from dust and debris buildup. *One of one sampled resident's (34) oxygen tubing was managed in a way that minimized the risk of contamination. *Physician's orders were followed for continuous oxygen administration for one of one sampled resident (1). Findings include: 1. Observation on 3/11/24 at 4:39 p.m. in resident 6 and 34's room revealed: *Resident 6's oxygen tubing was labeled with a handwritten date of 12/21/23. *Resident 34's oxygen nasal cannula was lying on the floor. -He was in bed and was not wearing his oxygen. *There were no dates written on resident 34's oxygen tubing or humidifier. *The foam filters on the back of both resident 6's and 34's oxygen concentrator machines were covered with a layer of dust. Observation on 3/11/24 at 5:00 p.m. revealed that resident 34 was now wearing the oxygen nasal cannula. Interview on 3/13/24 at 4:34 p.m. with LPN L about the above observations revealed she: *Confirmed resident 6's oxygen concentrator machine was dirty, and the foam filter was very dusty. *Thought the night staff had been cleaning the oxygen concentrator machines. *Denied that she put the oxygen tubing back on resident 34's face. *Was not aware if the nasal cannula had been cleaned or replaced after it had been sitting on the floor. Observation on 3/12/24 at 9:36 a.m. in resident 11's room revealed the oxygen tubing was labeled with a handwritten date of 12/22/23. Observation on 3/13/24 from 10:05 a.m. to 10:38 a.m. throughout the facility revealed: *In the front entrance room: -There was a multi-resident shared oxygen concentrator machine that was covered with a layer of dust, unidentified crumbs, and dead plant material. -There was a wall-mounted wooden podium. Inside the podium was a used oxygen tubing, tape, a thumb tack, dirt, and crumbs of unidentified food. *In resident 38's room, her oxygen concentrator machine and CPAP (continuous positive airway pressure) machine was covered in a layer of dust. -The foam filter on the back of the oxygen concentrator machine also had a layer of dust on it. -There was moisture buildup in the oxygen tubing. -There was no date on the oxygen tubing. Interview on 3/13/24 at 4:37 p.m. with licensed practical nurse L revealed: *Cleaning of oxygen equipment was completed at night. *She stated: -I don't know when it was last done or how quickly it gets dusty. -Honestly, I don't look at it. I don't have time. Seriously, it's not a good excuse. Interview on 3/14/24 at 11:02 a.m. with director of nursing (DON) B revealed: *The night staff were responsible for changing the resident's oxygen tubing. *Her expectation was if the staff see it's visibly dirty, to clean it. If you see a dirty surface, you clean it. *Other times she expected the oxygen tubing to have been changed including if the resident had been sick, or if the tubing was damaged. Continued interview on 3/14/24 at 3:32 p.m. with DON B revealed: *They used to have a hospitality aide that was assigned to clean the oxygen concentrator machines and change the tubing. -That hospitality aide was promoted to a certified nursing assistant (CNA) in December 2023. *She explained there may have been some miscommunication in job duties as that hospitality aide stopped maintaining the oxygen concentrator machines and changing the oxygen tubing after the promotion to a CNA. *The policy was to change a resident's oxygen tubing and to clean the oxygen concentrator machines as needed. *She confirmed that resident 6's oxygen concentrator foam filter was especially dirty. Review of resident 6's electronic medical record (EMR) revealed: *There was a physician's order for Change oxygen tubing. Clean oxygen filter, that was scheduled on the Treatment Administration Record (TAR) for each Saturday on the night shift. -The order started on 8/22/20. *The resident's TAR for January, February, and March of 2024 indicated that staff were documenting that the oxygen tubing was changed and the filter was cleaned as scheduled. -However, his oxygen tubing was dated 12/21/23 as mentioned above and the filter was very dusty. Review of resident 11, 34, and 38's EMR revealed there were no physician's orders to change the oxygen tubing or clean the oxygen filter. Review of the CPAP machine's Patient Instructions revealed the cleaning instructions on page eight indicated to wipe the exterior of the device with a dry cloth weekly. 49958 2. Observation and interview on 3/12/24 at 10:11 a.m. with resident 1 revealed: *He was on 3.5 liters of oxygen. *He stated he wore his oxygen all the time. *The humidifier bottle attached to the concentrator was empty. *There was no date on the oxygen tubing or humidifier bottle. *He stated he was not aware when staff had changed the oxygen tubing or the humidifier bottle. Review of resident 1's EMR revealed: *A Facsimile Transmission to resident 1's physician dated 3/6/24 requested, Can we get an order for 2-4L [liters] of continuous oxygen. -There was a reply of yes signed and dated 3/6/24 by the physician. *There was an order in the Treatment Administration Record (TAR) that indicated: -Oxygen to maintain O2 Saturation levels to > = 90 every day shift for Oxygen related to ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA (J96.21) -Start Date- 03/07/2024. *There were no parameters for the flow rate being administered. *There were no physician standing orders for oxygen reflected on the TAR. *The care plan revised on: 02/14/23 indicated: -I use oxygen therapy r/t COPD, and acute and chronic respiratory failure w/ hypoxia. -Give medications as ordered by physician. Monitor/document side effects and Effectiveness. Interview on 3/14/24 at 11:10 a.m. with DON B revealed: *There were physician standing orders for the use of oxygen. *If the doctor orders oxygen, the order would be written on the TAR with the parameters specified by the doctor. *Changing of the oxygen tubing and filling of the humidifier was done PRN [as needed] and was not on the TAR. *She expected staff to change the oxygen tubing and fill the humidifier as needed. -That task was as needed and not assigned, not on the TAR, and therefore there would have been no documentation of when it had been completed. Review of the provider's November 2018 Respiratory Care; Equipment Care and Handling policy revealed: *The policy statement read, Respiratory equipment is handled in a manner that maintains good working order and promotes proper infection control. *Under the Oxygen Administration section: -1. Oxygen is administered in accordance with professional scope of practice, state and federal regulation, and physician's orders. -4. Consider all disposable equipment as single patient use items. -5. General equipment guidelines will be observed unless otherwise specified by regulation or physician order. *In the table that described Recommended Change and Frequency: -Nasal Cannula or Face Mask, PRN [as needed], Discard and replace if heavily soiled. -Tubing, PRN, if soiled, malfunctioning, or damaged.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of one sampled discharged resident (1) with a facility acquired pressure ulcer received ongoing assessments and interventions to prevent the pressure ulcer from worsening. *One of one sampled resident (2) with a facility acquired pressure ulcer received ongoing assessments and interventions to prevent the pressure ulcer. *Three of three sampled residents (3, 4, and 5) admitted with pressure ulcers received ongoing assessments and interventions to prevent the pressure ulcers from worsening. Findings include: 1. Record review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE] for skilled care. *She was transferred to the hospital on 12/8/21. -She had respiratory distress. *She was readmitted on [DATE] for skilled care. *She was discharged on [DATE]. *She had two Braden Scale evaluations [used to determine the level of risk for a resident to develop skin issues] completed in her 26 days of admission. -On 11/24/21 her score was 17, indicating mild risk. -On 12/14/21 upon readmission her score was 18, indicating mild risk. *She should have had three completed per provider's skin integrity policy. -She would have had a Braden scale completed upon admission and weekly for 3 weeks. *She had received four weekly skin audits. -One in the month of November 2021 -Three in the month of December 2021 --Entry on 12/20/21 marked n [No] --Entry on 12/27/21 marked unknown notation. *Resident 1 had daily skilled charting completed 24 times. *Four times had a nonsurgical skin condition charted on: -11/24/21 bruising to the right eye, buttock, and lower back. -11/25/21 scattered bruising. -11/30/21 redness to peri area and buttock. -12/2/21 redness to peri area and buttock. *Daily skilled charting had not documented for her skin issue identified on 12/14/21. *A pressure injury had been observed on 12/8/21 to her left buttock prior to her being transferred to the hospital. *No measurements had been documented for the left buttock pressure injury. *An order dated 12/14/21 to change the dressing to left buttock every 3 days and as needed until healed. Clean wound with wound cleanser, pat dry and apply foam dressing. *No documentation on the treatment administration record (TAR) had been completed indicating the dressing had been changed. Interview on 2/8/22 at 10:55 a.m. with licensed practical nurse (LPN)/wound nurse B revealed: *She had the first observation of pressure ulcer to her left buttock on 12/8/21. *Her pressure ulcer looked better after she returned from the hospital on 12/13/21. *On 12/14/21 a wound measurement of 2.8 centimeter (cm) x 4.2 cm x 0.2 cm. *On 12/21/21 a wound measurement of 5.2 cm x 4.2 cm. *Weekly skin evaluations were completed if a skin issue was noted. *Two weekly skin evaluations were completed. *Agreed a Braden score had been missed. *Nurses charting daily skilled notes should have documented any skin issues. Review of resident 1's care plan dated 12/14/21 revealed: *She had a pressure injury on her left buttock. *Intervention/task included: -Administer treatment as ordered and monitor for effectiveness. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, and type of tissue and exudate. Interview on 2/8/22 at 12:50 p.m. with administrator A revealed: *She was not aware a Braden score had not been completed weekly. *All mattresses in the facility are pressure redistributing. *They utilized an algorithm and for stage 3 or above pressure ulcers residents received an air mattress to their bed. *Residents received a wheelchair gel cushion from the facility. *LPN/wound nurse B completed all the measurements of wounds weekly. *If a resident had a skin issue it was not always documented daily. Review of provider's policy dated August 2009 regarding skin integrity revealed: *Resident's skin integrity should have been evaluated using the Braden Scale Evaluation. *Nurses would complete the Braden Scale Evaluation on admission and then weekly for three weeks, annually, and with a significant change of condition. *Skin impairment identified upon admission should have been measured for color, presence of odor, exudate, and presence of pain associated with skin impairment should have been documented. *The medical provider was notified and staff implemented any treatment orders received. *Implemented interventions should have been documented on the resident's care plan. *If skin impairment was noted after admission, the nurse initiated alert charting. -Resident 1 did not have any alert charting related to skin integrity. 2. Observation on 2/7/22 at 1:45 p.m. of resident 2 during tour revealed: *She was lying in bed on her right side with a positioning pillow tucked under her left side. *She had an air mattress on her bed. *There was a pressure redistribution cushion in her wheelchair. Review of resident 2's medical record revealed: *She had been admitted on [DATE]. *Daily skilled evaluations had been completed from 1/7/22 through 1/29/22. -All daily skilled evaluations had indicated, Resident does not have other non-surgical skin conditions. *A skin/wound note on 1/31/22 stated, Resident has small open area on coccyx, [MEDICATION(S)] [absorbent foam dressing] was applied, and barrier cream [physical barrier between skin and contaminants]. No other concerns at this time. Review of resident 2's Braden Scale for Predicting Pressure Sore Risk revealed: *On 1/5/22: -She had a score of 14.0 indicating she was at moderate risk for developing a pressure ulcer. *On 2/2/22: -She had a score of 13.0 indicating she was at moderate risk for developing a pressure ulcer. *No other weekly Braden Scale assessments had been completed. *Braden Scale assessments had not been done weekly per facility policy. Review of resident 2's weekly skin evaluations revealed: *On 2/2/22, a weekly skin evaluation had been completed indicating she had a stage 2 pressure ulcer on her coccyx [one at the base of spine] that measured 1.1 cm x .5 cm. No depth was documented. *On 2/8/22, a weekly skin evaluation had been completed indicating the stage 2 pressure ulcer on her coccyx measured 1.2 cm x .5 cm. Depth was less than .1 cm. Review of resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *An order on 2/2/22 for the pressure ulcer Cleanse with wound cleanser, pat dry, apply duoderm dressing. Change every 3 days or prn [as needed] if loose or soiled. *On 2/2/22, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of resident 2's 2/2/22 revised care plan for pressure ulcers revealed: *I have a pressure injury on my coccyx r/t [related to] Immobility. *Interventions included: -Administer treatments as ordered and monitor for effectiveness. -Avoid laying on my back, encourage me to lay on my side. -I have a pressure redistribution mattress on my bed and a pressure redistribution cushion in my wheelchair. -The resident requires assistance to turn/reposition at least every 2 hours, more often as needed or requested. -Weekly treatment documentation to include measurement of each area of skin breakdown's width length, depth, type of tissue and exudate. 3. Observation and interview on 2/7/22 at 2:30 p.m. with resident 3 revealed: *She was in bed with the head of her bed raised up to about 75 degrees with pillows propped behind her head/shoulders. *Her head was tilted forward and turned slightly to the right. *She responded Yes when asked if she was comfortable. *She was hard of hearing, and her daughter sitting in a chair beside her bed carried on the remaining conversation. *The daughter reported the resident had current skin concerns on her bottom and her ankle. Observation and interview on 2/8/22 at 9:40 a.m. with resident 3 revealed: *She was positioned in bed as she had been when observed on 2/7/22. *Her son was sitting in a chair beside her bed. *She responded Yes that she had a sore on her ankle but did not agree she had a sore on her bottom. *The son confirmed she still had open areas on both her ankle and bottom. They would be going to see a doctor about them. Review of the EMR for resident 3 revealed: *On 1/24/22, the day of admission: -The admission progress note documented the resident had an ulcer to her right lower leg with a dressing that is changed q [every] 3 days and open areas to her coccyx. -The admission-readmission nursing evaluation documented skin issues included: --A right outer ankle vascular open area that measured 7.3 cm length by 5.5 cm width by 0.7 cm depth that was covered with [MEDICATION(S)] dressing. --A stage 3 pressure ulcer to her coccyx that measured 4.0 cm length by 0.5 cm width by 0.1 cm depth. -The Braden Scale was scored at 15 indicating she was at risk for the development of pressure ulcers related to: --Having slightly limited sensory perception. --Having occasionally moist skin. --Being chairfast with slightly limited mobility. --Needing moderate to maximum assistance with movement that could lead to friction and shear problems. *On 1/25/22, the daily skilled progress note (PN) documented: -Other skin observations included wounds to the arm, leg, and coccyx. -The same observations on 9 subsequent daily skilled PNs through 2/6/22 except the PN on 1/29/22, and two daily skilled PNs were missed on 2/3/22 and 2/6/22. *On 1/26/22: -The skin integrity issues section was blank on the admission care conference record. -The care plan included pressure injury on the coccyx and venous ulcer to right lateral ankle related to immobility, [CONDITION(S)], weakness, and [CONDITION(S)] with the interventions for: --Treatments as ordered. --Turn and reposition at least every 2 hours. --Weekly treatment documentation to include measurement of each skin breakdown's width, length, depth, the type of tissue, and exudate. --Pressure redistribution cushion in the wheelchair and air mattress on the bed were added on 2/1/22. *The 1/28/22 admission and 5-day Minimum Data Set (MDS) assessment documented: -The resident's mental status was scored 8 meaning her cognitive function was moderate to severely impaired. -She needed extensive to total weight-bearing assistance of two staff for bed mobility, transferring between surfaces, and toileting. -The presence of one stage 3 pressure ulcer but no venous ulcers. -Skin treatments checked included pressure reducing device for chair and bed, turning and repositioning program, pressure ulcer and injury care, application of ointments/medications. Application of dressings was not checked. *The 1/28/22 pressure ulcer care area assessment (CAA) that was signed on 2/2/22 documented: -The presence of an existing pressure ulcer but there were no notes related to the location, size, presence or type of drainage or odors, nor the condition of the surrounding skin. -The need for a special mattress and seat cushion, and a regular schedule of turning. *The TAR revealed: -A treatment order dated 1/24/22 to apply foam dressing to pressure ulcer on coccyx every 72 hours. This was checked as completed on 1/24/22, 1/27/22, and 1/30/22. -There was no order on the January 2022 TAR to complete a weekly skin audit, which should have been completed on 1/31/22. -A treatment order dated 2/7/22 for a weekly skin audit every night shift every Monday. *A 2/1/22 weekly skin evaluation, 9 days after admission, documented measurements of the two ulcers: -The right ankle was noted as an arterial ulcer measured at 7.0 cm length by 3.0 cm width by 0.4 cm depth with an irregular shape, a pink/beefy red and yellow color with minimal drainage and no odor. No was checked in response to if the ulcer was noted on admission and the wound status was noted as unchanged. -The stage 3 pressure ulcer on the coccyx was an irregular shape that measured at 1.6 cm length by 0.5 cm width without a depth measurement, with a pink/beefy red color, no drainage or odor, was noted on admission and was improving. *The 2/2/22 Braden Scale, 10 days after admission, was scored at 12 indicating high risk related to slightly limited perception, very moist, chairfast, very limited mobility, probably inadequate nutrition, and friction/shear problem. *The February 2022 task record directed staff to monitor the presence of the pressure-relieving mattress and cushion in the wheelchair. The task for the turning and repositioning program was not listed. 4. Observation and interview on 2/8/22 at 9:50 a.m. with resident 4 revealed: *She was seated in her wheelchair on a cushion in her room. *She reported she did not have any skin concerns or open areas other than a bruise she pointed out on her left wrist. *The mattress on her bed was a standard pressure-relieving mattress. Review of the EMR for resident 4 revealed: *On 1/25/22: -The admission PN noted her report of intermittent left hip and knee pain with a recent weakness. -A skin/wound PN revealed she had a stage 2 pressure wound to her upper right gluteal cleft that measured 2 cm and blanched well. -The admission-readmission nursing evaluation noted a stage 2 pressure ulcer to her right buttock with no measurements listed and no treatment. -The Braden Scale was scored at 18 indicating she was at risk related to having no sensory impairment, rarely moist skin, being chairfast, having slightly limited mobility, consuming adequate nutrition, and having a potential problem with friction and shear during movement. -The daily skilled PN noted Other skin condition included a stage 2 right buttock pressure sore and a right iliac crest scab. Subsequent daily skilled PNs through 2/6/22 did not note that skin condition. The daily skilled PNs for 1/26/22 and 1/31/22 were not done. *The baseline plan of care initiated on 1/25/22 included: -Skin at risk with the interventions of barrier cream, pressure-reducing mattress, and wheelchair cushion. -A goal was added on 1/28/22 to have no skin breakdowns. *On 1/26/22, skin integrity issues were blank on the care conference record. *On 1/28/22, the admission/5-day MDS revealed: -The resident's mental status was at 12 meaning her cognitive function was moderately impaired. -She needed extensive weight-bearing assistance of one to two staff for bed mobility, transferring between surfaces, and toileting. -The presence of one stage 2 pressure ulcer. -Skin treatments checked included pressure reducing device for chair and bed, turning and repositioning program. -Pressure ulcer and injury care, application of ointments/medications, and application of dressings were not checked. *The 1/28/22 pressure ulcer CAA that was signed on 2/2/22 documented: -The presence of an existing pressure ulcer/injury but there were no notes describing the location, size, presence or type of drainage or odors, nor the condition of the surrounding skin. -The need for a special mattress and seat cushion, and a regular schedule of turning. -The rationale for care planning pressure ulcers included: --The licensed nurse assesses skin each week, caregivers asses skin with each bath and each time the resident is dressed. --Caregivers assist with repositioning at least every two hours and as needed for comfort. *The January 2022 TAR revealed no order for treatment or weekly evaluation. *On 2/1/22 (8 days after admission): -The care plan was revised to address a pressure injury on my lower right buttock with interventions of pressure redistribution mattress and cushion in the wheelchair, monitor dressing to right buttock, assist to turn/reposition at least every two hours, and weekly documentation to include measurement .type of tissue and exudate. -The weekly skin evaluation noted a first observation of a stage 2 pressure ulcer on resident's right buttock that was noted on admission, that was irregular and measured 1.2 cm length by 1.0 cm width without a depth measurement, and that had a pink/beefy red color, with a superficial wound bed, normal wound edges, and no drainage or odor. -A skin/wound PN noted the resident was admitted with a stage 2 pressure ulcer to lower right buttock and had skin irritation that was extremely red to the resident's left abdominal area. A fax was sent to the physician for orders. *The 2/2/22 Braden Scale (9 days after admission) was scored at 17 indicating she was at risk related to no sensory impairment, occasionally moist skin, chairfast, slightly limited mobility, adequate nutrition intake and potential problems with friction/shear. *The February 2022 TAR included orders: -On 2/3/22, (10 days after admission) for weekly skin audit every night shift every Thursday, which was marked as N indicating no new impairment. -On 2/4/22, then discontinued on 2/5/22, (11 days after admission) for wound treatment to the right buttock, cleanse with wound cleanser, pat dry, and apply foam dressing every shift every three days, which was checked as completed on 2/4/22. -On 2/5/22 for wound treatment to right buttock to cleanse, dry, and apply Poop Goop two times per day every three days, which was marked as completed on 2/5/22. *The February 2022 task record did not include directions for monitoring the presence of the pressure-relieving mattress and wheelchair cushion, nor for turning and repositioning every two hours. Interviews on 2/8/22 at 9:35 a.m. with CNA C and at 9:55 a.m. with CNA D revealed they: *Monitored for skin concerns while assisting with daily care and during baths. *Reported any concerns to the nurse right away. *Could document a care concern or alert in the computer. 5. Observation and interview on 2/7/22 at 2:40 p.m. with resident 5 revealed: *She was in bed on a standard pressure-relieving mattress. *Her husband, sitting on a chair beside the bed, explained she needed help to transfer. *The resident reported she had something going on with my butt. Observation and interview on 2/8/22 at 10:00 a.m. with resident 5 revealed: *She was sitting on a cushion in her wheelchair in her room. *She confirmed her previous statement that there was a skin condition on her butt and agreed to show it to the surveyor. *The director of nursing (DON) E assisted the resident stand while the surveyor observed the resident's bottom and found deep purple areas on both buttocks. Review of the EMR for resident 5 revealed: *On 11/16/21: -The admission PN noted both buttocks were red and purplish and slow to blanch, with no measurements. Barrier cream was applied. -The admission-readmission nursing evaluation noted stage 1 pressure ulcers to both buttocks with no measurements. -The Braden Scale, the only one listed in the EMR since admission, was scored at 12 indicating the resident was at high risk related to limited sensory perception, very moist skin, chairfast, very limited mobility, and friction & shear problem with movement. *On 11/18/21, the daily skilled PN, the first one in the EMR since the resident's admission on 11/16/21, noted she had red buttocks with barrier cream applied. -There were no daily skilled PNs on 11/19/21 through 12/1/21. -The skin condition on her buttocks was not listed on any daily skilled PNs after 12/1/21. -Daily skilled PNs were not completed on 6 days in December 2021, including 12/11/21, 12/15/21, 12/17/21. 12/23/21, 12/28/21, and 12/30/21. *On 11/19/21, the admission/5-day MDS revealed: -The resident's mental status was scored at 15 meaning her cognitive function was intact. -She needed extensive weight-bearing to total assistance of two staff for bed mobility, transferring between surfaces, and toileting. -The presence of one stage 1 pressure ulcer. -Skin treatments checked included pressure-reducing devices for chair and bed. -Turning and repositioning program, pressure ulcer and injury care, application of ointments/medications, and application of dressings were not checked. *The 11/19/21 pressure ulcer CAA documented: -The presence of an existing pressure ulcer/injury but there were no notes related to the location, size, presence or type of drainage or odors, nor the condition of the surrounding skin. -The need for a special mattress or seat cushion to reduce or relieve pressure. -The resident requires staff assistance to move sufficiently to relieve pressure over any one site. *The November 2021 TAR included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -On 11/23/21 (8 days after admission), the order was marked with Y [yes], meaning a new skin impairment. -On 11/30/21, the order was marked with N [no], meaning no new skin impairment was found. -The weekly skin audits on the TARs for December 2022 through 2/8/22 were all coded as N. *On 12/5/21 (20 days after admission and 17 days after the MDS was completed), the care plan noted: -Problem statements for Limited physical mobility related to weakness and RLE [right lower extremity] injury and at risk for pressure ulcer development. --Interventions to use a wheelchair for mobility with staff assistance, extensive assistance for daily care, mechanical lift for transfers, encourage small frequent position changes, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. -On 2/8/22, the intervention for pressure-relieving cushion and bed were added. *The February 2022 task record noted: -Monitor for pressure relieving surface on the bed and in the chair. -No direction was related to a turning or repositioning program. Interview on 2/8/22 at 12:51 p.m. with administrator A revealed: *After the observation at 10:00 a.m. of resident 5's buttocks with the surveyor and DON E, three staff (LPN/wound nurse B, DON E, and administrator A) observed resident 5's buttocks after 20 minutes of offloading. *There was no purple area observed by the three of them at that time. *She found a foam cushion with a plastic cover on resident 5's wheelchair that the husband brought to the facility. *She replaced that cushion with a facility cushion. *She had been taught that a red area is a stage 1 ulcer and there should have been weekly evaluations after that until resolved.

Based on observation, interview, record review, and policy review, the provider failed to ensure the following: *One of one resident (30) who was of full code status received interventions to prevent his death. *Residents who were cognitively impaired understood what their code status entailed. *Registered nurse (RN) E was aware of which residents were full code and where the crash cart was located. *Code status book was updated with the most current code statuses of residents. Findings include: 1. Observation and interview on [DATE] at 9:09 a.m. RN E revealed: *She was the nurse in charge of the 100 and 200 hallway, that day. *Surveyor asked which residents were full code status. -She said she knew of one for sure. *They kept the code status' in the nurses station in a book. *They had two crash carts, one on for the ,d+[DATE] hallways and one on the 300 hallway. *Surveyor asked RN E where the crash cart for the ,d+[DATE] hallways was kept: -It took her four minutes to find it. *The crash cart was located behind a locked door in a room where employees clock in. *The crash cart had a box on top of it that contained an employee clock in a kiosk. *The cart contained: -A suction machine and Yankhauer tubing. -Oxygen canister and tubing. Review of the code status book for the ,d+[DATE] hallway revealed: *There were 34 residents located on the ,d+[DATE] hallway. -15 of those residents wished to be of full code status. 2. Review of resident 30's electronic medical record (EMR) revealed: *He was transported to the hospital the morning of [DATE]. *He passed away after arriving at the hospital. *Resident 30 was of full code status. *Licensed practical nurse (LPN) N documented the following: -On [DATE] at 9:49 a.m. Headed to resident's room around 5:40am. [a.m.] Upon entering the room (this nurse) notices he is clenching his mouth. There was saliva/snot around his mouth and nose. (This nurse) wiped off the substance with a towel. While doing this he points to the door. Vitals obtained around 0540 [5:40 a.m.] on [DATE] Blood Sugar 336. B/P [blood pressure] ,d+[DATE] HR [heart rate] 55. Resp [respirations] 16. 911 dialed approximately 0545 [5:45 a.m.]. Ambulance dispatch 0545. Second nurse appeared around 0554 [5:54 a.m.] to assist. [hospital name] Eltc [telemedicine for emergency long-term care] dialed at 0606 [6:06 a.m.]. Administer [Administrator] dialed at 0618 [6:18 a.m.]. Resident taken by EMS [emergency medical system] approx. [approximately] 0640- 0645 [6:40 to 6:45 a.m.] to [hospital name]. *On [DATE] at 10:02 a.m. administrator A documented: -Call placed to [hospital name] and spoke with [staff member's name] and she stated that they were running tests and that he was intubated and trying to get his blood pressures stable. She stated they would know more after lunch. Call then placed to his ex-wife and [ex-wife's name] was given an update and she stated she called up there and they told her the same. She thanked writer for the update. Spoke with the EMS [initials of staff], and she stated that she did not have to use the AED [automated external defibrillator] or [NAME] [lund university cardiac assist system] during the ride and that she only bagged him at this time. However the North charge nurse stated that they did use the [NAME] and AED at the facility and the EMS went through 3 cycles where no shock advised each time. Female EMS stated that he had a really faint pulse and if he did not have a pulse then the [they] would not have transported him. *Administrator A documented another entry on [DATE] at 2:09 p.m. which stated: -Received a call from [RN's name] at [hospital's name] and she stated that resident passed away. She stated that it happened so fast she could not put all the puzzle pieces together. This RN asked for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the report received from the hospital about resident 30 revealed: * .noted to be normal at 5 AM today but at 6 AM was noted to have agonal respirations and pulse. Then they lost the pulse and started cardiopulmonary resuscitation. 20 min [minutes] if CPR. EMS gave 3 mg [milligrams] of EPI [epinephrine] with return of pulse, but needed to resume CPR. Hypotensive [low blood pressure] during transport to hospital. Remained unresponsive the entire time. He arrested again in the [emergency department's name]. Did have a return of pulses . *Wife agreed to place resident 30 on comfort measures. *Resident 30 was extubated [removal of tube] and passed away on [DATE] at 1:14 p.m. Review of the provider's death report revealed: *Resident's age was [AGE] years older than his actual age. *Resident 30's time of death was listed as 6:00 a.m. 0n [DATE]. -Which was before EMS arrived and CPR had been started. Review of ELTC consultation report revealed: *Date of service was listed as [DATE] at 6:03 a.m. *Nurse was calling because resident passed away and wanted release of body order. Educated that ecare cannot provide and would need to call [physician's name]/or physician on call for her. Interview on [DATE] at 10:06 a.m. with LPN F revealed, she: *Arrived at the facility for her scheduled shift on [DATE] around 6:02 a.m. *Observed LPN N was on the phone with ELTC trying to get an order to release the body. *Went into resident 30's room and LPN D was in the room with two certified nursing assistants (CNAs]. *Stated LPN D was cleaning up the resident for transport to the funeral home. *Stated resident 30 did not have a pulse and his skin was still slightly warm. *Went back to the nurse's station to see what LPN N needed help with. *Observed the code status book was open on the desk. *Was asked by LPN N to call resident 30's wife and ask what funeral home she wanted resident 30 to be transported to. *Had known resident 30 was a full code so she assumed that they had already administered CPR. *Stated EMS showed up and asked what resident 30's code status was and began performing CPR in the nursing home. Interview on [DATE] at 11:04 a.m. with LPN D revealed he: *Arrived at the facility around 5:52 a.m. *Had been flagged down by LPN N. *Was informed by LPN N that resident 30 was not responding. *Went to look at resident 30, he was not responsive. *Stated LPN N went to call 911. *Was trying to see if resident 30 had a pulse. *Thought he had felt a slight pulse but stated he could have been feeling his pulse. *Tried to look at his airway, and tried to remove the saliva. *Stated LPN N came back to the room. *Used a stethoscope to see if he could hear anything. *Did not hear any air movement or breath sounds. *Was not aware of resident 30's code status, he thought he was a do not resuscitate (DNR) status. Interview on [DATE] at 11:46 a.m. with LPN N revealed she: *Went into resident 30's room to give his scheduled 6:00 a.m. medications. *Had noticed he had foaming around his mouth, his jaw was clenched, and his index finger was pointing towards the door. *Used the towel to wipe off the saliva from his mouth, she noticed he was sweating. *Left the room to get the vitals machine. *Recalled his respirations were very low around 7 or 8, his blood pressure was low, and he had a low heart rate. *Had left the room again to call 911. *Stated 911 was inquiring over the phone what his code status was. *Went back into resident 30's room and could not obtain vitals with the vitals machine. -His heart rate and blood pressure were not registering. *Thought that maybe she could feel a pulse. *Did not notice him breathing or his chest rising. *Had not placed any oxygen on resident 30. *Had not retrieved the crash cart and used the suction machine. *Stated she had not repositioned the resident or turned him on his side. *Informed this surveyor that she did not see EMS do CPR in the building but acknowledges that they left around 6:45 a.m. *Called ELTC to obtain an order to have his body released. Review of the EMS report from an encounter with resident 30 on [DATE] revealed: *They were dispatched to the nursing home for a report of a transfer. *When they arrived at the nursing home they were informed that resident 30 had gone on a journey. *They questioned staff further who stated resident 30 had died . *Staff was questioned about his code status, they reported it was unknown. *EMS found resident 30 laying on his back, without a pulse, foaming from his mouth, his skin was warm, and no lividity was noted. *Nursing home staff had come in the room to report that resident 30 was a full code. *Resident 30 was moved to the floor and CPR was administered by EMS personnel. *Mechanical CPR device ([NAME]) was applied, and the airway was suctioned. *EMS inserted an airway and began continuous compressions with ventilation. *Oxygen was administered at 15 liters per minute. *AED patches were applied, no shock was advised, CPR was continued. *Due to copious amounts of secretions from resident 30's mouth, suctioning had been continued through CPR. *Epinephrine was administered. *Resident 30 had a heart rhythm that became organized. *EMS staff were able to obtain a pulse at 82 beats per minute. *Resident 30 was transported to the hospital. *CPR was not administered during transport due to the return of heart rate and blood pressure. *Resident 30 was handed over to personnel at the hospital. Review of EMS time log of the event involving resident 30 revealed: *911 was called at 5:51 a.m. *Their unit was dispatched at 5:54 a.m. *Arrived at the nursing home at 6:09 a.m. *They were with resident 30 at 6:12 a.m. *They departed the nursing home at 7:06 a.m. *They arrived at the hospital at 7:32 a.m. Review of the provider's [DATE] CPR policy revealed: *CPR was not initiated in the following instances: -Decapitation- Removal of the head. -CPR would place rescuer in danger. -Dependent lividity- settling of blood. -Transection-[MEDICATION(S)] cut/cut in half. -Decomposition-state of rotting or decay. *CPR would be initiated for residents who: -Have requested, through advanced directive or POLST/POST [physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Have not formulated an advanced directive nor have a POLST in their medical record. -Do not have a valid DNR order. Review of the provider's admission packet revealed: *Advance Directives: Please notify the center of any changes to your Advance Directive by providing a current copy to the Center. Upon receipt, the center will abide by any instructions provided in your Advance Directive. If you have not provided an Advance Directive, the Center will take all actions possible during an emergency, including calling 911 and sending you to a hospital. Interview on [DATE] at 1:00 p.m. with divisional director of clinical operations B and administrator A regarding resident 30 revealed: *Surveyors had expressed their concern for the severity of the situation. *Surveyors had expressed concern that this situation could impact all other resident. *They did not provide any input or further information. Refer to F600 Finding 1 and 2.

A. Based on observation, interview, record review, testing, resident group meeting interview, and policy review, the provider failed to maintain a comfortable room temperature for fifteen random residents (1, 7, 8, 10, 11, 12, 13, 15, 17, 21, 24, 25, 35, 36, and 37) Findings include: Surveyor: 1. Review of the resident council minutes on: *4/5/21 documentation for maintenance/housekeeping/laundry department A/C's [air conditioners] in rooms. *5/10/21 documentation for maintenance/housekeeping/laundry department No window AC's. *6/25/21 documentation for other No air conditioning - explained doors open, air comes thru [through] halls - if windows open, then doors need to be shut. *7/12/21 documentation for maintenance Discussed air conditioning protocol thru out [throughout] the building. *There had been no further documentation of how this concern would have been investigated. Surveyor: Observation on 8/17/21 at 2:45 p.m. of the facility's 200 hallway revealed: *The hallway had felt very warm. *Thermostat on the wall stated the temperature was 77 degrees. Observation and interview on 8/17/21 at 3:45 p.m. with resident 37 revealed: *He had resided in the facility for the last couple of years. *His room was even warmer than the hallway. *They used to have air conditioner units in the windows of the residents rooms. -He stated they took those out and sold them. *They had put in rooftop air conditioning units, but none of the resident rooms had vents. *He stated he cannot close his door because otherwise he will not receive any air. *He was unable to close his door for privacy due to the temperature. *Choose to wear a hospital gown due to the temperature inside of his room. Observation and Interview on 8/18/21 at 11:38 a.m. with resident 36 revealed: *Her room had been very warm. *She stated she was unable to sleep last night because she was so hot. Surveyor: Interview on 8/18/21 at 11:47 a.m. with resident 36 stated: *They are not allowed to have a window A/C due to the hallway A/C. *It is miserable when the temperature outside is high. *I cannot rest properly and generally feel sick due to the heat. *The fans do nothing to bring cooler air in from the hallway. Interview on 8/17/21 at 4:15 p.m. and 8/24/21 at 2:15 p.m. with resident 17 revealed: *She does not like to come out of her room. *She ate all of her meals and did activities in her room. *The window air conditioning units had been removed last fall. *They had been told those air conditioning units had been sold when they fixed the air conditioning units on the roof. *The cool air never comes into the room. *Dreaded when the outside temperature went up. It just made her sick feeling and worn out. Surveyor: Interview on 8/18/21 at 11:00 a.m. during the resident group meeting revealed the ten residents present (1, 7, 8, 11, 12, 13, 15, 25, 35, and 36) stated the air conditioning had been brought up many times. They had been told they could not have window air conditioners as it would make the roof air conditioners not work correctly. They stated it was very uncomfortable in their rooms when it got really warm outside. Surveyor: Observation and interview on 8/24/21 at 9:51 a.m. with resident 21 regarding his room temperature revealed he: *Had quarantined in his room after his admission per facility policy. *Stated his room had no air conditioning. *Stated his room had been hot at times and he had developed a heat rash due to the excess temperature. *His physician had prescribed a cream for his heat rash. *Had voiced his concerns to staff and family members. *Had been provided a fan after his family requested one to help keep the room temperature more comfortable. *Thought his room had continued to be too warm at times. Surveyor: Interview on 8/24/21 at 2:20 p.m. with resident 24 she stated she sleeps in an adult brief with her shirt pulled up and a fan on her. She stated the reason she sleeps this way is It's just too damn hot. Interview on 8/25/21 at 11:00 a.m. with licensed practical nurse (LPN)/staff development coordinator C revealed: *The residents frequently complained about the heat in their rooms. *If a resident is quarantined or on isolation the room door is closed. *The room becomes very warm and uncomfortable for the resident, even with using a fan. *She had been told the air conditioning units had been sold. Interview on 8/25/21 at 1:30 p.m. with administrator A, interim director of nursing/divisional director of clinical operations B, and LPN/staff development coordinator C revealed they: *Agreed the residents had asked about the window air conditioning units. *Confirmed they had been sold when the roof air conditioning units had been repaired. *Were not aware some of the residents felt physically ill when it was hot in their rooms. *Agreed when a resident would be in quarantine or isolation the room would have been very warm without any air conditioning. B. Based on observation, interview, policy review, and checklist review, the provider failed to maintain a clean, homelike, and sanitary environment for all resident's who were residing in their facility. Findings include: Surveyor: 1. Observation on 8/17/21 at 2:45 p.m. of the facility's 200 hallway revealed: *There was a medication cart and a treatment cart in the hallway. *The medication cart had what appeared to be crushed up pill residue spilled on the floor in front of it. *The treatment cart contained: -A nail clipper with debris inside of it. -Mustard and ketchup packets with their bleach wipes. -A lighter that was unsecured. -A plastic cup with mustard packets, batteries, paperclips, and a used nail file. *A fan in-between rooms 204 and 206 was on and contained a large amount of dust and lint particles. *A half-empty Poweraide bottle was on the handrail propped up against the wall. *The wooden handrails with metal attachment brackets were scraped and rusty, and were not a cleanable surface. Observation 8/17/21 at 2:58 p.m. of the whirlpool room on the 200 hallway revealed: *The door was unlocked. *On top of a cart was a partially eaten plate of food. *Lying next to the partially eaten food was a comb with hair in it. *On the wall next to the soiled utility bin appeared to be fecal matter. Observation on 8/17/21 at 3:19 p.m. of a common area in between the 100 and 200 hallway revealed the trash was overflowing and there had been multiple pieces of trash on the floor. Observation on 8/17/21 at 3:45 p.m. of the provider's north conference/activity room revealed: *Chairs in the room contained visible stains on the cushions. *The floor was visibly dirty. *The trash had been overflowing. *That room was also used for resident activities. Observation on 8/19/21 at 2:00 p.m. of resident 2's room revealed: *Multiple large dried brown stains underneath a resident's bed. -Which appeared to be dried urine. *Many walls had areas of plaster showing. Observation on 8/19/21 at 2:05 p.m. of the soiled utility room on the facility's 200 hallway revealed: *There was a hopper, which contained a large smear of what appeared to be feces across the front of it. *Also appeared to be feces on the wall. *There were uncovered wheelchairs adjacent to the uncovered hopper. Observation on 8/19/21 at 2:10 p.m. of rooms 209 and 210 revealed: *The floors in both rooms were visibly dirty. *The heat register in room 209 was partially hanging off of the wall. *Both rooms had areas where the plaster had been exposed. Review of the provider's admission packet revealed: *Housekeeping staff endeavors to provide you with a clean environment. Everyday your room is cleaned, trash emptied, surfaces disinfected, the walls are spot cleaned, and the floors are vacuumed or mopped. We make sure your bathroom is properly cleaned and stocked with toilet paper, paper towels, and hand soap. In addition, housekeeping manages the cleanliness of common areas . 2. Observation on 8/17/21 at 3:00 p.m. of the 100 wing soiled utility and linen rooms revealed: *The soiled utility room had four - three drawer plastic containers stored by the sink. *The linen room had seven packages of adult incontinent briefs stored on the floor. Observation on 8/19/21 at 2:10 p.m. of the 100 wing resident rooms, hallway, soiled utility room, and linen room revealed: *Room 101: There were soiled paper towels laying by the sink. *Room 102: On the countertop by the sink there was a opened package of incontinence briefs and a sticky unknown substance. *Room 104: The bathroom fan had a large amount of dust and lint build-up. The nightstand next to the bed by the door had an uncleanable surface. The laminate top was cracked. *Room 105: Two-nightstands with uncleanable surfaces. The laminate tops were cracked. *Room 107: Two-nightstands with uncleanable surfaces. The laminate tops were cracked. There was a soiled hand towel on the floor in the bathroom. The bathroom fan had a moderate build-up of dust and lint. There was an open package of incontinence briefs on the floor by the toilet. *Room 108: Two boxes of incontinence briefs on the floor by the bed closest to the door. The bathroom fan had a moderate build-up of dust and lint. *Room 112: There were opened wound care supplies on the top of the built-in dresser. Those wound care supplies included wound vac supplies. They were not in a covered container. Some of the supplies were laying directly on the counter. *Room 114: The bathroom fan had a moderate amount of dust and lint build-up. *The 100 wing handrails from room 101 to just before room 110 had the paint scraped off and was rough to the touch. This made it an uncleanable surface. *The vents in the charting alcove between the 100 and 200 hallways had a moderate build-up of lint and dust. 3. Observation on 8/17/21 at 4:11 p.m. of 300 hallway shower room revealed: *A shower chair with hair on it. *An unlocked supply closet with: -Three rolls of used medical tape. -A roll of duct tape. -Three open bottles of body wash not labeled to a resident. -A soiled washcloth. -Two used body scrubbers. -A spray bottle of peroxide disinfectant. *A locked supply cabinet contained: -An empty quat bottle with spilled contents all over the shelf. -A used roll of paper tape. *Floor with dirt particles and dark residue next to the edges of the room. *A resident identification tag under the soiled linen cart. *A room next to the shower room was used for storage and contained: -A cloth chair with stains and paper stuck to the arm. -4 cardboard boxes containing adult briefs directly on the floor. *A sink that had rust stains. -A toilet that had a dark stain throughout the bowl area. *A plastic zip-tie on the floor. -Various wheelchairs garbage receptacles and an electric wheelchair. -The floor had dust and dirt particles with a dark residue near the edges of the room. -It appeared that it had not been cleaned for some time. Observation on 8/18/21 at 9:46 a.m. of room 306 revealed: *Dark brownish spots that were on the floor beside the window and bed. *The floor appeared to not have been mopped. Observation on 8/18/21 at 1:34 p.m. of the 300 wing resident rooms revealed: *Room 301: A gouge in the corner of the wall next to the bathroom down to the drywall. *Room 302: -Overflowing garbage can. -Scraps of paper lying on the floor by the bed. -Used alcohol pad lying next to the doorway. -Cracker crumbs on the floor by a chair near the door. -Dresser down to the bare wood and uncleanable. -Visible spots and lint particles on the floor. *Room 306: -Spots on the floor from the previous observation on 8/18/21 at 9:46 a.m remained unmopped. -Green plastic cap lying on the floor in the restroom. -Package of adult briefs lying directly on the floor. -Soiled shorts lying on the floor next to the bed. -Scrap of paper on the floor next to the doorway. *Room 307: -Overflowing garbage can. -Adult brief package stored directly on the floor. -Tube feeding nutrients in boxes directly on the floor. *Room 308: -A used surgical glove on the floor in the bathroom. -Worn off paint on the heating unit. -A gouge on the wall behind the recliner down to the drywall. Observation on 8/19/21 at 2:40 p.m. of shower room in 300 hallway revealed: *The zip-tie on the floor had not been moved from the previous observation on 8/17/21 at 4:11 p.m. *Toilet paper on the floor under the heating unit in the room used for equipment storage. *Two cardboard boxes of adult briefs directly on the floor of the storage room. *Cloth-covered chair in the same condition as the observation on 8/17/21 at 4:11 p.m. Observation on 8/19/21 at 3:23 p.m. of room 313 revealed: *Paint scraped off of the heating unit. *A dresser by the doorway was worn down to bare wood and an uncleanable surface. *An overflowing garbage can. *Toilet paper on the bathroom floor. *A C-PAP hose and mouthpiece hung over the top of the towel rack without a barrier. *Crumpled paper on the floor next to her electric scooter. *An open package of bladder control pads on the floor. 4. Observation and interview on 8/19/21 at 9:13 a.m. with district manager T for the contracted facility cleaning company revealed: *She had previously been contracted to work for the facility for three years before moving to another district. *She had filled in for the designated district manager and other cleaning staff at the facility when needed. *She had been familiar with the facility and had last worked there in January 2021. *She was now district manager over another group of contracted facilities. *The district manager for this facility came on a weekly basis but had been out that day working at another location. *She stated the facility had not been as clean as it used to when she was the district manager. *She thought things had gotten worse with the current administration. *Laundry/housekeeping manager R had been responsible for the daily cleaning operations of the facility. -She had not been reliable about coming in to work as scheduled. -She had currently been the only housekeeper on staff. *A part-time housekeeper had just left their employment to return to school the week prior. *Laundry/Housekeeping manager R filled in for laundry on her off days. *Checklists were used to keep track of cleaning duties. *Laundry/housekeeping manager R had been responsible for making sure the checklists had been completed. *Administrator A completed monthly reports of the condition of the facility that she sent to their company. Observation and interview on 8/19/21 at 10:52 a.m. with laundry/housekeeping manager R cleaning resident room 101 revealed she: *Had not used the agency cleaning checklists to keep track of what she had completed. *Stated she had been responsible for training the laundry and housekeeping staff and would expect them to use the cleaning checklists. *Had not been tracking the checklists as she had been the only housekeeper on staff at that time. *While cleaning room 101 she: -Had sprayed the peroxide disinfectant cleaner on the toilet. -Stated it had a three-minute wait time. -Cleaned other areas of the restroom and then continued wiping down the toilet. -Had not waited three minutes before wiping down the surface of the toilet. -Had not made it a practice to use a timer and had just estimated the time. -Used the same gloved hands she grabbed the mop and placed and clean mop head on it. -Had not dust-mopped the floor before wet-mopping because she found it had been easier for her to gather the dirt as she wet-mopped. -Wet-mopped the floor area and collected dirt on a pile in the center of the resident room. -Gathered the dirt on the pile using the wet mop-head she had removed. -Discarded the dirt into the garbage on her cart, then placed the mop-head into a plastic bag. *Agreed that her gloves should have been changed prior to using the mop. *Agreed that she should use a timer for the three-minute wait time. *Agreed she should have changed her gloves prior to touching the mop. *Agreed she had not followed the company policy or the room cleaning checklist. *Stated she had been slacking lately and had not cleaned the facility as well as it should have been. Further interview on 8/19/21 at 2:04 p.m. with laundry/housekeeping manager R revealed: *Her workdays had been long. *Her priority was to make sure the resident rooms were cleaned. *She was usually able to get all of the resident rooms cleaned each day. *If she had not completed all of the resident rooms she would start on those the next day. *She had not always had time to complete all tasks such as cleaning the shower/tub rooms or utility rooms. *Confirmation she had not used the cleaning checklists as was the policy of her agency. *She agreed she had not been able to keep up with all of her duties. *She was the only person doing housekeeping at that time and hoped they could get someone hired soon. *It had been difficult to find workers. Further interview on 8/24/21 at 8:56 a.m. with district manager T revealed: *She had been filling in until another housekeeper could be hired to replace the part-time worker that went back to school. *She stated the laundry/housekeeping manager R had been scheduled to work at 7:00 a.m. that day but had not come in yet. *She stated this had been typical for her to come in late. *She thought laundry/housekeeper R had not understood the importance of her job. *They used their own policies and not the facilities for cleaning the building. *A copy of those policies had been requested but had not been received. Review of the 9/5/2017 contracted company's daily patient room cleaning checklist revealed: *A. Announce yourself at the door. *B. Do quick straighten up. *C. Follow 5-step room cleaning method: -1. Empty trash. -2. Horizontal dusting. -3. Spot clean with a cloth and disinfectant all vertical surfaces. -4. Dust mop the floor. -5. Damp-mop *When disinfecting, please be sure to use an EPA-approved solution and to allow for the recommended solution dwell time. Review of the high touch services log for August 2021 revealed: *It was to be completed three times daily, in the morning, noon and afternoons. *There had been blank entries for: -8/6/21 on the a.m. and afternoon times. -8/10/21 on the noon and afternoon times. -8/11/21 on the noon time. -8/12 on the afternoon time. -8/17 all times. -8/18 all times. -8/21 all times. -8/22 all times. -8/23 afternoon time. Review of the laundry/housekeeping manager job description revealed: *Interviews, hires and orients, housekeeping, floor care, and laundry staff. *Communicates between various shifts to ensure completion of tasks. *Maintains proper staffing levels and schedules all environmental services staff. *Supervises, coordinates, and evaluates work of all environmental services employees. *Trains workers in housekeeping, floor care, and laundry methods and procedures and proper operation of equipment. *Daily inspection (quality control inspections) and follows through on all assignments, directives and projects to ensure task completion. Review of housekeeping services assessment reports submitted to the contracted cleaning company by administrator A revealed: *She had assessed housekeeping services for the following dates ranked on a scale of 1-70 points: *3/15/21 had given 58/70 points which was ranked as average to good services. *4/30/21 had given 61/70 points which was ranked as good to excellent services. *No report of May 2021. *6/29/21 had given 60/70 points which was ranked as good to excellent services. *7/29/21 had given 57/70 points which was ranked as average to good services. Interview with administrator A on 8/23/19 at 5:33 p.m. revealed: *She stated she had not completed environmental audits of the building. *She expected her unit managers to do walk-throughs and to check for problems or cleanliness issues with the building or resident rooms. *All staff should be helping out to keep the areas clean and safe for residents.

Based on interview, record review, policy review, job description review, the provider failed to provide necessary care and services resulting in neglect for one of one resident (30) who had needed life-saving interventions including cardiopulmonary resuscitation (CPR). Findings include: 1. Resident 30 had not been provided the necessary care to ensure his resuscitation choice had been followed. No nursing interventions that included: nursing assessment of abnormal vital signs, repositioning, suctioning. and oxygen administration had been provided. CPR had not been started when his respirations were absent and it was uncertain if he had a heart rate. Review of resident 30's [DATE] care plan revealed: *He had an alteration in his neurological status which was related to trauma. *Staff were to: -If [CONDITION(S)] activity occurs, place on side, maintain open airway. Remove obstacles to ensure safe environment. -Monitor/document/report PRN [as needed] s/sx [signs and/or symptoms] of tremors, rigidity, dizziness, changes in level of consciousness, slurred speech. *He had a feeding tube related to swallowing difficulty from trauma, he was to not have anything by mouth. *Staff were to: -Monitor for signs and symptoms of aspiration pneumonia such as SOB [shortness of breath], Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction . -Observe for Signs or Symptoms of aspiration, respiratory infection and cardiovascular distress (paroxysmal coughing, fever over 100F[Fahrenheit] for 24 hr. [hour], chills, respiratory distress, dyspnea, wheezing, frothy non-purulent sputum. 2. Review of the provider's [DATE] Licensed Practical Nurse job description revealed: *Under the direct supervision of the Director of Nursing Services, provides prescribed nursing care services to residents. Works collaboratively with members of the healthcare team. Maintains standards of professional nursing practice. Performs other duties as assigned by supervisor. Completes shift duties in an accurate and timely manner. *Essential functions included: -Observes residents and reports adverse reactions to medication or treatment to medical personnel in charge. *Other duties included: -Enforces Center policies and processes to promote quality of care and to assure resident safety. -Other duties as assigned and appropriate to the position. *Knowledge, skills, and abilities included: -Demonstrates knowledge of nursing process, particularly as it relates to geriatric residents, long-term care, and rehabilitation. 3. A neglect policy had been requested from administrator A. She stated they did not have one. Refer to F678, finding 2.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being of all forty-four residents. Findings include: 1. Interviews, observations, record reviews, and policy reviews, throughout the course of the survey revealed the administrator and director of nursing had not ensured the safe management and overall well-being of the residents. Review of the provider's undated job description for the administrator revealed: *General purpose: To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's operational and business objectives. *Essential Job Functions: -Monitors each department's activities, communicates policies, evaluates performance, provides feedback, and assists, observes, coaches and disciplines as needed. -Develops an environment that allows for creative thinking, problem solving and empowerment in the development of a facility management team. -Oversees regular rounds to monitor the deliver of nursing care, operation of support departments, morale of the staff, and ensures resident needs are being addressed. -Utilizes survey information to address areas of importance as defined by our customers. -Ensures consultants and other support resources are appropriately utilized and a high level of interdepartmental teamwork is maintained. *Facility staffing and retention: Monitor Human Resources practices to ensure compliance with employment laws and company polices and to ensure practices that maintain high morale and staff retention to include effective communication, prompt and effective problem resolution, proactive supervisory practices, and maintaining a positive work environment. Review of the provider's 4/18/17 job description for the director of nursing revealed: *Duties and responsibilities: -Insures staff educated on any changes and new polices and procedures. -Makes daily rounds, coordinates nursing services with other resident services. -Staffs the recommended number and levels of nursing personnel to be employed. -Participate in planning, budgeting, and the development and implementation of resident-care policies. -Participate in medical reviews as dictated by the resident's levels of care. -Maintains positive working relationships with co-workers and management. *Essential Functions: -Provides direction to nursing staff to execute tasks necessary to implement operational objectives. -Establishes criteria to assure that services provided meet established standards of quality and practice. -Supervises development of in-service education programs designed to equip nursing staff with sufficient knowledge and skills to provide nursing and nursing related services to each resident. -Conduct or provide staff to conduct resident assessments as required, developing plans of care, evaluating residents' responses to interventions, and documenting clinical records effectively in compliance with state and federal requirements. -Insures that medical records are maintained in an organized manner. Review of the provider's 5/5/14 Director of Clinical Services job description revealed: *Duties and responsibilities: -Provides consulting services, direction and support in the identification, development and implementation of programs, systems, processes and procedures that support clinical services of the health care facilities in the efficient and effective delivery of quality care and services to the residents. Monthly onsite visits. -Observes identifies, evaluates, and recommends, in concert with facility staff, performance and process management standards to effectively manage the delivery of quality care and services to residents to meet or exceed all federal, state and company regulations, policies, and procedures. *Functions: -Directs and manages the clinical services of assigned facilities and programs with the facility Director of Nursing. -Assists personnel in making comprehensive medical assessment of resident's conditions to determine appropriate coverage decisions. -Provide oversight of MDS (Minimum Data Set) compliance. -Assists the Director of Nursing with State and Federal surveys and plans of correction. -Assts (assists) with the implementation of corporate policies affecting the nursing department. -Provides training to new Directors of Nursing. *Standards: Residents always come first, and their needs will be met unless there is a conflict with the needs of others or the organization as a whole. Refer to F278, F280, F314, F360, F493, and F520.

Based on observation, interview, record review, and policy review, the provider failed to ensure three of three newly admitted sampled residents (1, 2, and 6) and one of one long-term admission sampled resident (3) had received the appropriate care and service to prevent new pressure injuries from occurring or to prevent current pressure injuries from worsening. Findings include: 1. Observation on 7/5/17 at 12:55 p.m. of resident 6 in a recliner in the south hallway revealed: *She was sitting with her feet in an elevated position. *There was no pressure-relieving cushion placed underneath the resident. Observation and interview on 7/5/17 at 3:00 p.m. with licensed practical nurse applicant (LPN applicant) D and resident 6 in her room revealed: *The resident had been using the bathroom and was being observed by the nurse due to her high risk of falls. *The resident had declined to have her wound observed at that time. *LPN applicant D was unaware of any areas of skin concerns that required observation or the use of a dressing. -She pointed to several dime-sized faint and fading bruises near the resident's left shoulder and front of left hip from recent falls. Observation on 7/5/17 at 5:25 p.m. of resident 6 in the south hallway revealed she was sitting in a wheelchair with no pressure-relieving cushion on the seat. Observation on 7/5/17 at 6:48 p.m. of resident 6 in the south hallway revealed she was sitting in the recliner with no pressure-relieving cushion on the seat. Observation and interview on 7/7/17 from 8:10 a.m. through 8:25 a.m. with resident 6, the director of nursing, and LPN E revealed: *She was lying in a recliner with her feet elevated. *There was no pressure-relieving cushion underneath the resident. *When asked if she slept in the chair all night she said, Yes. *The resident was assisted by the above staff to pivot and transfer to the wheelchair and was escorted back to her room for privacy. *While in the standing position in her room the resident was observed: -To have a deeply reddened area approximately the size of a deck of cards on the back side of her left upper thigh and lower buttock. -Within the reddened area was a nickel-size area of a very deep red/purple in the upper left corner. -There was a pencil eraser size scab in the lower left corner of the wound. *LPN E commented there was no dressing and placed a new [MEDICATION NAME] dressing on the wound. Review of the medical record for resident 6 revealed: *She was admitted on [DATE] for skilled care following a hospitalization and history of multiple falls. *She had [DIAGNOSES REDACTED]. *The initial nursing evaluation and interdisciplinary progress note on 6/27/17 revealed: -Scattered bruising to BUE (bilateral upper extremities), BLE (bilateral lower extremities), abdomen and left hip due to frequent falls. -It did not indicate any pressure-related wounds or treatments were present. *Her 6/27/17 Braden scale measurement was eighteen indicating she was at risk for developing pressure injuries. *The 6/29/17 registered dietician assessment indicated her skin was intact. *On 7/5/17 the section M, skin conditions was completed for her admission Minimum Data Set assessment. -It indicated she was not at risk for developing pressure ulcers and had no unhealed pressure areas. Review of the weekly wound documentation for resident 6 revealed: *On 6/28/17 LPN E had identified a stage one pressure ulcer concern measuring 5.5 centimeters (cm) by 4.2 cm. -The location was selected as the right gluteal fold. -Clarification from LPN E on 7/7/17 at 9:55 a.m. revealed the location was an error, and it should have read left trochanter (hip). -The current treatment was a foam dressing. -A small scab was noted on the distal end of the stage one ulcer that measured 0.3 cm by 0.6 cm. -The registered nurse (RN) analysis and plan along with RN signature and date were left blank. *On 7/5/17 LPN E noted the measurement of the stage one pressure injury was 6.8 cm by 6.8 cm. -The progress was marked as improved. -The current treatment was a foam dressing. -The RN analysis and plan along with the RN signature and date were left blank. *On 7/5/17 LPN E identified an additional area of a stage one pressure ulcer to the left trochanter. -It was 0.5 cm by 0.7 cm with a depth of 0.1 cm. -The progress was noted to be improved. -The current treatment was a foam dressing. -LPN E did not clarify if that was the scab noted in the 6/28/17 wound documentation. -The RN analysis and plan along with the RN signature and date were left blank. Review of the physician's orders [REDACTED]. *Foam dressing for wound with light to moderate drainage and for protection over bony prominence 1)left upper thigh/buttocks area of ecchymosis .changed dressing q (every) 3-5 days or as needed dependent on drainage. *That order was not present on the resident's treatment administration record to be completed by nursing staff. Resident 6's undated care plan revealed it did not address any skin concerns or interventions to prevent skin breakdown. Interview on 7/5/17 at 3:05 p.m. with CNA/medication aide/dietary aide G revealed resident 6 was frequently in the recliner during the night and most of the day due to her history of falls. Interview on 7/7/17 at 8:00 a.m. with LPN F regarding resident 6 revealed: *She frequently slept in a recliner near the nurses desk. *There was no pressure-relieving cushion placed in the recliner to help alleviate pressure areas. *She was able to move around in the chair, adjust herself, and would try to get up on her own at times. *LPN F was unaware of any skin issues with resident 6. -She acknowledged it was her responsibility to know who had wounds in the building. Interview on 7/10/17 at 4:40 p.m. with the director of nursing revealed it was her expectation: *The initial assessment and documentation was to include the skin. *Nursing staff were to be aware of skin concerns and appropriate interventions to prevent breakdown. *The care plan was to address areas of concern along with interventions. -She acknowledged that was not in place with resident 6's care plan. 2. Observation on 7/5/17 at 8:15 a.m. of resident 1 revealed: *She had been sitting in a wheelchair (w/c) by the nurses' station. *There had been a pressure relieving cushion in her w/c. *She had: -Made frequent, uncontrollable, and stiff movements with her arms. -Appeared to be very thin and frail. Interview on 7/5/17 at 8:20 a.m. with registered nurse (RN) A regarding resident 1 revealed she had: *Been admitted on [DATE]. *A [DIAGNOSES REDACTED]. *Been confused and required close monitoring from the staff related to a history of frequent falls. *A stage two pressure ulcer to her coccyx. -That pressure ulcer had been acquired after her admission into the facility. *A physician's orders [REDACTED]. At the time of the above interview with RN A the surveyor had requested to watch the staff assist resident 1 with any personal care, transfers, and dressing changes. Continued random observations on 7/5/17 from 8:15 a.m. through 11:30 a.m. of resident 1 revealed: *She had been up in her w/c the entire morning. *At 11:30 a.m. two staff members assisted the resident with changing her incontinence brief. -She had been incontinent of urine. -The urine had soaked through the brief and onto her pants. -There was no dressing in place to ensure the wound on her coccyx did not come in contact with the urine. -RN A applied a new protective dressing. Observation on 7/5/17 at 1:30 p.m. of resident 1 revealed: *She had been laying on her back in bed resting. *Her feet were not off-loaded to relieve pressure and had been laying directly on the bed. *Her coccyx where the pressure ulcer was located had been laying directly on the bed. *No pressure relieving devices had been observed in her bed. Continued observation on 7/5/17 at 2:30 p.m. of resident 1 revealed her position in bed was unchanged from the 1:30 p.m. observation. Review of resident 1's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She had been dependent upon the staff to: -Assist her with all of her mobility needs for transferring from place-to-place and moving in bed and activities of daily living (ADL). -Implement any preventative interventions to ensure skin breakdown would not have occurred. *She had no nursing physical assessment to support an area of concern on her coccyx at the time of her admission. *On 6/13/17 her Braden pressure ulcer risk assessment score was fourteen. -That score indicated she had been at moderate risk for developing pressure injuries. *On 6/22/17 a reddened area had been identified on her coccyx. -The staff had been instructed to apply a barrier cream for protection and position her onto her side while in bed. *On 6/25/17 she had acquired a stage two pressure ulcer. *That pressure ulcer had been: -Located on her coccyx. -Acquired within thirteen days of her stay in the facility. *No documentation to support the dietician had been notified of the opened area to her coccyx. Review of resident 1's initial 6/19/17 comprehensive care plan revealed: *A focus area: Skin: my skin is intact. -Initiated 6/19/17 with no revision date. *Goal under that focus area was: I want to keep my skin clean, dry, and intact. *Interventions under that focus area were: -I want staff to monitor for any potential skin breakdown. -I have a pressure relieving pad on my chair. -I have a pressure relieving mattress on my bed. *No documentation to support: -She had been at risk for skin breakdown. -How often she should have been repositioned. -If she should have been positioned on her side as indicated on 6/23/17. -If her feet should have been elevated or off-loaded to ensure pressure relieving had occurred. *A focus area: Diet/Eating: I require total assistance in eating. -Initiated 6/23/17 with no revision date. -Did not identify an opened area to her coccyx. *Interventions under that focus area did not support a diet change to ensure the healing of a wound to her coccyx. *On 7/3/17 five focus areas on her care plan had been reviewed and revised but had not supported: -A stage two pressure ulcer to her coccyx. -A repositioning program with preventative skin measures to ensure no further skin break down occurred. Continued medical record of resident 1 revealed there was no initial or temporary care plan to review for resident 1 from the time of admission on 6/13/17 through 6/19/17. Interview on 7/5/17 at 3:10 p.m. with CNA/dietary aide G revealed: *Resident 1 sat in her w/c most of the day. *She had required increased monitoring from the staff due to her history of falls. *Residents should have been repositioned or toileted every two hours. Review of resident 1's nursing progress notes from 6/13/17 through 7/5/17 revealed: *On the 6/13/17 admission note: -Multiple bruises noted to bilat (bilateral) UE (upper extremities), bilat LE (lower extremities), buttocks, legs from falls at home. -Pt (patient (resident)) is 2 assist for all transfers, NWB (non-weight bearing) at this time. *On 6/22/17: -Coccyx is reddened, barrier cream applied and resident laying side to side in bed. -Resident is 2 assist with transfers. *On 6/25/17: -Resident has new stage 2 to buttock. -No documentation to support what preventative measures were put in place to ensure no further skin break down had occurred. Review of resident 1's 6/25/17 and 7/3/17 weekly wound documentation report revealed: *The documentation supported the opened area to her coccyx. *A fax was sent to the physician for a treatment order. *Had not described what preventative measures or plan had been put in place to ensure no further skin break down. Review of resident 1's 6/20/17 Minimum Data Set (MDS) admission assessment, section M, skin conditions revealed she had been at risk for skin break down but did not require a repositioning program. Review of resident 1's 6/27/17 MDS fourteen day assessment, section M, skin conditions revealed: *She continued to be at risk for skin break down with no repositioning program. *No documentation to support a stage two pressure ulcer had been identified during this assessment time period. Interview on 7/5/17 at 5:35 p.m. with RN A regarding resident 1 revealed: *She had been a nurse manager until 6/1/17. -At that time she became a charge nurse. *She confirmed the resident: - Would sit in her w/c at the nurses' station for long periods at a time. -Had acquired a stage two pressure ulcer after her admission and while receiving care from them. -Should have had skin concerns identified on her care plan. *She had an air mattress for pressure relief upon admission. -That air mattress had been removed and given to another resident who needed it worse. *She agreed the resident: -Had been at high risk for skin break down and preventative measures should have been implemented upon admission. -Should have been repositioned or toileted every two hours. -Should have been using repositioning and off-loading devices when resting in bed. Observation on 7/7/17 at 7:40 a.m. of resident 1 revealed: *She had been laying on her back in bed. *Her feet were not off-loaded to relieve pressure and had been laying directly on the bed. *Her coccyx where the pressure ulcer was located had been laying directly on the bed. *No pressure relieving devices had been observed in her bed. Interview on 7/7/17 at 8:00 a.m. with LPN F revealed she: *Had been a charge nurse and primarily worked the night shift. *Had not been aware resident 1 had a stage two pressure ulcer to her coccyx. Review of the 6/29/17 registered dietician's report revealed: *He had been in the facility to complete resident chart reviews. *No documentation to support the dietician had reviewed resident 1's medical record for a stage two pressure ulcer. Interview on 7/7/17 at 9:25 a.m. with the registered dietician revealed: *He confirmed he was in the facility to do chart reviews on 6/29/17. *He had not been informed nor was he aware of the stage two pressure ulcer resident 1 had on her coccyx at the time of this interview. *He agreed: -The staff or dietary manager should have informed him of the wound. -The resident should have had an increase of protein in her diet to ensure proper healing of that wound. -The care plan should have been updated about a wound to her coccyx with dietary support interventions. *He stated She eats very poorly and does not get enough protein in her diet. 3. Interview on 7/5/17 at 8:25 a.m. with RN A regarding resident 2 revealed she had: *Fallen at home and fractured her right wrist and right hip. *Two days after her admission the staff had identified an unstageable wound to her right heel. *She stated: That wound had required [MEDICATION NAME] a while back. *Been out of the facility that morning for a procedure. Random observations on 7/5/17 from 1:00 p.m. through 3:00 p.m. of resident 2 revealed: *She had returned from her appointment and was sitting in a recliner in her room. *She was alert, oriented, and capable of making her needs known. *There was a blue pressure relieving boot laying on her bed. *She stated: -I do not wear that thing when I am in bed or walking, but all the other times I do. -Not sure why. *She confirmed she had a wound located on her right heel that caused her no discomfort. Observation on 7/7/17 at 8:45 a.m. with LPN E of resident 2's right heel during a dressing change confirmed the wound located on her right heel. Review of resident 2's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She had been dependent upon staff to assist her with all of her mobility needs and ADLs. *Her admission nursing physical assessment had no documentation to support a fully body skin assessment. *No Braden pressure ulcer skin assessment had been completed to determine her level of skin break down risk until 5/7/17. -That score was a nineteen indicating she was at low risk for skin breakdown. -The Braden assessment supported her mobility was slightly limited, she walked occasionally, and there was a potential for friction and shearing to occur. *On 4/18/17 she had acquired a suspected deep tissue pressure injury. *That pressure injury had been: -Located on her right heel. -Acquired within two days of her stay in the facility. Review of resident 2's initial 4/25/17 comprehensive care plan revealed: *A focus area: Skin: I have a skin issue: Pressure ulcer to my right heel. -That focus area was not initiated until 4/25/17 which was ten days after her admission and seven days after an area of concern had been identified. *Interventions under that focus area supported a repositioning program with pressure relieving devices. -Was not initiated until 4/25/17 which was ten days after her admission and seven days after an area of concern had been identified. *A focus area: Diet/Eating: I am independent in eating. -Initiated 5/3/17 with no revision date. -Did not identify a wound to her right heel. *Interventions under that focus area did not support a diet change to aide in the healing of a wound to her right heel. Continued medical record review for resident 2 revealed there was no initial or temporary care plan to review for resident 2 from the time of admission on 4/15/17 through 4/25/17. Review of resident 2's nursing progress notes from 4/15/17 through 7/5/17 revealed: *On the 4/15/17 admission note: -Other skin conditions present: Scattered bruising to BUE, some bruising to the buttocks, bruising and surgical incision to right hip. -No documentation so support a wound to her right heel. *On 4/18/17: Right heel has water blister distally and suspected deep tissue loss, order for air boots. -No documentation to support: --What other preventative measures would be put in place to ensure no further skin break down. --The care plan was updated or initiated to support the area of concern with preventative measures. Review of resident 2's 4/19/17 weekly wound documentation report revealed: *The documentation supported the deep tissue injury to her right heel. *No documentation to support when the physician was notified. *The plan and analysis section stated Will monitor. There had been no weekly wound documentation reports to review for that deep tissue injury from 4/20/17 through 6/13/17. Interview on 7/5/17 at 3:45 p.m. with RN A regarding resident 2 revealed: *She confirmed: -There was no skin assessment completed on the resident upon admission. -The deep tissue injury to her right heel was observed two days after her admission. -There were no preventative measures in place to ensure no skin break down would occur. *She agreed there was no plan put into place after the wound had been identified in a timely manner, and there should have been. Interview on 7/10/17 at 10:40 a.m. with the medical director regarding resident 2 revealed: *He was her primary physician and had been notified of the wound to her right heel during his weekly rounds. *He stated: -She should not have gotten a pressure ulcer. -No pressure ulcer should have happened on their watch. *He agreed she was admitted in a weakened state, and the staff should have identified that. 4. Observation and interview on 7/5/17 at 8:00 a.m. with CNA/bath aide B regarding resident 3 revealed:*He utilized an electric wheelchair to get around in the building. *He had recently returned from the hospital and had a pressure ulcer on his buttocks. *She was unsure if he had been admitted with the pressure ulcer or if it was acquired in-house prior to his hospitalization . *She had only worked for the provider for about a month. Interview on 7/5/17 at 8:20 a.m. with CNA/medication aide C regarding resident 3 revealed: *He used an electric wheelchair to get around in the building.*She thought he had a stage two pressure ulcer on his buttocks. *The nurses did the treatments for any residents' pressure ulcer areas. Interview on 7/5/17 at 8:25 a.m. with LPN applicant D revealed:*She had started working at the facility about one year ago and was a medication aide prior to completing nursing school. -She still needed to complete her boards test. *She was the nurse for the east and west wings that day. *When asked which residents had pressure ulcers or skin concerns she did not mention resident 3. Observation and interview on 7/5/17 from 10:15 a.m. through 10:50 a.m. with resident 3 in his room revealed: *He was laying in bed on his back.*He had lived there about two and one-half years. *Recently he had been hospitalized because of the pressure ulcer on his buttocks. *He had a history of [REDACTED]. *He stated he could move a little by himself, but the staff helped him with all his care and transfers. *He had a spinal injury and had lost some of his feeling from his waist down. *He was unable to walk and used an electric wheelchair to get around. *At 10:40 a.m. LPN applicant D came to his room and stated she needed to do his skin treatments. *She assisted him to roll to his right side and pulled down his pants. *He had a large, approximately baseball-sized pressure ulcer to his sacrum that had a large black-like center and was pink/red to the surrounding area and edges. *There was another pressure ulcer to his right buttock approximately quarter-sized that was pink/red and appeared to be a stage two injury. *Both those areas had no dressings on them. *She stated the physician's orders [REDACTED]. *She used the [MEDICATION NAME] swab sticks, painted the [MEDICATION NAME] onto his pressure ulcers, then pulled his pants back up, and rolled him onto his back again. *She stated the charge nurses just did the treatments they did not do the wound assessments. -The staff development nurse did the assessments weekly on Wednesdays. Interview on 7/5/17 at 5:45 p.m. with RN A revealed:*She was a charge nurse and had been a nurse manager and MDS assessment nurse until recently. *Resident 3 was at high risk for skin breakdown due to his immobility and history of pressure ulcers. *His current large unstageable pressure ulcer to his coccyx had worsened significantly since it had started as a stage two injury. *He had a history of [REDACTED]. -When that happened they started his as needed treatment which usually healed it up quickly. *This time his pressure ulcer kept getting worse, and she was unsure what had changed. *She confirmed there were missing documented wound assessments to monitor the progress of his pressure ulcers. -Wound assessments should have been completed weekly and put into his electronic medical record. *Her and the other nurse manager had been responsible for the wound assessments until the beginning of June 2017 when the staff development nurse had taken them over. -Prior to June they were unable to get their wound assessments done, because they had to cover as charge nurses and had many other job duties. Interview on 7/7/17 at 7:55 a.m. with LPN F regarding resident 3's skin revealed:*She was aware of his pressure ulcers on his buttocks. *The sacrum pressure ulcer had worsened significantly since she had started working in March 2017. Interview and record review on 7/7/17 at 9:25 a.m. with the registered dietitian regarding resident 3 revealed:*Sometimes it was difficult to find out which residents had pressure ulcers when he asked the staff. *He was aware of the resident's current pressure ulcers. *On 6/2/17 he had given a recommendation for the resident to have a high protein bedtime snack to aid in healing. *When he made recommendations for a resident he gave a copy to the charge nurse, DON, and dietary manager. *He expected those recommendations to be completed and followed-up on. -He was unsure if the resident was getting that bedtime snack as recommended. Review of resident 3's medical record revealed:*He was initially admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He had a history of [REDACTED]. *He was dependent on staff for ADLs. *His 1/12/17, 3/3/17, 5/31/17, and 6/29/17 Braden assessment scores were sixteen. -Those scores indicated he was at risk for skin breakdown. -Notes on those included he had a cushion in his wheelchair and an air mattress on his bed. --No other interventions were listed. Review of the resident 3's physician's progress notes and orders from December 2016 through 7/7/17 related to his skin revealed: *There was no mention of skin concerns from his 2/6/17 physician visit. *On 2/22/17 a faxed order was received in response to an update of his stage two coccyx pressure ulcer. *On 3/6/17 the treatment was discontinued from a faxed update that the area was healed. *On 4/10/17 a treatment was started to his coccyx again. *On 6/2/17 the treatment was changed in response to a request related to three pressure ulcers on his coccyx. *On 6/22/17 he saw a wound specialist who changed his treatment orders and diagnosed and unstageable pressure injury to his coccyx. -An order was given to reposition him every hour and a half to two hours and avoid lying on his back. *He was hospitalized from [DATE] through 6/29/17 with [DIAGNOSES REDACTED]. -His 6/28/17 hospital progress note indicated he had an unstageable ulcer to his sacral area with eschar. Review of resident 3's 12/30/16 through 7/7/17 interdisciplinary (IDT) progress notes related to his skin revealed:*There was no mention of opened areas or pressure ulcers until 2/3/17. *On 2/3/17 Observed skin after shower. Patient had 3 areas of discoloration and redness to his coccyx and buttocks. All areas blanch. Applied barrier cream and encouraged side lying . *The next note was on 2/21/17 stated Stage II (two) observed after shower. Change in condition completed and faxed to Dr. (name) for orders . -The note did not mention where the area was located. *The 2/21/17 change in condition evaluation form mentioned a new stage two pressure ulcer to his sacrum/coccyx. -There were no measurements or other descriptions of the ulcer. *On 2/27/17 Resident has stage II pressure ulcer to left buttock that has reopened. MD notified and treatment order obtained, family notified, and dietitian notified. Root cause analysis completed and determined pressure ulcer reopened due to resident not repositioning and being up in wheelchair for majority of the day. Resident has been educated on importance of laying down in between meals or offloading at least hourly while up in chair. -There was no mention if the repositioning or time in the wheelchair was due to staff or resident non-compliance. *On 4/11/17 .He has a 2.5 x 3 and 4 x 3 pressure ulcer on his coccyx area. wound note completed. orders for [MEDICATION NAME] in chart. *On 6/1/17 the registered dietitian assessment indicated his skin was intact, and no interventions were listed. *On 6/1/17 nursing wrote Patient has 2 open areas to coccyx. Faxed physician to see if we can switch the current order of [MEDICATION NAME] to [MEDICATION NAME] around the site and apply Santyl instead to the wounds. *On 6/2/17 the registered dietitian wrote .res has 3 unstageable wounds to coccyx. Also has wound in groin area . *On 6/8/17 .noted improvement since changing the wound order to Santyl and [MEDICATION NAME] daily. *On 6/16/17 .Coccyx and buttocks have worsened and it appears as though the dressing is causing a reaction to the skin surrounding the wound beds. A note will be faced to Dr. (name) . -Family was updated, and a wound clinic appointment was set up. *On 6/22/17 he went to the wound clinic. *On 6/24/17 he was sent to the emergency room and admitted to the hospital. *On 6/29/17 he returned from the hospital. -The skilled status note stated .unstageable to coccyx with eschar, necrosis, slough. [MEDICATION NAME] applied and ota (open to air) . *On 7/3/17 pressure ulcers to coccyx. stage 2 to left buttock 2.5 x 1.5. unstageable with eschar to coccyx 9.5 x 6.5. [MEDICATION NAME] and ota . *On 7/5/17 the dietary manager's nutritional review indicated he had a stage one or two pressure ulcer. -That did not match the nursing documentation of unstageable areas. -There were no further notes related to his skin status and interventions in that section. *There was minimal documentation to support the resident was non-compliant with repositioning or offloading. Review of resident 3's wound assessments documentation from December 2016 through 7/7/17 revealed: *On 7/5/17 at 1:30 p.m. all wound assessments were requested from the DON and nurse consultant. -The nurse consultant stated all wound assessments should have been in the medical record.*The only completed weekly wound assessment form in his electronic medical record was on 3/2/17. -That assessment listed a stage two pressure ulcer to his sacrum that was healed. *There were no assessments for: -The sacrum/coccyx area that started on 2/21/17, other than the 3/2/17 note. -The left buttock pressure area that started on 2/27/17. -The coccyx area that started on 4/11/17 -The two coccyx areas that had started on 6/1/17 and had worsened. *On 7/5/17 later that day a handwritten paper flow sheet was provided that indicated: -Measurements and treatments for pressure ulcers on his coccyx and sacrum on 5/16, 5/23, 6/7, 6/14, and 6/21. --There was no documentation of what year they were from or who had done the documentation. -On 5/16 the coccyx pressure ulcer was 1.5 cm by 2.0 cm with no stage listed. -By 6/21 it had worsened to a coccyx pressure ulcer of 6.0 cm by 3.3 cm and a sacrum pressure ulcer of 2.5 cm by 2 cm with no stages listed. Review of resident 3's 6/29/17 a Comprehensive Evaluation of Skin Inspection and Risk Factors form at the time of his hospital return indicated he had: *An existing pressure ulcer and was chairfast. *Fragile skin. *Contributing [DIAGNOSES REDACTED]. *An unstageable left buttock pressure ulcer measuring 8.8 cm by 4.3 cm. *An unstageable left buttock pressure ulcer measuring 6 cm by 2 cm. *A stage two right buttock pressure ulcer measuring 0.6 cm by 0.5 cm. *A stage two right buttock pressure ulcer measuring 0.5 cm by 1.1 cm. *A stage three right buttock pressure ulcer measuring 2.9 by 1.5 cm. *Excoriation to his groin. *Stag

Based on observation, interview, record review, job description review, and policy review, the governing body failed to ensure the facility was managed in a manner that ensured the safe management and overall well-being for all forty-four residents in the facility. Findings include: 1. The following deficiencies were repeated deficiencies from the previous complaint and recertification survey on 12/7/16: F280, F314, F490, F493, and F520. The following were newly cited deficiencies for the current survey: F278 and F360.

Based on observation, interview, record review, and policy review, the provider failed to ensure an effective quality assurance (QA) program had been implemented and followed through for resolution for identified deficiencies and to develop and implement corrective actions for all residents. Findings include: 1. Review of the provider's 6/15/17 Quality Assurance and Performance Improvement (QAPI) Agenda and Meeting Minutes revealed: *The administrator, DON, medical director, previous nurse mangers, social services, business office manager, activity director, dietary manager, maintenance director, director of rehabilitation, and staff development nurse had attended the meeting. *Quality measures including pressure ulcers were reviewed. The analysis included: -In April .saw increase in pressure ulcers, . -In June Increase noted in falls, increase in pressure. --There was no mention of what was done about those increases. *For the topic of pressure ulcers which should have included trends and root cause analysis there were no percentages listed for January, March, April, or May 2017. Notes included: -In January Will start implementing weekly measurement assessments into binder monthly for February and then going forward. PU PIP (performance improvement plan) completed in February. -In February For February there were 9 PU's. 1 facility acquired - which was a resident who was healed and then re-opened. 8 admitted . -In March 9 PU with 1 acquired, the rest were admitted . -There was nothing listed for April or May. *For the regulatory topic they discussed past survey deficiencies. -For F314 Audits have been in compliance. -There was no mention that the audits had not been occurring since April. *Current month Action Plan included pressure ulcers with the DON and previous nurse manager as the persons accountable. -Root cause analysis was Identify current system and what else needs to be added. -The goal included Subgroup to address root-cause analysis/prevention methods. -Action steps included Modify audit tool. *Performance improvement projects listed Pressure ulcers and stated see attached. -There were no attachments related to pressure ulcers; there were attachments on call lights and weight inconsistencies only. Interview on 7/10/17 at 10:45 a.m. with the medical director revealed: *He usually attended the monthly QAPI meetings. *Areas covered at the meetings consisted of: -Casper reports. -Specifics on individual residents. -Issues for the month. -Call light concerns. -Grievances. *Pressure ulcers had been discussed at the QA meetings, but no changes or action had taken place to his knowledge. *He was not always informed of skin concerns with his residents. *He was aware that the director of nursing (DON) was currently working on skin assessment upon admission. -Those had not always been happening. *He was unsure why the audits from the previous survey had stopped in April 2017. *Communication in the facility had been poor with several role/job changes recently occurring. -Those role/job changes had created a lot of turmoil with the staff. *He agreed the poor communication had affected the care and services the residents required. Interview on 7/10/17 at 3:45 p.m. with the administrator revealed: *He had started on 4/24/17 and had worked with the interim administrator for the first few weeks. *She was still available as a resource after that if he needed along with administrators in other facilities. *When he started they were still working on the plan of correction from the December 2016 recertification survey. -He was unsure why the audits had just stopped happening after April 2017. *The June 2016 mock survey identified a concern with pressure ulcers but they had just started working on the plan of correction for that survey. *He agreed the mock survey document did not address all the concerns with pressure ulcers that the surveyors had identified currently. *He knew they had been working on the admission nursing assessment of the residents to ensure all skin concerns were identified promptly. *He agreed the QA notes indicated an increase in pressure ulcers in April 2017 and June 2017 with no plan identified on how to improve that. *He confirmed staff should have known which residents had skin concerns and especially the leadership team. *Communication between departments had been a problem, and that could have affected the residents' care. Interview on 7/10/17 at 4:40 p.m. with the DON revealed: *She had started in the middle of April 2017. *She was aware of the provider's history of pressure ulcers identified during recertification survey in December 2016. *Sometimes there was a reactive versus proactive approach to concerns in the past and she was working to improve that. *The previous nurse managers had been responsible for the weekly wound assessments and overseeing wound care. -She had not followed up with them to ensure that had occurred. *She confirmed there was a high percentage of acquired pressure ulcers. *All nursing staff should have known which residents had pressure ulcers or who was at risk for skin breakdown. *Staff should have implemented interventions to prevent and help heal pressure ulcers. *Communication between departments had not been good. *The IDT should have worked collaboratively to improve resident care. *She was unsure why the audits from the previous survey had stopped in April 2017. -They should have continued. *She stated the staff development nurse who was now responsible for the wound assessments would confirm the same concerns as her. -She stated there was no need for her to be interviewed because her responses would have been the same Interview and record review on 7/10/17 at 5:30 p.m. with nurse consultants K, L, and M and the director of operations revealed: *Earlier in the day nurse consultant K had brought a section of the 6/7/17 and 6/8/17 mock survey document and the 7/6/17 and 7/9/17 Ad Hoq quality meeting minutes for the surveyors to review. *They had identified a problem with pressure ulcers during their mock survey, but the correction plan had not been implemented and audits had not started yet. *The mock survey document included: -The deficient practice of: --Weekly wound assessments showed the wound had declined on a resident, and the physician was not notified. --Wound documentation had not indicated wounds were being monitored weekly. -Corrective action was supposed to have been: --Weekly wound documentation would be implemented in the electronic medical record. --CNAs would be educated on documenting refusals. --Visual wound checks every shifts would be added to the nurses treatment record. -Systematic changes included: --Education to be provided to nurses and medication aides on 6/28/17. --Dressing change competencies for nurses to be completed by 7/15/17. --CNA education along with competencies to be completed by 7/15/17. *The mock survey had not identified all the areas of concerns with pressure ulcers that the surveyors had found currently. *The Ad Hoq quality meeting minutes indicated the meeting had been conducted after the survey had begun and surveyors had been questioning staff about pressure ulcers. -Root cause analysis was Admission checklist not being completed appropriately to include completion of the initial skin assessment within 2 hours of admission. Audits were being completed monthly through April, then with change in position of previous unit managers, the audits were not reassigned and were not completed in May and June. Review of the provider's 2014 QAPI Purpose, Guiding Principles, and Scope for QAPI policy revealed: *Mission Statement: To exceed customer expectations through [MEDICATION NAME] quality care, innovative services and positive operational outcomes. *Core Values: Respect .I will show consideration and appreciation toward the residents for whom we care, the families who entrust their loved ones to us, our co-workers who share in the desire to serve, and all others who enter through our doors. *The administrator with assistance from the DON were responsible for leading and directing the QAPI program. *The program was to have addressed systems of care and management practices,and included clinical care, quality of life, and residents' choices. Refer to all findings in: F278, F280, F314, F360, F490, and F493.

A. Based on observation, record review, interview, and policy review, the provider failed to ensure assessments and interventions were in place for two of two sampled residents (3 and 15) who had a history of [REDACTED]. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 11/30/16 at 5:45 p.m. to the administrator, the director of clinical services, and the director of nursing (DON). The administrator was asked for an immediate plan of correction to ensure all residents would be safe from elopement risk. PLAN: On 12/1/16 at 2:23 p.m. the administrator provided the surveyors with an immediate written plan of correction (PoC). That PoC dated 12/1/16 was accepted at 2:25 p.m. by the surveyors and included: Elopement: Resident #3 was reassessed by NM-A (nursing manager A) on 11/30/2016. Based on the new assessment the following interventions were added to the care plan for Resident #3: · I become more agitated when my husband is out of the building at appointments. Please encourage me to attend activities and provide 1:1 supervision until my anxiety subsides. · Attempt to change conversation to redirect resident's persistence and perseveration on leaving facility. · Offer PRN (as needed) medication when redirection, distraction and non-pharmacological interventions are ineffective. The Elopement, At Risk policy and procedure was reviewed on 12/1/2016 by the Director of Nursing and Director of Clinical Services and remains current. 15 other residents identified as cognitively impaired and independently mobile were reassessed for elopement risk: care plan updates were implemented for the following residents on 11/30/2016: · Residents #18 - 33 (residents 2, 12, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29) Education to all staff by DON or her designee on elopement policy and procedures was immediately implemented and will continue until all staff have been reeducated. Education to all staff will also include re-education prior to or during next shift, regarding response to the facility door alarm system, making sure no resident has left the building by physically checking outside and the need to respond immediately to any exit alarm. During the survey on 12/1/16 at 2:25 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Observation on 11/29/16 at 10:00 a.m. of resident 3 revealed she had been sitting on her FWW seat by the east exit door looking out the window. No staff had attempted to redirect her away from the door. Surveyor Observation on 11/30/16 at 11:15 a.m. of resident 3 revealed she had been sitting on her front wheeled walkers (FWW) seat by the east exit door looking out the window. Certified nursing assistant (CNA) J asked the resident how she was doing but had not attempted to redirect her away from the door. Surveyor Review of resident 3's 9/30/16 Minimum Data Set (MDS) assessment revealed her thinking was severely impaired. Review of incident reports not reported to the South Dakota Department of Health (SD DOH) regarding resident 3 revealed: *She had eloped or left the faciity on [DATE], 8/3/16, 8/20/16, 8/30/16, 9/8/16 (twice), and 9/10/16 (twice). *The 6/8/16 report stated Charted that resident left building, staff was aware as she set off alarm and staff went outside with her. *The 8/3/16 report stated Resident exited building, staff was aware as they saw her leave and she set off alarm. Staff then sat outside with her. *The 8/20/16 report stated Nurse charted that CNA went to check on resident d/t (due to) elopement earlier this shift. Staff interviewed and resident did not truly elope but left the building setting off the alarm alerting staff and staff immediately went out with resident and sat outside with her. *The 8/30/16 report stated Charted that resident exited building on own, resident set off alarm and staff went out with resident immediately and able to get resident back inside building. *The 9/8/16 report stated Charted that resident exited building twice, staff was aware as she set off alarm and they were outside with her. *The 9/10/16 report stated Charted that resident left facility twice this shift. When staff interviewed, stated alarm went off and staff followed resident outside, sat with her and able to redirect resident back into building. *There had been no documentation those incident reports had been investigated. *There had not been an incident report for the 8/2/16 elopement documented in the interdisciplinary notes below. Review of resident 3's 9/14/16 incident report sent to the SD DOH revealed: *A staff member was on her lunch break and had gone to the store when she noticed (resident name) walking with her walker about two blocks from the facility. *The staff member redirected her back to the facility . *Resident became violent towards staff and residents . *Resident continued to attempt to elope but was stopped by staff. *Writer contacted eLTC to see if we could get something to calm resident down. *Received a verbal order for Haldol 2 mg (milligrams) IM now. *Writer drew up Haldol from e-kit. *Resident's family notified of incident. *Nursing management decided to withdraw from using the Haldol and decided it would be best to contact non-emergency transport to transport her to the Avera ER . *The resident was not capable of providing an explanation of the event or able to participate in the investigation. *The conclusion of their investigation stated: -Resident is currently hospitalized at Avera Behavioral Health Center in Sioux Falls, SD. -Staff that where (were) in the facility where (were) interviewed and no one turned the alarm off that they recall. -The door alarms where (were) checked by the Adm. all where (were) working at 11:30 a.m. -There where (were) visitors in the room beside the east door and they do not recall anyone going out the door when they came in. -(Resident name) was seen at 10:45 a.m. in her room that is located right beside the east door. Review of resident 3's 7/2/16 through 11/29/16 interdisciplinary notes revealed: *On 8/2/16 at 11:29 a.m., Resident exited the facility on her own. Staff sat with resident outside. Resident was later found across the street. Resident was redirected into the facility. Resident states that she's upset with her husband. *On 8/2/16 at 5:44 p.m., The resident was attempting to leave the facility. The resident's husband kept telling her to 'stay put' the resident came back into her room and slammed the door shut. *On 8/3/16 at 3:00 p.m., Resident exited the facility alone after returning to the facility from her doctor's appointment. Resident was upset with her husband and accused him of cheating on her. Staff sat down with the resident to visit about her concerns and spent about 30-45 minutes outside. *On 8/20/16 at 3:30 a.m., CNA went to check on resident d/t (due to) elopement earlier this shift and found resident sitting on bed frame and had mattress pushed up along the wall behind her. *On 8/30/16 at 9:55 a.m., Resident exited the building alone. Staff redirected inside building. *On 9/8/16 at 6:23 p.m., Resident exited the building two times this shift. Resident said she just wanted to go outside when she felt like it and not be watched or followed. Resident was upset most of the shift because she felt staff was telling her what she can and cannot do. *On 9/10/16 at 7:23 p.m., Resident left the facility twice today without being assisted by staff. She stated her husband is messing around with all of the women around this place. Writer sat and spoke to her about keeping her safe and needing to have a staff member assist her outdoors. Resident continued to call husband and CNA's inappropriate names. Writer told resident to address all of her concerns with the charge nurse. *On 9/12/16 at 6:07 p.m., The resident was seen leaving the dining room crying. This writer and administrator PW followed resident to her room to see what was wrong. Resident was in her rocking chair crying. She stated that those people out there are railroading her and she was just minding her own business but they were rude to her. At approximately 1700 this writer went to the front of the building to ask the resident to come in and eat supper. She stated she didn't want to eat. Because of the elopement risk this writer asked the resident if she could come to our gated patio and sit. Resident didn't have an issue with that. She was sitting with a blanket on her head and socks on her hands as mittens. She came into the building willingly and in 1 minute time had forgotten why she was coming in. She started to head right back outside. The writer intercepted and stated that we were going to go sit in the patio area. Resident stated oh yes. Resident went to area where we could observe her. She was then brought into supper where another incident occurred. When we started talking to the resident in her room she was talking about the bozos out in the dining area. She then saw a picture of her grandson or great-grandson on her closet door and started talking about how the ducks never have done anything to anybody and the little boy trusts the ducks and the ducks trust him. It was very disorganized thought pattern and resident appeared to calm after about 30 minutes of talking with her. *On 9/14/16 at 11:24 a.m., This writer was notified that the resident had eloped and was coming back in the building at this time. -She continued to have behaviors and the police were called to transport her to behavioral health. *On 9/14/16 at 2:41 p.m., This writer received a phone call from (the) ER (emergency room ) that the resident was in their building and they didn't know why. She was acting very calm and just stated that she must have made somebody very mad because that's why she was there. The nurse stated the doctor was going to send the resident back to us because she was being so calm. This writer explained what had happened that morning and that she needed to be evaluated for behavioral health. Nurse stated she would give the message to the provider and let him make a decision. *On 9/14/16 at 5:22 p.m., Facility was notified of resident's elopement this morning. A staff member saw her walking with her walker about two blocks from the facility. The staff member redirected her back to the facility. *On 9/28/16 the resident returned to the facility from her stay at the behavioral health facility. Review of resident 3's current undated care plan revealed: *A focus area for displaying maladaptive behaviors that included elopement was initiated on 8/2/16 and revised on 10/26/16. *The interventions had been: -Please report incident to appropriate parties and follow facilities and policy and procedure in regards to elopement incidents or another incidents of inappropriate maladaptive behaviors. --Initiated on 8/2/16 and revised on 10/26/16. -Redirect me if I am loitering by the doors. --Initiated on 8/2/16 and revised on 10/26/16. -Remind me that I can go outside but will need staff or a family present to ensure my safety. --Initiated on 8/2/16 and revised on 10/26/16. -Staff will stay with me to ensure my safety and redirect me back into the facility. --Initiated on 8/2/16 and revised on 10/26/16. -Visit with me in a empathic matter allowing me to vent my frustrations and assist in coming up with suggestions for me to deal with my feelings. Family has suggested that I can be redirect by asking me questions about grandchildren and to encourage me (to) look at my pictures of them. --Initiated on 8/2/16 and revised on 10/26/16. Review of resident 3's discontinued care plan revealed there had been no other interventions implemented for elopements other than what was listed above. The care plan had not been updated on 6/8/16, 8/3/16, 8/20/16, 8/30/16, 9/8/16, 9/10/16 or on 9/14/16 when she had eloped from the facility. Review of resident 3's elopement risk assessments revealed: *One completed on 5/12/15 upon admission. The care plan intervention was to Monitor for elopement risk, actions, or activities that suggest patient (resident) may be at risk for elopement. -There had been nothing written in the box Summary: Is the resident an elopement risk? Explain. *There were no other elopement assessments completed until 9/14/16. *The 9/14/16 assessment revealed: -There had been nothing written in the box Summary: Is the resident an elopement risk? Explain. -The care plan intervention box stated I have eloped in the past and have stated I will continue to do so. I tend to be very quiet about leaving the building. Staff need to monitor me frequently. Observation on 11/30/16 at 9:45 a.m. in the front lobby with three surveyors present revealed: *No one had been sitting in the front office monitoring the door. *The blinds to that office had been closed. *The door alarm had been set off by the surveyors. *The alarm was turned off without staff checking the door to see who had set off the alarm. *The alarm was set off a second time, and again the alarm was turned off without staff checking the door to see who had set it off. Interview immediately following the above observation with CNA K revealed: *She had shut the door alarm off both times. *She stated she had checked the door. *When asked who had been at the door she was unable to correctly identify the three surveyors who had set off the alarm. *She would not finish answering questions and walked away from this surveyor. 2. Review of resident 15's 6/16/16 incident report sent to the SD DOH revealed: *She had eloped out the north exit door on 6/13/16. *She was found at 7:00 p.m. by a staff member who was just leaving her shift, and whose car was parked by the north entrance. *The staff member was getting into her car when she saw a wheelchair sitting at the bottom of the hill. -She found the resident in the bushes. -The resident had scratches on her neck and face. *They had checked the alarm on the door, and it was not working. *They turned it off and then on again, and at that point it was working. *They thought a power surge had caused the issue. *Prior to entering another resident's room a staff member had seen resident 15 in the hallway in her wheelchair. *When the staff member came out of the other resident's room she had not been concerned that resident 15 was not in sight, as she moved around the building quite frequently. Review of resident 15's elopement risk assessments revealed: *She had one completed assessment on 5/20/16. *Her admitted had been 3/16/15. *She had a history of [REDACTED]. *She had tried to elope and did elope at one point when first admitted . *She had not displayed any kind of wandering. *In the Summary area they had Resident is no longer an elopement risk. *Not a risk at this time was typed under the care plan intervention box. Review of resident 15's discontinued care plan revealed: *She was no longer a resident at the facility. *She had a focus area of having a history of elopement or exit seeking behavior initiated on 3/23/15 with no revisions prior to it being canceled on 9/21/16. *The interventions had been: -Reassure (resident name) that she is going to be OK and that this is her home. If (resident name) appears tired or tearful offer her time to rest and lay down, offer her 'her elephant' to help calm her down, provide reassurance that she has people that care about her. Ensure her safety and document the incident of elopement/exit seeking. --It was initiated on 3/23/15 with no revisions prior to it being canceled on 9/21/16. -Report any injuries of elopement to the appropriate parties and follow facilities policy and procedure. --It was initiated on 3/23/15 with no revisions prior to it being canceled on 9/21/16. -Provide medications as ordered. --It was initiated on 3/23/15 with no revisions prior to it being canceled on 9/21/16. -Redirect (resident name) to another activity such as spending 1/1 time conversing with her, take her for a walk, look at the garden, listening to music, having her fold cloths. --It was initiated on 3/23/15 with no revisions prior to it being canceled on 9/21/16. 3. Interview on 11/30/16 at 11:50 a.m. and 12:20 p.m. and on 12/7/16 at 2:20 p.m. with the director of nursing regarding residents 3 and 15 revealed: *She had not felt resident 3's above mentioned incidents had been elopements, because staff had heard the alarm and went after her. *She agreed she had been exit seeking. *The interventions on both residents' care plans had not been updated when incidents had occurred. *She stated they had attempted to change resident 3's room. Her doctor had not agreed to it, as he felt it might cause her more stress because of her dementia. *Resident 3 usually got more frustrated and would exit seek on the days her husband was out of the building. -That information had not been documented in her care plan or the progress notes. *Resident 15 was always moving around the building on her own in her wheelchair. -After her elopement on 6/13/16 they had locked the door between the dining room and the north hall. -There were still at least four other doors she could have gotten out of on her side of the building. *The elopement risk assessments had not been done upon admission, quarterly, or with a significant change in condition. Review of the provider's April 2016 Elopement At Risk policy revealed: *Residents who leave the facility without the knowledge of staff, wandering with no rational purpose, and are unaware to needs or safety are at risk for elopement. *The procedures included: -During the pre-admission process assess residents for risk of elopement. -Elopement assessment will also be completed at time of admission, quarterly (or a review of last assessment if no change since the time last assessment completed); annually and with a change of condition/exhibits new exit seeking behaviors or has an elopement. -Care plan team members should consider the following things when identifying risk of elopement: --Wandering behavior. --History of elopement. --Cognitive impairment. --Attempts to leave facility. --Unable to find way about familiar areas. --Vehicular traffic in parking lots and adjacent streets or highways. --The presence of railroads, streams, ponds, rivers, drainage ditches, etc., near the facility. --Location of facility, i.e. urban or rural. -Residents who are upon admission identified with a risk of elopement will be assessed and interventions put into place on the comprehensive plan of care immediately. -Residents who are identified as at risk of elopement during their stay in the facility will be assessed by the interdisciplinary care plan team during care plan conferences. -Individualized measures will be put into place and addressed on the comprehensive care plan, within seven days of assessment. Review of the provider's December 2016 Door Alarm policy revealed All staff are required to respond immediately to a door alarm by going and physically checking to see if any residents exited the facility. B. Based on observation, interview, and job description review, the provider failed to maintain an even sidewalk surface in two of seven exit or entrance areas (front entrance and 200 wing) to prevent potential falls. Findings include: 1a. Observation on 11/28/16 at 11:45 a.m. of the front entrance sidewalk revealed: *A long sidewalk from the entrance of the building to a parking area near the road. *There were four areas where the concrete slabs had approximately one-half to one inch differences between the surfaces. *Two areas had the edges painted orange to identify the difference between surfaces, and two had not been painted. b. Observation on 11/28/16 at 5:00 p.m. of the 200 wing exit door revealed: *A sidewalk from the doorway to a sidewalk ramp and the parking lot. *Between two slabs of concrete there was approximately one inch difference between the surfaces and about a one inch gap between the two slabs. *The edges were painted orange, and there was a black rug covering about two-thirds of the gap. Observation and interview on 11/30/16 at 11:15 a.m. with CNA J by the 200 wing exit door revealed: *Residents used that door sometimes when they went out with family or to appointments. *The concrete had been painted orange and had the rug over the top of those uneven surfaces for a long time. *It was a potential fall hazard because of the uneven surfaces. c. Observation and interview on 12/6/16 from 10:40 a.m. through 11:20 a.m. of the front entrance sidewalk and the 200 wing sidewalk with the maintenance director revealed: *He was aware of the raised concrete. *He agreed there were differences between the surfaces. *He agreed residents used those areas, and they could have been a potential trip hazard. *The provider had been aware of those sidewalk areas since the last survey in February 2016. *They had received a bid but had not gotten the work completed. *A copy of the bid or work invoice was requested from him and had not been received by the end of the survey on 12/7/16. Interview on 12/7/16 at 10:40 a.m. with nurse manager B, the DON, the administrator, and the director of clinical services revealed: *They were aware of the recommendation to correct the sidewalk areas on the 200 wing and front entrance during the last survey in February 2016 due to the potential safety hazard. *They had received bids, but the work had not been completed. Review of the provider's 4/1/13 maintenance supervisor's job description revealed: *Duties and responsibilities included Supervises, schedules and performs skilled technical and preventive maintenance, functions in building and ground maintenance, alteration and repair of the facility, follows maintenance checklist functions and maintenance procedures, and equipment repairs. *Essential functions included: -Ensures safety of all residents, visitors and staff. -Report unsafe conditions immediately. *Maintenance and repairs for ground maintenance: -Had not included inspection of the sidewalks. -Had included Lay forms, mixes, pours, and finishes concrete for buildings, sidewalks and slabs.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being of all fifty-one residents. Findings include: 1. Interviews, observations, record reviews, and policy reviews, throughout the course of the survey revealed the administrator and the director of nursing had not ensured the safe management and overall well-being of the residents. Review of the provider's undated job description for the administrator revealed To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's operational and business objectives. Review of the provider's 6/8/15 job description for the director of nursing revealed: *Maintains nursing service objectives and standards of nursing practice. *Ensures staff were educated on policies and procedures. *Manages nursing staff in the provision of care and services to residents. Refer to F159, F160, F166, F221, F224, F225, F241, F246, F253, F256, F280, F281, F314, F323, F353, F356, F431, F441, F456, F493, F514, and F520.

Based on observation, interview, record review, job description review, and policy review, the governing body failed to ensure the facility was managed in a manner that ensured the safe management and overall well-being for all fifty-one residents in the facility. Findings include: 1. The following deficiencies were repeated deficiencies from the previous complaint survey on 8/24/16 and the recertification survey on 2/18/16: F280, F281, F323, F441, and F520. The following were newly cited deficiences for the current survey: F159, F160, F166, F221, F224, F225, F241, F246, F253, F256, F314, F353, F356, F431, F456, F514, and F490.

Based on interview, record review, and policy review, the provider failed to ensure an effective quality assurance (QA) program had been implemented and followed through to resolution for identified deficiencies and to develop and implement corrective actions for all residents. Findings include: 1. Interview on 11/30/16 at 3:15 p.m. with the medical director revealed: *He usually attended the monthly Quality Assurance and Performance Improvement (QAPI) meetings. *The meeting was usually a couple hours long. *The provider's QAPI's template was extensive. *Areas covered at the meetings consisted of: -Casper reports. -Specifics on individual residents. -Issues for the month. -Progress of the performance improvement projects (PIP). -Discussion of new PIP needs. -Complaints. *Answering resident call lights in a timely fashion had not been brought to QAPI. *Grievances from resident council had not been discussed at QAPI. *Staffing had not been discussed at QAPI. Interview on 12/7/16 at 10:40 a.m. with the administrator, director of nursing (DON), director of clinical services, and nurse manager (NM) B revealed: *The QAPI committee had monthly meetings. *The QAPI committee consisted of the administrator, DON, NM A and B, medical records coordinator, physical, occupational, or speech therapy representative, medical director, consultant pharmacist, social services designee, activity coordinator, dietary manager or consultant registered dietitian, laundry director, and maintenance supervisor. *The medical director had been in attendance on 3/9/16, 4/6/16, 5/12/16, 7/8/16, 7/13/16, 9/14/16, 10/12/16, and 11/9/16. *The process used to identify QAPI activities consisted of the following: -Corporate template. -Casper reports. -Medical director input. -Quality conferences. -Patterns and trends. -Daily rounds by management. *The administrator, DON, and NM B agreed they talked a lot about things in QAPI and more needed to have been done to: -Have identified deficiencies. -Have developed and implemented corrective actions. Review of the provider's 2014 QAPI Purpose, Guiding Principles, and Scope for QAPI policy revealed: *The administrator with assistance from the DON were responsible for leading and directing the QAPI program. *The program was to have addressed systems of care and management practices, and included clinical care, quality of life, and resident choice. Review of the provider's QAPI Agenda and Meeting Minutes Instructions policy revealed the committee developed and implemented appropriate plans for action to correct identified quality deficiencies. Refer to all findings in: F159, F160, F166, F221, F224, F225, F241, F246, F253, F256, F280, F281, F314, F323, F353, F356, F431, F441, F456, F490, F514, and F493.

Based on observation, interview, record review, and policy review, the provider failed to ensure sufficient nursing services had been provided to meet all aspects of residents' care needs. Findings include: 1. During a confidential group interview on 11/29/16 from 11:10 a.m. through 12:15 p.m. seven residents revealed: *Concerns they had brought up in the past but had not received resolutions for were: -Having their bedding changed weekly. -Getting their baths at least weekly. -Missing items such as clothing. -Getting their call lights answered faster. -Residents being left on the toilet for extended periods of time. Interviews, observations, record review, and policy review, throughout the course of the survey from 11/28/16 through 12/1/16 and 12/6/16 through 12/7/16 revealed the provider failed to ensure resident needs had been met. Refer to F166; F224; F246, statement B; F314; F323, statement A; F356; F441; and F520. Interview on 12/7/16 at 2:20 p.m. with the director of nursing (DON) and the administrator revealed: *Their current census was fifty-one residents. *They attempted to have six certified nursing assistants (CNA) on the floor during the day and four CNAs during the night shift. *At night staffing levels varied, and sometimes they would have to call people in. *The schedules had not reflected when a staff member called in or was a no call or no show for a scheduled shift. *The schedules had not accurately reflected who had been working. Review of the provider's January 2015 Sufficient Staffing policy revealed: *Nursing direct care staffing ratios will be figured with changes in census and level of care needs. *Daily reviews of staffing patterns will be reviewed by the scheduler, HR (human resources), and DON. *Changes will be made based on numbers of resident and their case mix RUG or level of care necessary with administrator approval. *In addition to licensed nurses and nursing assistants, resident hospitality aides and activity assistants may also be included in the daily equation of staffing ratios for resident needs. *Random scheduled resident interviews are conducted to assess satisfaction with care needs being met and considered when staffing ratios are determined. Review of the provider's 6/8/15 job description for the DON revealed she: *Maintained nursing service objectives and standards of nursing practice. *Ensured staff were educated on policies and procedures. *Managed nursing staff in the provision of care and services to residents. Review of the provider's undated job description for the administrator revealed To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's operational and business objectives.

1. Observation and interview on 11/28/16 at 12:10 p.m. of resident 6 in her room revealed she: *Had been admitted on [DATE] for wound healing. *Had a large wound on her lower right leg covered with a bandage. *Stated it had started as a pressure injury at another facility. She had been sent to Sioux Falls for surgery, and then here for wound healing. *Had a commode but had not been able to use it, because there was no step the correct height to support her legs. *Had a cushion in her wheelchair, but she had not felt it was of much support. *Was in a double bed with a pressure relieving mattress and transfer bars on the sides. *Was laying on her back with the head of the bed slightly raised to prevent back pain. *Had a Foley drainage bag on the side of the bed. *Confirmed she had a Foley catheter to protect her skin. Observation and interview on 11/30/16 from 11:23 a.m. through 12:33 p.m. with resident 6, licensed practical nurse (LPN) I, and certified nursing assistants (CNA) G and P doing the wound dressing change revealed: *LPN I's cord from her ear piece dangled in the aseptic area of the wound dressing change. *LPN I stated she was not going to measure the wound. *At 11:40 a.m. following the completion of the wound dressing change the resident agreed to turn on her side, so her back could be viewed. -The resident stated she needed assistance to turn. *After she was assisted onto her left side her back and the backs of her thighs and legs were visible and revealed: -Approximately six inch long dark blackish red mark, the thickness of a pencil, across her left buttocks. -A thick dressing approximately two inches by four inches in size applied to upper mid level of the far right side of her back. That dressing had a one inch long wrinkle in it. Across from the dressing on the next skin fold was an opened, red, weeping wound approximately one and one half inch long and three-fourths of an inch wide that corresponded to the location of the wrinkle in the dressing. She said it hurt there and in front a little. CNA P stated that opened area had not been there last weekend. LPN I agreed the wound corresponded to the location of the wrinkle in the dressing. -Just in front of that wound was an opened area where the top layer of skin was gone, about the size of a nickel. CNAs G and P agreed they had not seen that before. -The lower area of the right buttock had two opened slits in the skin each about one-half an inch long, and two dark red circular areas about the size of pencil eraser tops. The entire area was darker reddish tan in color. -Another thick dressing of the same type and size that was on her upper mid level on the far right side of her back had been applied to the middle of her right leg, calf area. -LPN I removed both dressings. Nothing was noted under the dressing on the upper mid level of the far right side of her back. There was a one-half inch open area under the dressing on her right mid calf area. -LPN I and CNAs G and P agreed those changes in skin condition had not been seen before, and they were not aware of why or when the two thick dressings had been applied. There had been no date or initials on either dressing. -Area under right breast was red and damp. -Area under stomach skin fold was red and damp. The staff left the room for supplies. *At 11:58 a.m. the resident stated They never rolled me over and looked at my back. They don't wash between my legs either. *The staff returned to her room. *Her skin was washed and dried. Antifungal cream was applied under the skin folds. *She stated she needed to use the bedpan. -The CNAs put a plastic bag over the bedpan. -She commented the plastic bag stuck to her skin and made it difficult to use the bed pan. -The CNAs removed the plastic bag and repositioned the bedpan. -She requested time to use the bedpan. 2. Observation on 12/7/16 at 11:20 a.m. of resident 16's newly found stage 2 pressure injury with registered nurse (RN) N revealed: *The resident was laying in the bed positioned on her right side. *A dressing over the coccyx area had been dated 12/5/16. *RN N decided to not remove the dressing, since it had just been changed and was in good condition. Interview on 12/7/16 at 2:25 p.m. with nurse manager B revealed she agreed residents 6 and 16 had skin alterations occur since they had been admitted . Interview on 12/7/16 at 2:50 p.m. with the director of nursing and the administrator revealed they agreed residents 6 and 16 had skin alterations occur since they had been admitted . 3. Review of the provider's February 2014 Prevention of Pressure Ulcers policy and procedure revealed: *Staff were to have reviewed the resident's care plan to assess for any special needs of the resident. *Pressure ulcers could come from bandages and wrinkles in the bed linen. *If not treated when discovered pressure ulcers could quickly get larger, become painful, and get infected. *Once a pressure ulcer developed it could be difficult to heal. *Interventions to prevent pressure ulcers for a person in bed included: -Changing position at least every two hours or more frequently if needed. -Raise the head of the bed a little and for short periods of time. *Interventions to prevent pressure ulcers for a person in a chair included: -Changing position at least every hour. -Lifting not sliding. -Encourage active and passive range of motion exercises to improve circulation in the extremities. -Routinely assess and report changes in skin condition. *All care was to have been documented when completed. Review of the provider's January 2014 Repositioning policy and procedure revealed:*Staff were to review the resident's care plan to evaluate for any special needs of the resident including turned schedule and number of staff needed to assist. *Repositioning was a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. *Repositioning was critical for a resident who was immobile or dependent upon staff for repositioning. *A turning or repositioning program included a continuous consistent program for changing the resident's position and realigning the body. -A program was defined as a specific approach that was organized, planned, documented, monitored, and evaluated. -Residents in bed should have been turned or repositioned every two hours. -Residents in a chair should have been repositioned every hour. -Care provided was to be documented when completed. Review of the provider's February 2014 Pressure Ulcer Treatment policy and procedure revealed: *Purple or maroon localized area of discolored intact skin could have been deep tissue injury due to damage of underlying soft tissue from pressure and/or shearing. *Turning schedule was suggested to prevent pressure ulcers from occurring or expanding. *Documentation data was to include color, size, pain, and drainage when inspecting the wound. Based on observation, interview, record review, and policy and procedure review, the provider failed to ensure one of three sampled residents (6) and one provider identified resident (16) with a previously undocumented alteration in skin integrity remained free of new pressure injuries. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 11/30/16 at 5:45 p.m. to the administrator, the director of clinical services, and the director of nursing (DON). The administrator was asked for an immediate plan of correction to ensure all residents would be safe from further skin breakdown. PLAN: On 12/1/16 at 2:23 p.m. the administrator provided the surveyors with an immediate written plan of correction (PoC). That PoC dated 12/1/16 was accepted at 2:25 p.m. by the surveyors and included: Pressure Ulcers: Resident #6 was reassessed by NM- B on 11/30/2016 and new skin concerns were identified. The new skin concerns were measured and documented in the resident's medical record. The resident's plan of care has been updated to reflect the newly identified alterations in skin integrity. A head to toe skin assessment was completed and documented for all residents on 11/30/2016 by NM-A, NM-B, and DON. The following residents were identified as having previously unidentified alterations in skin integrity: · Resident #16 The newly identified alterations in skin integrity were measured and documented in each resident's medical record for the afore/mentioned residents. Care plan updates were completed to promote uncomplicated wound healing. The skin program policy was reviewed on 12/1/2016 by the Director of Nursing and Director of Clinical Services. The policy remains current. Education was implemented immediately for all nursing staff regarding the skin program policy. The education included: providing care to prevent pressure ulcers, following established care planned interventions such as timely turning and repositioning, offloading and incontinence cares/skin care to prevent skin breakdown as well as following MD orders for wound treatment orders and timely notification of newly identified skin concerns. Education will continue prior to or during next shift for all nursing staff. Catheter Cares The policy and procedure for Catheter Care was reviewed by the Director of Nursing and the Director of Clinical Services on 12/1/2016 and revised to clarify when to provide catheter care. The following changes were made to the section titled Infection Control {2.A} to clarify Routine hygiene: 2. a. Routine hygiene (e.g., cleansing of the meatel surface with soap and water or with perineal wipes during daily cares) is appropriate and should be performed with AM and HS cares and with each episode of performing peri-care. Immediate catheter care education was implemented on 11/30/2016 by NM-A, NM-B and DON with all nursing staff and included a return demonstration. Education also included when catheter cares should be completed in accordance with the policy updates. Education will be completed prior to or during next shift of all nursing staff. During the survey on 12/1/16 at 2:25 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include:

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (4) had not been left sitting on the toilet for an extended period of time. Findings include: 1. During a group interview on 11/29/16 from 11:10 a.m. through 12:15 p.m. resident 4 revealed: *She had been left on the toilet one night from 6:50 p.m. through 8:20 p.m. *She stated one of the certified nursing assistants (CNA) had left during her shift. *She thought it had been a few weeks ago when the incident had occurred. Review of resident 4's interdisciplinary notes from 8/11/16 through 11/28/16 revealed: *On 11/8/16 the Bath aide called this writer into the shower room to look at residents arms. Resident has rash/hives on BUE (bilateral upper extremities). She states that this is stress induced from a couple of nights ago when she was left on the toilet from 6:50 p.m. until 8:20 p.m. Will fax dr for PRN (as needed) [MEDICATION NAME] as she states it itches and will report to DON (director of nursing). *There had been no documentation prior to the above that she had been left on the toilet. *There was no documentation in the notes of an investigation into the above incident to determine if neglect had occurred. Review of resident 4's 11/9/16 fax sent to the physician revealed they had requested an order for [REDACTED]. Review of resident 4's 9/15/16 Minimum Data Set assessment revealed: *Her Brief Interview for Mental Status score was fifteen. -A score of thirteen to fifteen meant her thinking ability was not impaired. *She required extensive assistance of two staff members to use the bathroom. Review of resident 4's 11/7/16 internal investigation form revealed: *It had been completed by the administrator. *The date of the incident was 11/6/16. *Under description of the incident it stated Resident reported being left on toilet from 7:30 p.m. to 8:30 p.m. -That timeframe had not matched the above progress note or resident statement. *The alleged perpetrator was unknown. *Assessment of the resident was Resident does not have any reddened marks on bottom. *Resident interview summary was States she was put on toilet by new NA (nurse aide) and wasn't removed for an hour. *The following sections of the report were blank: -What measures were taken immediately to protect the resident and/or other residents? -Care plan reviewed. -Care plan revised. -A call must be placed to administrator/designee immediately to notify of incident. -Report to specific state agency. -Summary/Outcome of Investigative findings. -Notification to the physician, state agency, and ombudsman. -Signature of person completing form. *Interview conducted with the DON on 11/7/16 at 12:00 noon stated I toileted resident at 5 a.m. and she didn't mention the incident. She stated she had a rash on her arms. I put some cream on her arms because she said it was itchy. *Interview conducted with CNA C on 11/7/16 at 1:00 p.m. stated Interviewed (NA O) to see if when she got (resident 4) up on 11/6/16 if she had any hives. She stated no. (NA O) was also asked if she put (resident 4) on the toilet that evening. She did not remember working with her only in a.m. -That interview had been conducted with NA O instead of CNA C as stated at the top of the form. *Interview conducted with CNA V on 11/7/16 at 1:30 p.m. stated She worked east and left at 6:00 p.m. Did not remember any hives. Remembers bathrooming her at 5 p.m. -The witness signature box was filled in with CNA V's name and dated 11/7/16. -Her title had not been documented on the report. *There had been no documentation of who had put resident 4 on the toilet or who had taken her off. -She was an extensive assist of two staff members. *There had been no documentation in the investigation of who had been working down that hall at the time of the incident. Review of the staffing schedule for 11/6/16 revealed: *CNA Q and R were scheduled to work from 6:00 p.m. through 6:30 a.m. *NA S was scheduled to work from 6:00 p.m. through 6:30 a.m. *They were in need of a staff member for the 5:00 p.m. through 1:00 a.m. shift. *They were also in need of a staff member for the 7:00 a.m. through 7:30 p.m. shift. *NA O was scheduled from 8:00 a.m. through 8:30 p.m. *Medication aide (MA) U was scheduled from 8:00 a.m. through 8:30 p.m. *Registered nurse (RN) T was scheduled to work from 6:00 p.m. through 6:30 a.m. *Those would have been the staff present at the time resident 4 had been assisted to the bathroom at 6:50 p.m. *There was no documentation of interviews conducted with CNA Q or R; NA S; MA U, or RN T. *There had been no changes made to the schedule at the time of review by this surveyor. Interview on 11/29/16 at 4:00 p.m. with the administrator revealed: *She had completed the investigation into the above issue. *Resident 4 had come to her on the morning of 11/7/16 and reported the incident. -The incident had not been reported or documented by any of the staff members working on 11/6/16. *NA S had been scheduled to work on the floor but had left the building during her shift. -She was unsure of what time she had left. -That information had not been documented in the progress notes or in the investigation. *She was unsure of who had been supervising the two NAs working that shift including NA S. *They attempted to call NA S to see if she had assisted resident 4 into the bathroom, but she had not returned their calls. *She was unsure who had assisted the resident into the bathroom or out of the bathroom. -The resident needed two staff members to assist her to the bathroom. *She had spoken to the resident, but she had focused on the hives. The resident had only told her it was a NA that helped her. *She was unsure if the social services designee (SSD) had gotten involved. *They had not reported the incident to the state agency as their corporate office had told them not to. *The time listed on the investigation report was 7:30 p.m. through 8:30 p.m. -She stated that information was pulled from the call light computer system. *She agreed the resident would have been in the bathroom prior to putting the call light on. Record review and interview on 11/29/16 at 5:30 p.m. with the DON and the administrator revealed: *The call light computer system confirmed resident 4's call light had been activated on 11/6/16 from 7:32 p.m. through 8:34 p.m. -She agreed the resident had probably been in the bathroom prior to putting the light on. -The DON was unable to print a report of resident 4's call light logs. -She stated they had not had training on how to run the reports. -They have had that current call light system for approximately 1.5 years. -Anytime they received a complaint on call light times she reviewed the information for that room. -She was unable to provide any documentation any call light audits had been completed on any complaints by residents, resident council, or families. *They had been short staffed on 11/6/16 as CNA Q had not shown up for her shift that evening. -She was supposed to supervise NA S. *The DON had received a call from NA S at 7:05 p.m. stating she was unsure what to do as CNA Q had not shown up for work. *The DON arrived in the facility at 7:54 p.m. to work as a CNA. -At that same time she received a message from the day nurse who was still in the building stating NA S had left the building. -She attempted to call NA S, but she was unable to get in touch with her. *They had to call the dietary manager (DM) and activities staff in to assist, as they were short staffed. *They did not update their schedules if someone was a no call or no show. *If they had called people in to work it was not updated on the schedule. *None of the above information had been documented anywhere or included in the investigation of resident 4 being in the bathroom for over an hour. Interview on 11/29/16 at 6:15 p.m. with RN T regarding resident 4 revealed: *She had been the nurse scheduled on 11/6/16 from 6:00 p.m. through 6:30 a.m. *CNA Q had not shown up for work which left one CNA working the evening shift. *She had not been informed of the incident until hours later. *She had been administering medications to the resident when she had informed her she had been left in the bathroom. *The resident had informed her that her arms hurt because of anxiety. *The activities director, the DM, and other staff had been called in to assist with putting the residents to bed. *There was no documentation RN T, the activities director, or the DM had been interviewed as part of the investigation. *She stated she had not reported or documented the information shared with her by resident 4. Interview on 11/30/16 at 3:15 p.m. with the medical director revealed call light wait times had not been addressed in the quality assurance meetings. Interview on 11/30/16 at 4:30 p.m. with resident 4 revealed: *She was still fearful of being left in the bathroom, because of the incident that had occurred on 11/6/16. *She had gotten hives, because she had become so anxious waiting for someone to answer her call light. *She had not been talked to by the DON until last night. *The DON had told her You should talk to someone. *The resident stated she used a counseling service and would speak with them. Interview on 12/6/16 at 2:50 p.m. with the SSD revealed: *She had not been informed of the incident with resident 4 until November 9 during the resident council meeting. *Resident 4 had shared she had been left in the bathroom for over an hour. *The DON at that time said she would check into it. -She had never reported back to the SSD the resolution to that incident. Interview on 12/6/16 at 5:10 p.m. with NA O revealed: *She had been working 8:00 a.m. through 8:30 p.m. on 11/6/16. *She did not recall helping resident 4 that evening. *She remembered seeing the resident come out of her room crying. -The resident had gone up to the person working the medication cart. *It was not normal to see resident 4 crying. *She had not gone up to the resident or reported it, because the resident had already been talking to the nurse. Review of the provider's November 2016 Abuse Prevention Plan policy revealed: *All residents have the right to be free from abuse, neglect, involuntary seclusion, exploitation, and misappropriation of property. *The intent of the policy is to provide a safe living environment to all residents of the facility and to provide guidelines for investigating and reporting of suspected maltreatment. *Facility will investigate all incidents. *All incidents will be reviewed with the following disciplines: -Nursing. -Social Services. -Administrator. -Activities. -Therapies. *The facility will identify staff members responsible for: -The initial report. -Initiating the investigation. -Reporting the results to the proper authority within the 5 calendar days state requirement. Review of the provider's June 2015 Answering the Call Light policy revealed: *Staff were to answer the call light as soon as possible. *The following information should be recorded in the resident's medical record: -Requests or complaints made by the resident. -How the request or complaint was satisfied. -If support personnel or family members assisted, and how. -If the resident refused treatment/solution, and the reason(s) why. -The name and title of the individual(s) who performed the procedure.